Elimination of pethidine and bupivacaine in the newborn.

Pethidine or an epidural injection of bupivacaine are common forms of obstetric analgesia in Britain. Bupivacaine has been thought to have little effect on the fetus, but neurobehavioural studies have cast doubt on this. We therefore investigated the elimination of these drugs by babies in similar population groups. Bupivacaine was largely eliminated in just over one day, while pethidine required between 2 and 6 days. This could account for the persisting depression in babies whose mothers had received pethidine.     

Reduction of incarcerated inguinal hernia in infants using caudal epidural anaesthesia

Incarcerated inguinal hernias in infants are commonly encountered. Reduction with intravenous sedation using morphine and related drugs carries risks of apnoea and/or respiratory arrest, especially in small, ex-premature babies who have an increased incidence of incarceration and thus opiate use is best avoided. Caudal epidural anaesthesia is widely used as pre- and post-operative analgesia in elective inguinal herniotomy in infants. In this study we sought to determine if caudal epidural anaesthesia would allow reduction of an incarcerated inguinal hernia in the acute setting, thereby obviating the need for intravenous sedation. A retrospective review of 12 male infants, with irreducible, incarcerated inguinal hernias was done. Each hernia was successfully reduced with the help of caudal epidural anaesthesia. This group of babies was treated at The Royal Belfast Hospital for Sick Children. Twelve male infants were identified with an incarcerated inguinal hernia in whom attempted reduction, without sedation had failed. Using Bupivacaine (1 ml/kg 0.25%), placed into the caudal space, these hernias were successfully reduced non-operatively. Ages at presentation ranged from 2 to 17 weeks with a median gestational age of 36 weeks (range 29–39 weeks). Caudal epidural anaesthesia is a safe, feasible and effective method of achieving reduction of irreducible, incarcerated inguinal hernias. It is especially useful in low-birth weight, premature infants where intravenous opiate sedation is best avoided.     

Birth weight at Changlang, Arunachal Pradesh

The data on birth weight of 524 (male-287, female-237) live born singleton babies of Changlang have been subjected to analysis in relation to sex, mean birth weight and low birth weight (LBW). For the purpose of comparison, the present data were sub-divided into three categories-Tangsa Tribe (T.T.), Tribes excluding Tangsa (T) and other groups (O.G.). Tribal babies of Changlang are found to be heavier than babies of other groups. It has also been observed that occurrence of LBW among tribal babies of Changlang is less than that of the babies of other groups of Changlang and it is much less than that of Bengali babies of Calcutta and Marathi babies of Pune District. It is apparent that tribal babies of Changlang are more hearthier than caste babies of N.E. India.     

Developmental assessment of intrauterine growth retarded babies of varying maternal etiology

Head circumference was measured serially and developmental performance assessed at the age of 9 months in 41 full-term intrauterine growth retarded babies of varying maternal etiologies. 18 full term and 12 preterm babies who were appropriate for gestational age (AGA) served as controls. The IUGR babies of undernourished mothers had maximum retardation in head circumference.The IUGR babies of small sized mothers had head circumference equal to that of fullterm AGA babies. The IUGR babies of mothers with toxemia of pregnancy and idiopathic group also reached very close to that of fullterm AGA babies for head circumference demonstrating catch up growth. 19.5 per cent of IUGR (as homogenous group) babies were found to have delayed development compared to 16.7 per cent of preterm and 5.6 per cent of fullterm AGA babies. Amongst IUGR groups, babies of undernourished mothers were found to suffer most, followed by babies of mothers with toxemia of pregnancy. None of the babies in the idiopathic group and only one out of 12 in small maternal size group were found to have delayed development.     

Additional congenital anomalies in babies with gut atresia or stenosis: when to investigate, and which investigation

A wide variety of additional congenital anomalies occur in babies born with a gut atresia or stenosis. The specific pattern of anomalies depends on the location of the atresia. The serious nature of many of them makes perioperative diagnosis imperative. Eighty-six babies born with pure oesophageal atresia (OA), duodenal atresia (DA) or stenosis, or jejuno-ileal atresia (JIA) have been studied. These, combined with over 2,000 cases in the literature, have been used to develop a protocol to optimally investigate babies with gut atresia for associated anomalies. The authors recommend routinely obtaining anterio-posterior and lateral chest and abdominal radiographs for babies with pure OA, DA and intestinal atresia, making sure the entire spine can be visualised. Cardiac and renal ultrasonography (US) should be routine in all babies with pure OA or DA. A micturating cystourethrogram should be done in those babies with abnormal urinary tract US or an associated anorectal anomaly. A sweat test should be obtained in babies with JIA, and a rectal biopsy should be taken in babies with the combination of Down's syndrome and DA to exclude Hirschsprung's disease.     

