Natalie Malachowski

Sequelae of maternally derived cytomegalovirus infections in premature infants

Eighteen of 106 (17%) infants of seropositive mothers, with birth weights less than 1500 gm, acquired cytomegalovirus from a maternal source. Neutropenia, lymphocytosis, thrombocytopenia, and hepatosplenomegaly developed in some infants concomitant with the onset of CMV excretion. Infected infants who excreted CMV at less than 7 weeks of age had longer oxygen requirements than infants who did not excrete CMV until they were older. Passively derived maternal antibody to CMV fell more rapidly over the first few months of life in sick premature infants than would be expected in term infants. Among six infected premature infants, five had undetectable antibody titers when CMV excretion began. Loss of passively acquired antibody and early excretion of virus appear to be associated with symptomatic CMV infections in premature infants of seropositive mothers.

Refractory hypoxemia associated with neonatal pulmonary disease: The use and limitations of tolazoline

Thirty-nine critically ill infants with pulmonary disease received tolazoline because of severe hypoxemia refractory to administration of 100% O2 and mechanical ventilation. Twenty-seven (69%) of the infants responded with an increase in PaO2 greater than or equal to 20 torr in the first umbilical arterial gas after completion of the initial ten-minute infusion (1 to 2 mg/kg) of the drug. A response was not correlated with survival. The overall survival was 46%, essentially unchanged from our previous report (44%). Infants with hyaline membrane disease had the poorest survival rate (33%). Complications associated with the use of tolazoline occurred in 82% of the infants. A hypotensive reaction, defined as a 25% decrease in mean arterial pressure from the pre-tolazoline level, occurred in 67% of the infants, and more commonly in the infants with RDS (87%). In 11 infants who did not respond to the initial dose of tolazoline, the dose was increased up to 10 mg/kg/hour; only one infant responded, and eight (73%) had a hypotensive reaction.

Prognosis of children surviving with the aid of mechanical ventilation in the newborn period.

Fifty-five infants who survived respiratory failure in the neonatal period with the aid of assisted ventilation were studied in order to evaluate their long-term prognosis. Over 80 per cent of these infants had normal intelligence and either minimal or no neurologic abnormalities. Only four infants had I.Q. scores of less than 85. The incidence of neurologic and intellectual handicaps was highest in low-birth-weight infants (

Sequelae of acquired cytomegalovirus infection in premature and sick term infants

To assess the risk of long-term sequelae after acquired cytomegalovirus (CMV) infection in premature and sick term infants, 55 CMV infected patients were matched prospectively with 55 control patients and these matched pairs were evaluated at 3 years of age. Sensorineural hearing losses were present in four of 43 CMV infected patients (all mild-moderate) and in two of 43 controls (one severe). The incidence of neurologic sequelae was not increased in CMV infected patients with birth weight greater than 2000 gm. Among patients with birth weight less than 2001 gm, moderately abnormal EEGs were found in four (17%) of 23 CMV infected patients and in one (4%) of 23 controls, and severe handicaps occurred in four (14%) of 29 CMV infected patients and in two (7%) of 29 controls. Severe handicaps in premature infants were significantly (P less than 0.05) associated with early onset of CMV excretion (less than 8 weeks of age) and severe cardiopulmonary disease. Among the premature infants who were documented early excretors, three of 13 had severe neuromuscular impairment, four of 13 had severe handicaps (DQ less than 70, severe neuromuscular impairment, or profound loss of vision or hearing), and an additional four had DQs of 70 to 79. Among their matched control subjects, none of 13 had severe neuromuscular impairment, two of 13 had severe handicaps, and an additional two had DQs between 70 and 79. None of the premature infants who were documented late excretors (greater than or equal to 8 weeks of age) had any neurologic sequelae. The risk of neurologic sequelae and handicap may be increased in premature infants with onset of CMV excretion in the first 2 months of life.

Use of sodium nitroprusside in neonates: efficacy and safety.

Sodium nitroprusside was administered to 58 neonates, including 11 with severe respiratory distress syndrome, 15 with persistent pulmonary hypertension of the newborn, 28 with clinical shock, three with systemic hypertension, and two with pulmonary hypoplasia, all refractory to conventional intensive therapy. Nitroprusside was infused at 0.2 to 6.0 micrograms/kg/min for periods of 10 minutes to 126 hours. Infants with severe respiratory distress syndrome had increased PaO2 and decreased PaCO2 or peak inspiratory pressure, and nearly all (82%) survived. Infants with persistent pulmonary hypertension of the newborn had variable responses; improvement did not correlate with survival, but survival (47%) was identical to that in an earlier series of infants given tolazoline. Infants in shock had improved perfusion, urine output, and serum bicarbonate levels, and these responses were significantly related to survival. Hypertension was controlled in all three hypertensive infants. Adverse effects were very uncommon. Toxic effects were not observed. Sodium nitroprusside is effective and can be used safely in circulatory disorders in the neonate.

