Lawrence J. Fenton

Parathyroid function in infants of diabetic mothers

Serum parathyroid hormone and total and ionized Ca, Mg, and P levels were determined serially from birth to 96 hr of age in 28 infants of diabetic mothers (IDM, 15 Class A, 13 Class B, C, D) and their respective mothers at the time of delivery. In spite of marked decreases in concentrations of serum total and ionized Ca from birth to 24 to 48 hr, there was an insignificant increase in serum PTH values over this period in infants of insulin-dependent mothers. Infants of Class A diabetic mothers had an equivocal PTH response. Nineteen term control infants were similarly examined and had a significant increase in serum PTH postnatally. Relatively higher values of serum ionized Ca at birth in IDM were followed by greater decreases in ionized Ca from birth to 24-48 hr of age, and by decreased neonatal parathyroid function. The data support functional hypoparathyroidism as a basis for the hypocalcemia and hyperphosphatemia of IDM. It is speculated that increased concentrations of serum ionized Ca in utero and suppression of activity in the fetal parathyroid glands may be a cause for the functional hypoparathyroidism.

Alternative Pathway of Complement Activation in Full Term and Premature Infants

Summary: Classical and alternative pathway complement levels were measured in the cord blood sera of 60 newly born infants, with weights ranging from 1200–4165 g. The impact of maternal illness and infant illness on the complement levels was also evaluated. The mean values for CH50, C3, C4, PH50, factor B, and properdin were all significantly less than normal adult levels (P < 0.0001). AH of the above determinations were significantly correlated with one another except for the relationship between properdin and factor B.CH50, PHS0, C4, and properdin levels were significantly correlated with birth weight although there was much residual scatter. Neither maternal illness nor mild to moderate illness in the newborn altered the birth weight-complement relationships. Severe infant illness did significantly alter the relationship between birth weight and complement. However, the impact of this variable on the birth weight-complement relationships was not consistent among the various components. These inconsistencies and the small sample size preclude drawing any strong conclusions about severe illness and complement levels.Speculation: The alternative pathway activation sequence appears to be deficient to the same degree as the classical pathway activation sequence. This suggests that the entire serum complement system develops as a single unit. Severe illness in very low birth weight babies may be associated with abnormalities in serum complement levels greater than would be expected from the low birth weight alone.

1460 MORTALITY OUTCOME IN A TERTIARY NEONATAL INTENSIVE CARE UNIT UTILIZING NURSE CLINICIANS IN PLACE OF PEDIATRIC HOUSESTAFF

Neonatal nurse clinician programs have been developed in part to meet the needs for clinical management skills and technical expertise usually provided by pediatric house officers. The question as to whether patient care can be effectively delivered by nurses has not been fully answered. Neonatologists became actively involved in neonatal care in South Dakota in 1978. Con-comitantly, a nurse clinician training program was developed which included over 300 hours of didactic teaching, six weeks of applied clincial experience and a 34 week preceptorship in a tertiary nursery. Neonatal clinicians were taught to manage the transport and daily care of seriously ill neonates. The mortality for the unit fell from 20% in 1977 to 5.5% for the 1st 9 months of 1980. In addition, there were no fluctuations in mortality associated with housestaff rotation. Nurse clinicians now perform nearly 60% of all procedures. Neonatologists, in concert with nurse clinicians, can provide care at a level which compares favorably with other tertiary care centers. This care provides a high level of consistency and continuity not obtainable in the usual housestaff program. Neonatal clinicians are an effective alternative for situations in which there are an insufficient number of pediatric house officers.

