Milk bolus obstruction in the neonate.

Seventeen cases of neonatal intestinal obstruction due to inspissated milk curds were seen at this hospital in the 9 years 1964-1972. The obstruction started on the 2nd to 10th day of life. Half the babies passed blood from the rectum and in most the x-rays were diagnostic. All survived, 14 after operation and 3 after medical treatment with a Gastrografin enema. Incomplete absorption of solids, particularly the fat from cows'' milk feeds, is suggested as the cause.     

Nasal obstruction in infancy.

OBJECTIVE--To test the hypothesis that reduced fetal growth leads to altered plasma insulin-like growth factor-1 (IGF-1) concentrations in childhood. DESIGN--A follow up study of 4 year old children whose birth weights were recorded, and of 7 year old children whose weight, length, head circumference, and placental weight were measured at birth. SETTING--Pune, India, and Salisbury, England. SUBJECTS--200 children born during October 1987 to April 1989 in the King Edward Memorial Hospital, Pune, weighing over 2.0 kg at birth and not requiring special care, and 244 children born during July 1984 to February 1985 in the Salisbury Health District and still living there. MAIN OUTCOME MEASURE--Plasma IGF-1 concentrations. RESULTS--In both groups of children, and consistent with findings in other studies, plasma IGF-1 concentrations were higher in taller and heavier children, and higher in girls than boys. Allowing for sex and current size, concentrations were inversely related to birth weight (Pune p = 0.002; Salisbury p = 0.003). Thus at any level of weight or height, children of lower birth weight had higher IGF-1 concentrations. The highest concentrations were in children who were below average birth weight and above average weight or height when studied. Systolic blood pressures were higher in children with higher IGF-1 concentrations (Pune p = 0.01; Salisbury p = 0.04). CONCLUSIONS--Children of lower birth weight develop higher circulating concentrations of IGF-1 than expected for their height and weight. This is consistent with the hypothesis that under-nutrition in utero leads to reprogramming of the IGF-1 axis. The increase of plasma IGF-1 concentrations in low birthweight children may also be linked to postnatal catch-up growth. High IGF-1 concentrations may be one of the mechanisms linking reduced fetal growth and high blood pressure in later life.     

Symptomatic atrial septal defect in the neonate and infant.

Atrial septal defect, secundum type, is rarely diagnosed and seldom produces symptoms in infancy. 7 patients, aged between 2 weeks and 8 months, who developed congestive failure, are presented. 6 of them had an atrial LR-shunt documented at cardiac catheterization. 1 diagnosis was made at post mortem in the only infant who died. The clinical signs of an ASD do not vary from those normally found in the older child; the causes for early failure are probably rapidly decreasing pulmonary vascular reistance and disturbances of left ventricular compliance. 6 infants improved with conservative or no treatment, although spontaneous closure or significant diminution of the shunt did not occur. Surgical closure can be deferred to a later optimal age for operation. ASD secundum type should be considered as a cause of heart failure in the neonate and infant.     

Musculoskeletal sonography in the neonate and infant

Babies are ideal subjects for investigation by sonography. They are small and easily examined with the use of high-frequency transducers. Their unique status in US imaging tends to get lost amid the array of other available modalities, such as MRI and CT imaging. Some of the questions posed in pediatric musculoskeletal imaging that are routinely directed to other imaging modalities can be solved quickly at a lower cost by sonography in neonates and infants without sedation or any known clinical risk. These small children not only have thinner soft tissues but they have long bones and midline spine structures whose ends are largely composed of cartilage, which provides an early opportunity to examine these regions by US. And we cannot overestimate the value of new parents being able to stay next to their baby during imaging in a warm, friendly and non-threatening environment.     

Bladder outlet obstruction in the neonate

Seven neonates with severe bladder outlet obstruction causing urine retention and presenting with a large, palpable lower abdominal mass are reported. The obstruction was due in two cases to posterior urethral valves, in one case each to prune belly syndrome, prolapsing ureterocele, urethral diverticle, and in two cases to pelvic neuroblastoma. Diagnosis was based on physical examination and roentgenographic studies. Therapy and prognosis of bladder outlet obstruction in neonates are discussed. Of the seven patients, 3 neonates died, the rest are developing well.     

Supraventricular tachycardia in the neonate and infant

Supraventricular tachycardia (SVT) is the most common sustained arrhythmia to present in the neonatal and infancy age group. Predisposing factors (congenital heart disease, drug administration, illness and fever) occur only in 15% of infants. The presentation of SVT in the neonate is frequently subtle, and may include pallor, cyanosis, restlessness, irritability, feeding difficulty, tachypnea, diaphoresis and grunting. Congestive heart failure is more common in infants under 4 months of age (35% incidence). Age-related differences in the distribution of SVT mechanisms occur in different age groups. In infants under 1 year of age, the mechanisms underlying SVT are atrial tachycardia (15%), AV nodal re-entry tachycardia (5%), and AV reciprocating tachycardia (80%). Options for acute management include: use of the diving reflex, intravenous adenosine, transesophageal pacing, and cardioversion. Intravenous administration of verapamil should be avoided. Data regarding freedom from recurrence of untreated SVT in the first year of life are limited, and may be in the range of 25-60%. Chronic therapy with digoxin, beta-blockers, flecainide, sotalol and amiodarone has proved effective in controlling recurrent episodes of SVT. Radiofrequency ablation can be employed successfully in medically refractory cases, but should be avoided in this age group (increased complication rate).     

