Our expanding South Carolina Medicaid managed care program.
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Adult↗
Biomedical subjects
W B Pittard
Publications and source records attributed to W B Pittard.
A new method to examine very low birth weight fetal and hebdomadal mortality in a regionalized system of perinatal care.
OBJECTIVE: Aggressive maternal transport of very low birth weight (VLBW) live births from community hospitals to regional perinatal centers may artificially increase community fetal death rates. By allocating maternal transports according to the location of antepartum and intrapartum care and separately computing antepartum and intrapartum fetal mortality rates, a more appropriate measure of hospital-based mortality may be determined. METHOD: Delivery charts were reviewed for 568 VLBW deliveries (including 97 fetal deaths and 77 hebdomadal deaths) occurring between 1990 and 1992 in a geographically defined perinatal region. Maternal transports were analyzed with community hospitals for antepartum mortality rates and with the regional center for intrapartum mortality rates. RESULTS: Using traditional methods, the fetal mortality rates for community hospitals and the regional center were antepartum 385.1 vs. 45.2, respectively, and intrapartum 120.9 vs. 24.9, respectively. When regional center live births (maternal transports) are placed with community hospitals for analysis of antepartum mortality, the new antepartum mortality rates were 185.7 vs. 72.8, respectively. The hebdomadal mortality rate for community hospitals was 250.0 as compared to 145.8 for the regional center. CONCLUSION: Maternal transports to a regional center represent successful antepartum management by community care providers. Even though they delivered in the regional center, they should be analyzed with community hospitals for antepartum fetal mortality comparisons. Therefore, antepartum and intrapartum fetal mortality should be examined separately in a functioning regionalized perinatal care program where the location of patient care differs from location of delivery.
Adolescent↗
Special properties of human milk.
In this review, several nutritional and nonnutritive differences between mothers' milk and formula and their relationship to neonatal gastrointestinal and immune processes are discussed. The dynamic relationship of human milk as evidenced by its changing composition, unique bioactive and immunologic properties, and specialized cellular components is further delineated. The clinical significance and relevance of these findings to the clinician are then presented. Lastly, educational strategies, their effectiveness in promoting breastfeeding, and an approach that might be taken by the clinician to encourage breastfeeding are outlined.
Breast Feeding↗
Effect of age on the intestinal absorption of vitamin D3-palmitate and nonesterified vitamin D2 in the term human infant.
This study was undertaken to investigate the utility of vitamin D3-palmitate as a nutritional supplement and thus define the intestinal absorption profile of vitamin D2 and vitamin D3 liberated after its cleavage from vitamin D3-palmitate in the human infant at various postnatal ages. The subjects for study consisted of 48 normal infants that were simultaneously administered 0.07 and 0.08 micromol/kg BW vitamin D as vitamin D3-palmitate and nonesterified vitamin D2 respectively, by orogastric tube. Blood samples were obtained before and 6, 12, and 24 h postadministration and analyzed simultaneously for vitamins D2 and D3. For data analysis, the infants were divided into two groups based on postnatal age: group 1, 1 day of age; and group 2, more than 10 days of age. Data were analyzed using the integrated peak area under the absorption curve for each subject. All subjects demonstrated the ability to absorb vitamin D after oral administration, although postnatal age as well as vitamin form had a profound effect on the absorption of vitamin D2 and vitamin D3 liberated from vitamin D3-palmitate. Nonesterified vitamin D2 is well absorbed both in very young and older infants, although absorption efficiency increases with age, perhaps due to increased bile acid secretion. Liberation of vitamin D3 from vitamin D3-palmitate was shown to increase, perhaps due to gastrointestinal tract maturation, beyond 10 days of age, probably coinciding with the secretion of intestinal esterases. Our data indicate that both forms of the orally administered vitamin approach equivalency in their abilities to elevate circulating vitamin D levels in the human infant at a postnatal age of approximately 89 days. Thus, vitamin D3-palmitate would appear not to be dietarily equivalent to free vitamin D as a nutritional source of vitamin D in the human neonate.
Aging↗
Supplemental oxygen and gastric pH in unfed preterm infants.
