George J. Peckham

Effects of indomethacin in premature infants with patent ductus arteriosus: results of a national collaborative study.

Among 3559 newborn infants with birth weight less than 1750 gm, 421 developing a hemodynamically significant patent ductus arteriosus were entered into a randomized trial to evaluate the role of indomethacin in the management of PDA. Indomethacin given concurrently with usual medical therapy at the time of diagnosis resulted in ductal closure in 79%, versus 35% with placebo (P less than 0.001). Indomethacin as backup to usual medical treatment resulted in similar closure rates. To assess overall effects through hospital discharge, three management strategies were compared. Although mortality did not differ significantly, infants given indomethacin only if usual therapy failed (strategy 2) had a lower incidence of bleeding than those to whom indomethacin was given with initial medical therapy (strategy 1) and lower rates of pneumothorax and retrolental fibroplasia than those to whom no indomethacin was administered, with surgery the only backup to medical therapy (strategy 3). Thus the administration of indomethacin only when medical treatment fails appears to be the preferable approach for the management of symptomatic PDA in premature infants.

Physiologic factors affecting pulmonary artery pressure in infants with persistent pulmonary hypertension.

Indwelling pulmonary artery catheters were used for continuous monitoring of pulmonary artery pressure in ten infants with severe persistent pulmonary hypertention of the newborn. The labile nature of pulmonary artery pressure, with changes up to 50 mm Hg, was documented. Pulmonary artery pressure in the eight infants with suprasystemic pulmonary hypertension was analyzed at the time of maximum decrease in pressure (mean 36.1 mm Hg) and physiologic measurements were compared over an eight-hour period. During the study period when the infants were hyperventilated, as the Paco2 decreased from 48.9 to 28.3 mm Hg (P less than 0.02) the mean pulmonary artery pressure decreased by 36 mm Hg (P less than 0.001) to subsystemic pressure levels, and the mean AadeltaO2 decreased by 146 mm Hg (P less than 0.001). After the decrease in pulmonary artery pressure, patients were mechanically ventilated to maintain Paco2 in the range of 25 to 30 mm Hg until pulmonary hypertension gradually resolved in the six survivors.

The Clinical Profile of the Newborn with Persistent Pulmonary Hypertension Observations in 19 Affected Neonates

In 19 neonates with severe cyanosis, normal chest x-rays, anatomically normal hearts, and a high incidence of perinatal complications, the clinical course was characterized by variable sustained cyanosis. Cardiac catheteriza tion data showed high systemic or suprasystemic pulmonary artery pressure with right to left intracardiac shunting via the foramen ovale and ductus arteriosus. Arterial oxygen tension at an inspired oxygen concentration above 65 per cent was helpful in distinguishing these patients from those with congenital heart disease, and for predicting prognosis.

Hospitalization of very low birth weight children at shcool age

OBJECTIVE To assess whether very low birth weight (VLBW) increases the risk of hospitalization at school age. DESIGN Prospective, multisite cohort study. PARTICIPANTS Selected from a previous multisite, hospital-based trial, 611 VLBW children, and, from a prior representative sample, 724 children who weighed 1501 to 2500 gm and 533 who weighed > 2500 gm. All the children were re-contacted at 8 to 10 years of age for this study. METHODS Maternal interview with the use of standardized questions. MAIN OUTCOME Hospitalization in year before interview. RESULTS The VLBW children were three or four times more likely to be rehospitalized than children of normal birth weight, both in the year before the interview (7% vs 2%) and since birth (50% to 60% vs 22%). Morbidity and Medicaid coverage increased the risk of hospitalization in the year before the interview; non-white race decreased it. After control for other factors, however, lower birth weight remained a significant risk factor for hospitalization. CONCLUSIONS The VLBW children continue to have an increased risk of hospitalization; the risk is similar in magnitude to that seen in infancy.

When you're only a phone call away: a comparison of the information in telephone and face-to-face interviews.

Telephone interviews offer an economical method of obtaining information, but little published experience addresses the use of telephone interviews for the sometimes lengthy questionnaires composed of scales with multiple-category items often required in developmental and behavioral research. In a study of the outcomes of very low birth weight infants, circumstances required that we administer a questionnaire, including seven scales composed of several Likert-type items each, to a substantial portion of the study population. Those contacted by telephone (n = 1067) differed from those responding face-to-face (n = 822) in being less likely to have a very low birth weight child and more likely to be white and of higher maternal education. The length of the interview was only slightly shorter by telephone (60.7 ± 27.9 vs 66.4 ± 21.0 minutes,p < .001), but respondent fatigue, as indicated by lower completion rates for scales at the end of the interview (92.5%) compared with those near the beginning (99.5%) did not differ by mode. Internal consistency of parental response (Cronbachs α) was high for most scales and did not differ by mode. Because assignment to mode was not random, other factors may influence our findings. However, high completion rates and comparable consistency of response supports the use of telephone interviews.J Dev Behav Pediatr 14:250–255, 1993. Index terms:health survey, child health status.

