"What can I do to enhance the development of a premature infant with chronic lung disease?".
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Brain Damage, Chronic↗
Biomedical subjects
Y Vaucher
Publications and source records attributed to Y Vaucher.
"What can I do to enhance the development of a premature infant with chronic lung disease?".
CASE. Timmy was born at 32 weeks of gestation after an uncomplicated pregnancy until there was a spontaneous rupture of the membranes and preterm labor associated with chorioamnionitis. A 2-month hospitalization in the neonatal intensive care unit (NICU) was associated with pneumonia, a Grade II intraventricular hemorrhage, chronic lung disease, and a slow weight gain in the nursery. He was discharged to home with plans for ongoing care by his pediatrician. The primary care pediatrician attended a multidisciplinary conference with the NICU staff and Timmy's parents. At the time of discharge from the nursery, at 38 weeks postconceptual age, Timmy still required oral diuretics and supplemental oxygen, as well as other medications such as iron. Timmy's respiratory rates were between 40 and 60 breaths per minute at rest, with mild intercostal retractions. He was discharged with a cardiorespiratory monitor. The discharge examination revealed mild to moderate symmetrical hypotonia with intact deep tendon reflexes, shoulder girdle weakness, and a mild head lag. Timmy would regard a human face and a bright object and would follow them briefly. He became active and would thrash his extremities with minimal tactile, bright light, or auditory stimulation. Typically, he settled slowly with swaddling and a pacifier. Nursing was slow to develop; he was currently receiving one half of his calories at the breast and the remainder of his calories from bottle-feeding of fortified expressed breast milk. As she prepared for the first office visit with Timmy and his parents, the pediatrician asked herself, "What can I do to enhance the developmental outcome for this child?"
Bronchopulmonary Dysplasia↗
Electroencephalographic and neuroimaging findings in neonates undergoing extracorporeal membrane oxygenation.
Electroencephalograms (EEGs) were recorded on 36 infants who were treated with arteriovenous extracorporeal membrane oxygenation (ECMO) between 1986 and 1989. Twelve of 36 infants had EEGs prior to and during ECMO. Twenty-one infants who met ECMO criteria but were treated with mechanical ventilation only served as a comparison (COMP) group. Electrographic seizures occurred in 7 of the 36 (19%) ECMO patients and in 3 of the 21 (14%) COMP patients. Five of 7 ECMO infants had electrographic status epilepticus. Three infants developed electrographic seizures during ECMO in association with an acute cerebral injury. These patients did not have significant hemispheric predominance in the origin of electrographic seizures (2 right, 3 left and 2 bilateral). Repetitive or periodic discharges (RPD) with frequencies between 0.5 and 5 Hz were seen after starting therapy in 23 of the 36 (64%) ECMO patients and 15 of the 21 (71%) of the COMP group. Only in the ECMO patients did RPD arise significantly more frequently from the right hemisphere (13 right, 4 left and 6 bilateral; p = 0.015). Neuroimaging studies showed evidence of ischemic lesion in 8 of the 36 (22%) ECMO patients with significantly right-sided predominance (5 right, 1 left and 2 bilateral; p = .05). Cerebellar hemorrhages occurred in 3 ECMO patients. Ischemic lesions occurred in 3 of the 21 (14%) COMP patients, all occurring on the left side. In the ECMO group, severe outcome or death was significantly associated with the presence of electrographic seizures, status epilepticus, and suppression-burst pattern (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Brain Injuries↗
Randomized, placebo-controlled trial of human surfactant given at birth versus rescue administration in very low birth weight infants with lung immaturity.
