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BACKGROUND AND OBJECTIVES: Clinicians are urged to optimize communication with families, generally without empirical practical recommendations. The objective of this study was to identify core behaviors associated with good communication during and after an unsuccessful resuscitation, including parental perspectives. METHODS: Clinicians from different backgrounds participated in a standardized, videotaped, simulated neonatal resuscitation in the presence of parent actors. The infant remained pulseless; participants communicated with the parent actors before, during, and after discontinuing resuscitation. Twenty-one evaluators with varying expertise (including 6 bereaved parents) viewed the videos. They were asked to score clinician-parent communication and identify the top communicators. In open-ended questions, they were asked to describe 3 aspects that were well done and 3 that were not. Answers to open-ended questions were coded for easily reproducible behaviors. All the videos were then independently reviewed to evaluate whether these behaviors were present. RESULTS: Thirty-one participants’ videos were examined by 21 evaluators (651 evaluations). Parents and actors agreed with clinicians 81% of the time about what constituted optimal communication. Good communicators were more likely to introduce themselves, use the infant's name, acknowledge parental presence, prepare the parents (for the resuscitation, then death), stop resuscitation without asking parents, clearly mention death, provide or enable proximity (clinician-parent, infant-parent, clinician-infant, mother-father), sit down, decrease guilt, permit silence, and have knowledge about procedures after death. Consistently, clinicians who displayed such behaviors had evaluations >9 out of 10 and were all ranked top 10 communicators. CONCLUSIONS: During a neonatal end-of-life scenario, many simple behaviors, identified by parents and providers, can optimize clinician-parent communication.

BACKGROUND: Overuse of antibiotics can facilitate antibiotic resistance and is associated with adverse neonatal outcomes. We studied the association between duration of antibiotic therapy and short-term outcomes of very low birth weight (VLBW) ( METHODS: We included VLBW infants admitted to NICUs in the Canadian Neonatal Network between 2010–2016 who were exposed to antibiotics but did not have culture-proven sepsis in the first week. Antibiotic exposure was calculated as the number of days an infant received antibiotics in the first week of life. Composite primary outcome was defined as mortality or any major morbidity (severe neurologic injury, retinopathy of prematurity, necrotizing enterocolitis, chronic lung disease, or hospital-acquired infection). RESULTS: Of the 14 207 included infants, 21% (n = 2950), 38% (n = 5401), and 41% (n = 5856) received 0, 1 to 3, and 4 to 7 days of antibiotics, respectively. Antibiotic exposure for 4 to 7 days was associated with higher odds of the composite outcome (adjusted odds ratio 1.24; 95% confidence interval [CI] 1.09–1.41). Each additional day of antibiotic use was associated with 4.7% (95% CI 2.6%–6.8%) increased odds of composite outcome and 7.3% (95% CI 3.3%–11.4%) increased odds in VLBW infants at low risk of early-onset sepsis (born via cesarean delivery, without labor and without chorioamnionitis). CONCLUSIONS: Prolonged empirical antibiotic exposure within the first week after birth in VLBW infants is associated with increased odds of the composite outcome. This practice is a potential target for antimicrobial stewardship.

Published reports of extremely preterm birth outcomes provide important information to families, clinicians, and others and are widely used to make clinical and policy decisions. Misreporting or misunderstanding of outcome reports may have significant consequences. This article presents 7 recommendations to improve reporting of extremely preterm birth outcomes in both the primary and secondary literature. The recommendations should facilitate clarity in communication about extremely preterm birth outcomes and increase the value of existing and future work in this area.

OBJECTIVES: Cobedding of preterm twin infants provides tactile, olfactory, and auditory stimulation and may affect pain reactivity. We carried out a randomized trial to assess the effect of cobedding on pain reactivity and recovery in preterm twin neonates. METHODS: Stable preterm twins (n = 67 sets) between 28 and 36 weeks of gestational age were randomly assigned to a cobedding group (cared for in the same incubator or crib) or a standard care group (cared for in separate incubators or cribs). Pain response (determined by the Premature Infant Pain Profile [PIPP]) and time to return to physiologic baseline parameters were compared between groups with adjustment for the nonindependence of twin infants. RESULTS: Maternal and infant characteristics were not significantly different between twin infants in the cobedding and standard care groups except for 5-minute Apgar CONCLUSIONS: Cobedding enhanced the physiologic recovery of preterm twins undergoing heel lance, but did not lead to lower pain scores.

