Hans Versmold

Postnatal body weight curves for infants below 1000 g birth weight receiving early enteral and parenteral nutrition

No body weight curves are available for preterm infants < 1000 g birth weight receiving early enterai and parenteral nutrition. Postnatal weight changes of 136 infants with a birth weight < 1000 g were analysed retrospectively. Body weight curves for the first 30 days of life were generated for five separate birth weight groups (430–599 g, 600–699 g, 700–799 g, 800–899 g, 900–999 g). All infants had received intravenous glucose and amino acids from day 1 and intravenous lipids from day 2. Enterai feeding was started on day 1. Thus caloric intake (±SD) was advanced to 384 ± 46 kJ/kg per day (92 ± 11 kcal/kg/day) in the 1st week of life. In 136 preterm infants mean postnatal weight loss was 10.1% ± 4.6% of birth weight, birth weight was regained at a mean postnatal age of 11 ± 3.7 days, but significantly earlier (7.8 ± 3.5 days) in the lowest compared to the highest weight group. Mean subsequent weight gain was 15.7 ± 7.2 g/ kg per day. This was accomplished by exclusive enterai nutrition from day 20 (median).ConclusionAt time of diagnosis, patients with primary ciliary dyskinesia have partially reversible obstructive airway disease. During regular follow up and therapy, there is no evidence of a further decline in lung function. Patients with associated immunodeficiency or important damage at the start of therapy may have a worse prognosis.

Body temperatures and oxygen consumption during skin-to-skin (kangaroo) care in stable preterm infants weighing less than 1500 grams

BACKGROUND More and progressively smaller preterm infants are taken out of the incubator and placed skin to skin on their mothers chest to promote bonding, despite concerns that the infants are exposed to cold during this intervention. OBJECTIVE To test the hypothesis that skin-to-skin care is a cold stress for preterm infants weighing less than 1500 gm, with a decrease in rectal temperature, a decrease in peripheral skin temperature, or an increase in oxygen consumption compared with conditions monitored during incubator care. STUDY DESIGN We studied 22 stable, spontaneously breathing preterm infants weighing less than 1500 gm (appropriate in size for gestational age), who had their first skin-to-skin care in the first week of life. We continuously measured rectal temperature, peripheral skin temperature (foot), and oxygen consumption (indirect calorimetry) for 1 hour in a thermoneutral incubator, during 1 hour of skin-to-skin care, and for another hour in the incubator. Mean values for the three periods were compared by analysis of variance. RESULTS During skin-to-skin care the mean rectal temperature was 0.2 degree C (p < 0.01) and the peripheral skin temperature was 0.6 degree C (p < 0.01) higher than during the preceding hour in the incubator. Back in the incubator, body temperatures returned to values recorded before skin-to-skin care. Oxygen consumption during skin-to-skin care (6.1 +/- 0.9 ml/kg per minute) was not significantly higher than in the incubator (5.8 +/- 0.8 ml/kg per minute). CONCLUSION For stable preterm infants weighing less than 1500 gm and less than 1 week of age, 1 hour of skin-to-skin care is not a cold stress compared with care in a thermoneutral incubator.

An outbreak of pyodermas among neonates caused by ultrasound gel contaminated with methicillin-susceptible Staphylococcus aureus.

OBJECTIVE To investigate an outbreak of methicillin-susceptible Staphylococcus aureus (MSSA) infections in a neonatal clinic. DESIGN Prospective chart review, environmental sampling, and genotyping by two independent methods: pulsed-field gel electrophoresis (PFGE) and randomly amplified polymorphic DNA polymerase chain reaction (RAPD-PCR). A case-control study was performed with 31 controls from the same clinic. SETTING A German 1,350-bed tertiary-care teaching university hospital. RESULTS There was a significant increase in the incidence of pyodermas with MSSA; 10 neonates in good physical condition with no infection immediately after birth developed pyodermas. A shared spatula and ultrasound gel were the only identified infection sources. The gel contained MSSA and was used for hip joint sonographies in all neonates. PFGE and RAPD-PCR patterns from 6 neonates and from the gel were indistinguishable and thus genetically related clones. The case-control study revealed no significant risk factor with the exception of cesarean section (P=.006). The attack rate by days of hip-joint sonography between April 15 and April 27, 1994, was 11.8% to 40%. CONCLUSIONS Inappropriate hygienic measures in connection with lubricants during routine ultrasound scanning may lead to nosocomial S. aureus infections of the skin. To our knowledge this source of S. aureus infections has not previously been described.