Jaundice in the newborns

Hyperbilirubinemia is the commonest morbidity in the neonatal period and 5–10% of all newborns require intervention for pathological jaundice. Neonates on exclusive breast-feeding have a different pattern and degree of jaundice as compared to artificially fed babies.. Latest guidelines from American Academy of Pediatrics (AAP) for management of jaundice in a normal term newborn have been included in the protocol. Separate guidelines have been provided for the management of jaundice in sick term babies, preterm and low birth weight babies, for hemolytic jaundice and prolonged hyperbilirubinemia.     

Ethics of care for the micropreemies. Just because we can,should we?

Debates about treatment for the tiniest premature babies focus on three different approaches – universal non-resuscitation, selective resuscitation, and universal resuscitation. Doctors, hospitals, and professional societies differ on which approach is preferable. The debate is evolving as studies show that survival rates for babies born at 22 and 23 weeks of gestation are steadily improving at centers that offer active treatment to these babies. Still, many centers do not offer such treatment or, if they do, actively discourage it. The doctors and centers that discourage treatment have concerns about the chances for survival, neurodevelopmental impairment among survivors, and cost. Centers that offer and encourage treatment cite evidence that many babies born at 22 weeks can survive, that most survivors have good neurodevelopmental outcomes, and that NICU care for tiny babies is cost-effective compared to many common and uncontroversial treatments. The debate touches on many fundamental ethical issues that have been present in neonatology since its inception as a medical specialty.     

Oxygen monitoring in preterm babies: too high,too low?

A small randomised trial in 1952 showed that excess oxygen use might well be causing a major epidemic of retinal blindness in preterm babies. That single study of just 65 babies was enough to throw doubt on a longstanding treatment strategy of oxygen therapy and highlighted just how powerful a tool the randomised controlled trial could be. Confirmatory evidence from a co-operative trial 4 years later involving 212 babies banished all residual doubt and we should reproach ourselves that we have still not learnt after 50 years how to optimise oxygen delivery to the preterm baby, making further use of this powerful research tool. Two well-conducted trials have recently shown that avoiding subclinical hypoxaemia (a fractional SaO(2) of less than 92%) in babies more than a month old does nothing to improve later growth or development. It is now time the same question was asked of babies less than a month old. This is particularly important in babies of less than 28 weeks' gestation, who currently remain at serious risk of chronic lung disease and permanent retinal damage.     

The pneumographic and medical investigation of infants suffering apparent life threatening episodes

Investigation of 340 babies who suffered from apparent life threatening episodes (ALTE) was performed using pneumographic studies and a variety of medical investigations. A number of medical abnormalities were demonstrated by history or investigation, including gastro-oesophageal reflux (211), airways pathology (17), evidence of fits (25), brain-stem tumour (2), hypoglycaemia (2), respiratory syncytial virus (8) and possible Munchausen by proxy (5). Pneumographic abnormalities were detected in 27 of the 340 infants. Home monitors were used for 135 infants. Future central apnoeas occurred in 20 of the 26 infants on home monitors that had had an abnormal pneumogram, compared with one of the 109 infants on home monitors after a normal pneumogram. Thus pneumograms have a sensitivity and specificity of 95% for predicting central apnoeas in babies who have already suffered an ALTE. The effect of eyeball pressure on the heart rate was measured in 65 babies and was found to cause a brisk drop in heart rate in 32 babies. Twenty-two of the 32 babies had future white apnoeas (usually associated with gastro-oesophageal reflux), compared with five of the 33 babies who had no drop in heart rate in response to eyeball pressure. Thus this test has a sensitivity of 81% and a specificity of 74% at predicting white apnoeas in babies who have already suffered an ALTE.     