Longitudinal growth and late morbidity of survivors of gastroschisis and omphalocele.

Of 22 survivors of gastroschisis and omphalocele, most had poor weight gain. Although one-third of gastroschisis babies were small-for-gestational age at birth, no other predisposing factors for poor growth could be demonstrated. No child had intrinsic gastrointestinal or metabolic sequelae at 3 years of age, as demonstrated by radiographic studies, fecal fat excretion, or serum chemistry screen. One-third of those tested had IQs less than 90; five had abnormal electroencephalograms; one had impaired hearing. Intellectual impairment was related to length of hospitalization due to a variety of nongastrointestinal factors. Neither growth nor intellectual development was related to the type of lesion present, even when IQ is corrected for prematurity. Impairment of growth and intellectual outcome may be related to prematurity, small-for-gestation birth weight, and nongastrointestinal neonatal complications.

Four factors that accurately predict hearing loss in «high risk» neonates

Two simple overall measures of health—length of stay in the Intensive Care Nursery (ICN) and gestational age-predict hearing loss in ICN graduates. Craniofacial anomalies, congenital perinatal infections, and meconium aspiration are strong predictors of hearing loss, especially in term infants. Findings are based on univariate and multivariate analyses of a number of variables that might be associated with permanent hearing loss. Study variables included all seven High Risk Register items and a number of other features of the ICN history. They were examined in 799 ICN graduates whose hearing had been monitored in their first few years of life. These babies composed 40% of the ICN population and were selected because they had one or more “high risk” factors in their neonatal history. Prevalence of hearing loss in this high risk sample was similar to that found in other ICN samples. Prevalence of hearing loss associated with individual Risk Register items was similar to other published findings for some items and not for others.

Prevalence of sensorineural hearing loss in premature and sick term infants with perinatally acquired cytomegalovirus infection

Audiologic follow-up was obtained on 40 premature or sick term infants with perinatally acquired cytomegalovirus (CMV) infection and on 40 prospectively matched control subjects. Final evaluation was postponed until 3 years of age to assess any long-term hearing sequelae of perinatal CMV infection in this population, and to obtain reasonably complete audiometric results. One experimental subject had a bilateral sensorineural hearing loss above 4000 Hz. Four control subjects had sensorineural hearing losses, three requiring binaural hearing aids. The prevalence of confirmed hearing loss requiring amplification (3.75%) in this study group was consistent with that observed in all graduates of the Intensive Care Nursery who were considered at risk for hearing loss in the same time period (4.2%). These data suggest that perinatally acquired CMV infection is not associated with significant sensorineural hearing loss in premature or full term infants through age 3.

Evaluation of a walking-donor blood transfusion program in an intensive care nursery

A prospective study was carried out to identify the immediate and long-range advantages and disadvantages of a walking-donor transfusion program for an intensive care newborn nursery. The effect of heparin on coagulation of blood was evaluated and found to be minimal. There was no evidence of transmission of HBSAg. The prevalence of CMV infection at the time of follow-up was higher in infants who had received blood from donors seropositive for CMV than in infants who had been transfused from seronegative donors. In our experience, a walking-donor program has been a safe and effective method for the provision of small transfusions of blood to sick neonates.

Infant hearing screening: program implementation and validation.

Congenital and early-onset hearing losses were discovered in 6.1% of 975 Intensive Care Nursery (ICN) graduates. The methods used were neonatal screening by Crib-0-Gram (COG) and high risk register, in combination with repeated behavioral hearing tests at 1 to 3 years. This 7-year longitudinal study had follow-up hearing evaluations for a remarkably high 84% of all subjects. Significant losses that interfered with speech and language development (1000 to 8000 Hz average loss >45 dB HL bilaterally) were found in 4.3% of infants. COG in combination with subsequent behavioral hearing screening was a sensitive strategy for detecting significant hearing loss: only one child was missed with this combination. Alone, COG sensitivity to significant hearing losses was 79.3%, but would have been higher had a stricter passing criterion been adopted. Behavioral hearing screenings detected bilateral hearing losses of even mild (>20 dB HL) degree. Sensitivity to significant hearing losses was 82.6% and would have been improved if test frequencies >3000 Hz were included in the screen. Even if screening failure occurred at 1 year of age, the age of actual confirmation of hearing loss depended on severity of the loss and ear involvement. Significant hearing losses were confirmed earlier than less severe or unilateral losses. Although behavioral screenings could be done during the first year of life, continued follow-up was required to detect progressive hearing losses.