August L. Jung

Necrotizing enterocolitis in low-birth-weight infants fed an elemental formula

The incidence of necrotizing enterocolitis in the newborn infant has increased within the same time period that increasing emphasis has been placed on oral alimentation of very small infants. A prospective investigation was conducted to determine the nutritional efficacy as well as the incidence of necrotizing enterocolitis of a standard cow milk formula compared with an elemental formula. Sixteen infants who weighed less than 1,200 gm were randomized and fed one of the two formulas. The clinical status of the two groups was similar. Seven of eight (87.5%) infants fed the elemental formula and two of eitht (25%) fed the standard cow milk formula developed necrotizing enterocolitis (p less than 0.02). The hypertonicity of the elemental diet may have contributed to the increased incidence of necrotizing enterocolitis in infants fed this formula.

Effects of continuous positive airway pressure on pulmonary function and blood gases of infants with respiratory distress syndrome

Summary: Nitrogen washout measurements and blood-gas analyses were made on 32 newborn infants with severe RDS at continuous positive airway pressures (CPAP) of 5, 10, and 15 cm H2O. Increases in airway pressure resulted in significant increases in PaO2 and functional residual capacity (FRC). It also produced significant decreases in alveolar turnover rates of the “fast” and “slow” alveolar spaces of a two-space lung model. Changes in CPAP did not significantly affect the distribution of ventilation.The changes in PaO2, due to changes in CPAP, did not correlate well with changes in FRC/wt nor with changes in alveolar turnover rates. Thus, the effects of increasing CPAP on PaO2 were not simply due to increases in FRC. The changes in PaO2 are due to a complex relationship between changes in FRC, alveolar turnover rates, and to other alterations in cardiopulmonary function that are yet to be fully understood.Speculation: Results from this study show that large portions of the lung have alveolar turnover rates below normal. Increasing airway pressures could lead to decreases in the rate of pulmonary perfusion and to an improvement in the ventilation-perfusion ratio of these alveolar units. This could partially account for the observation that increases in CPAP generally produce increases in PaO2.

A multicenter randomized, masked comparison trial of natural versus synthetic surfactant for the treatment of respiratory distress syndrome

OBJECTIVE To compare the efficacy and safety of two surfactant preparations in the treatment of respiratory distress syndrome (RDS). METHODS We conducted a randomized, masked comparison trial at 21 centers. Infants with RDS who were undergoing mechanical ventilation were eligible for treatment with two doses of either a synthetic (Exosurf) or natural (Infasurf) surfactant if the ratio of arterial to alveolar partial pressure of oxygen was less than or equal to 0.22. Crossover treatment was allowed within 96 hours of age if severe respiratory failure (defined as two consecutive arterial/alveolar oxygen tension ratios < or = 0.10) persisted after two doses of the randomly assigned surfactant. Four primary outcome measures of efficacy (the incidence of pulmonary air leak (< or = 7 days); the severity of RDS; the incidence of death from RDS; and the incidence of survival without bronchopulmonary dysplasia (BPD) at 28 days after birth) were compared by means of linear regression techniques. RESULTS The primary analysis of efficacy was performed in 1033 eligible infants and an analysis of safety outcomes in the 1126 infants who received study surfactant. Preentry demographic characteristics and respiratory status were similar for the two treatment groups, except for a small but significant difference in mean gestational age (0.5 week) that favored the infasurf treatment group. Pulmonary air leak (< or = 7 days) occurred in 21% of Exosurf- and 11% of infasurf-treated infants (adjusted relative risk, 0.53; 95% confidence interval, 0.40 to 0.71; p < or = 0.0001). During the 72 hours after the initial surfactant treatment, the average fraction of inspired oxygen (+/-SEM) was 0.47 +/- 0.01 for Exosurf- and 0.39 +/- 0.01 for infasurf-treated infants (difference, 0.08; 95% confidence interval, 0.06 to 0.10; p < 0.0001); the average mean airway pressure (+/-SEM) was 8.6 +/- 0.1 cm H2O; for Exosurf- and 7.2 +/- 0.1 cm H2O for Infasurf-treated infants (difference, 1.4 cm H2O; 95% confidence interval, 1.0 to 1.8 cm H2O; p < 0.0001). The incidences of RDS-related death, total respiratory death, death to discharge, and survival without bronchopulmonary dysplasia at 28 days after birth did not differ. The number of days of more than 30% inspired oxygen and of assisted ventilation, but not the duration of hospitalization, were significantly lower in Infasurf-treated infants. CONCLUSION Compared with Exosurf, Infasurf provided more effective therapy for RDS as assessed by significant reductions in the severity of respiratory disease and in the incidence of air leak complications.

