Rochelle Burstein

INCIDENCE AND EVOLUTION OF SUBEPENDYMAL AND INTRAVENTRICULAR HEMORRHAGE: A STUDY OF INFANTS WITH BIRTH WEIGHTS LESS THAN 1,500 GM

We have performed brain scanning by computed tomography on 46 consecutive live-born infants whose birth weights were less than 1,500 gm; 20 of them had evidence of cerebral intraventricular hemorrhage. Nine of the 29 infants who survived had IVH. Four grades of IVH were identified. Grade I and II lesions resolved spontaneously, but there was prominence of the interhemispheric fissue on CT of the infants at six months of age. Hydrocephalus developed in infants with Grade III and IV lesions. Seven of the surviving infants with IVH did not have clinical evidence of hemorrhage. There were no significant differences between the infants with and without IVH in birth weight, gestational age, one- and five-minute Apgar scores, or the need for resuscitation at birth or for subsequent respiratory assistance.

Relationship of intravenous sodium bicarbonate infusions and cerebral intraventricular hemorrhage

The incidence of cerebral intraventricular hemorrhage was determined by computed tomography in 100 infants with birth weights less than or equal to 1,500 gm. A comparison of IVH with serum sodium concentrations and the amount of intravenous sodium bicarbonate administered did not reveal a significant relationship. Analysis of the method of infusion of sodium bicarbonate indicated that the rapid infusion of hyperosmolar (M to M/12) sodium bicarbonate is associated with a significantly increased incidence of IVH.

Posthemorrhagic hydrocephalus in low-birth-weight infants: Treatment by serial lumbar punctures

We have performed weekly computed tomographic brain scans on 28 surviving low-birth-weight infants with cerebral intraventricular hemorrhage and acute ventricular dilatation. Evolving hydrocephalus was observed in 15 infants. Twelve of the 15 infants were treated by removing large volumes of cerebrospinal fluid with serial lumbar punctures. Arrest in the progression of hydrocephalus was evident in 11 of the 12. Clinical hydrocephalus requiring surgical intervention occurred in one of the treated infants and in all three untreated infants. No complications of serial lumbar punctures were noted, whereas shunt-related morbidity was 100%. Our results suggest that serial lumbar punctures are effective in arresting the development of posthemorrhagic hydrocephalus.

Effect of patent ductus arteriosus on left ventricular output in premature infants

A 5 MHz range-gated portable pulsed Doppler velocity meter was used to measure mean ascending aortic blood flow velocity noninvasively. Studies were performed from a suprasternal approach in 18 preterm infants with patent ductus arteriosus. Measurements were made in each patient before and after medical or surgical closure of the PDA. The internal ascending aortic diameter was determined echocardiographically and aortic cross-sectional area calculated according to the equation AAo = pi d2/4. Ascending aortic blood flow was computed as QAo (ml/min) = VAo (cm/sec) x AAo (cm2) x 60 (sec/min). Prior to PDA closure, QAo averaged 343 ml/min/kg, well above predicted normal values. After PDA closure, QAo fell to 252 ml/min/kg, significantly lower than the preclosure level (P less than 0.001), but slightly higher than the mean cardiac output of healthy newborn infants. The mean QAo after surgical ligation of the PDA was closer to the predicted normal value than after treatment with indomethacin alone. This study reflects the effect of left-to-right ductus shunting on left ventricular output and emphasizes the demands placed on the neonatal left ventricle by PDA.

1144 NON-SURGICAL TREATMENT OF ACQUIRED HYDROCEPHALUS: EVALUATION OF SERIAL LUMBAR PUNCTURE

Serial lumbar puncture (LP) as a method of treating hydrocephalus was evaluated in ten infants of birthweights ≤ 1500 grams, who had a cerebral intraventricular hemorrhage(CVH) and ventricular dilatation identified by computed tomography (CT).Each of the infants had an initial CT scan within the first ten days of life. Follow-up CT scans were done at weekly intervals. If progressive ventricular dilatation was observed, daily LP was attempted. Ventricular size remained stable or decreased throughout the tapping period and remained so after the cessation of tapping in eight of the ten infants. Follow-up CT scans at six months of age on eight of the ten infants showed no increase in ventricular size and an increase in the thickness of the cerebral mantle. The two infants from whom cerebrospinal fluid could not be obtained had progressive ventricular dilatation and required the placement of a ventriculo-peritoneal shunt.This approach to early intervention of progressive ventricular dilatation secondary to CVH by means of serial LP may arrest the development of hydrocephalus and eliminate the need for a shunt.

Medical management of three asymptomatic infants with severe valvar Aortic stenosis

SummaryWe report on the clinical course and serial hemodynamic studies of three patients with severe valvar aortic stenosis diagnosed in the neonatal period. None of the children were symptomatic in the first year of life. In each case, a conservative initial management approach was adopted. Between the time of initial study (mean age, 1.8 months) and the follow-up at 12–27 months of age (mean, 14.3 months), mean left ventricular systolic pressure decreased from 151 to 125 mmHg, the mean peak systolic pressure gradient across the aortic valve decreased from 61 to 33 mmHg, and the mean calculated aortic valve area index increased from 0.24 to 0.60 cm2/m2. One patient was operated on for symptoms that appeared at 14 months of age. The patient followed longest is now 5 years old, is growing well, has a normal electrocardiogram and an echo-predicted left ventricular systolic pressure of 128 mmHg. This experience suggests that not all asymptomatic neonates with severe valvar aortic stenosis require surgical intervention early in life. In some, the aortic valve orifice may increase in size with somatic growth and obviate the need for surgery in infancy or early childhood.

