End‐tidal carbon dioxide monitoring in very low birth weight infants: Correlation and agreement with arterial carbon dioxide

Background: In order to know the response of the skin microcirculation to local warming, we determined changes in the skin blood volume (Vol), velocity (Vel) and flow (F) by using a new laser Doppler device on newborns. Methods: The study subjects were 39 infants whose gestational age was 34.1~2.8 weeks and birth weight was 2189~572 g. The study was performed from 8 h postnatally to 28 postnatal days. We measured skin blood volume, velocity and flow at 36°C (Vol36, Vel36, F36), and each value at 5 min (Vol44–5, Vel44–5, F44–5) and 10 min (Vol44–10, Vel44–10, F44–10) after local warming was applied at 44°C and the response curve of each parameter was obtained. Subsequently, serial changes in the response of skin microcirculation to local warming were investigated in nine very low birth weight (VLBW) infants (28.3~0.9 weeks, 1150~148 g) and 12 low birth weight (LBW) infants (32.8~1.3 weeks, 1971~292 g). The F36, the increment rate of blood volume (ΔVol) and the increment rate of blood velocity (ΔVel) were obtained within 24 h, from day 1 to day 7 and from day 8 to day 30 in both VLBW and LBW infants and from day 31 to day 60 and at more than 61 days in VLBW infants. The F36, ΔVol and ΔVel were compared during the study periods in VLBW and LBW infants. All results were expressed as mean~SD. Results: The results showed that F36/F44–10 and F44–5/F44–10, Vol36/Vol44–10 and Vol44–5/Vol44-10, Vel36/Vel44-10 and Vel44–5/Vel44–10 were 0.25~0.09 and 0.74~0.17, 0.58~0.14 and 0.94~0.08, 0.42~0.12 and 0.79~0.15, respectively. Different modes of delivery did not have a significant effect on this response. The F36 in VLBW infants was high during the early neonatal period and gradually decreased with postnatal age. The ΔVol was low in VLBW infants during the neonatal period and gradually increased. The F36 in VLBW1–7 was significantly higher than in LBW1–7 (P<0.01) and full-term controls (P<0.001). The ΔVol in VLBW1–7 was 0.26~0.23, which is significantly lower than in LBW1–7 (0.57~0.17, P<0.001) and full-term controls (0.77~0.21, P<0.001). The ΔVel in VLBW1–7 and LBW1–7 was significantly higher than in controls (P<0.05). Conclusions: The skin blood flow increased continuously when local warming was applied at 44°C. This high blood flow and limited potential of vasodilatation are the characteristics of the skin microcirculation in VLBW infants during the neonatal period.

In order to know the response of the skin microcirculation to local warming, we determined changes in the skin blood volume (Vol), velocity (Vel) and flow (F) by using a new laser Doppler device on newborns. The study subjects were 39 infants whose gestational age was 34.1 +/- 2.8 weeks and birth weight was 2189 +/- 572 g. The study was performed from 8 h postnatally to 28 postnatal days. We measured skin blood volume, velocity and flow at 36 degrees C (Vol36, Vel36, F36), and each value at 5 min (Vol44-5, Vel44-5, F44-5) and 10 min (Vol44-10, Vel44-10, F44-10) after local warming was applied at 44 degrees C and the response curve of each parameter was obtained. Subsequently, serial changes in the response of skin microcirculation to local warming were investigated in nine very low birth weight (VLBW) infants (28.3 +/- 0.9 weeks, 1150 +/- 148 g) and 12 low birth weight (LBW) infants (32.8 +/- 1.3 weeks, 1971 +/- 292 g). The F36, the increment rate of blood volume (delta Vol) and the increment rate of blood velocity (delta Vel) were obtained within 24 h, from day 1 to day 7 and from day 8 to day 30 in both VLBW and LBW infants and from day 31 to day 60 and at more than 61 days in VLBW infants. The F36, delta Vol and delta Vel were compared during the study periods in VLBW and LBW infants. All results were expressed as mean +/- SD. The results showed that F36/F44-10 and F44-5/F44-10, Vol36/Vol44-10 and Vol44-5/Vol44-10, Vel36/Vel44-10 and Vel44-5/Vel44-10 were 0.25 +/- 0.09 and 0.74 +/- 0.17, 0.58 +/- 0.14 and 0.94 +/- 0.08, 0.42 +/- 0.12 and 0.79 +/- 0.15, respectively. Different modes of delivery did not have a significant effect on this response. The F36 in VLBW infants was high during the early neonatal period and gradually decreased with postnatal age. The delta Vol was low in VLBW infants during the neonatal period and gradually increased. The F36 in VLBW1-7 was significantly higher than in LBW1-7 (P < 0.01) and full-term controls (P < 0.001). The delta Vol in VLBW1-7 was 0.26 +/- 0.23, which is significantly lower than in LBW1-7 (0.57 +/- 0.17, P < 0.001) and full-term controls (0.77 +/- 0.21, P < 0.001). The delta Vel in VLBW1-7 and LBW1-7 was significantly higher than in controls (P < 0.05). The skin blood flow increased continuously when local warming was applied at 44 degrees C. This high blood flow and limited potential of vasodilatation are the characteristics of the skin microcirculation in VLBW infants during the neonatal period.