Brain Changes in Newborns from an Intensive Care Unit

A study of the brains of 105 newborns (82 pre‐term and 23 term infants), who failed to survive after treatment for severe respiratory distress in an intensive care unit, revealed that 63 of the pre‐term infants died as a result of subependymal germinal plate hemorrhage. Additional lesions were found in the cerebral cortex, hippocampus, cerebral white matter and cranial nerve nuclei. The clinical course of 25 of the 105 infants was studied intensively. In these infants the severity of the lesions appeared to correlate roughly with the length of survival under anoxic and acidotic conditions.

Stricture of the nasal vestibule: A complication of nasotracheal intubation in newborn infants†

Nasal vestibular stenosis after prolonged nasotracheal intubation has been observed in two newborn infants. The causes of this deformity are felt to be pressure on the nasal vestibule andlor excessive motion of the tube The deformity has undesirable cosmetic potential and may require corrective surgery.

Effectiveness of chest tube evacuation ofpneumothorax in neonates

This is a retrospective review of the effectiveness of 149 chest tubes placed in attempts to evacuate 91 pneumothoraces among 57 infants. Forty-four percent of initial evacuation attempts were ineffective; 42% of total chest tubes throughout the clinical courses were ineffective. The largest number of these ineffective chest tubes lay posterior in the pleural cavity. Fifty-six percent of posterior tubes were ineffective whereas only 4% of anterior tubes were ineffective. Other causes for failure included tubes which had perforated the lung, diaphragm, or mediastinum or were lying subcutaneously. On some occasions, chest tubes were mistakenly used to evacuate intrathoracic air which was actually a pulmonary pseudocyst or pneumomediastinum. Two thoracostomy sites were chosen: the superior and lateral. Eighty-five percent of chest tubes inserted through the superior approach lay anteriorly in the pleural cavity whereas only 47% of the laterally inserted tubes lay anteriorly. Superior thoracostomy tubes were significantly more effective than lateral tubes because of their more frequent anterior location. There were also fewer complications with superior thoracostomy tubes. Whereas only 10% of superiorly inserted tubes encroached upon the mediastinum, 32% of lateral tubes did so. To be effective, chest tubes should be placed anteriorly in the pleural space; this location is more often achieved via the superior thoracostomy approach.

NECROTIZING ENTEROCOLITIS IN INFANTS FED AN ELEMENTAL FORMULA

Necrotizing enterocolitis (NEC) is a catastrophic disease that occurs in 5% of admissions to our neonatal ICU. Although a number of associations have been suggested, the pathogenesis of NEC has not been defined. Based on observations in our nursery that: 1) the incidence increases with prematurity (60% of cases occur in < 1200 G infants), 2) the incidence increased at about the time increased emphasis was placed on oral alimentation, 3) we have found increased fecal reducing substances in 10-14 infants for 1-5 days prior to developing NEC, 4) fat absorption is decreased in the newborn, we initiated a controlled clinical study to determine the effect of formula on development of NEC. Infants <1200 G were randomized and fed either a standard premature formula (PF) or a 0.67 cal/ml elemental formula (EF) with medium chain triglycerides. The gestational age, birth weight and severity of illness was similar in the two groups. The average rate of increase of formula feeding during the first 8 days was similar (EF=19.4, PF=16.7 ml/kg/day). NEC developed in 7 of 8 infants fed EF and in 2 of 8 fed PF (p <.005). The incidence of NEC in the PF group was unchanged from that occurring during the previous 16 months when 20 of 76 infants <1200 G developed NEC. In a retrospective review, 5 infants with 2 or more episodes of NEC had been fed EF on recovery from the first episode. The high osmolarity of EF may be important in the increased incidence of NEC in EF fed infants.

Neonatal back-transport. Cost-effectiveness.

This study examines the cost-effectiveness of returning previously ill neonates to community hospitals after treatment in a tertiary center, a concept known as “back-transport.” The authors compared the charges for medical care during convalescence of a group of back-transported infants (BT infants; n = 20) with a similar group of infants who remained in a tertiary center for convalescence (NT infants; n = 20). The total charges for convalescent care (inpatient plus transport charges) for 20 representative BT infants was

Ligation of the Patent Ductus Arteriosus in the Newborn Intensive Care Unit

(61,840, compared with

Pulmonary Hemorrhage Secondary to Chest Tube Placement for Pneumothorax in Neonates

68,240 for 20 matched NT infants, an average savings of