Management Of Preterm Infants Research Articles

The Use of Human Milk and Breastfeeding in Premature Infants

Human milk is beneficial in the management of premature infants. The beneficial effects generally relate to improvements in host defenses, digestion, and absorption of nutrients, gastrointestinal function, neurodevelopment, and maternal psychological well-being. The use of fortified human milk generally provides the premature infant adequate growth, nutrient retention, and biochemical indices of nutritional status when fed at approximately 180 mL/kg/day compared with unfortified human milk. Human milk can only support the needs of the premature infant if adequate milk volumes are produced. Intensive efforts at lactation support are desirable. Therefore, neonatal centers should encourage the feeding of fortified human milk for premature infants along with skin-to-skin contact as a reasonable method to enhance milk production and promote success with early breastfeeding, while potentially facilitating the development of an enteromammary response.

Transcutaneous penile oxygen pressure during bicycling.

To evaluate the blood supply to the penis during bicycling and thus determine whether the associated perineal compression might be responsible for some cases of impotence. The transcutaneous penile oxygen partial pressure (pO2 ) at the glans of the penis was measured in 25 healthy athletic men; pO2 is readily measured by noninvasive techniques currently widely used in the management of premature infants, and which have been shown to give pO2 levels that correlate with arterial pO2 levels. The measurements in the healthy subjects were taken in various positions, before, during and after bicycling. The mean (sd) pO2 of the glans when standing before cycling was 61.4 (7.2) mmHg; it decreased after 3 min of cycling to 19.4 (4. 7) mmHg. After 1 min of cycling in a standing position it increased significantly to 68 (7.6) mmHg; when cycling was continued in a seated position, after 3 min the pO2 fell to 18.4 (4.2) mmHg and there was a full return to normal pO2 values after a 10-min recovery period. The pO2 seems to correlate with the blood supply to the penis. The present results support the hypothesis that as the penile arteries are compressed against the pubic bone by the saddle during bicycling, the pO2 values decrease. Additionally, shifting from a seated to a standing position while cycling significantly improved the pO2 value of the penis and penile blood oxygenation was then even greater. Therefore, we suggest that cyclists change their body position frequently during cycling. Correcting the handlebars or the height of the saddle, tipping the nose of the saddle to produce a more horizontal, or even downward pointing position, and attention to the design of the saddle may be the only required precautions.

Advances in parenteral nutrition.

Parenteral nutrition is an expensive therapy that is often necessary in certain situations, such as short-bowel syndrome. In many other conditions, its efficacy remains controversial. Providing optimal parenteral nutrition can be particularly challenging in premature infants while managing metabolic and catheter complications. Use of special nutrients, glutamine, and growth hormone may have benefits in the nutritional management of premature infants and trauma patients. Metabolic complications of parenteral nutrition such as cholestasis might be reduced by early enteral feedings, ursodeoxycholic acid, and cholecystokinin-octapeptide. Trace-element deficiencies may still occur, and thus patients must be monitored carefully. Methods that have been used to prevent or reduce catheter occlusion or infection include heparin, oral anticoagulants, antibiotics, and thrombolytic agents such as urokinase and tissue plasminogen activator.

Pharmacologic management of apnea of prematurity.

Apnea of prematurity is one of the most common problems in the neonatal intensive care unit. Management of premature infants with apnea involves pharmacologic and nonpharmacologic therapies. Drugs such as theophylline and caffeine are used when nonpharmacologic measures are ineffective. The article discusses the different types of apnea seen in premature infants, how these drugs affect premature infants, how to recognize early signs of toxicity, and implications for nursing assessment and management.

Assessment of Glomerular Filtration Rate in Preterm Infants by Serum Creatinine: Comparison With Inulin Clearance

Dosage regimens of drugs that are cleared mainly by glomerular filtration as well as fluid management in preterm infants should be based on the glomerular filtration rate (GFR) of the individual patient. However, GFR measurements and collection of urine in newborns are difficult to perform. The 24 to 48 h continuous inulin infusion technique does not require the collection of urine and is considered the most reliable indicator of GFR.1,2 This method is invasive, time-consuming, and expensive. In contrast, serum creatinine measurements can be obtained easily and determined quickly in the clinical chemistry laboratory. Most laboratories use an automated kinetic Jaffé method, which is subject to negative interference by plasma hemoglobin above 0.06 mmol/L, and to negative interference by bilirubin (about 35 µmol/L by a serum bilirubin of about 100 µmol/L).