Hypoxia has been associated with decreased gastric acidity in infants and children. In neonates, an inverse relationship between gestational age and gastric acidity may confound this association. To assess the relationship between oxygen supplementation and gastric acidity in premature neonates, mean 24-hour continuous measurements of gastric pH, obtained by an indwelling flexible gastric pH probe, were compared in infants requiring and not requiring oxygen. Patients were < 36 weeks' gestational age and were unfed before and during the assessment period. The gestational age of infants who required oxygen was less than that of infants who did not (30.5 +/- 3.0 vs 32.9 +/- 1.5 weeks, respectively). Other comparison variables were not different. The mean pH for infants requiring oxygen (4.4 +/- 1.7) was significantly greater than that of those not needing oxygen (2.7 +/- 1.2). After controlling for population characteristics and gestational age, we found that infants requiring oxygen still had significantly reduced gastric acidity.
Female↗
Variation in the biochemical forms of transforming growth factor-alpha present in human milk and secreted by human milk macrophages.
OBJECTIVE: Transforming growth factor-alpha (TGF-alpha), present in human milk, is thought to play a significant role in postnatal gut development. Macrophages, which abound in human milk, are known to secrete various isoforms of TGF-alpha in other areas of the body. It was hypothesized that human milk macrophages (HMM) secrete TGF-alpha, and HMM are a source of TGF-alpha isoforms present in human milk. We sought to measure in vitro HMM TGF-alpha secretion, and to compare the TGF-alpha isoform(s) present in human milk with those secreted by HMM. STUDY DESIGN: Colostrum and mature milk samples, obtained from mothers (n = 48) on postpartum days 3-30, were centrifuged. HMM were isolated, placed in culture for 24 h, and cell-free media collected. The biochemical forms of TGF-alpha in media in human milk supernatant samples were identified by Western blot analysis under reducing conditions. The concentration of the mature (6-kD) TGF-alpha isoform in those samples was quantified using a radioimmunoassay. RESULTS: Western blot analysis under reducing conditions identified a single 6-kD TGF-alpha isoform in all human milk supernatant samples tested, but variable (6- and 30- to 46-kD) TGF-alpha isoforms in HMM media. The mean (+/- SE) concentration of the 6-kD TGF-alpha isoform found in human milk supernatants was 706 +/- 88 pg/ml and 17.6 +/- 2.6 pg/ml in HMM media. CONCLUSION: These experiments show that HMM secrete TGF-alpha in biochemical forms both similar to and distinct from that found in human milk supernatant.
Blotting, Western↗
Neonatal enteral and parenteral nutrition.
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Enteral Nutrition↗
Continuing evolution of regionalized perinatal care: community hospital neonatal convalescent care.
We describe the convalescent care of 169 back-transported (to community hospitals) and 285 eligible but not back-transported very low birth weight (VLBW) infants. Eligible infants who were not back transported to a level I or II community hospital were transferred to a level II nursery within the Medical University of South Carolina (MUSC) for convalescent care. Study infants were admitted to the neonatal intensive care unit (NICU) at MUSC from July 1985 through June 1989. They were admitted after maternal transport to MUSC for imminent delivery (N = 159), out-born community delivery (N = 55), or in-born MUSC delivery (N = 240). The mean +/- SD birth weight and gestational age and the NICU admission diagnoses for the back-transported and non-back-transported neonates were similar. The mean +/- SD weight of neonates at the time they were back transported was significantly greater than the weight of neonates at the time of intrahospital transfer. In contrast, the discharge weight to home and total days hospitalized were significantly less in the back-transported infants. Five back-transported neonates (3%) and 12 non-back-transported neonates (4%) were readmitted to the NICU. The back-transported infants used more than 3,800 bed days at community hospitals that would otherwise have been spent in the regional center, thus facilitating increased parental and primary physician involvement in their care.
Hospitals, Community↗
Osteocalcin, skeletal alkaline phosphatase, and bone mineral content in very low birth weight infants: a longitudinal assessment.