CEREBRAL INTRAVENTRICULAR HEMORRHAGE (CVH) IN INFANTS 1500 GRAMS

A prospective study using Computed Tomography (CT) was initiated to determine the incidence of sub-ependymal (SEH) and intraventricular hemorrhage (IVH) in infants ≤ 1500 grams. All 38 infants ≤ 1500 grams who were admitted to the Newborn Intensive Care Unit during a five month period have been evaluated.The initial CT waa performed between the third and seventh postnatal day. If a CVH was noted, follow-up CT was done at one and three weeks after the initial CT. Nine of the 23 infants who survived had SEH and/or IVII present on the initial CT. Only one of these nine infants was suspected of having a CVU on clinical findings. Of these nine, five who had a small SEH and/or IVH with nornal ventricular size, had complete resolution of the hemorrhage at three weeks. The other four infants who demonstrated some degree of ventricular dilatation with the hemorrhage on the initial CT, required medical intervention to prevent the development of clinical hydrocephalus.This study documents, for the first time, the relatively high incidence of CVH in infants ≤ 1500 grams and indicates that there are at least two types of CVH: 1) CVH with no ventricular dilatation which resolves spontaneously and 2) CVH with ventricular dilatation which requires medical intervention to prevent the development of clinical hydrocephalus.

HEAD GROWTH IN INFANTS WITH CONGENITAL HEART DISEASE (CHD)

We studied patterns of head and somatic growth (height-ht, weight-wt and head circumference-OFC) in 30 infants with CHD. Infants referred in the first 3 mos of life for CHD requiring chronic medical or surgical therapy were enrolled if they had no recognizeable syndrome, intrauterine infection or chromosomal anomaly. Measurements of ht, wt, OFC and were made at 3, 6, 12, 15, and 24 mo of age. 8 initially were cyanotic, 3 have died, and 22 have undergone surgery at a mean age of 15 mos. As a group, the infants developed normally but grew poorly, with wt (20th percentile-%-at 18 months) affected more than OFC and ht (30th % at 18 months) .11 of the 30 showed no growth failure; 2 of those 11 were cyanotic, 1 has died and 6 are post-op. Of the 19 with growth failure, 10 were cyanotic, 2 have died and 16 are post-op. Therapy made no impact on growth patterns of 12 of the 19; but 7 of the growth failure group exhibited catch-up growth (wt> ht>OFC) following surgery at a mean age of 8 months. Mean OFC increased from the 10th to the 25th S> following surgery, even though OFC fell below the 5th % in 4 subjects. Catch-up head growth can accompany catch-up growth in ht and wt following successful surgery in some children with CHD; in others, normal or delayed growth patterns are unaffected by therapy.

THE UNNATURAL HISTORY OF AORTIC STENOSIS

We report on the clinical course and serial hemodynamic studies of three patients with severe valvar aortic stenosis diagnosed in the neonatal period. None of the subjects was symptomatic in the first year of life. In each case, a conservative initial management approach was adopted. Between the time of initial study (mean age 1.8 months) and the follow up at 12-27 months of age (mean 14.3 months), mean left ventricular systolic pressure fell from 151 to 135 mmHg, the mean peak systolic pressure gradient across the aortic valve fell from 54 to 42 mraHg, and the mean calculated aortic valve area index increased from 0.20 to 0.39 cm2/meter2. One of the patients was operated on for symptoms which appeared at 14 months of age. The patient followed longest is now 5 years old, is growing well, has a normal electrocardiogram and an echo-predicted left ventricular systolic pressure of 128 mmHg. This experience suggests that not all asymptomatic neonates with severe valvar aortic stenosis require surgical intervention early in life. In some, the aortic valve orifice may increase in size with somatic growth and obviate the need for surgery in early childhood.

1246 EVALUATION OF BRONCHOPULMONARY DYSPLASIA BY CARDIAC CATHETERIZATION

Six infants, 10 mos.-2½yrs., were evaluated for bronchopulmonary dysplasia (BPD) by concurrent cardiac catheterization and echocardiography. Mean estimated gestational age=30wks; mean birth weight=1350gms. All infants required oxygen and diuretic therapy (mean FIO2 28%). Measurements in room air included oxygen consumption (VO2); oxygen capacity; oxygen saturations; pulmonary artery (PA) and wedge pressures; right ventricular dp/dt (RVdp/dt) and right sided systolic time intervals from a Millar catheter tracing; and derived pulmonary vascular resistance (PVR). Measurements were repeated in 40% and 88% oxygen. Ventricular function and systolic time intervals were measured concurrently by echocardiography. Pulmonary wedge angiograms were performed at the conclusion of study. Mean values in room air were mean PA pressure 32mmHg; RVdp/dt 515mmHg·sec−1; RPEP/RVET 0.271; VO2 132 m1 O2·M2−1 ·min−1; pulmonary flow index 3.4 L·min−1 ·M2−1; PVR 6.7 units; PO255 torr, PCO241 torr, pH 7.37. 2 of 6 children responded to O2 with a significant fall in PA pressure and PVR. The two children who responded had the highest mean PA pressures, PCO2s and PVRs of the group (means 46mmHg, 48 torr and 9.6 units). Echo measurements of RPEP/RVET correlated well with values from the Millar catheter, but neither measurement reflected PVR accurately. LV function studies and pulmonary wedge angiograms were normal. These studies suggest invasive studies may aid in management of children with BPD.