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The early use of surfactant therapy in newborns with meconium aspiration syndrome (MAS) seems to result in quicker improvements in lung function and shorter hospital stays as compared to placebo. Researchers compared the effects on lung function of 40 newborns with MAS treated with either surfactant therapy or placebo (controls) within 6 hours of birth. The 20 newborns treated with surfactant showed significant improvement after three treatments and none required a fourth treatment. Only one patient treated with surfactant required artificial lung support and none of these patients developed air leaks. In contrast, 5 of the 20 patients in the control group developed air leaks and 6 required artificial lung support. Patients treated with surfactant had shorter hospital stays and required less time on a ventilator than the control group. However, there were similar requirements for the home use of oxygen in both groups., Objective. The pathophysiology of meconium aspiration syndrome (MAS) is related not only to mechanical obstruction of the airways and chemical injury to the respiratory epithelium but also to surfactant inactivation by meconium. A randomized, controlled study was performed to determine whether high-dose surfactant therapy improves the pulmonary morbidity of term infants ventilated for MAS. Methods. Forty term infants receiving mechanical ventilation for MAS were enrolled in this trial, in which the infants in the study group (n = 20) received up to four doses of 150 mg (6 mL)/kg beractant (Survanta), instilled every 6 hours by continuous infusion for 20 minutes via a side hole endotracheal tube adapter, and the infants in the control group (n = 20) received 6 ml/kg air placebo. Results. Mean arterial-to-alveolar P[O.sub.2], ratio values increased from 0.09 to 0.11 at 1 and 6 hours with a concomitant slight decrease in oxygenation index values from 23.7 to 19.7 at 1 hour and 20.7 at 6 hours after the first dose of surfactant. Oxygenation improved cumulatively after the second and third dose of surfactant, with mean arterial-to-alveolar P[O.sub.2] ratios and oxygenation indices of 0.18 and 12.1 at 6 hours after the second dose of surfactant and 0.31 and 5.9 at 6 hours after the third dose of surfactant, eliminating the need for a fourth dose in any infant in the study group. After three doses of surfactant, persistent pulmonary hypertension had resolved in all but one of the infants in the study group versus none of the infants in the control group. No air leaks developed in any of the 20 infants in the study group after surfactant therapy, and only 1 infant required extracorporeal membrane oxygenation. Air leaks developed in 5 of the 20 infants in the control group, and 6 underwent extracorporeal membrane oxygenation. The duration of mechanical ventilation, oxygen therapy, and admission was significantly shorter in the surfactant group than in the control group. Conclusion. Surfactant replacement therapy, if started within 6 hours after birth, iinproves oxygenation and reduces the incidence of air leaks, severity of pulmonary morbidity, and hospitalization time of term infants with MAS. Pediatrics 1996,97:48-52; meconium aspiration syndrome, surfactant, oxygenation, chronic lung injury., ABBREVIATIONS. MAS, meconium aspiration syndrome; ECMO, extracorporeal membrane oxygenation; OI, oxygenation index; a:A, arterial-to-alveolar; F[IO.sub.2], fractional inspired oxygen. Intrauterine hypoxia and acidosis can trigger the passage of meconium into the [...]

Information concerning the adverse effects of cocaine on the human fetus is mounting. Cocaine passes from the mother through the placenta to the fetus. Fetuses exposed to cocaine during pregnancy have an increased risk for growth retardation, congenital malformations, blood clots and hemorrhages within the brain, and neurological and behavioral abnormalities. Cocaine prevents the re-uptake of neurotransmitter chemicals, called catecholamines, at nerve endings. Catecholamines produce a variety of physiological changes which can alter blood flow. To determine whether cocaine affects blood flow in the brain, cerebral blood flow velocity was studied among 20 full-term infants exposed to cocaine during pregnancy and 20 nonexposed infants. During the first two days of life, there was an increase in blood pressure and blood flow velocity in the brains of the cocaine-exposed infants. After two days, both groups had similar cerebral blood flows. Cocaine can be detected in the urine of newborns up to 96 hours after birth. Since only two infants had low birth weights (a known risk factor for altered cerebral blood flow), the decreased blood flow must be the result of cocaine exposure. These changes in the force and flow of blood through the brain may increase the risk of cerebral hemorrhage in infants exposed to cocaine. (Consumer Summary produced by Reliance Medical Information, Inc.)

In the past 10 years, abuse of cocaine by pregnant women has risen substantially. Cocaine is known to affect the cardiovascular system in adults and experimental animals, causing such abnormalities as elevated blood pressure and racing heart rate. These effects may be related to the fact that cocaine increases the blood levels of catecholamine hormones such as epinephrine (adrenaline) and norepinephrine. The effect of maternal cocaine use on the fetus was investigated in a study of 15 full-term newborn infants. All mothers and infants had urine tests that were positive for cocaine, demonstrating that the drug had been used in the several days before delivery. One specific measure of heart function that was tested was the cardiac output, the volume of blood pumped through the heart per minute. Compared to healthy control infants, babies whose mothers used cocaine had lower cardiac output and higher blood pressure on the first day of life. On day two postpartum, no significant differences between the control and cocaine groups were detected, probably because the drug was being excreted by the infants. The cardiovascular effects seen in the babies exposed to cocaine may have been due to elevated blood norepinephrine levels. Prenatal cocaine exposure may be particularly detrimental to babies whose hearts do not function well during a high-risk delivery. (Consumer Summary produced by Reliance Medical Information, Inc.)