Timing of Caffeine Therapy in Very Low Birth Weight Infants

Magnesium metabolism in preterm infants: Effects of calcium, magnesium, and phosphorus, and of postnatal and gestational age

Influence of increased survival in very low birth weight, low birth weight, and normal birth weight infants on the incidence of sudden infant death syndrome in the United States: 1985-1991.

Fungal infections in neonates, especially in Very Low Birth Weight (VLBW) infants, are mostly caused by Candida species and may lead to morbidity and mortality. A systematic review and a meta-analysis were conducted to determine the extent to which fluconazole, an antifungal prophylactic, was effective and safe to use in VLBW or premature infants in preventing Invasive Fungal Infection (IFI), by including Randomized Controlled Trials (RCTs) carried out worldwide. The investigation started with searching process through publication databases: MEDLINE, Cochrane, ScienceDirect, and Garuda, for Randomized Controlled Trials (RCTs) that compared the prophylactic effects of fluconazole and placebo on IFI in VLBW infants. The selected eight RCT studies indicated that, compared to placebo, fluconazole accounted for 68% risk reduction of overall fungal colonization (RR=0.32; 95% confidence interval [CI]=0.24-0.42, p=0.00001, I-square=0%) and 60% risk reduction of IFI (RR=0.40; 95%[CI]=0.22-0.72, I-square=56%, p=0.002). However, fluconazole did not significantly reduce mortality in VLBW infants (RR=0.79; 95%[CI]=0.60-1.03; p=0.08, I-square=0%). Also, regarding its safety, fluconazole prophylaxis did not result in significant elevations of SGOT/SGPT levels (RR=1.22; 95%[CI]=0.50-3.00, p=0.66, I-square=0%) nor cause intestinal perforation (RR=0.96; 95%[CI]=0.25-3.68, p=0.96, I-square=59%). Fluconazole is an effective prophylaxis agent against invasive fungal infection when given to preterm infants with birth weight &lt;1500, but not proven in reducing the mortality incidence in VLBW infants.

Oral probiotics reduce the incidence and severity of necrotizing enterocolitis in very low birth weight infants