Survival after gastrointestinal perforation from esophageal atresia and tracheoesophageal fistula

Management of premature infants with esophageal atresia (EA), tracheoesophageal fistula (TEF), and respiratory distress syndrome (RDS) can be one of the most challenging aspects in the surgical care of the newborn. Although not common, there have been reports of EA, TEF, and RDS with gastric perforation, but an associated duodenal perforation has not been reported. Two premature infants weighing less than 1,200 g with EA, TEF, and perforation are described. One baby developed a gastric perforation and the other a duodenal perforation. Emergency thoracotomy and fistula ligation were necessary after gastrostomy placement. These patients are the smallest infants reported to survive gastrointestinal perforation complicated by EA, TEF, and RDS.

Surfactant Replacement Therapy for Pulmonary Diseases

Surfactant therapy has clearly been a meaningful addition to the therapeutic armamentarium in the management of premature infants with RDS. Pediatricians and others involved in the care of newborn infants should familiarize themselves with the various surfactant preparations, the indications for their use, the techniques of administration, and the possible side effects. All such care provides should also be skilled in endotracheal intubation and ventilation of neonates; recognition of the clinical and radiographic signs of RDS; and have the appropriate equipment to monitor cardiopulmonary status, oxygenation, and ventilation in these infants until transport to a tertiary care facility can be accomplished. In addition to the two current FDA-approved surfactants, several other surfactants are in various stages of evaluation. When administered to infants with established RDS, both natural and synthetic surfactants have clearly been shown to improve survival, decrease requirements for ventilatory support, and reduce the incidence of air leak complications. Although by no means conclusively demonstrated, certain infants, particularly those delivered at < 30 week gestation, may benefit from immediate treatment in the delivery room. It should be emphasized that, except under extenuating but controlled circumstances and except in the hands of an experienced physician, surfactant treatment should not be viewed as an integral part of neonatal resuscitation. Adequate treatment requires the administration of a minimum of two surfactant doses, although some infants may benefit from additional doses or treatment with an alternative preparation. Massive pulmonary hemorrhage, although rare, is observed with prophylactic and rescue treatment protocols and may result from hemorrhagic pulmonary edema due to a hemodynamically significant PDA. Currently there are no data to recommend the use of one surfactant preparation over another. The short- and long-term benefits may be similar with different products. Therefore, we must await results of trials with then necessary power (large number of subjects) and unbiased design to discern any clinically relevant differences. Results of studies directly comparing the relative efficacy of Survanta and Exosurf, conducted under the auspices of the National Institutes of Health, are expected in 1993. Multicenter trials comparing prophylactic and rescue administration of Exosurf versus CLSE and Survanta versus CLSE are currently underway. It is encouraging to note that follow-up studies up to 2 years of age do not reveal an increase in physical or neurodevelopmental handicaps, BPD, or other problems in preterm infants who received surfactant preparations either for prophylaxis or rescue therapy. Results of long-term follow-up studies, however, are not yet available.(ABSTRACT TRUNCATED AT 400 WORDS)

Suspended judgment Memories of the 1953–54 oxygen trial and its aftermath: The failure of success

Results of of the earliest multicenter randomized trials conducted in the United States (the NIH-sponsored cooperative study of the use of supplemental oxygen in the management of premature infants) were announced on September 19, 1954 [1,2]. The study was hailed widely as a convincing example of the power of a then new investigative tool: the randomized clinical trial format recently imported from Britain. The collaborative exercise seemed to provide a definitive answer to questions about unexpected consequences of a thoroughly entrenched and highly regarded treatment. Journalists spread the exciting news that the cause had been found of a disorder (it was then called RLF----retrolental fibroplasia--literally fibrous mass behind the lens) that blinded ca. 10,000 prematurely born infants throughout the world over a period of 12 years. Routine administration of high concentrations of supplemental oxygen to improve the outlook for small premature babies (weighing less than 1.5 kg at birth), introduced without formal clinical testing in the early 1940s, was declared to be responsible for the enormous therapeutic disaster. The story of the confusion and of the numerous controversies concerning more than 50 suspected causes of the blindness epidemic, in the years before the national trial, received a great deal of attention in the popular press. A well-known science reporter wrote a prize-winning article entitled Mystery of the Blinded Babies, which appeared in the Saturday Evening Post [3]. Prior to the national trial, he pointed out, caretakers were extremely reluctant to accept evidence which suggested that one of their best friends [supplemental oxygen] was guilty. One doctor had asserted, It's alright to curtail