BACKGROUND: The acceptability of simulated death has been debated by experts, but there is scarce information regarding trainees' perspective. METHODS: Trainees in a large pediatric program were invited to perform mock codes, including pre and post questionnaires. Participants were exposed to 2 mock codes of neonates born pulseless. In the RESUSC scenario, the manikin responded to adequate resuscitation; in the DEATH scenario, the manikin remained pulseless. Mock codes were videotaped and evaluated by using the Neonatal Resuscitation Program score sheet. Debriefing was analyzed by using qualitative methodology. RESULTS: Fifty-nine of 62 trainees answered the questionnaire, and 42 performed a total of 84 mock codes. All trainees found mock codes beneficial and would appreciate being exposed to more. Most found them realistic and 78% agreed with the following statement: “During mock codes the manikin improves when adequate resuscitation steps are provided.” The scenario or order of scenario did not affect performance (RESUSC versus DEATH). Only 1 trainee stopped resuscitation after 10 minutes of asystole; 31% had not ceased resuscitation efforts by 20 minutes. During debriefing and post questionnaire, trainees found the DEATH scenario more stressful than RESUSC. Trainees all answered the following question during debriefing: “How did this go for you?” Two themes were identified in their answers: (1) the manikin does not die; and (2) death equals inadequate resuscitation. CONCLUSIONS: The death of the manikin was stressful, but trainees thought this was acceptable and prepared them for their future. Trainees did not state that “death disclosures” were necessary before a simulated death.

The practice of mouth-to-mouth resuscitation was the first natural experiment using hypoxic gas mixtures for resuscitation. Although supplemental oxygen is now the standard during neonatal resuscitation, this practice has never been validated in prospective controlled trials. Neonatal resuscitation is primarily directed toward establishing early lung aeration and maintaining lung volume during expiration to overcome the initial vagal and hypoxic bradycardia. It remains unclear whether supplemental oxygen facilitates this process or contributes to potential hypoxia/reoxygenation injury, inhibition of breathing, and possible aggravation of atelectasis by the attenuation of nitrogen splinting. Accumulating evidence over the last decade has challenged clinicians to reconsider the optimal oxygen concentration for resuscitation of the newborn term infant. A critical review of 6 randomized trials that compared the use of room air (RA) and 100% oxygen reported that RA was associated with a significant lowering of mortality rate from 13% to 8% ( P = .0021), with a typical odds ratio (OR) of 0.57 (95% confidence interval [CI]: 0.42–0.78); however, no difference was observed for infants with a 1-minute Apgar score of 1000gm) revealed a greater reduction in mortality rate in the RA group, from 35% in the 100% O2 group to 21% in the RA group (typical OR: 0.51 [95% CI: … Address correspondence to Neil Finer, MD, UCSD Medical Center, 402 W Dickinson St, MPF Building, Suite 1-140, San Diego, CA 92103-8774. E-mail: nfiner{at}ucsd.edu

BACKGROUND:The measurement of head circumference (HC) at birth reflects intrauterine brain development. HC charts currently used in Canada are either dated, mixed-gender, nonrepresentative of lower gestational ages (GAs), or reflective of other populations.METHODS:To create both birth weight and HC curves, we combined weight and HC data from the Canadian Neonatal Network (CNN) database (admissions in NICUs across Canada) with McGill’s Obstetrical Neonatal Database (MOND; all births at a tertiary hospital in Montreal, Canada). We included CNN data for GAs of 23 to 34 weeks (2003–2007) and MOND data for GAs of 35 to 41 weeks (1995–2006). Nonsingletons, congenital anomalies, and measurements greater than ±4 SD from the mean were excluded. Distributions of birth weight and HC at each GA were statistically (penalized spline regression) smoothed. Birth weight curves were compared with recent Canadian reference curves and HC curves with historical and/or frequently used curves.RESULTS:We included 39 896 births (3121 births at 90th percentiles were misclassified.CONCLUSIONS:We developed recent gender-specific reference curves for HC at birth for singletons at 23 to 41 completed weeks’ GA, which included a large number of very premature infants, reflecting the current geotemporal Canadian population.

