Peter N McDougall

Surfactant abnormalities in infants with severe viral bronchiolitis.

To determine whether abnormalities of pulmonary surfactant occur in infants with acute viral bronchiolitis, surfactant indices were measured in lung lavage fluid from 12 infants with severe bronchiolitis and eight infants without lung disease. Compared with controls, the bronchiolitis group showed deficiency of surfactant protein A (1.02 v 14.4 micrograms/ml) and disaturated phosphatidylcholine (35 v 1060 micrograms/ml) which resolved as the disease improved. Surfactant functional activity was also impaired (minimum surface tension 22 v 17 mN/m). These findings indicate that surfactant abnormalities occur in bronchiolitis, and may represent one of the pathophysiological mechanisms causing airway obstruction.

Epidemiology of late onset haemorrhagic disease: A pooled data analysis

Classical haemorrhagic disease (HD) of the newborn has been recognized since the end of the last century.’ While bleeding in this condition can be severe and require transfusion, deaths and intracranial haemorrhage (ICH) are rare. In Sutherland’s clinical trial of the efficacy of Vitamin K3 in the prevention of classical HD, there were no deaths in 207 infants who bled, and ICH occurred in only 0.5% of all who bled, and 4% of those with moderate and severe bleeding.2 Moderate and severe bleeding was much more common in breast-fed infants, with 25 cases compared to one case in formula-fed infants. This study was confined to the first 5 days of life. In the mid-1960s occasional cases of unexplained severe bleeding were reported in much older infants, with laboratory evidence of Vitamin K deficiency. The earliest reports of what is now called late onset HD appeared in the late 1 9 6 0 ~ . ~ ~ Hoh’s report of 23 cases over a 5 year period in Singapore contains a detailed epidemiological analysis of risk factors3 The age range was 3-9 weeks, with a peak incidence at 4-6 weeks. All infants were exclusively breast fed, and had a normal neonatal course. There was a high mortality (56%), and most cases had intracranial haemorrhage. These very early observations have been confirmed in more recent reports.6~~ It is interesting to note that this highly relevant early study is not mentioned in major reviews of HD.7-9 In 1983, McNinch et a/. reported an increasing number of cases of late onset HD in the United Kingdom, following a change in the practice of Vitamin K prophylaxis, which occurred in the early 1980s.’O In the years before this report, a substantial number of infants in the United Kingdom did not receive prophylaxis, some received a single oral dose, 1.0 mg, whilst others received Vitamin K,, 1 .O mg, by injection. Controversy regarding the best method of prophylaxis has continued through the past d e ~ a d e . ~ The recent report of an association between the intramuscular, but not oral, usage of vitamin K,, and an increased risk of subsequent childhood cancer, has caused many clinicians to re-evaluate this issue.” For these reasons the present analysis of the epidemiology of late onset HD was undertaken. This study reports an analysis of the epidemiological factors associated with late onset HD, based upon all available report& cases up to the end of 1992.

Use of 2-Channel Bedside Electroencephalogram Monitoring in Term-Born Encephalopathic Infants Related to Cerebral Injury Defined by Magnetic Resonance Imaging

OBJECTIVE. Single-channel amplitude-integrated electroencephalography has been shown to be predictive of neurodevelopmental outcome in term infants with hypoxic-ischemic encephalopathy. We describe the relationship of quantifiable electroencephalogram (EEG) measures, obtained using a 2-channel digital bedside EEG monitor from term newborn infants with encephalopathy and/or seizures, to cerebral injury defined qualitatively by MRI. METHODS. Median values of minimum, mean, and maximum EEG amplitude were obtained from term-born encephalopathic infants during a 2-hour seizure-free period obtained within 72 hours of admission. Infants underwent MRI with images qualitatively scored for abnormalities of cortex, white matter, deep nuclear gray matter, and posterior limb of the internal capsule. Eighty-six infants had EEG measures related to qualitative MRI outcomes. RESULTS. The most common diagnosis was hypoxic ischemic encephalopathy (n = 40). For all infants there was a negative relationship between EEG amplitude measures and MRI abnormality scores assessed on a scale from 4 to 15, with a higher score indicating more abnormalities. This relationship was strongest for the minimum amplitude measures in both hemispheres; that is, for every unit increase in score there was a mean drop of 0.41 μv for the left cerebral hemisphere, with 35% of variance explained. This relationship persisted on sub-group analyses for infants with hypoxic-ischemic encephalopathy, infants with other diagnoses and infants monitored after the first 24 hours of life. Using an MRI abnormality score cutoff of 8 or worse for cerebral injury in infants with hypoxic-ischemic encephalopathy, a minimum amplitude of 4 μV showed a higher specificity (80%: left hemisphere), whereas a minimum amplitude of 6 μV showed a higher sensitivity (92%: left hemisphere). CONCLUSIONS. Bedside EEG measures in term-born encephalopathic infants are related to the severity of cerebral injury as defined by qualitative MRI. A minimum amplitude of <4 μV appears useful in predicting outcome.