Exposure to open tuberculosis on a neonatal unit

The mother of a baby on the neonatal intensive care unit was found to have untreated open pulmonary tuberculosis. Tuberculin skin testing and chemoprophylaxis was offered to selected mothers and babies, depending on level of exposure. One of 3 mothers sharing a room with the index mother and 2 of 20 mothers whose babies were on the neonatal unit subsequently converted to tuberculin and were given isoniazid chemoprophylaxis. Isoniazid chemoprophylaxis was given to 13 exposed babies, none of whom tuberculin converted. Two babies were treated empirically for tuberculosis.     

A study of infant growth in relation to the type of feeding

A total of 133 breast fed newborn babies, and 106 bottle fed babies, were selected and studied prospectively. Details taken of feeding practices have shown that by 5–7 wk of age bottle feeds had been introduced in about 50% of breast fed babies. Entirely breast fed babies received their first solid food later than breast-and-bottle fed or entirely bottle fed babies when such babies were in social class I, II or III, but in social class IV and V entirely breast fed babies were weaned at a similar age to those in the other two groups of babies. In the first 5–7 wk of life there was a significant negative correlation between the increase in skinfold thickness and the skinfold thickness at birth. The study has also shown that the present practice of feeding babies modified milks retards weight gain and the increase in subcutaneous fat in male babies.     

Plasma albumin and total protein in preterm babies from birth to eight weeks

We have measured albumin and total protein concentrations over the first eight weeks of life in a group of preterm babies. The albumin concentration in newborn babies rose from about 20 g/l in 28 weeks gestation babies to about 30 g/l in term babies. The total protein concentration in newborn babies rose from about 40 g/l in 28 week gestation babies to about 60 g/l in term babies. In babies of postnatal age up to 8 weeks the albumin concentration continues to rise at the same rate as the in utero rise in concentration with increasing gestation, regardless of the clinical state of the baby. The total protein concentration, however, remains about the same as at birth. These results allow better clinical interpretation of albumin and total protein concentration in "older" preterm babies.     

Giving small babies oxygen: 50 years of uncertainty

A small landmark trial in 1952 showed that excess oxygen use might well be causing a major epidemic of retinal blindness in preterm babies. That a single study of just 65 babies was enough to throw doubt on a long-standing treatment strategy revealed just how powerful a tool the randomized controlled trial could be. Confirmatory evidence from a cooperative trial involving a further 212 babies banished all residual doubt just 4 years later, and it remains a major reproach that we have still not learnt, after 50 years, how to optimize the delivery of oxygen to the preterm baby with further help from this powerful tool. Two well-conducted trials have recently shown that avoiding subclinical hypoxaemia (fractional SaO₂<92%) in babies more than a month old does nothing to improve later growth or development. It is now time the same question was asked of babies less than a month old, because we might reduce their need for ventilatory support. This is particularly important in babies of less than 28 weeks' gestation, who remain, currently, at serious risk of chronic lung disease and permanent retinal scaring.     

Rickets in exclusively breast fed babies

Articles appear periodically in Indian and western literature, about occurrence of vitamin D deficiency in exclusively breast fed babies. Some countries have formulated guidelines for prevention of vitamin D deficiency in such babies. In this study, twenty cases of nutritional rickets were diagnosed in exclusively breast fed babies between December 2003 and December 2006. None of them received vitamin D supplementation. Through this study, we hope to initiate further research and debate among the policymakers on whether or not vitamin supplementation should be given to all exclusively breast fed babies and lead to a formulation of clear cut guidelines in the Indian context.     

Asian neonatal mortality in Blackburn.

Neonatal mortality among Asian and non-Asian babies in Blackburn was determined for 1982-84. Though Asian mothers have more low birthweight babies, proportionately fewer babies require intensive care. Preterm delivery and asphyxia were not major factors in neonatal mortality among Asian babies, most deaths being due to lethal congenital malformations.     