A randomized, placebo-controlled trial of human surfactant given intratracheally at birth (prophylactic) versus rescue administration after the onset of severe respiratory distress syndrome (RDS) was conducted among preterm infants born at 24 to 29 weeks of gestation. Singleton fetuses were randomly assigned to receive (1) placebo (air), (2) prophylactic surfactant treatment, or (3) rescue surfactant treatment; infants of multiple births received either (1) prophylactic or (2) rescue treatment. Of 282 potentially eligible fetuses, 246 infants received treatments at birth and 200 infants had RDS. Outcomes are presented both as an intention-to-treat analysis (including infants who met exclusion criteria at or after birth) and as a full treatment protocol analysis for those infants with RDS and likely to benefit from surfactant. Preterm infants (mean 1.0 kg birth weight, 27 to 28 weeks of gestational age) randomly assigned to receive prophylactic treatment received surfactant soon after birth; those assigned to receive rescue surfactant had instillation at a mean age of 220 minutes if the lecithin-sphingomyelin ratio was less than or equal to 2.0 and no phosphatidylglycerol was detected in either amniotic fluid or initial airway aspirate, oxygen requirements were a fraction of inspired oxygen of greater than 0.5, and mean airway pressure was greater than or equal to 7 cm H2O from 2 to 12 hours after birth. Up to four treatment doses (or air) were permitted within 48 hours; approximately 60% of surfactant-treated infants required two or more doses. Surfactant-treated infants had significantly less pulmonary interstitial emphysema than placebo-treated infants (p = 0.02), but there were no other significant differences in mortality rates or morbidity. Indexes of oxygenation and ventilation were improved in surfactant recipients during the first 24 hours. An intention-to-treat analysis found no significant differences between infants given placebo and surfactant-treated infants or between prophylactic- and rescue-treated infants; an improved total mortality rate (p = 0.002) was found among surfactant-treated infants in Helsinki but not in San Diego. Among infants with RDS, the total mortality rate was significantly improved (p = 0.004) with surfactant treatment but not the proportion alive and without bronchopulmonary dysplasia at 28 days (p = 0.052), or the proportion alive and without bronchopulmonary dysplasia at 38 weeks of postconceptional age (p = 0.18) to adjust for differences in prematurity. Deaths caused by RDS or bronchopulmonary dysplasia were significantly reduced among surfactant recipients (p = 0.0001). Neither among singletons nor among multiple-birth infants was there a selective advantage to prophylactic versus rescue treatment.(ABSTRACT TRUNCATED AT 400 WORDS)
Bronchopulmonary Dysplasia↗
Diabetes in pregnancy in Mexican Americans.
Diabetes in pregnant Mexican-American women is a serious and expensive health problem. At the University of California, San Diego Medical Center, 44% of pregnant women are Mexican American. In the Diabetes in Pregnancy Clinic, only 7% of women with insulin-dependent diabetes are in this ethnic group compared with 66% of non-insulin-dependent diabetic patients and 51% of those with gestational diabetes mellitus (GDM). GDM is the most common complication of pregnancy in Mexican Americans with a prevalence approximately three times higher than that of whites (4.5 vs. 1.5%). Mexican-American obese GDM subjects had more frequent cesarean sections and were more likely to have complications of premature rupture of membranes and preterm labor (NS). Polycythemia and sepsis also occurred more often in their infants. Anthropometric measurements in infants of both lean and obese GDM subjects differed from those of infants of mothers without GDM. Infants of lean mothers with GDM were heavier and longer than those of lean mothers without GDM. In addition, they had increased waist-hip ratio and triceps and subscapular skin folds. Infants of obese mothers with GDM were heavier than those of lean mothers with GDM. Moreover, they were longer (P less than 0.04); had a higher body mass index (P less than 0.04); and larger waist and hip circumferences (P less than 0.03) and buccal (P less than 0.01), subscapular (P less than 0.01), and sum of skin-fold measurements (P less than 0.03). Our observations indicate that pregnant diabetic Mexican-American women have predominantly GDM and non-insulin-dependent diabetes. They represent a major public health problem because of increased maternal and neonatal morbidity.
Adult↗
Impact of surfactant treatment on cost of neonatal intensive care: a cost-benefit analysis.
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Canada↗
Differences between individuals in high-molecular weight glycoproteins from mammary epithelia of several species.
Milk fat globules are secreted by envelopment in plasma membrane of the lactating cell. SDS-gel electrophoresis of proteins from this membrane has revealed differences between milk donors in two mucin-like glycoproteins. One of these glycoproteins resolves in 3% acrylamide stacking gel and the other in 4% running gel. The proteins vary in number of bands (one or two) and band mobilities. This polymorphism arises, at least in part, from expression of hypervariable genes. In this study, gel electrophoretic evidence of similar polymorphism in glycoproteins from cow, chimpanzee, horse and human milks is presented. In distinction to the other species, the cow expressed only one of these proteins which was detected in the running gel at Mr 180,000 to 200,000. The electrophoresis pattern for this protein from six cows was highly varied with respect to number (one or two) and position of bands. Peanut agglutinin, wheat germ agglutinin and concanavalin A all were bound specifically by bands of the bovine glycoprotein. Binding of concanavalin A distinguishes the bovine protein from the two human glycoproteins. Further studies of species differences should help shed light on the evolution of these unique glycoproteins and their possible functions in mother and young.
Animals↗
Antenatal origin of neurologic damage in newborn infants. I. Preterm infants.