Serum osteocalcin (Gla) and skeletal alkaline phosphatase (SAP) concentration both reflect osteoblast activity in the dynamic process of bone formation. To assess the relation in premature infants between change in bone mineral content (BMC) and both Gla and SAP serum concentration, we longitudinally measured BMC via photon absorptiometry and serum Gla and SAP concentration from birth to 16 wk in 20 very low birth weight infants. Serum total calcium, phosphorus, parathyroid hormone, and vitamin D metabolite concentrations were also monitored. All serum values were measured in the 20 mothers at delivery. Cord blood Gla concentrations were significantly (p less than 0.03) greater than maternal levels, and by 1 wk had significantly (p less than 0.001) increased from birth values. Total calcium, parathyroid hormone, phosphorus, and vitamin D concentrations remained in the normal range throughout the study. The increase in serum Gla concentrations, birth to 1 wk, were significantly correlated with the simultaneous increase in 1,25-dihydroxyvitamin D concentrations. The correlation between the change in BMC, however, over the first 4 mo of life and both Gla and SAP serum concentrations failed to reach statistical significance. Finally, a significant (p less than 0.003) negative correlation was measured between serum Gla and SAP concentrations at wk 4, and, although not significant, a consistently negative correlation was measured from 1-16 wk of age.(ABSTRACT TRUNCATED AT 250 WORDS)
Age Factors↗
How much vitamin D for neonates?
To assess the adequacy of different dosages of neonatal vitamin D, 25-hydroxyvitamin D serum concentrations were longitudinally monitored in 27 low-birth-weight and 25 full-term well infants from birth to 16 weeks after delivery. The infants were randomly assigned to receive either 10 micrograms/d (400 IU/d) or 20 micrograms/d (800 IU/d) of vitamin D or 0.85 or 1.5 micrograms/d of 25-hydroxyvitamin D3. In each infant who received 10 or 20 micrograms/d of vitamin D 25-hydroxyvitamin D, serum concentrations greater than 20 ng/mL were maintained, with some low-birth-weight infants reaching 60-ng/mL concentrations. Similarly, in the low-birth-weight infants receiving 1.5 and 0.85 micrograms/d of 25-hydroxyvitamin D3, serum 25-hydroxyvitamin D levels greater than 12 ng/mL were maintained. In the full-term infants who received 1.5 micrograms/d of 25-hydroxyvitamin D3, serum 25-hydroxyvitamin D concentrations of greater than 12 ng/mL were maintained, but in those who received 0.85 micrograms/d, serum 25-hydroxyvitamin D concentrations of 10 ng/mL could not be maintained. These vitamin D status data document that 10 micrograms (400 IU) of vitamin D represents a sufficient daily intake for both premature and full-term well infants. These data also indicate that while as little as 0.85 micrograms/d of 25-hydroxyvitamin D3 may facilitate vitamin D sufficiency in low-birth-weight neonates, it does not do so in full-term infants.
Administration, Oral↗
Bacterial contamination of human milk: container type and method of expression.
Common questions from nursing women include: is the bacterial contamination of expressed milk different if collected manually versus mechanically and is there a large increase in bacterial contamination if the milk is collected into clean versus sterile containers. Similarly, there are mixed reports, and secondarily confusion, among lactating women regarding the benefit of discarding the initial portion of a milk expression to limit bacterial contamination with skin flora. To answer these concerns, we have measured the number of colony-forming units (CFU)/milliliter in expressed milk from 16 women. The experimental design, used in a randomized fashion with each woman, employed both sterile and clean containers for collection and both the manual and mechanical techniques for milk expression. The number of milk specimens containing greater than 10(4) CFU/ml was not different between those collected in clean versus sterile containers or between those collected with a manual versus a mechanical technique. Finally, the initial milk expressed did not have a significantly greater amount of bacterial contamination than the milk collected later in the milk expression.
Adult↗
Regionalized perinatal transport systems: association with changes in location of birth, neonatal transport, and survival of very low birth weight deliveries.