Clinical Evalution of a Direct Colorimetic Method for Determination of Amniotic Phospholipids

Evaluation of amniotic phospholipids, which are a parameter of fetal lung maturation, is important in the management of premature infants. The method available for measuring the lecithin/sphingomyelin (L/S) ratio, which appears to provide an index to fetal lung maturity, is laborious, involving determinations of phospholipids, and so is unsuitable for rapid quantitative measurement of phospholipids in the amniotic fluid in the perinatal period. We developed a simple, sensitive colorimetric assay for phospholipids without their extraction. This assay is based on the fact that phospholipids form stable hydrophobic complexes with Co(SCN)4, Fe(SCN)2- and Fe(SCN)3 within about 1 hr. Amniotic fluid samples (n = 115) were collected from women with normal and abnormal pregnancies in week 16-41 of pregnancy, and these samples were examined both by thin layer chromatography (TLC) and by our method of phospholipid determination. Good correlations were observed between the L/S ratio determined by TLC and the values obtained by this method. Moreover the distributions of the dipalmitoylphosphatidylcholine (DPPC) content and DPPC/sphingomyelin (SM) ratio were similar to those of the PC content and L/S ratio. This method was proved to be more accurate than other methods such as TLC and the shake test for predicting neonatal RDS.

VITAMIN C-INDUCED ANEMIA IN PREMATURE INFANTS

The evidence provided by our studies suggests that ascorbic acid therapy places the erythrocytes of premature infants at risk of oxidative damage. . . The significance of these findings to the routine management of premature infants remains to be determined.

Acquired subglottic cysts in premature infants

Advances in the management of premature infants have resulted in improved survival. However, long-term intubation may produce associated laryngeal complications. We report 12 infants and children who developed subglottic cysts following long-term intubation as newborns. The majority of the cysts were in the posterior subglottic larynx. Laser excision of the cysts was undertaken in 8 patients and 3 underwent removal with cupped forceps. Recurrent cysts in 3 patients required more than one endoscopic procedure. The differential diagnosis of stridor in infants who have required long-term intubation includes subglottic cysts. The cysts are not always obvious at endoscopy and indeed may be buried below the mucosa within a soft tissue subglottic stenosis. Their presence may be suspected when tiny beads of mucus are released when laser surgery of a soft tissue stenosis is applied. Successful management of these cysts includes early precise diagnosis, with careful identification of these cysts to differentiate them from other types of subglottic stenosis. An initial attempt of conservative management with endoscopic excision is made. If this fails, an anterior cricoid split may be indicated in cases where the cysts are associated with soft tissue subglottic stenosis. Tracheostomy may be unavoidable in some cases.

Neuromuscular Relaxants in the Neonate

Neuromuscular blockade frequently is employed to facilitate mechanical ventilation and other therapeutic interventions in adults and children. In recent years it has been suggested that the use of neuromuscular blockade in the management of premature infants who are ventilated for respiratory distress will reduce the incidence of barotrauma and intracranial hemorrhage. Subsequently, neuromuscular blocking agents have become some of the most commonly used medications in the intensive care nursery. A discussion of these drugs is included in this article to improve the understanding of their pharmacology, the indications and consequence of their use, and their potential side effects. Additionally, the recent introduction of new, shorter-acting agents warrants a review of current practice.