Diversification of Ig Heavy Chain Genes in Human Preterm Neonates Prematurely Exposed to Environmental Antigens

Preterm neonates are exposed to extrauterine environmental Ags during the time period that corresponds to the last trimester of normal intrauterine development. To study whether this precocious exposure to Ags accelerates the Ig repertoire diversification, we compared IgH chain genes of preterm neonates (gestational age, 25–29 wk) during their first postnatal months with those of term neonates. Preterm infants approaching their expected date of delivery after 8–13 wk of extrauterine life used a similar VH, DH, and JH gene segment repertoire as term neonates born after intrauterine development. Furthermore, the length increase of the NDN region between VH and JH by 0.25 nt per gestational week (r = 0.556, p < 0.0001) was not accelerated. Thus, the generation of the VH region gene repertoire is developmentally controlled and independent of environmental influences. However, exposure to extrauterine Ags induced class switch and somatic mutations in IgH chain genes within 2 wk after premature birth and IgG transcript diversity and mutational frequency increased with the duration of extrauterine life. Three-month-old preterm infants expressed a heterogeneous IgG repertoire at their expected date of delivery with VH region genes carrying significant numbers of somatic mutations with evidence for Ag selection. Term neonates, however, had no such IgG repertoire. We conclude that restrictions in the neonatal Ig VH region gene repertoire persist until term despite exposure to environmental Ags. Yet, many weeks before term the immune system of the preterm neonate can already support germinal center reactions in response to environmental Ags.

Impaired CD14-dependent and independent response of polymorphonuclear leukocytes in preterm infants.

Abstract Preterm newborn infants are especially susceptible to Gram-negative sepsis that is associated with a lethality of up to 40%. Aims: We tested whether polymorphonuclear leukocytes (PMN) from preterm infants exhibit an impaired antibacterial response upon stimulation with lipopolysaccharide (LPS) from Escherichia coli when compared to full term newborns or adults. Methods: We studied the effect of LPS on the expression of the surface proteins CD11b and CD14 and the secretion of elastase by PMN from preterm infants, term infants and adults ex vivo. Results: We found a significantly reduced antibacterial activity of PMN from preterm infants upon stimulation with LPS as indicated by low surface expression of the adhesion molecule CD11b and the reduced secretion of PMN elastase. LPS-induced CD11b expression was dependent on binding of LPS to the surface protein CD14 as CD14 antibodies inhibited LPS dependent CD11b upregulation. Furthermore CD14 expression was lower on PMN from preterm infants than from adults. In addition, CD14 independent upregulation of CD11b in response to tumor necrosis factor (TNF-α), N-formyl peptides (FMLP) and phorbol ester (PMA) was impaired. Conclusion: PMN from preterm infants are distinctly hyporesponsive to LPS, which may explain the predisposition of these children to invasive disease due to gramnegative bacteria.

Oral Glucose before Venepuncture Relieves Neonates of Pain, but Stress Is Still Evidenced by Increase in Oxygen Consumption, Energy Expenditure, and Heart Rate

Oral glucose was recommended as pain therapy during venepuncture in neonates. It is unclear whether this intervention reduces excess oxygen consumption (V˙o2), energy loss, or cardiovascular destabilization associated with venepuncture, and whether <2 mL glucose solution is effective. We tested the hypothesis that oral glucose solution attenuates the increases in neonatal oxygen consumption, energy expenditure (EE), and heart rate associated with venepuncture for two different volumes of glucose solution (2 and 0.4 mL). In this prospective, randomized, controlled, double-blind trial, 58 neonates (gestational age, 31–42 wk; postnatal age, 1–7 d) were randomized to 2 mL glucose 30%, 0.4 mL glucose 30%, or 2 mL water by mouth before venepuncture. The videotaped behavioral pain reactions were scored with the Premature Infant Pain Profile. Cry duration, V˙o2, EE (indirect calorimetry), and heart rate were measured. The 2 mL glucose solution reduced pain score and crying after venepuncture compared with controls [median pain score, 5.5 (interquartile range, 4–9) versus 11 (7–12), p = 0.01; median duration of first cry, 0 s (0–43 s) versus 13 s (2–47 s), p < 0.05, respectively]. The 0.4 mL glucose solution had no effect. The 2 mL glucose solution did not attenuate the V˙o2 increase during venepuncture (1.5 ± 0.2 mL/kg min (water) versus 1.7 ± 0.5 (0.4 mL glucose) versus 1.1 ± 0.2 (2 mL glucose) (mean ± SEM) nor EE nor heart rate. We conclude that oral administration of 2 mL glucose 30% before venepuncture reduced pain expression and crying, but did not prevent the rise in V˙o2, EE, or heart rate. Alternative therapies against the stress of nonpainful handling during venepuncture should be explored.

Growth and development of children to 4 years of age after repeated antenatal steroid administration

Abstract. It is common practice to repeat antenatal steroid administration after 7 to 10 days in women who continue to be at risk for preterm delivery. However, safety and efficacy of repeated courses have not been established. Mothers of singleton infants who had more than five courses of betamethasone (80–120 mg cumulative dose) were eligible for this cohort study. Index patients (IP) were compared to concurrent controls who had ≤1 course but were matched for sex and gestational age. Of 35 IP born between 1986 and 1995 in a single perinatal centre, 28 were available for follow-up and could be matched. There was no difference between groups with respect to maternal age and gestational age at delivery. Median gestational age at initial treatment was 26.3 weeks (25th percentile 25.1 weeks, 75th percentile 27.2 weeks) in IP. There was no significant difference between groups in head circumference, length and body weight at birth and at age 4 years. The ability to sit and to walk without assistance and to use two-word phrases was attained at similar ages. The use of glasses or hearing aids, allergies, asthma or recurrent upper respiratory infections were not reported more frequently in IP. Conclusion: this study failed to ascertain adverse long-term effects of repeated antenatal steroid administration in infants and children to the age of 4 years. In contrast to a similar Australian study, we were unable to demonstrate a lower birth size in exposed infants even though our sample size for women with more than five courses and their cumulative doses were larger.

