Joan E. Hodgman

Polygraphic Studies of Normal Infants during the First Six Months of Life. I. Heart Rate and Variability as a Function of State

Extract: This study examined spontaneous heart rate (HR) and variability as a function of age and sleep state in eight normal full term infants from birth to 6 months of age. Heart rates recorded during sleep were lower and less regular at 1 week (quiet sleep (QS) mean rate = 128, interquartile range = 6.4 beats/min; rapid eye movement (REM) = 134.5, 11.6) than at 1 month (QS = 138.6, 3.4; REM 139.6, 4.2). Rate decreased sharply from 1 to 3 months (QS = 118; REM 123.8) and decreased only slightly thereafter (6-month QS = 113.5; REM 118.9). Variability decreased rapidly in REM from 2 to 4 months (from 11.4 to 9.1) and less quickly from 4 to 6 months (from 9.1 to 8.2), while QS variability decreased at 1 month (from 6.4 to 5.7) and became stable from that point (6.0 at 6 months). Waking heart rate and variability were both relatively low at 1 week (163, 11.2 beats/min) and increased from that age to 1 month (167.4, 14.3). Rate decreased rapidly in waking at 3 months (152 beats/min) and more slowly thereafter (152 beats/min at 4 months, 149 beats/min at 6 months), whereas variability remained elevated until after 3 months, becoming stable at a lower level during later infancy (3 months = 14.8, 6 months 11.7). Lowest values of rate and variability were found in QS and the highest values were found in waking at all ages, except at 1 week. Heart rates during REM closely approximated those in QS, whereas variability values more closely resembled those of waking.Speculation: It would appear that, in the normal infant, there are at least three relatively discrete stages in the ontogenetic sequence of cardiac rate and variability characteristics: a newborn period, early infancy (1–3 months), and later infancy. Since regulation of cardiac activity is greatly modified by sleep and waking behavior, the measurement of heart rate and variability must consider state as a factor in such regulation. Moreover, since states undergo both qualitative and quantitative changes during the first 6 months of age, the nature of cardiac regulation during this period may be a function of state maturation.

Cardiogenic shock associated with perinatal asphyxia in preterm infants

Fetal and neonatal biophysical and biochemical changes were studied in four preterm infants who developed cardiogenic shock as a result of severe perinatal asphyxia. Fetal distress was documented by the presence of severe late and variable decelerations associated with decreased fetal heart rate variability. Severity of fetal acidosis was decumented by scalp and umbilical cord blood pH. Apgar scores at 1, 5, and 10 minutes were all equal to or less than 5. Although the clinical findings shortly after birth resembled respiratory distress syndrome, it was possible to make a primary diagnosis of cardiac failure with the recognition of cardiomegaly, hepatomegaly, electrocardiographic changes of myocardial hypoxia, decreased myocardial contractility, elevated central venous pressure, and severe lactic acidosis. The treatment of heart failure, including use of inotropic agents, resulted in rapid improvement in the clinical condition, with reversal of the abnormal findings within 24 to 36 hours. Concomitant with this improvement, the increase in arterial blood pressure was paralleled by increase in peripheral (toe) temperature.

Cardiopulmonary and intracranial pressure changes related to endotracheal suctioning in preterm infants

Although endotracheal (ET) suctioning is performed frequently in sick newborn infants, its effects on cardiorespiratory variables and intracranial pressure (ICP) have not been thoroughly documented in neonates greater than 24 h who were not paralyzed while receiving mechanical ventilation. This study evaluates these changes in preterm infants who required ventilatory assistance. We measured transcutaneous PO2 and PCO2 (PtcO2 and PtcCO2, respectively), intra-arterial BP, heart rate, ICP, and cerebral perfusion pressure (CPP) before, during, and for at least 5 min after ET suctioning in 15 low birth weight infants less than 1500 g and less than or equal to 30 days of age. One infant was studied twice. A suction adaptor was used to avoid disconnecting the patient from the ventilator and to attempt to minimize hypoxemia and hypercapnia during suctioning. The patients were studied in the supine position and muscle relaxants were not used. PtcO2 decreased 12.1% while PtcCO2 increased 4.7% 1 min after suctioning; however, greater increases in mean BP (33%) and ICP (117%) were observed during suctioning. CPP also increased during the procedure. ICP returned to baseline almost immediately, whereas BP remained slightly elevated 1 min after suctioning. Our findings demonstrate that ET suctioning significantly increases BP, ICP, and CPP in preterm infants on assisted ventilation in the first month of life. These changes appear to be independent of changes observed in oxygenation and ventilation.