This study tested common assumptions that very low birth weight (VLBW) infants (less than 1500 g) adversely affected families and that if affected parents could choose again, they would prefer not to save potentially handicapped VLBW infants. A survey of parents, which used a validated impact-on-family questionnaire, was sent to families of all 144 traceable VLBW infants (72.2% response), and families of 25 randomly selected healthy term infants (60% response), born in Newfoundland between 1983 and 1987 (median age 36.5 months, range 12 to 71 months). This revealed that families with developmentally delayed VLBW infants perceived no worse impact on the family than those with healthy term infants. Families with developmentally normal VLBW infants perceived a more positive family impact than the other two groups (P less than .05). Most parents of both VLBW and healthy term infants supported saving all infants regardless of outcome (greater than 80%), believed that parents should be the principal decision makers regarding treatment decisions (greater than 92%), and supported the role of physicians (greater than 59%), but not nurses, ethics committees, or other regulatory bodies, in this decision. For the VLBW group, parental attitudes toward saving VLBW infants were related to their perceptions of family impact (P less than .05) but independent of sociodemographic factors or of the developmental normality of the infant. It is concluded that VLBW infants did not adversely affect these Newfoundland families or change their attitudes toward saving potentially handicapped infants. In the current debate about whether VLBW infants should be saved, cognizance must be taken of parental desires.

Breastfeeding Trends Among Very Low Birth Weight, Low Birth Weight, and Normal Birth Weight Infants

Tracheal aspirates (TAs) from mechanically ventilated very low birth weight (VLBW) infants are frequently obtained during the evaluation of suspected sepsis, tracheitis, or ventilator-associated pneumonia (VAP). Purulence and bacteria in Gram stain of bronchopulmonary secretions are considered signs of respiratory infection, and medical decisions are made on the assumption that they are predictors of positive bacterial tracheal cultures (TCs). The purpose of this retrospective investigation was to establish the relationship of purulence and bacteria in TA from ventilated VLBW infants with positive TC and to identify its clinical significance. One hundred and seventy consecutively born VLBW infants (1996 to 1998) who remained on mechanical ventilation longer than 1 week were studied. Demographic, laboratory, and clinical data were obtained from hospital medical records. Purulence, defined by the number of polymorphonuclear leukocytes (PMNs) per low power field (LPF), was reported as light (<25 PMNs/LPF) or moderate/heavy (>or=25 PMNs/LPF) for every TA. Purulence was absent in 469 of 646 (72%) TA taken from 170 infants. Light purulence was present in 17% and moderate/heavy purulence in 11%. TCs were positive in 58% of non-purulent, 94% of light, and 100% of moderate/heavy purulent TA. Bacteria on Gram stain were present in 12% of non-purulent, 70% of light purulent, and 83% of moderate/heavy purulent TA. Moderate/heavy purulence in TA was predictive of a positive TC with Gram-negative bacilli (GNB) with 70% sensitivity, 100% specificity, 100% positive predictive value, and 67% negative predictive value. Purulence in TA, as well as GNB airway colonization, became more frequent as mechanical ventilation progressed and was not associated with a particular GNB species. There were 79 infants who never had purulent TA and 91 who, at some time during the hospitalization, did. At the time of first purulent TA, 65 (71%) of 91 infants were asymptomatic. Twenty-six infants (29%) had clinical deterioration for which they underwent sepsis work-up. Three had blood stream infection, 5 VAP, 5 tracheitis, and 13 respiratory complications of non-infectious etiology. Four of five VAP infants died; all others survived. In VLBW infants, purulence in TA is associated with prolonged endotracheal intubation and is temporally related to GNB airway colonization. At the time of the first purulent TA, the majority of mechanically ventilated VLBW infants are asymptomatic. Only a few symptomatic VLBW infants had nosocomial respiratory infection. Understanding the clinical significance of purulence and GNB in TA from this unique patient population is important for management and prognosis, and it may decrease concern for infection and the associated use of antibiotics.

Very low birth weight infants after discharge: What do parents describe?