Immune status of low birth weight babies

An attempt was made to evaluate the humoral and cellular immune status of preterm and small for dates babies born at All India Institute of Medical Sciences Hospital. The study sample included 24 term small-for-dates babies and 12 preterm babies (gestation of less than 37 weeks) and 20 term appropriate-for-dates babies who served as controls. The small-for-dates babies were subdivided into the following 2 subgroups on the basis of severity of intrauterine growth retardation (IUGR): mild IUGR -- babies weighing between 3rd and 10th percentile for their gestation; and severe IUGR -- babies weighing less than 2 S.D. or 3rd percentile for their gestation. The levels of immunoglobulin G (IgG), M (IgM), and A (IgA) were determined in the cord blood using the single radical diffusion technique. The B-lymphocytes were identified and counted by the surface membrane immunoglobulin (SmIg) using immunofluorescence technique. The cellular immune response was assessed by counting T-lymphocytes by E-rosette technique employing sheep red blood cells. The neonates with severe IUGR and preterm babies had significantly lower levels of IgG. The levels of IgM and IgA did not differ significantly in the 4 groups. The preterm babies had significantly higher percentage of B-lymphocytes though the absolute count was not significantly different from normal newborn babies. The absolute count B cells was significantly low in babies with severe IUGR. The babies with severe IUGR had significantly low absolute and percentage count of E-rosette forming cells as compared to normal newborn babies. The findings suggest that low birth weight babies with severe IUGR are at a greater risk to develop bacterial infection due to deficiency of both humoral and cellular immune host defenses. In contrast, preterm babies are immunologically competent though passively transferred maternal IgG levels are low. It is desirable to study the duration of immunodeficiency caused by severe IUGR and its reversibility on nutritional rehabilitation. In view of the wide prevalence of IUGR in India it is possible that inadequacy of cell mediated immune response in these infants may be associated with poor "takes" following at birth BCG and small pox vaccinations. The vaccination schedule may have to be modified depending upon the duration of immunodeficiency in babies with IUGR.     

The management of polycythaemia in the newborn infant

The management of polycythaemia with hyperviscosity in newborn babies who are clinically well, or who only have minor signs, is not clear. Forty-nine such babies were randomly divided so that 24 were given a partial plasma exchange transfustion and the others were left hyperviscous. The babies were compared with normal controls. Clinical signs were more frequent in exchanged babies, and one developed necrotizing entercolitis. Of the hyperviscous babies 41% had plethoric lungs, 12% abnormal electrocardiograms, 9% were hypocalcaemic and 30% hypomagnesaemic. Behavioural testing after birth revealed differences in both groups when compared with controls. There were more poor scores in the exchange transfusion group. Neurological examination did not reveal marked differences among the groups.Developmental and neurological achievement at 8 mth of age was normal in all the babies. In the present study it is suggested that newborn babies with hyperviscosity who are clinically well or who only have minor signs do not necessarily benefit from partial plasma exchange transfusion.     

Milk pH, acid base status, and growth in babies.

Metabolic acidosis is common in babies fed cows' milk-based formulae. Therefore the effects of adding alkaline salts (sodium and potassium citrate) to a demineralised whey formula were studied in vitro and in 26 low birthweight babies fed on the formula or formula plus citrate. The alkali altered the pH and titratable acidity to a value nearer human milk but it increased the buffering capacity to a value further away. This may effect the bacterial flora of the intestine. The babies fed on formula plus citrate did not make greater gains in weight, length, head circumference, skinfold thickness, or midarm muscle circumference, although they had a greater blood base excess. Some of these babies developed a mild metabolic alkalosis and 3 had hyponatraemia despite their increased sodium intakes. These babies also had lower levels of plasma transferrin but showed no differences in urea, albumin, cholesterol, and calcium levels. No baby fed on the demineralised whey formula without added citrate had a base deficit exceeding 5 mmol/l; late metabolic acidosis is less common in babies fed on this formula and the routine addition of alkali can have untoward metabolic effects.     

Pressure volume characteristics of the lungs in sudden infant death syndrome.

Data on the pressure volume characteristics of left lungs obtained from 23 babies dying from sudden infant death syndrome were compared with results from 18 length-matched babies dying from established but primarily non-pulmonary causes. Volume distension at 30 cm of water and deflation flow volume characteristics were very similar in the two groups. These findings do not suggest that babies dying from sudden infant death syndrome have abnormally stiff lungs.     

Jaundice in the Newborn

Hyperbilirubinemia is the commonest morbidity in the neonatal period and 5–10% of all newborns require intervention for pathological jaundice. Neonates on exclusive breast-feeding have a different pattern of physiological jaundice as compared to artificially fed babies. Guidelines fromAmerican Academy of Pediatrics (AAP) for management of jaundice in a normal term newborn have been included in the protocol. Separate guidelines have been provided for the management of jaundice in sick term babies, preterm and low birth weight babies, for jaundice secondary to hemolysis and for prolonged hyperbilirubinemia. Although hour specific bilirubin charts are available, these have to be validated in Indian infants before they are accepted for widespread use.