Jerald King

Heated, Humidified High-Flow Nasal Cannula Versus Nasal CPAP for Respiratory Support in Neonates

BACKGROUND AND OBJECTIVE: Heated, humidified high-flow nasal cannula (HHHFNC) is commonly used as a noninvasive mode of respiratory support in the NICU. The safety and efficacy of HHHFNC have not been compared with other modes of noninvasive support in large randomized trials. The objective was to assess the efficacy and safety of HHHFNC compared with nasal continuous positive airway pressure (nCPAP) for noninvasive respiratory support in the NICU. METHODS: Randomized, controlled, unblinded noncrossover trial in 432 infants ranging from 28 to 42 weeks’ gestational age with planned nCPAP support, as either primary therapy or postextubation. The primary outcome was defined as a need for intubation within 72 hours of applied noninvasive therapy. RESULTS: There was no difference in early failure for HHHFNC (23/212 [10.8%]) versus nCPAP (18/220 [8.2%]; P = .344), subsequent need for any intubation (32/212 [15.1%] vs 25/220 [11.4%]; P = .252), or in any of several adverse outcomes analyzed, including air leak. HHHFNC infants remained on the study mode significantly longer than nCPAP infants (median: 4 vs 2 days, respectively; P < .01), but there were no differences between study groups for days on supplemental oxygen (median: 10 vs 8 days), bronchopulmonary dysplasia (20% vs 16%), or discharge from the hospital on oxygen (19% vs 18%). CONCLUSIONS: Among infants ≥28 weeks’ gestational age, HHHFNC appears to have similar efficacy and safety to nCPAP when applied immediately postextubation or early as initial noninvasive support for respiratory dysfunction.

Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants

Objective:To study whether a cue-based clinical pathway for oral feeding initiation and advancement of premature infants would result in earlier achievement of full oral feeding.Study Design:Age of achievement of full oral intake was compared for two groups of preterm infants; a prospective study group vs historic cohort controls. Study infants had oral feedings managed by nurses using a clinical pathway that relied on infant behavioral readiness signs to initiate and advance oral feedings. Controls had oral feedings managed by physician orders.Result:Fifty-one infants (n=28 study and n=23 control) were studied. Gender distribution, gestational age, birth weight and ventilator days were not different between groups. Study infants reached full oral feedings 6 days earlier than controls (36±1 3/7 weeks of postmenstrual age (PMA) vs 36 6/7±1 4/7 weeks of PMA, P=0.02).Conclusion:The cue-based clinical pathway for oral feeding initiation and advancement of premature infants resulted in earlier achievement of full oral feeding.

Should All Newborns Who Undergo Patent Ductus Arteriosus Ligation Be Examined for Vocal Fold Mobility

To determine the incidence of left vocal fold paralysis (LVFP) in premature infants who undergo patent ductus arteriosus (PDA) ligation.

Aspergillosis in a 24-week newborn: A case report

Aspergillosis is an uncommon neonatal infection, diagnosed with an increasing frequency over the last two decades. We report a premature neonate who developed aspergillosis while receiving amphotericin B and fluconazole for candidiasis. Despite early recognition and diagnosis, the infant died. We review the clinical appearance of Aspergillus species, the distinctions between primary cutaneous aspergillosis and invasive aspergillosis, and advances in diagnosis and treatment.

“NEONATE”—an expert application for the “HELP” system; Comparison of the computer's and the physician's problem list

NEONATE is a prototype of an expert application for the HELP Hospital Information System. Its goal is to improve documentation in the Newborn Intensive Care Unit. The decision module of NEONATE is designed to produce an admission problem list. In this paper, the admission problem list that NEONATE generates was compared to the admission problem list of the current CETUS system for 30 patients. These were compared to a retrospectively constructed gold standard problem list. Of 101 problems in the gold standard list, 56 were on the current admission reports; 82 were found by NEONATE. NEONATE found 31 problems missed on the current admission reports; the current admission reports contained 5 problems missed by NEONATE. The current admission reports contained 9 false positives; whereas NEONATEs reports contained 27. Of the 27, 16 were caused by a single rule in NEONATE. We conclude that an expert system has great potential for improving the documentation of the patient problem list.

Pseudoaminopterin syndrome and trisomy 9.

We report on a male twin of a 40-year-old Hispanic mother born at 32 weeks of gestation with trisomy 9 and findings similar to pseudoaminopterin syndrome.The infanthad severe oligohydramnios andmultiple congenital anomalies. Themale twin died within an hour after birth due to respiratory failure. The female twin was of appropriate size for gestational age with normal physical findings. A full autopsy was not performed but consent was obtained for an external examination and chromosome analysis. Themother had had three previous normal pregnancies and deliveries of healthy children. The parents were unaware of any consanguinity. Fetal ultrasound examination at 19 weeks showed concordant growth of twins, but at 32 weeks growth was discordant. There was no history of maternal diabetes, druguse, or theuse of aminopterin. The infantswere conceived through in vitro fertilization. The mother delivered the twins by cesarean section due to fetal distress. The male twin had intrauterine growth retardation with a weight of 750 g with length of 34 cm and head circumference of 22 cm. The Potter sequence was manifested by a flat left ear, depressed tip of nose, the left knee having been pressed against the left costal margin, and the right foot having been pressed under the right axilla. The baby had a turribrachycephalic skull with a high forehead and receding hairline. There was mild upsweep of the eyebrows, hypertelorism with a very pronounced bridge of the nose, and upward slant of the palpebral fissures. The palpebral fissures were short with bilateral microphthalmia (left palpebral fissure closed). The nasal bridgewasbroadand the tip of thenosewas shortwithan exceedingly short nasal septum and columella. Choanal atresia was present on the left. The upper lip was short without a philtrum and minimal indication of the vermilion border of the lips. There was a wide submucous cleft of the palate, severe micrognathia, and a short neck. The right ear wasvery small,malformed, antevertedandanteflexed, and low set. The handsweremalformedwith short thumbswebbed into the palms of the hands. There were indistinct creases of the hands and hypoplastic fingernails with minimal cutaneous syndactyly between the third and fourth fingers and camptodactyly of fingers two through five bilaterally. There was bilateral axillary webbing, flexion contracture at the elbows, and extension contracture of the knees. The back was straight but there was a wide spina bifida occulta at S1. The external genitalia were male; testes were undescended. The anus was minimally patent (0.2 cm). The feet had a rocker-bottom shape bilaterally (Fig. 1). Examination of the placenta showed a three-vessel cord, normal fetal membranes without inflammation, and focal degeneration of 10% of villi with a 1 cm infarct. A fetal MRI was the only imaging study performed. Information from the MRI was limited and inconclusive due to small fetal size and coil rock causing motion artifact. We were, therefore, unable to evaluate skull ossification adequately. Metaphase cells analyzed from cultures of tissue showed an additional chromosome 9 in each metaphase of 20 cells analyzed at the 400-band level (47,XY,þ9). The phenotypes of the aminopterin syndrome and pseudoaminopterin syndrome are so similar that we presume the same defect of pattern formation could be due to inhibition of folicacid-directed DNA synthesis. We are aware of nine previous reports of the pseudoaminopterin syndrome (aminopterin syndrome sine aminopterin) [Herrmann and Opitz, 1969; Reich et al., 1978; Fraser et al., 1987; Chen et al., 1990; Verloes et al., 1993; Krajewska-Walasek, 1994; Garcia-Minaur and Botella, 2000]. Barnicoat et al. [1994] reported on a fetus with findings suggestive of both Crane–Heise syndrome and pseudoaminopterin syndrome; overlap between these two conditions and Juberg–Hayward syndrome has been