OBJECTIVE: To determine whether parental characteristics affect estimates of best interests and intervention decisions for preterm infants. DESIGN AND METHODS: The study consisted of an anonymous questionnaire given to nurses, physicians, and students. The study included scenarios of 3 sets of parents, including a 16-year-old teenager, a couple who were lawyers, and a couple with a history of in vitro fertilization, about to deliver at 2257 weeks, 24 weeks, or 2757 weeks. Respondents were asked whether active intervention is in the infant's best interests and whether they would comply with family decisions. RESULTS: A total of 1105 questionnaires were sent out, with 829 respondents in Canada and the United States. At 2257 weeks' gestation, 21% of the respondents thought that resuscitation was in the infant's best interest; among respondents who did not agree, 59% would intervene if the parents wished. At 2757 weeks' gestation, 95% of respondents thought that resuscitation was in the infant's best interest, yet 34% would accept comfort care. Estimates of best interest, and willingness to comply, varied significantly by parental characteristics. At 2257 weeks' gestation, 17% of respondents believed that resuscitation was in the best interest of the teenaged mother's infant compared with 26% of respondents who believed that resuscitation was in the best interest for the infants of the others; this difference persisted at 24 weeks. At 2257 and at 24 weeks' gestation, compliance with active care despite believing that it not in the infant's best interest was significantly more frequent for the in vitro fertilization couple and the lawyers than for the teenaged mother. At 27 weeks' gestation, more than 93% of respondents complied for all parents. CONCLUSIONS: Caregivers frequently are ready to intervene actively, or not, despite believing that it is against the infant's best interest. Willingness to do so varies according to parental characteristics.

Periodic breathing (PB) is a pattern of breathing that is frequently recognized in infants being studied for possible sleep apnea. Infants presenting to a sleep laboratory over a 3½-year period who had evidence on their initial study of prolonged (>15% of total sleep time) PB were prospectively studied in an effort to determine the significance of this pattern of breathing. Of the 331 infants studied, 40 demonstrated prolonged PB. Sixteen of these infants, who were of 37 weeks's gestation or greater at birth and did not receive pharmacologic therapy, were studied on at least two occasions (group 1). Of the remaining 24 infants, 11 were treated with methylxanthines by their attending physician (group 2), and 13 did not return for sequential studies (group 3). All infants who were of less than 37 weeks' gestation at birth were separately evaluated (group 4). For group 1, who were studied at a mean age of 5 postnatal weeks, there was a mean of 36.4% periodicity which decreased on the second study to 18.0%. By the fourth study, this had decreased to 9.2%. In group 2, there was a mean of 41.3% periodicity during the first study which decreased to 6.4% on the second study. Infants of group 3 had a mean of 31.4% PB on their initial study and the premature infants, group 4, had 30.1% PB. All infants showed a decrease in PB with sequential studies and no infant was known to have died of sudden infant death syndrome or any other disorder in the first year of life. For the majority of infants, the abnormal duration of PB was the only abnormality noted on the sleep recording. The results suggest that excess PB as an isolated abnormality on a sleep recording is not an indicator of subsequent risk. Additional longitudinal evaluations of this respiratory pattern are needed.