Effects of metaproterenol on pulmonary mechanics, oxygenation, and ventilation in infants with chronic lung disease

Changes in pulmonary resistance, dynamic compliance, tidal volume, and transcutaneous PO2 and PCO2 after nebulized administration of metaproterenol were evaluated in eight newborn infants (birth weight 650 to 1060 g, gestational age 25 to 28 weeks) with chronic lung disease receiving mechanical ventilation. The infants were monitored continuously before and for 15 minutes after nebulization of metaproterenol during 3 consecutive days at mean age 34 days. There were significant increases in compliance, tidal volume, and tcPO2, and significant decreases in pulmonary resistance and tcPCO2. These data show that bronchospasm contributes significantly to the high pulmonary resistance in preterm infants with chronic lung disease and that metaproterenol is beneficial in the therapy of infants with chronic lung disease requiring mechanical ventilation.

Usefulness of cardiac troponin T and echocardiography in the diagnosis of hypoxic myocardial injury of full-term neonates.

Background: Perinatal asphyxia constitutes a significant problem influencing neonatal mortality and morbidity. Objectives: The aim of the present work was to provide evidence of the usefulness of cardiac troponin T (cTnT) and echocardiographic investigations in the diagnosis of heart damage in full-term infants after intrauterine hypoxia. Material and Methods: The subjects were 39 asphyxiated and 44 term infants without fetal anoxia. Quantitative determinations of cTnT were performed between 12 and 24 h of life. Two-dimensional Doppler and color Doppler studies were performed at the bedside. We evaluated fractional shortening (FS), cardiac output (CO), cardiac index (CI), tricuspid (TI) and mitral (MI) insufficiency. Results: Asphyxiated infants presented increased cTnT (mean 0.141 ± 0.226 vs. 0.087 ± 0.111ng/ml; p < 0.01) and TI (38.5 vs. 11.4% of population; p < 0.05) compared to healthy infants. CO, CI and FS remained in the same range. Conclusions: We found cTnT to be the most useful among accessible diagnostic tools used in post-hypoxic heart damage in neonates. The data from our relatively small population study suggest a cTnT value of >0.1 ng/ml as a reliable marker of myocardial injury in neonates. Further study should be performed to generate a receiver-operator characteristic curve to discover what the cut-off level should be.

Mechanics of Breathing after Surgical Ligation of Patent Ductus arteriosus in Newborns with Respiratory Distress Syndrome

The aim of the study was to detect changes in pulmonary function following ligation of a patent ductus arteriosus (PDA). Pulmonary function was recorded in 16 newborns (birth weight 1,081 ± 166 g, gestational age 27.6 ± 1.7 weeks) before and after ligation. No change in resistance of airways or mean airway pressure was observed. We found an increase in dynamic compliance (Cdyn) of 77% (p < 0.01), in tidal volume (TV) of 29% (p = 0.004), and in minute ventilation (MV) of 17% (p < 0.01) after the procedure. We demonstrated that pulmonary function improves after surgical ligation of the PDA. Because of considerable variation in intubated and spontaneously breathing premature newborns, we recommend the analysis of three main parameters: Cdyn, TV and MV for estimation of pulmonary mechanics in these infants.