467 MARSHALL-SMITH SYNDROME: ANDROGEN ABNORMALITIES

In 1971 Marshall et al described a syndrome consisting of markedly accelerated skeletal maturation, relative failure to thrive and dysmorphism. Since then 11 cases have been reported. With the exception of an elevated testosterone in a neonatal female, hormonal evaluations have been normal. We present a male with Marshall-Smith Syndrome with abnormal adrenal androgen production. A.S. was noted at birth to have a bone age of 2 yrs. At age 8 mos. the bone age was 6 yrs. Noted were generalized hirsutism, prominent forehead, low set ears, shallow orbits with prominent eyes, small triangular upturned nose, hypoplasia of facial bones, long, tapered fingers, inguinal testes, small scrotum and a penile length of 5¼ cm. The following were normal for age: T4, FSH, LH, somatomedin-C, testosterone, testicular response to HCG, and androgen receptors in cultured skin fibroblasts. Seventeen hydroxyprogesterone (17-OHP) was elevated (840 ng/dl; nl 30-100) as was androstenedione (67 ng/dl; nl<50). An ACTH stimulation test was done. A 30 min. increase in 17-OHP of 23.4 ng/dl/min. suggested an adrenal enzymatic defect and hydrocortisone 20 mg/m2/day was begun. The androstenedione decreased to 13/ng/dl and on therapy has remained normal. ACTH stimulation tests were performed on both parents. The 30 min. increase in 17-OHP was elevated in both (father-13.8 ng/dl/min; mother-8.9 ng/dl/min; nl<6.5 ng/dl/min) suggesting a heterozygous state for congenital adrenal hyperplasia. It is speculated that an inherited abnormality in androgen production may be contributory to the osseous maturation seen in the Marshall-Smith Syndrome.

HOME UTILIZATION OF INFANT APNEA MONITORS

To investigate the home utilization of apnea monitors, 44 mothers of monitored infants were interviewed by telephone 6 to 8 weeks following discharge from a Level III NICU. Monitoring was prescribed for clinical apnea and bradycardia in 57%, for pneumogram abnormalities in 27%, and for other reasons in 16% of the sample. The infants had a mean gest. age of 32.4 ± 4.1 weeks (± 1 SD) .The mothers were asked if they “always”, “sometimes”, or “never” used the monitor in three situations: (1) at night, (2) during naps, (3) when the infant was out of sight. Ninety-five percent of the mothers reported “always” using the monitor at least at night. Among this group, 34% “always” use the monitor at night only, 25% “always” use it at night plus one other situation and 36% “always” use it in all three situations. Five percent reported that they do not consistently use the monitor in any situation. Chi-square analyses show no significant relationships between use of the monitor and the infants gest. age, sex, length of hospital stay, maternal age, marital status, number of siblings, farm or city residence, reason for monitoring or socioeconomic status. Compliance with a monitor prescription is difficult to establish due to probable variation in counseling given to parents by physicians, nurses and monitor companies. However, it is clear that many parents do not maintain consistent use of home monitors at times when apnea is possible.

601 STATE REPORTING OF LIVE NEWBORNS WEIGHING LESS THAN 500 GRAMS AT BIRTH

In 1981 there was large variation in state reported incidence of live births of newborns weighing less than 500 grams at birth (.3 to 2.4 per 1,000 live births). The states with the lowest neonatal mortality rate (NMR) have the lowest incidence of birth weights less than 500 grams (rho=.70). Assuming that mortality for this weight category is 100%, there is marked variation (5 to 24%) in the contribution of this weight cohort to a states total NMR. Major deficiencies in reporting may exist. For example, Alaska, Arizona and North Dakota report no Native American live births with weights less than 500 grams. Reporting may also depend on the definition of live birth. The American Academy of Pediatrics and American College of Obstetricians and Gynecologists Guidelines for Perinatal Care uses the World Health Organization (WHO) definition of live birth as a baby with signs of life “irrespective of duration of pregnancy”. Standard obstetric and pediatric textbooks offer guidance on this issue varying from adherence to the WHO definition to describing a live birth as greater than 500 grams. Thirty-six states officially use the WHO definition of live birth and nine states have definitions without gestational criteria. Four states have no definition of live birth including Vermont which has the nations lowest NMR. There is evidence to suggest inconsistency in reporting the births of previable newborns which potentially affects national neonatal mortality statistics.