OBJECTIVE. Legal and ethical standards require resuscitation when it is considered to be in the patient's best interest. We hypothesized that newborn infants might be dealt with according to different standards, compared with older patients.METHODS. An anonymous questionnaire describing 8 currently incompetent patients with potential neurologic sequelae who required resuscitation was administered to groups of physicians and students. Survival and morbidity rates were explicitly described; a very preterm infant, a full term infant and a 2-month-old infant had identical outcomes. Two patients, a 7-month-old infant and an 80-year-old patient, were previously significantly impaired. Respondents were asked whether resuscitation was in the patient's best interest and whether they would comply with the families' wishes if resuscitation was refused.RESULTS. There was an 85% response rate (n = 524). The largest proportions of respondents stated that it was in the best interests of the 2-month-old infant and the 7-year-old child to be resuscitated (97% and 94%, respectively), followed by the 50-year-old patient and the term infant (87%), the 2 patients with 5% chance of survival (76% and 80%), the premature infant (69%), and finally the 80-year-old patient (32%). Approximately one fifth of the respondents who thought that it was in a patient's best interests to be resuscitated would nevertheless accept the family's refusal of resuscitation for all scenarios except the 80-year-old patient (72% acceptance) and the preterm infant (54% acceptance).CONCLUSIONS. Whether resuscitation is considered in a patient's best interests is not closely related to survival rates or disability. Newborn infants and particularly preterm infants are systematically devalued, in comparison with older patients whose outcomes are the same or worse. Accepting a family's refusal of resuscitation, even among respondents who thought that resuscitation was in the patient's best interest, was much more common for the newborns.

OBJECTIVE. Our goal was to determine whether, for preterm newborn infants with respiratory disease, inhaled nitric oxide reduced the rates of death, bronchopulmonary dysplasia, intracranial hemorrhage, or neurodevelopmental disability. METHODS. We searched Medline, Embase, Healthstar, and the Cochrane Central Register of Controlled Trials using the search terms “nitric oxide,” “clinical trial,” and “newborn” and covering 1985–2006. We also searched abstracts of the Pediatric Academic Societies. RESULTS. Eleven randomized, controlled trials of inhaled nitric oxide therapy for preterm infants were found. The trials were grouped into 3 categories according to the entry criteria, that is, entry in the first 3 days of life on the basis of oxygenation criteria (early rescue), enrollment after 3 days on the basis of elevated risk of bronchopulmonary dysplasia, and routine use for intubated preterm infants. Early rescue treatment based on oxygenation criteria did not seem to affect mortality or bronchopulmonary dysplasia rates. Routine use for intubated preterm infants showed a barely significant reduction in the incidence of the combined outcome of death or bronchopulmonary dysplasia (relative risk [RR]: 0.91 [95% confidence limits (CLs): 0.84, 0.99]). Later treatment based on the risk of bronchopulmonary dysplasia showed no significant effect on this outcome. Early rescue treatment showed a trend toward increased incidence of severe intracranial hemorrhage, whereas routine use for intubated preterm infants seemed to show a reduction in the incidence of either severe intracranial hemorrhage or periventricular leukomalacia (RR: 0.70 [95% CLs: 0.53, 0.91]). CONCLUSIONS. Inhaled nitric oxide as rescue therapy for very ill preterm infants undergoing ventilation does not seem to be effective and may increase severe intracranial hemorrhage. Later use of inhaled nitric oxide to prevent bronchopulmonary dysplasia does not seem to be effective. Early routine use of inhaled nitric oxide for mildly sick, preterm infants seems to decrease the risk of serious brain injury and may improve rates of survival without bronchopulmonary dysplasia.

To the Editor .— Kaempf et al1 have presented a hospital-based guideline designed to reduce “variability by call schedule” in counseling and decision-making practices for resuscitation of extremely preterm infants. Although this indeed is an important goal, we were disappointed that the guidelines seem to fail in many ways to adequately reflect the ethical duty of the perinatal team to the infant about to be born. Indeed, the article seemed to focus more on diminishing variability between neonatologists than on advocating for a vulnerable patient. Although the fetus may have limited rights (or, in Canada at least, virtually no rights), once born the infant has a right to be treated as an individual to whom there is an obligation of care, and his or her best interests must be the guiding principle for intervention. The standard neonatal resuscitation text used in North America states: “The ethical principles regarding resuscitation of newborns should be no different from those followed in resuscitating an older child or adult.”2 This by no means signifies resuscitation at all costs but that we should treat infants with the same …