Diagnosis and Risk Factors of Acute Kidney Injury in Very Low Birth Weight Infants

Objective. To determine whether skin and subcutaneous blood flow measurements using a novel laser Doppler flow meter are useful for evaluating the cardiovascular status of very low birth weight (VLBW) infants during the early postnatal period.Methods. In eight VLBW infants and eight non-VLBW infants born at Tokyo University Hospital between May 2007 and April 2008, forehead and lower limb skin blood flows were measured continuously for 72 h. Data were averaged every 8 h, and the t-test was used for analysis.Results. In VLBW infants, forehead blood flow started to increase from the start of measurement to 32 h (16.6 ± 3.9 ml/min vs. 24.1 ± 2.1 ml/min; p = 0.002 compared with 8 h) and remained constant thereafter. Lower limb blood flow increased rapidly after 24 h (22.2 ± 5.5 ml/min vs. 29.5 ± 5.0 ml/min; p = 0.002 compared with 8 h) and continued increasing thereafter. In contrast, blood flows remained constant in non-VLBW infants.Conclusions. The results showed that skin and subcutaneous perfusion in VLBW infants increased spontaneously at around 24 h. Differences in blood flow changes between VLBW and non-VLBW infants demonstrate that these parameters successfully identified physiological changes in tissue perfusion in VLBW infants.

Although pediatricians and neonatal nurses influence parents' treatment decisions, little is known about their attitudes toward active treatment of very low birth weight (VLBW) infants (less than 1500 g) and how they compare with parental attitudes. A survey of all 50 pediatricians in Newfoundland (72% response), all 53 neonatal intensive care nurses at the Janeway Child Health Centre (73.6% response), parents of all 144 traceable VLBW infants (72.2% response), and parents of 25 randomly selected normal term infants (60% response), born in Newfoundland between 1983 and 1987, revealed significant differences in attitudes among parents, nurses, and pediatricians about whether active treatment should be offered to potentially severely handicapped VLBW infants. Most parents of both VLBW and normal term infants (greater than 80%) agreed, pediatricians were divided, whereas most nurses (79.5%) objected. Both pediatricians and nurses tended to overestimate (P less than .05) the morbidity, mortality, and costs of care of VLBW infants. There was a direct correlation (P less than .05) between a negative attitude toward saving VLBW infants and a negatively false perception of neonatal morbidity, mortality, and costs. All groups favored a role for parents and physicians in treatment decisions and objected to a role for regulatory bodies. Pediatricians and nurses also favored a role for nurses and hospital ethics committees but parents disagreed. While most nurses (71%) believed it was unethical to save potentially severely handicapped infants, few pediatricians (36.9%) agreed. Only 27.8% of pediatricians and 10.3% of nurses would seek court intervention if they disagreed with a parental decision not to actively treat a potentially handicapped infant.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal meningitis is associated with significant morbidity and mortality. We speculated that meningitis may be underdiagnosed among very low birth weight (VLBW) infants because of the failure to perform lumbar punctures (LPs) in infants with suspected sepsis. This study was undertaken to review the epidemiology of late-onset meningitis in VLBW (401-1500 g) infants and to evaluate the concordance of cerebrospinal fluid (CSF) and blood culture (BC) results. VLBW infants (excluding those with intraventricular shunts) born at centers of the National Institute of Child Health and Human Development Neonatal Research Network from September 1, 1998, through December 31, 2001, were studied. Late-onset meningitis was defined by culture-based criteria and classified as meningitis with or without associated sepsis. Unadjusted comparisons were made using chi2 tests and adjusted comparisons using regression models. Of 9641 VLBW infants who survived >3 days, 2877 (30%) had > or = 1 LPs, and 6056 (63%) had > or = 1 BC performed after day 3. One hundred thirty-four infants had late-onset meningitis (1.4% of all patients; 5% of those with an LP). Pathogens associated with meningitis were similar to those associated with sepsis. One third (45 of 134) of the infants with meningitis had negative BCs. Lower gestational age and prior sepsis increased risk for meningitis. Compared with uninfected infants, those with meningitis had a longer time on mechanical ventilation (28 vs 18 days), had longer hospitalizations (91 vs 79 days), were more likely to have seizures (25% vs 2%), and were more likely to die (23% vs 2%). Meningitis is a serious complication among VLBW infants, associated with increased severity of illness and risk of death. Of note, one third of the infants with meningitis had meningitis in the absence of sepsis. Because CSF cultures were performed only half as often as BCs, this discordance in blood and CSF culture results suggests that meningitis may be underdiagnosed among VLBW infants.