Long-term follow-up of newborns with persistent pulmonary hypertension

Persistent pulmonary hypertension of the newborn (PPHN), is a syndrome associated with high morbidity and mortality. Mechanical ventilation attempts to maintain a Paco2 < 30 torr and a pH > 7.5 until pulmonary hypertension resolves. To assess whether the disease or its therapy adversely affects neurodevelopmental or cardiorespiratory outcome, 11 infants diagnosed and treated for PPHN were evaluated at a mean age of 31 months. Nine had normal developmental quotients (DQs) and 2 had mildly delayed DQs. Eight children were entirely normal neurologically, 2 had slightly increased lower-extremity tone, and 1 had unilateral hypertonia. All cardiac exams, echocardiograms, and ECGs were normal. Four children had chronic lung disease requiring either daily or intermittent bronchodilator therapy; however, their activity levels were unaffected. These results suggest that subsequent normal development with little significant medical compromise may be expected in this group of critically ill infants.

Maternal cocaine abuse and necrotizing enterocolitis: Outcome and survival

Since 1987, multiple complications related to maternal cocaine abuse have been reported. Necrotizing enterocolitis-(NEC) of the newborn has been observed with increasing frequency. We report a comparative analysis of infants with NEC born to cocaine abusing mothers (n = 11) to a standard population of newborns with NEC (n = 50) treated in this institution from January 1987 to July 1989. We also evaluated whether prenatal cocaine abuse predisposes infants to NEC by performing a case-control analysis using 51 of 61 infants and controls matched for race, sex, and birthweight +/- 250g. Significant differences were apparent between the cocaine-affected infants (COC) and the noncocaine-affected infants (Non-COC) with regard to surgical intervention (72.7% v 38%, P less than .05), the presence of massive gangrene (54% v 12%, P less than .01), mortality (54.5% v 18%, P less than .01), and maternal age (28.13 +/- 3.82 years v 24.12 +/- 6.21 years P less than .05). No differences between these groups could be demonstrated for other known NEC risk factors such as gestational age, birthweight, feeding patterns, umbilical artery catheters, or asphyxia. In the matched case-control study, infants born to mothers who were cocaine abusers demonstrated a 2.5-fold increased risk of developing NEC (95% Cl = 1.17 to 5.32, P = .02) when compared with the noncocaine-exposed group. Maternal cocaine abuse appears to play a contributory role in the pathogenesis of NEC, its extent, and its outcome.

Clinical course to 1 year of age in premature infants with patent ductus arteriosus: Results of a multicenter randomized trial of indomethacin

Reported are 1-year follow-up results of a randomized clinical trial comparing three strategies of managing clinically significant patent ductus arteriosus at the time of diagnosis in premature infants: (1) immediate administration of a three-dose course of intravenously administered indomethacin in addition to usual medical therapy (fluid restriction and use of diuretics or digitalis or both), with surgery as a backup measure, (2) usual medical therapy alone initially, with indomethacin as the first and surgery as the final backup measure, and (3) usual medical therapy alone initially, with surgery alone as backup. Of primary concern were the relative merits of these three managements strategies in the terms of the long-term occurrence of a wide range of health problems. Although at the time of neonatal hospitalization there was a significant excess of bleeding episodes in infants receiving indomethacin as part of initial treatment, and a significantly higher rate of retrolental fibroplasia in the those given usual medical therapy with surgery as backup, there were no statistically significant differences at 1 year of age related to these intermediate outcomes. In other regards, too, the treatment strategies appeared interchangeable in terms of the 1-year outcome.

1000 NECROTIZING ENTEROCOLITIS-ENDEMIC VS. EPIDEMIC FORM

Necrotizing enterocolitis (NEC) is a disease of undefined etiology affecting premature infants. A number of hypotheses have been suggested for NEC, and clusters of cases have been reported in nurseries. During Dec. 1974 and Jan. 1975, 14 cases of NEC occurred in patients admitted to the infant ICU. In the 12 months prior to this period a total of 11 cases of NEC occurred. Distinguishing features of the epidemic group vs. the endemic group are summarized:Results of a stool culture survey showed an association between Klebsiella colonization and illness. In a 2 month period in 1976 a 2nd clustering of NEC occurred with characteristics similar to those described in the epidemic group above. The awareness of an epidemic form of NEC is important in evaluating the effects of therapy and/or prophylaxis of NEC in premature infants.

The PaO2 response to changes in end expiratory pressure in the newborn respiratory distress syndrome.

To quantitate the effect of changes in end-expiratory pressure (EEP) upon PaO2 in infants with the respiratory distress syndrome, arterial blood gas (ABG) data was reviewed in 28 neonates. A total of 94 ABG specimen pairs were analyzed (specimen I taken before EEP adjustment; specimen II taken after EEP change). An overall change in PaO2 of 15 torr was noted per cm H2O change in EEP. Patients in whom the level of EEP was low (0–3 cm H2O) at the time of Sample I had a greater change in PaO2 (p < 0.01) than infants whose Sample I ABG was taken at mid-range of EEP (4–6 cm H2O) or at high ranges (7–12 cm H2O). At the high ranges of EEP a minimal and variable PaO2 response was observed. The PaO2 response was not statistically different between neonates on controlled ventilation and those breathing spontaneously. Survivors had a greater PaO2 response than did nonsurvivors, but because of the variables affecting respiratory distress syndrome (RDS) patients, it could not be determined if this PaO2 response had a prognostic value. From this data, the clinician is provided with a guide to the expected PaO2 response when a change in EEP is made.