Objective. Carnitine is thought to be a conditionally essential biological cofactor for premature infants. A preliminary study suggested that carnitine could significantly reduce apnea of prematurity. The objective of this study was to evaluate critically the role of carnitine in idiopathic apnea of prematurity and to determine whether the use of carnitine would facilitate discontinuation of mechanical ventilatory support, shorten the duration of ventilatory support, and reduce the amount of time that such infants are exposed to both mechanical ventilation and oxygen. We also wanted to determine the effects of supplemental carnitine on weight gain, time to regain birth weight, time to achieve full enteral feedings, and length of hospital stay. Methods. A prospective, randomized, blinded trial was conducted on 44 preterm infants who were from the same neonatal intensive care unit and who were ≤32 weeks’ gestational age with a postnatal age Results. There were no significant differences between the 2 groups in the occurrence of apnea as detected by cardiorespiratorygram or nursing observation. There were no significant differences between the groups in regard to total days on ventilator, days of nasal continuous positive airway pressure, time to regain birth weight, time to reach enteral feedings of 120 mL/kg/d, discharge weight, adjusted age at discharge, need for oxygen at 28 days’ and 36 weeks’ adjusted age, or length of stay. The plasma carnitine level was a median of 15.5 μmol/L (range: 7.6–30.5) for the placebo infants compared with a median of 195.3 μmol/L (range: 71.7–343.6) for the carnitine infants. Conclusions. In this blinded, randomized, placebo-controlled study, we found that infants who received supplemental carnitine did not demonstrate any reduction in apnea of prematurity, ventilator or nasal continuous positive airway pressure days, or the need for supplemental oxygen therapy. Although carnitine may be of significant nutritional benefit for very low birth weight infants, our study does not support its use to reduce apnea of prematurity or decrease dependence on mechanical ventilation.

Since its first appearance, the Pediatric Advanced Life Support (PALS) course has recommended a minimum dose of atropine of 0.1 mg regardless of the body weight of the child. The most recent update of PALS, after the extensive International Liaison Committee on Resuscitation (ILCOR) process, designed to develop the evidence base of resuscitation recommendations, still contains this same recommendation.1 This recommendation is frequently quoted by pediatric residents fresh from their PALS courses; I have often been informed that a lower dose causes “paradoxical bradycardia.” Indeed, the computerized printouts for resuscitation drugs and doses from our hospital information system are based on the PALS guidelines and give the same recommended dose. Thus, if the computerized printout were to be followed, a 2-kg infant would receive 0.1 instead of 0.04 mg of atropine. If the indication persisted and a second dose were to be given, potentially lethal overdosage could occur. This minimum dose is widely repeated. The 12th edition of The Harriet Lane Handbook 2 states that the preanesthesia dose (30–60 minutes before operation) for a child is “0.01 mg/kg/dose SC/IV/IM, max. dose: 0.4 mg/dose; min. dose: 0.1 mg/dose; may repeat Q4–6 hr” and for “Cardiopulmonary resuscitation (see remarks): Child,” the recommended dose is “0.02 mg/kg/dose IV Q5 min × 2–3 doses PRN; min. dose: 0.1 mg”; the remarks to which the authors refer included: “Doses < 0.1 mg have … Address correspondence to Keith J. Barrington, MB, ChB, Division of Neonatology, Saint Justine University Hospital Center, 3175 Cote St Catherine, Montreal, Quebec, Canada H3T 1C5. E-mail: keith.barrington{at}umontreal.ca