Temporal sequencing in sleep and waking states during the first 6 months of life

All-night polygraphic recordings of 25 normal infants were carried out to describe the early development of sleep-waking-state sequencing. Each minute of the 12-h recordings was coded into quiet sleep, active sleep, or waking states. These data were then transformed into a binary series and subjected to spectral analysis using the fast Fourier transform for determination of periodicity of each state. Spectral estimates of sleep- and waking-state periodicities displayed a high variance early in life, but by 3 to 4 months of age, there was a principal rhythm approximating 1 cycle/h in the active and quiet sleep states. The average frequency for the quiet and active sleep states increased significantly from 0.87 to 1.07 cycles/h during this 6-month period. These data offer evidence that the establishment of the periodic organization of sleep states requires 4 months to develop in the normal infant.

Apparent Life-Threatening Events and Sudden Infant Death Syndrome: Comparison of Risk Factors

OBJECTIVE To compare the risk factors of 153 cases of apparent life-threatening event (ALTE) enrolled in the multicenter Collaborative Home Infant Monitoring Evaluation (CHIME) from 1994 to 1998 with the published risk factors for sudden infant death syndrome (SIDS). STUDY DESIGN Trained CHIME interviewers gathered histories of infants with ALTE who met the criteria. The following risk factors were analyzed: male predominance, gestational age, low birth weight, very low birth weight, incidence of small for gestational age (SGA), age at the event, multiparity, maternal age, and smoking. Population-based SIDS studies with >100 deaths, focusing on 1 or more pertinent risk factors and carried out during the decade in which CHIME data were collected, were chosen for comparison. RESULTS One of the 153 infants with ALTE in this study died during follow-up (0.6%). CHIME ALTE differed significantly from SIDS in 4 respects: fewer infants with low birth weight and SGA at birth, fewer teenage pregnancies, and a younger infant age at ALTE. CONCLUSIONS Although a number of risk factors for ALTE are similar to those for SIDS, the differences warrant a separate focus on ALTE beyond that on SIDS.

Prediction of Neurodevelopmental Outcome in Infants with and Without Bronchopulmonary Dysplasia

In a group of 236 very low birth weight (VLBW) surviving infants, 60 had developed bronchopulmonary dysplasia (BPD) in the nursery. When compared with the 176 infants without BPD, infants with BPD were smaller, more immature, with lower one- and five-minute Apgar scores. Infants with BPD had a greater incidence of cardio-pulmonary and central nervous system (CNS) complications in the nursery. On follow-up, 25 (42%) of these infants were abnormal developmentally compared to 7% of infants without BPD (p less than .001). When comparisons were made within the group of infants with BPD, very few differences were found in maternal or infant risk factors between the normal and abnormal infants. The infants with BPD who had poor outcome more often had seizures and severe intraventricular hemorrhage (IVH). The infants with BPD who had good outcome were more often small for gestational age (SGA) and resuscitated with intubation at birth. They had apnea in the nursery more frequently than did abnormal infants with BPD. We conclude that VLBW infants with BPD are at greater risk for poor neurodevelopmental outcome than those without BPD. The risk for the infant with BPD relates to CNS complications rather than to chronic lung disease.

New endotracheal tube adaptor reducing cardiopulmonary effects of suctioning.

The continuous recordings of arterial oxygen saturation (SaO2) and beat-to-beat heart rate before, during, and after tracheobronchial suctioning were studied in eight preterm infants with severe RDS receiving mechanical ventilation. Two suctioning procedures were alternatively performed in each infant; In procedure A, disconnection of the ventilator and preoxygenation preceded suctioning; in procedure B, a special suction adaptor was used without ventilatory interruption or preoxygenation; 128 suctionings were performed with each procedure and the changes in heart rate (HR) and SaO2 during suctioning were compared. Although in both procedures, HR and SaO2 decreased during suctioning, the degree of bradycardia and arterial blood oxygen desaturation were significantly smaller in magnitude and shorter in duration during procedure B. These data indicate advantages of the suction adaptor in minimizing bradycardia and hypoxia from airway suction.