Changes in both the location of very low birth weight births and in the number of infants selected for transport were chosen for the evaluation of regionalized perinatal care and its effectiveness in the Lowcountry Perinatal catchment area. The four-year period reviewed was characterized by the initiation of a well-defined regionalized perinatal transport program at the Medical University of South Carolina. In conjunction with this increased availability of transport, there was a statistically significant (p less than 0.02) increase in the number of VLBW neonates transported to MUSC after being delivered in community hospitals. This increase was accompanied by an increase in the proportion of infants referred for transport within the first hour of life. Among those neonates referred within the first four hours of life, survival was inversely proportional to the infant's age when the transport team arrived, suggesting that a rapid response by the neonatal transport team was associated with a significantly increased VLBW infant survival. Among all transported infants, in-utero continues to be the most efficacious means of transport for VLBW infants and that delivery of VLBW infants at regional medical centers continues to result in the most optimal survival.
Catchment Area, Health↗
Longitudinal changes in the bone mineral content of term and premature infants.
With the use of photon absorptiometry, bone mineralization was measured at birth and 8 and 16 weeks after delivery in 12 very-low-birth-weight premature (mean +/- SD gestational age, 31 +/- 1.5 weeks) infants who required minimal medical support. Simultaneously, 19 healthy term infants were studied. Throughout the study, each neonate received modified 84-kJ/30 mL formula containing no added calciferol. The recommended daily allowance (400 IU) of calciferol was given to each infant as an oral supplement. Serum 25-hydroxyvitamin D, calcium, phosphorus, and parathyroid hormone concentrations were monitored biweekly and were normal. Bone mineral content and bone width significantly differed at birth between the term and premature infants. However, by 16 weeks after delivery, the premature infants had exceeded the bone mineral status of the term infants at birth, and their bone mineral content was not significantly lower than that of the term infants. These data indicate improved bone mineralization as compared with previously reported data from very-low-birth-weight neonates.
Absorptiometry, Photon↗
Group-specific component in neonatal breast secretion: relationship to the cellular content.
Group-specific component (Gc) and total albumin concentrations in the breast secretions from 20 full-term infants were measured. The Gc concentrations as well as the albumin concentrations correlated significantly (p less than 0.02) with the total cell count and the absolute concentration of each white blood cell type in the breast fluid. The ratio of albumin in neonatal breast secretion to that in neonatal serum was similar to the comparable ratio for Gc. Since albumin and Gc are of similar molecular size, these observations suggest leakage of these two proteins from serum to breast secretion and a possible chemotactic relationship between these proteins and the mononuclear cells in neonatal milk.
Albumins↗
Newborn lymphocyte subpopulations: the influence of labor.
Cord blood mononuclear cell subsets were enumerated in 31 neonates delivered after maternal labor, in 25 neonates delivered by cesarean section without preceding labor, and in 60 healthy adults. In neonates born with and without preceding labor percentages of CD3 cells were lower than those in adults (63% and 60% as opposed to 83% in adults). However, the absolute numbers of CD3 cells were significantly greater in newborn infants delivered without preceding labor (3.287 +/- 1.451 cells per microliter) than in both neonates born after labor (2.660 +/- 800 cells per microliter) and in adults (2.189 +/- 807 cells per microliter). The increase in CD3 cells in infants delivered without preceding labor reflects increased numbers of CD4-positive cells. This increase in the absolute number of T lymphocytes and CD4 (helper) lymphocytes was significant (p less than 0.02). These data indicate that labor-related stress significantly decreases the total number of neonatal T lymphocytes and the CD4 (helper) T-cell subpopulation in cord blood.
Antigens, Differentiation, T-Lymphocyte↗
Regionalized perinatal care in South Carolina.
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History, 20th Century↗
The immunologic composition of neonatal milk: cellular components.
The cellular content of neonatal mammary gland secretions from 12 full-term infants less than 2 weeks postdelivery was studied. The predominant cell types observed were lymphocytes and macrophages with greater than 90% viability in each. The concentration of lymphocytes was significantly (P less than 0.001) correlated with the concentration of macrophages. The immunoglobulin content of this fluid was predominantly IgG with minimal concentrations of IgA, and no IgM detected. These data suggest both the presence of regulatory mechanisms for the cellular composition of neonatal breast secretions and that neonatal milk may bear a significant connection with the developing mucosal immune system.
Humans↗