Currently, the diagnosis of white matter necrosis may be performed with echoencephalography when cysts are observed in the white matter adjacent to the lateral ventricles. One hundred twenty-seven infants with a gestational age less than 36 weeks (mean [+/- SE] gestational age = 31 +/- 3.2 weeks) were studied in the neonatal period with echoencephalography to determine the incidence of white matter necrosis and the perinatal variables associated with this complication. Twenty-three infants (18.3%) had white matter necrosis. Thirteen (10.3%) had cysts by day 3 (11 on day 1), indicating that the onset of white matter necrosis occurred antenatally. The incidence of antenatal white matter necrosis was inversely related to birth weight and was more frequent in infants weighing less than 1000 gm (19%). Stepwise logistic regression analysis of 31 antenatal variables showed that placental vascular anastomoses in multiple pregnancies, funisitis, and purulent amniotic fluid were the only complications associated with antenatal white matter necrosis. Follow-up neurologic evaluations were abnormal in four of six patients with antenatal white matter necrosis. The findings in this study focus attention on prenatal, rather than intrapartum and postnatal, factors as causative agents of neurologic morbidity and emphasize the importance of early and sequential evaluation of neonatal brain structures.
Cerebral Hemorrhage↗
Insidious hydrocephalus in the preterm newborn following discharge from the nursery.
Posthemorrhagic ventriculomegaly may be due to perinatal brain damage and consequent cerebral atrophy, or represent progressive hydrocephalus due to impairment of CSF flow and reabsorption. 'Arrested' hydrocephalus occurs when the CSF pathways are adequate and, hence, intracranial hypertension no longer exists. The differential diagnosis is often difficult and insidious progressive hydrocephalus should always be a concern in the high-risk preterm newborn. We report 10 preterm infants who were discharged with the diagnosis of arrested hydrocephalus (7) or cerebral atrophy (3), and who later developed progressive severe hydrocephalus 1.5-15 months after the discharge. Five had been treated with intermittent lumbar punctures, while 4 had not received any treatment prior to nursery discharge. One infant died prior to the shunt procedure. Progressive insidious hydrocephalus should be suspected in preterm infants with intracranial hemorrhage following discharge from the nursery.
Cerebral Ventricles↗
Absorption of TSH and ACTH in biologically active form from the gastrointestinal tract of suckling rats.
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Adrenalectomy↗
Congenital diaphragmatic hernia: immediate preoperative and postoperative oxygen gradients identify patients requiring prolonged respiratory support.
We reviewed 22 patients with congenital diaphragmatic hernias in whom operative repair was undertaken within 24 hours of age, in the period between 1970 and 1981. An improvement in survival rates since 1977 was observed. Preoperative pH, PO2, and alveolar-arterial O2 gradients (P[A-a]O2) were found to have predictive value. Patients with P(A-a)O2 greater than 500 torr both before and immediately after surgery did not survive. After an initial improvement in oxygenation some infants experienced a period of deterioration beginning at approximately 12 to 24 hours, peaking at 36 hours and improvement by 72 hours after surgery. Special attention should be directed toward maintaining aggressive cardiopulmonary support during this critical period. Reducing support prematurely may accentuate right-to-left shunting via fetal channels.
Apgar Score↗
Ultrasonic evaluation of intracranial pathology in infants: a new technique.
A prospective study had demonstrated the clinical usefulness of water-delay ultrasound as a means of routinely imaging the intracranial contents in infants younger than one year of age. Correlation between ultrasound and CT images was excellent, showing both normal and pathological anatomy. This technique is most helpful in the detection of hydrocephalus and other "fluid lesions" (subdural hygroma or hematoma, Dandy-Walker cyst, porencephalic cyst) and in evaluation of response to therapy. Because small amounts of intraventricular and subependymal hemorrhage cannot be detected by ultrasound, CT remains the procedure of choice when these conditions are suspected. The water-delay method is accurate and inexpensive, rarely requires patient sedation, and avoids exposure to ionizing radiations.
Dandy-Walker Syndrome↗
Eosinophilia in premature infants: relationship to weight gain.
Serial eosinophil counts were determined in 38 hospitalized, appropriately grown premature infants whose gestational ages ranged from 27 to 35 weeks. Absolute eosinophilia (greater than 700/mm3) was documented in 76% (29/38). Eosinophilia was mild (700 to 999/mm3) in 9, moderate (1,000 to 2,999/mm3) in 17, and marked (greater than or equal to 3,000/mm3) in 3 patients. The average time of onset was day 19. Peak eosinophilia was usually seen within one week of onset and lasted an average of 16 days. A consistent relationship (r = 0.86) was found between the day of peak eosinophilia (mean = day 27) and the day on which birthweight was regained (mean = day 22). No association was apparent between the occurrence or degree of eosinophilia and gestational age, birth stress, presence of umbilical catheter, parenteral alimentation solution, and time of beginning or type or oral feeds. The data suggest that eosinophilia is strongly associated with the establishment of an anabolic state.