Pathogenesis and therapy of non-oliguric hyperkalaemia of the premature infant

Abstract. Non-oliguric hyperkalaemia is a common and serious complication of extreme prematurity, resulting from a potassium loss from the intra- into the extracellular space during a specific post-natal period. Treatment of this disorder has been adapted from the treatment of hyperkalaemia in renal failure, an entity of completely different pathophysiology. A few years ago, the administration of salbutamol, which induces cellular potassium uptake, was proposed as a new therapeutic option. In this review article we discuss the pathogenesis and current therapy of non-oliguric hyperkalaemia of the premature infant, with special emphasis on the presently available knowledge and concerns with regard to the use of salbutamol. Being aware of the paucity of studies on non-oliguric hyperkalaemia, we propose treatment recommendations which are based on best available evidence. These comprise the administration of calcium, infusion of insulin plus glucose, correction of acidosis, and exchange transfusion or peritoneal dialysis as a last resort therapy. Before controlled trials on efficacy of salbutamol treatment of non-oliguric hyperkalaemia of the premature infant can be initiated, more data on safety are needed.

Comparison of face mask, head hood, and canopy for breath sampling in flow-through indirect calorimetry to measure oxygen consumption and carbon dioxide production of preterm infants < 1500 grams.

Complete sampling of expired air is essential for accurate O2 consumption(CO2 production) [VO2(VCO2)] measurements with flow-through indirect calorimetry. In preterm infants complete sampling is critical, because only low sampling flows can be used. The accuracy of the various breath sampling systems at low flows and their patient compatibility is untested. We therefore measured 1) the accuracy of VO2(VCO2) measurements with a face mask, a head hood, and a canopy in vitro at low sampling flows; 2) the effect of breathing on measurements with the face mask; and 3) the effect of breath sampling systems on activity and body temperature of preterm infants. VO2(VCO2) were measured with a Deltatrac II™. In vitro we used a methanol miniburner incorporated into a doll, which could simulate low VO2(VCO2) and tidal breathing. In vivo we studied seven preterm infants <1500 g. With the face mask VO2(VCO2) measurements were accurate at a flow of 3 L/min (error-1 ± 0.8%), when tidal volume was <15 mL/breath and the distance between mask and manikin <1 cm. With hood and canopy VO2(VCO2) were underestimated at a flow of 3 L/min (error -13± 1% and -14 ± 5%), and results were markedly influenced by body position. For accurate measurements, the hood needed a flow of 4.5 L/min, the canopy 8.3 L/min. In vivo the face mask did not increase heart rate, respiration, activity, or rectal temperature, but hood and canopy increased rectal temperature by 0.3-0.4°C. For VO2(VCO2) measurements in infants <1500 g, a face mask should be used, which is accurate at low flows and does not change body temperature. Accuracy at low flows and patient compatibility of breath sampling systems should be evaluated and reported for VO2(VCO2) measurements in preterm infants.

Leukocyte and endothelial activation in a laboratory model of extracorporeal membrane oxygenation (ECMO).

An inflammatory response and a capillary leak syndrome frequently develop during the treatment of neonatal respiratory failure by extracorporeal membrane oxygenation (ECMO). The present study was performed to investigate leukocyte activation and endothelial cell dysfunction that are associated with prolonged contact of blood components with synthetic surfaces. Laboratory ECMO was performed with fresh human blood at 37°C for 8 h (n = 6). Leukocyte activation was measured by l-selectin (CD62L) and CD18 integrin surface expression and by neutrophil-derived elastase release. To monitor endothelial activation, endothelial cell ICAM-1 (CD54) expression was measured in cultured endothelial cells from human umbilical veins (HUVEC) after incubation with plasma from the ECMO experiments. CD18 integrin expression was found significantly up-regulated on polymorphonuclear neutrophils and monocytes after 2–4 h of laboratory ECMO. l-selectin was reduced on both cell types during the total duration of the experiments. Soluble l-selectin (sCD62L) and total and differential leukocyte counts remained unchanged during the experiment. Neutrophil-derived elastase content was maximal after 8 h of ECMO. Plasma from the ECMO experiments did not induce ICAM-1 expression of cultured HUVEC. We conclude that prolonged contact with synthetic surfaces during ECMO activates phagocytes, which may contribute to the inflammatory response seen in ECMO-treated patients. Activated phagocytes do not accumulate in the extracorporeal system nor release humoral factors inducing ICAM-1 expression on endothelial cells.