BACKGROUND: Despite limited data, international guidelines recommend the use of intravenous immunoglobulin (IVIg) in neonates with rhesus hemolytic disease. OBJECTIVE: We tested whether prophylactic use of IVIg reduces the need for exchange transfusions in neonates with rhesus hemolytic disease. DESIGN AND SETTING: We performed a randomized, double-blind, placebo-controlled trial in neonates with rhesus hemolytic disease. After stratification for treatment with intrauterine transfusion, neonates were randomly assigned for IVIg (0.75 g/kg) or placebo (5% glucose). The primary outcome was the rate of exchange transfusions. Secondary outcomes were duration of phototherapy, maximum biliru- bin levels, and the need of top-up red-cell transfusions. RESULTS: Eighty infants were included in the study, 53 of whom (66%) were treated with intrauterine transfusion (s). There was no difference in the rate of exchange transfusions between the IVIg and placebo groups (7 of 41 [17%] vs6of39 [15%]; P = .99) and in the number of exchange transfusions per patient (median [range]: 0 [0-2] vs 0 [0-2]; P = .90) or in duration of phototherapy (4.7 [1.8] vs 5.1 [2.1] days; P = .34), maximum bilirubin levels (14.8 [4.7] vs 14.1 [4.9] mg/dL; P= .52), and proportion of neonates who required top-up red-cell transfusions (34 of 41 [83%] vs 34 of 39 [87%]; P = .76). CONCLUSIONS: Prophylactic IVIg does not reduce the need for exchange transfusion or the rates of other adverse neonatal outcomes. Our findings do not support the use of IVIg in neonates with rhesus hemolytic disease. [ABSTRACT FROM AUTHOR]

Abstract. Radiant heat is known to increase insensible water loss and, to a certain extent, oxygen consumption. Little is known about its cardiovascular effects. We measured cardiac output, stroke volume, heart rate, and lower limb and skin blood flow in 20 preterm newborn infants nursed in an incubator and under a radiant warmer at an abdominal skin temperature of 36.5 Celsius. Mean (+/-SEM) birth weight was 1.57 (0.06) kg, gestational age 31.7 (0.4) weeks, and weight at examination 1.69 (0.02) kg; median postnatal age was 15 days. Skin and limb blood flow measurements increased by 44% to 55% with radiant heat (P < .001 and P < .01, respectively). Cardiac output increased by 5.4% (P < .02) under the radiant warmer secondary to a small but significant (P < .05) increase in heart rate. The changes in cardiac output during radiant heat administration are comparable to those reported for oxygen consumption. Pediatrics 1987;80:235-239; cardiac output, peripheral blood flow, radiant heat, preterm newborns. [ABSTRACT FROM AUTHOR]

Abstract. Phototherapy is known to increase peripheral blood flow in neonates, but information on the associated cardiovascular effects is not available. Using pulsed Doppler echocardiography we evaluated cardiac output and stroke volume in 12 preterm and 13 term neonates during and after phototherapy. We concomitantly measured arterial limb blood flow by strain gauge plethysmography and skin blood flow by photoplethysmography. Cardiac output decreased by 6% due to reduced stroke volume during phototherapy, whereas total limb blood flow and skin blood flow increased by 38% and 41%, respectively. Peripheral blood flow increments tended to be higher in the preterm than in the term infants. The reduced stroke volume during phototherapy may be an expression of reduced activity of the newborn during phototherapy. For healthy neonates the reduction in cardiac output is minimal, but for sick infants with reduced cardiac output, this reduction may further aggravate the decrease in tissue perfusion. Pediatrics 1985;76:918-921; cardiac output, blood flow, phototherapy, echocardiography, plethysmography. [ABSTRACT FROM AUTHOR]

Abstract. Noninvasive monitoring of cardiac output can greatly facilitate the clinical assessment and management of neonates with cardiovascular compromise. To assess normal values of cardiac output in neonates, mean blood flow velocity was measured in the ascending aorta from a suprasternal approach using a range-gated, pulsed Doppler velocity meter, and aortic root diameter was determined from an M-mode echocardiogram. These techniques were combined, and cardiac output was evaluated in 59 healthy premature and 62 term newborn infants during the first week of life. Birth weights ranged from 780 g to 4,740 g and gestational age from 27 to 42 weeks. Cardiac output values increased linearly with advancing birth weight (r = +.94, P < .001) and gestational age (r = +.95, P < .001). Mean cardiac output values (+/-SD) per kilogram of body weight were 249 +/- 34 mL/ min/kg and decreased with advancing birth weight: <1,500 g = 265 +/- 32 mL/min/kg; 1,500 to 2,500 g = 253 +/- 34 mL/min/kg; and >2,500 g = 241 +/- 33 mL/min/kg. For clinical use, 325 mL/min/kg and 200 mL/min/kg can be used as upper and lower limits of normal, respectively. Doppler cardiac output estimates compared favorably with studies using invasive techniques. Pediatrics 1985; 76:829-833; cardiac output, neonate, pulsed Doppler technique, echocardiography. [ABSTRACT FROM AUTHOR]