Body Weight↗
Interaction of maternal and neonatal obesity.
Maternal weight and height before pregnancy and weight gain during pregnancy were recorded for each of 109 mothers who were delivered of normal infants after gestations of 37 to 43 weeks. Infant parameters obtained included gestational age, birth weight, bilateral mid-arm circumference, and eight skin fold thickness measurements. The eight skin fold thicknesses were summed (SSFT) for each infant. Infants with SSFTs greater than 40 mm (N = 8) for the group were classified as "fatter" infants. All of the fatter infants were large for gestational age (LGA), but accounted for only one third of the LGA infants in the study. Birth weight, length, and cross-sectional mid-arm fat area were significantly increased in the fatter LGA group when compared to other LGA infants. Cross-sectional mid-arm muscle area was not significantly different for the fatter LGA infants compared to the other LGA group. Mothers were defined as obese or nonobese according to pregnant weight for height. Obese mothers had infants with significantly increased SSFTs when compared with infants of nonobese mothers. Mulitple regression analysis showed that both prepregnant weight for height and weight gain during pregnancy were associated with increased subcutaneous fat in the neonate. Weight gain during pregnancy was associated with increased neonatal fatness and length, while prepregnant weight for height was associated with neonatal fatness independent of neonatal length.
Birth Weight↗
Theophylline poisoning.
Three cases of theophylline poisoning in young children, two of which occurred after erroneous administration of commonly prescribed pediatric drugs, are presented. The possible association of hyperglycemia and ketoacidosis with severe theophylline toxicity is discussed. Serial serum theophylline levels and half-life determinations for two patients suggest that, although serum half-lives (8.5 hours and 9.0 hours) may be slightly longer than average, drug disappearance followed first order kinetics even at extremely high erum theophylline levels.
Female↗
Echocardiographic detection of large left to right shunts and cardiomyopathies in infants and children.
Diagnostic separation of infants with signs of cardiac failure (hypoglycemia, sepsis, myocarditis, hypoxemia) but no congenital cardiocirculatory malformation from those with a large left to right shunt is crucial in newborn management. Echocardiographic studies of 218 infants and children allowed group separation and distinction from normal by the assessment of mean velocity of circumferential fiber shortening (Vcf) and the ratio of left atrial to aortic root diameter at end-systole (LA/Ao). In normal premature and full-term infants, Vcf (1.51 +/- 0.04 [mean +/- standard error]) was significantly lower than in infants with a large shunt (2.12 +/- 0.08, P less than 0.01) and higher than in infants with nonstructural heart disease (1.18 +/- 0.06, P less than 0.001). LA/Ao ratios were comparable in the groups with a large shunt and nonstructural heart disease (1.14 +/- 0.1 and 1.26 +/- 0.2, respectively) and were significantly higher in both groups than in normal subjects (0.77 +/- 0.01, P less than 0.001). Similar echocardiographic distinctions could be made when 10 older children (aged 2 to 10 years) with cardiomyopathy were compared with 45 normal older children. Serial determination of these variables was of major assistance in patient management.
Cardiomyopathies↗
Focal necrosis of the white matter (periventricular leukomalacia): sonographic, pathologic, and electroencephalographic features.
Eleven preterm infants (gestational ages 27-35 weeks) with echogenic paraventricular white matter identified shortly after birth were studied with serial echoencephalograms to fully delineate the sonographic findings characterizing the pathologic stages of white-matter necrosis. Echoencephalograms were compared with autopsy findings and CT scans. Cerebral function was assessed by electroencephalograms and later by neurodevelopmental evaluations. Echogenic areas were observed in the paraventricular white matter in the acute stage. Microscopically, the echogenic white matter consisted of vascular congestion and petechial hemorrhages, but not always with foci of necrosis. Anechoic areas, which characterized the chronic stage, corresponded to cavitary lesions, and these generally appeared within 2 weeks of birth. However, six infants had anechoic lesions by day 4, suggesting that the onset of white-matter damage was antenatal. CT showed mildly decreased attenuation when paraventricular echogenic areas alone or in association with small anechoic areas were observed. Markedly decreased attenuation on CT scans corresponded to large anechoic areas. Resolution of the sonographic and CT findings did not indicate normalization of the white matter since all surviving infants were neurologically abnormal at 1 year. Electroencephalograms with central (rolandic) positive sharp waves were associated with echogenic white matter alone or with evolving anechoic areas. All patients with positive sharp waves on electroencephalograms had large anechoic areas in later studies. Early and serial echoencephalograms are necessary to evaluate white-matter necrosis in preterm infants. When echogenic white matter is identified, electroencephalography can suggest the presence of white-matter necrosis.
Echoencephalography↗