Nasal obstruction in the pediatric patient

Early signals of pathologic causes of nasal obstruction in childhood may pass unnoticed by the unsuspecting physician because these signals mimic innocuous problems such as the common cold, sinusitis, and allergic rhinitis. The hope for early recognition of the more serious causes of nasal obstruction in children depends upon a high degree of suspicion. Some of the common and uncommon causes of nasal obstruction are enumerated by categorizing the possible etiologies into congenital, traumatic, iatrogenic, inflammatory, and neoplastic classifications. With a systematic approach that utilizes history, physical examination, and special diagnostic studies, misdiagnosis can be avoided and treatment initiated more rapidly and effectively.     

Nasal obstruction in neonates and infants

The main functions of the nasal airway are respiration and olfaction. The nose and sinuses condition air before reaching the lower respiratory tract by providing almost 100% humidification, warming, filtering and trapping of foreign particles. The airway epithelium contributes to the host defense system. Any alteration of this clearance system may produce significant problems, particularly in neonates, who are obligate nasal breathers until they are at least two months old. Nasal obstruction, and the inability to remove nasal secretion by nose blowing, may have serious consequences, such as respiratory distress or discomfort, altered sleep cycle, increased risk of obstructive apnoea and feeding difficulties. Most cases of nasal obstruction in neonates and infants are due to generalized nasal airway obstruction associated with neonatal rhinitis, viral upper respiratory tract infections, and possibly milk/soy allergies. Saline nasal lavage is recommended as an adjunct therapy for rhinosinusitis and allergic rhinitis, and in most cases of nasal congestion or obstruction in newborns, infants and children. In two recent experiences, was deemed to be the Narhinel method safe and effective for treatment of nasal congestion in babies with viral infections of the upper respiratory tract, or for the prevention of acute otitis media (AOM) and acute rhinosinusitis (AR) in children. Due to the efficacy, ease of use, tolerability and the lack of alternative medications in children younger than 12 years of age, nasal irrigation with physiological saline solution, followed by gentle aspiration, represent an effective method for the prevention and control of nasal congestion or obstruction in term or preterm neonates, infants and children.     

Nasal and intrapulmonary haemorrhage in sudden infant death syndrome.

BACKGROUND: Fresh intrapulmonary and oronasal haemorrhages in cases of sudden infant death syndrome (SIDS) might be markers for accidental or intentional smothering inappropriately diagnosed as SIDS. AIM: To compare the incidence, epidemiological association, and inter-relation of nasal haemorrhage, intrapulmonary haemorrhage, and intrathoracic petechiae in infant deaths certified as SIDS. METHODS: In SIDS cases from a large nationwide case-control study, a wide range of variables were compared in cases with and without reported nasal haemorrhage and, in a subgroup of cases, in those with and without pathologically significant intrapulmonary haemorrhage. RESULTS: Nasal haemorrhage was reported in 60 of 385 cases (15%) whose parents were interviewed. Pathologically significant intra-alveolar pulmonary haemorrhage was found in 47% of 115 cases studied, but was severe in only 7%. Infants with nasal haemorrhage had more haemorrhage into alveoli and air passages than age matched cases without nasal haemorrhage. In multivariate analysis, nasal haemorrhage was associated with younger infant age, bed sharing, and the infant being placed non-prone to sleep. Intrapulmonary haemorrhage was associated with the same three factors in univariate analysis, but in multivariate analysis only younger infant age remained statistically significant. There was no significant association between nasal or intra-alveolar haemorrhages and intrathoracic petechiae. CONCLUSIONS: Nasal and intrapulmonary haemorrhages have common associations not shared with intrathoracic petechiae. Smothering is a possible common factor, although is unlikely to be the cause in most cases presenting as SIDS.     

Brain development in the fetus, neonate and infant

In structural brain development eight interrelated but distinguishable events can be recognized: (1) neuronal induction, (2) neuroblast proliferation, (3) neuronal migration, (4) neuronal selective aggregation, (5) neuronal differentiation and formation of specific patterns of connection, (6) neuronal death, (7) selective synapse elimination and (8) myelination. The basic mechanisms regulating these developmental events are genetically determined but at any stage of development epigenetic and environmental factors modulate the genetic regulation. This paper reviews representative samples of work in animal experiments and knowledge in human fetal brain development by several authors.     

Nonpolio enterovirus infection in the neonate and young infant

Nonpolio enterovirus infections are common in the neonatal period, accounting for a large portion of febrile illness during the summer months. Unlike older children and adults, some neonates with enterovirus infection progress to multisystem disease and death. Multiple clinical syndromes of varying severity are associated with neonatal enterovirus infection: asymptomatic viral shedding, nonspecific febrile illness, aseptic meningitis, hepatic necrosis and coagulopathy, and myocarditis. In the present paper, a typical case of neonatal febrile illness is presented and the English-language literature is reviewed with respect to enteroviral infection in early infancy. The virology, epidemiology, transmission, clinical features, diagnosis and treatment of neonatal enteroviral infection are presented. Although the majority of infections in the neonate are benign, timely diagnosis in the febrile neonate will expedite efficient management. Clinicians also need to recognize the clinical manifestations and risk factors for severe disease to anticipate complications and implement intensive management of infants at high risk of adverse outcomes.