Changing Outcome for Infants of Birth‐weight 500‐999g Born Outside Level 3 Centres in Victoria

Summary: The aim of this study of extremely low birth‐weight (ELBW, birth‐weight 500–999 g) infants born in Victoria was to determine the changes between 3 distinct eras; 1979‐80, 1985‐87, and 1991‐92, in the proportions who were born outside level 3 perinatal centres (outbom), the proportions of outborn infants who were transferred after birth to a level 3 neonatal unit, the survival rate for outborn infants, and sensorineural impairment and disability rates in outborn survivors. The proportion of ELBW livebirths who were outborn fell significantly over successive eras, from 30.2% (106 of 351) in 1979‐80, to 23.0% (129 of 560) in 1985‐87, and to 15.6% (67 of 429) in 1991‐92. Between 1979‐80 and 1985‐87, die proportions who were outborn fell predominantly in those of birth‐weight from 800–999 g, whereas between 1985‐87 and 1991‐92 the proportions who were outborn fell predominandy in those of birth‐weight 500–799 g. The proportions of outborn infants who were transferred after birth to a level 3 neonatal unit were similar in die 3 eras, at 49.1%, 38.0% and 41.2%, respectively. The survival rates for outborn infants were lower in each era dian for infants born in a level 3 perinatal centre. Only 1 outborn infant not transferred after birth to a level‐3 unit survived in any era. The survival rates for infants transferred after birth were similar in the first 2 eras, but rose significantly in 1991‐92 (34.6%, 36.7% and 60.7%, respectively). The rates of sensorineural impairments and disabilities in survivors fell significantly between die first 2 eras, and remained low in the last era. It is pleasing that the proportion of tiny babies who were outborn fell significantly over time, reflecting increased referral of high‐risk mothers to level 3 perinatal centres before birth. For ELBW outborn infants, survival prospects free of substantial disability are reasonable, but not as good as for those born in level 3 perinatal centres.

The cost of improving the outcome for infants of birthweight 500-999 g in Victoria: THE VICTORIAN INFANT COLLABORATIVE STUDY GROUP

The aim of this study was to conduct an economic evaluation of neonatal intensive care for extremely low birthweight (ELBW) infants born in the state of Victoria. Two distinct eras (1979–80 and 1985–87) were compared. Follow‐up data at 2 years of age were available for all 89 survivors from the 351 live births in 1979–80, and for 211 of 212 survivors from the 560 live births in 1985–87. The overall cost‐effectiveness for ELBW infants during 1985–87 compared with 1979–80 was

Therapeutic lung lavage in meconium aspiration syndrome: A preliminary report

104 990 (

Neonatal diabetes mellitus: Insulin pump as an alternative management strategy

A 1987) per additional survivor, or

Does intramuscular vitamin K1 act as an unintended depot preparation

5390 (

Predictors of survival for infants with congenital diaphragmatic hernia

A 1987) per additional life year gained. Cost‐effectiveness improved with increasing birthweight. If the quality of life of the survivors was considered, the economic outlook was more favourable. The cost per quality‐adjusted life year gained was

Combination pharmacotherapy for severe neonatal pulmonary hypertension

5090 (