Objective. There is little information on the response to very low doses of inhaled nitric oxide (iNO) in hypoxic near-term infants. The potential toxicities of iNO are dose related; thus, the ability to use lower doses safely and effectively may be advantageous. We hypothesized that there is no difference in the acute improvement in oxygenation between treatment with inhaled nitric oxide at 1 to 2 parts per million (ppm) or 10 to 20 ppm. Methods. We randomized near-term and term infants with hypoxic respiratory failure with oxygenation indices (OIs) of ≥10 and Pao2 Results. Thirty minutes after the study gas was initiated, Pao2 increased significantly overall in the low-dose (90.7 ± 41 torr to 166.8 ± 95.6 torr) and high-dose (76.2 ± 32.7 torr to 198.7 ± 142.8 torr) groups; the maximal increase was seen in the infants who initially were treated with 10 ppm. The OI also decreased significantly overall and also was significant in the high-dose group (21.0 ± 13.7 to 11.4 ± 10.4; low-dose: 18.3 ± 7.1 to 13.2 ± 12.3). There was a nonsignificant fall of Paco2 with iNO treatment (low dose 35 ± 7.3 to 30 ± 8.5 torr vs high dose 35.2 ± 9.9 to 32.4 ± 10.7 torr). A sustained response (ie, maintaining a Pao2 and OI gain greater than 20% for the duration of the study gas administration) was greater in the high-dose group (53.3% vs 30.0%). In addition, dose increases were required more often in the low-dose group than in the high-dose group (80.0% vs 57.1%). Among patients who did not respond to the initial iNO dose, 100.0% and 83.3% responded at higher doses of iNO for the low- and high-dose groups, respectively. There were no differences for death, need for extracorporeal membrane oxygenation, or other outcomes between the groups. Conclusions. We did not find any significant difference in response to low- versus high-dose iNO. An initial exposure to low-dose iNO does not compromise the response to higher doses if required and may result in less toxicity.

Steroids have been given in pharmacologic doses for the prevention or treatment of bronchopulmonary dysplasia since initial reports in the 1970s showed acute improvements in respiratory status.1 Since then there have been >40 randomized, controlled trials evaluating their use. It is now clear that this treatment leads to an acute increase in lung mechanics and gas exchange in the injured lung, leading to a reduction in requirements for assisted ventilation,2 but there is no published long-term pulmonary outcome data. Postnatal steroids in pharmacologic doses impair growth, including growth of the brain, leading to dramatic reductions in cortical gray matter volumes.3 Other short-term morbidities include hyperglycemia, hypertension, cardiac hypertrophy, gastrointestinal hemorrhage and perforation,4,,5 sepsis,2 and periventricular leukomalacia.4,,6 Despite the large numbers of randomized infants (>2300) only 8 studies (679 infants) reporting neurodevelopmental outcomes were found for a systematic review just published in BioMed Central Pediatrics 7 a new on-line journal, with rigorous and completely open peer review, which is linked to the PubMed …

Objective. To determine whether noninvasive, nasal synchronized intermittent mandatory ventilation (nSIMV) improves the likelihood that very low birth weight infants will be successfully extubated. Methods. Infants of 70; Fio2 >0.7; or severe recurrent apnea (>2 apneas requiring intermittent positive-pressure ventilation in 24 hours or >6 apneas >20 seconds per day). The study ended after 72 hours postextubation or when infants satisfied failure criteria. A sample size of 54 was determined by power analysis. Results. Mean birth weight (831 standard deviation [SD]: 193 g) and gestation (26.3 SD: 1.8 weeks) did not differ between groups. Mean age at extubation was 7.6 (SD: 9.7) days, range 1 to 40 days. The nSIMV group had a lower incidence of failed extubation 4/27 compared with the continuous positive airway pressure group, 12/27. This was attributable to both a decreased incidence of apnea and a decreased incidence of hypercarbia. There was no increase in the incidence of abdominal distension or feeding intolerance. Discussion. nSIMV is effective in preventing extubation failure in very low birth weight infants in the first 72 hours after extubation. Noninvasive ventilation may have other roles in the care of the very low birth weight infant.