Objective: Positive-pressure ventilation (PPV) using a manual ventilation device and a face mask is recommended for compromised newborn infants in the delivery room (DR). Mask ventilation is associated with airway obstruction and leak. A nasal tube is an alternative interface, but its safety and efficacy have not been tested in extremely preterm infants., Methods: An unblinded randomized controlled trial was conducted in Australia, and the Netherlands. Infants were stratified by gestational age (24-25/26-29 weeks) and center. Immediately before birth infants were randomly assigned to receive PPV and/or continuous positive airway pressure with either a nasal tube or a size 00 soft, round silicone mask. Resuscitation protocols were standardized; respiratory support was provided using a T-piece device commencing in room air. Criteria for intubation included need for cardiac compressions, apnea, continuous positive airway pressure >7 cm H2O, and fraction of inspired oxygen >0.4. Primary outcome was endotracheal intubation in the first 24 hours from birth., Results: Three hundred sixty-three infants were randomly assigned; the study terminated early on the grounds of futility. Baseline variables were similar between groups. Intubation rates in the first 24 hours were 54% and 55% in the nasal tube and face mask groups, respectively (odds ratio: 0.97; 95% confidence interval: 0.63-1.50). There were no important differences in any of the secondary outcomes within the whole cohort or between the 2 gestational age subgroups., Conclusions: In infants at <30 weeks' gestation receiving PPV in the DR, there were no differences in short-term outcomes using the nasal tube compared with the face mask.

Objective: Neonatal resuscitation guidelines recommend techniques to minimize heat loss in the delivery room. The use of humidified and heated gas is standard of care for preterm infants who need respiratory support in the NICU, but international resuscitation guidelines do not stipulate use of this therapy during stabilization at birth. We aimed to investigate the effect of humidified and heated gas on admission temperature in preterm infants who require respiratory support at birth., Methods: Two cohorts of very preterm infants born at < or = 32 weeks' gestational age in the Leiden University Medical Center were compared prospectively before (the "cold" cohort) and after (the "heated" cohort) introduction of the use of heated and humidified gas during respiratory support at birth (continuous positive airway pressure or intubation). The primary outcome was the infant's rectal temperature at admission in the NICU., Results: There was a difference in the mean (SD) rectal temperature between the cold and heated cohorts (35.9 [0.6] vs 36.4 [0.6], respectively; P < .0001). Normothermia (36.5 degrees C-37.5 degrees C) occurred less often in the cold cohort than in the heated cohort (12% vs 43%; P < .0001). There was no difference in occurrence of mild hypothermia (36.0 degrees C-36.4 degrees C) between groups (33% vs 35%; not significant). Moderate hypothermia (<36.0 degrees C) occurred more often in the cold cohort (53% vs 19%; P < .001)., Conclusions: The use of heated and humidified air during respiratory support in very preterm infants just after birth reduced the postnatal decrease in temperature. Heating and humidifying the gas during stabilization merits additional investigation.

Objective: The goal of this study was to investigate the effect of basic elements of developmental care (incubator covers and positioning aids) on days of respiratory support and intensive care, growth, and neuromotor development at term age in infants who were born at <32 weeks' gestation., Methods: Infants were randomly assigned within 48 hours of birth to the developmental care group or the standard care control group (no covers or nests). The intervention continued until the infant either was transferred to a regional hospital or was discharged from the hospital. Length, weight, and head circumference were measured (bi)weekly and at term age. Neuromotor development was defined as definitely abnormal (presence of a neonatal neurologic syndrome, such as apathy or hyperexcitability, hypotonia or hypertonia, hyporeflexia or hyperreflexia, hypokinesia or hyperkinesia, or a hemisyndrome), mildly abnormal (presence of only part of such a syndrome), or normal., Results: A total of 192 infants were included (developmental care: 98; control: 94). Thirteen infants (developmental care: 7; control: 6) were excluded according to protocol (admitted for less than or died within the first 5 days: n = 12; taken out at parents' request: n = 1), which left a total of 179 infants who met inclusion criteria. In-hospital mortality was 12 (13.2%) of 91 in the developmental care group and 8 (9.1%) of 88 in the control group. There was no significant difference in the number of days of respiratory support, number of intensive care days, short-term growth, or neuromotor developmental outcome at term age between the developmental care and control groups. Duration of the intervention, whether only during the intensive care period or until hospital discharge, had no significant effect on outcome., Conclusions: Providing basic developmental care in the NICU had no effect on short-term physical and neurologic outcomes in infants who were born at <32 weeks' gestation.