Objective.None of the 20 previously reported infants weighing Study Design.We retrospectively reviewed the outcomes of all inborn infants with birth weights Results.Of the infants with birth weight Conclusions.Our results indicate that intact survival is possible for infants weighing

We thank Truog et al for their interest in our review article. It was not clear to us while reading the original publication1 that the main analysis of the primary outcome variable had used the multiple outputation technique. The authors' letter has confirmed that this indeed was the case. We continue to have concerns about the use of this technique, however; it cannot be replicated by readers or reviewers of an article and is understood by very few. If, rather than using this new approach, data from all of the enrolled …

Therapies for hypotension in very preterm infants are among the most common interventions given to these fragile patients. The proportion of very low birth weight infants who receive potent and potentially toxic interventions varies dramatically from one NICU to another.1 A prospective cohort study of extremely low gestational age newborns (the ELGAN study), results of which are published in this issue of Pediatrics ,2 shows even greater variation in interventions for hypotension than previously reported. The proportion of infants under 28 weeks' gestation who were treated ranged from 32% to 98%, and the proportion that received either hydrocortisone or vasopressor agents ranged from 8% to 86%. The investigators examined the reasons for these variations and were unable to show that hypotension was more frequent or severe in the high-intervention centers. Indeed, the only consistent factor associated with intervention was the NICU in which the infant … Address correspondence to Keith Barrington, MBChB, McGill University, Department of Pediatrics, Room C7.68, Royal Victoria Hospital, 687 Pine Ave W, Montreal, Quebec, Canada H3A 1A1. E-mail: keith.barrington{at}mcgill.ca

We appreciate the interest in our article. Our study was not designed to investigate the motivations behind the answers that were given, and it is likely that Dr Morrison is correct in some of her analyses. However, we think she overestimates the likely concerns of respondents about the potential burden of therapy. The student respondents, many of whom (in anthropology and in law) had no experience of the likely “burden” of neonatal intensive care, had exactly the same responses as experienced physicians. This result suggests to us that it is something …

Doron et al1 have provided us with important new insights regarding decisions for neonatal resuscitation in the extremely low birth weight (ELBW) infant. The authors frequently refer to parental wishes and it is important to realize that the reported views of the parents were the perceptions of the neonatologists. In the absence of independent parental input, we are uncertain regarding their comprehension of physician counseling, parental attitudes toward resuscitation, and the accuracy of the physicians' perception of parent(s) wishes. Although the authors felt that the administration of a parent questionnaire may have been “confusing or hurtful to families in emotional crisis,” they should be reminded that parents want greater involvement in medical and ethical decision-making and that their involvement in such a study would …

Eighteen infants with idiopathic apnea of prematurity refractory to therapeutic levels of aminophylline were treated with incremental doses of doxapram beginning at 0.5 mg/kg/h. Continuous recording of heart rate, thoracic impedance, and transcutaneous Po2 demonstrated that 47% of the infants satisfied objective response criteria at the lowest dose, 53% responded at 1.0 mg/kg/h, 65% at 1.5 mg/kg/h, 82% at 2.0 mg/kg/h, and 89% at the highest allowed dose of 2.5 mg/kg/h. The mean serum doxapram concentration at the response dose was 2.9 ± 1.3 µg/mL, and all infants who responded had levels greater than 1.5 µg/mL. BP was significantly elevated at doses higher than 1.5 mg/kg/h (P < .05). Minute ventilation significantly increased and Pco2 significantly decreased as the doxapram dosage was increased (P = .02). Terminal elimination half-life was 9.9 ± 2.9 hours. When doxapram is used for treatment of refractory neonatal apnea the starting dosage should be no more than 0.5 mg/kg/h.

A prospective study was performed to ascertain the incidence of, and risk factors for, the developmént of a contralateral pneumothorax in 32 neonates with respiratory distress, without evidence of pulmonary hypoplasia, who had an initial unilateral air leak requiring pleural drainage. The mean postnatal age of occurrence of the first pneumothorax was 31.04 hours (range 0.1 to 92 hours); a subsequent contralateral pneumothorax developed in 14 infants (44%) at a mean postnatal age of 61.5 hours (range 8 to 106 hours). Thirteen of the 14 infants with a subsequent contralateral pneumothorax had pulmonary interstitial emphysema visible on the chest radiograph taken immediately after drainage of the first pneumothorax, compared with eight of the 18 infants without a contralateral pneumothorax (P