Randomized controlled trial of very early continuous distending pressure in the management of preterm infants

Application of continuous distending pressure at birth (very early CDP) should stabilize the immature airways and reduce the severity of respiratory distress syndrome (RDS) in preterm infants. Eighty-two preterm infants of less than 32 weeks gestation were randomly assigned at birth to early treatment group (TG), in which CDP of 6 cm water pressure was applied at birth by the nasopharyngeal route (NP-CDP), or to control group (CG), in which CDP was applied when indicated for established criteria (pO 2 < 50 mmHg in FiO 2 > 0.5). Characteristics of the infants in the two groups were comparable. No statistically significant difference between the two groups was found in the incidence of RDS. The course of RDS, and oxygen and ventilatory requirements also did not appear to be changed. In blood gas parameters of most of the time frames, no significant difference was found between the two groups when the results were analyzed according to the assigned group. When the results were analyzed separately for the infants who developed RDS, infants in TG appear to have fared worse from the therapy in terms of oxygenation, as indicated by significantly higher FiO 2 ( P < 0.01) and lower a/A ( P < 0.01) values on the third day of the course of RDS, as compared to infants in CG. The incidence of complications was comparable in the two groups. Four infants from TG (9.3%) and one from CG (2.6%) died ( P = NS). We conclude that VECDP by nasopharyngeal route does not reduce the incidence of RDS and does not appear to improve the outcome and may worsen the severity of RDS when compared to application of CDP for established criteria

Application of Program Evaluation and Review Technic (PERT) to laboratory research and development planning.

Software for the personal computer dramatically changes the ease with which managers of research and development can use network planning to guide projects to completion in the academic medical center setting. A case study of the use of the Critical Path Method (CPM) and Project Evaluation and Review Technic (PERT) in planning and implementing transcutaneous pCO2 monitoring by a department of laboratory medicine illustrates the utility and efficiency of these network planning technics. By means of iterative PERT analyses, the project was kept on track, despite an overly optimistic estimate of the completion date initially and intense demand by clinicians for use of the new monitoring technic in the management of premature infants with respiratory disease. Additionally, the iterative management approach improved project participants' expertise in estimating and meeting deadlines. Network planning is fully adaptable to the IBM PC or an equivalent microcomputer. This article summarizes several excellent project management software packages that have become available recently.

Social and sensory environment of low birth weight infants in a special care nursery. An anthropological investigation.

Ten infants of 900 to 1500 gram birthweight and 28 to 32 weeks gestational age were observed for a total of 552 hours in an intensive care nursery. Auditory environment and tactile experience were recorded by tape recorder and observers' notes for a period of 24 consecutive hours at weekly intervals in each of the first 3 weeks of life. Besides regular recording of heart rate and motor activity, episodic events were also noted such as interaction with staff or parents, or periods of apnea. Results are primarily descriptive of this environment, denoting sound level of ground noise, kinds of sounds that penetrate the isolette, responses of the infants to these sounds, differences in auditory environment with different caretakers, and motor activity as related to auditory and tactile events. In response to questions of the usefulness of sensory stimulation programs for preterm infants, these descriptive results suggest some of the deficiencies and complexities of this life experience at this gestational age, and suggest some areas for further research as well as for clinical management of premature infants.

1370 THE MICROENVIRONMENT OF PREMATURE INFANTS UNDER A PLEXIGLASS DOME AND PLASTIC BLANKET

We measured air temp (Ta-micro), relative humidity (rh) and air velocity (V) surrounding 6 non-distressed prematures, <11 days old, 28-36 wks, in the thermoneutral zone in a forced convection incubator. Core temperature (Te), mean skin temperature (Tsk), abdominal heat flux (q) and O2 consumption (VO2) were also measured. Results are means at thermal equilibrium:Under these environmental conditions: (1) the air under the dome or bubble blanket is warmer and less turbulent. (2) rh measurements are confounded by ↑Ta-micro. (3) Abdominal heat flux is reduced and is associated with an increase in Te and Tsk. (4) VO2 is reduced when the infants are covered. These data help to clarify the mechanisms and support the use of a heat shield in the management of premature infants.

Failure of indomethacin therapy to induce closure of patent ductus arteriosus in premature infants with respiratory distress syndrome

MANAGEMENT of premature infants with respiratory distress syndrome complicated by patent ductus arteriosus continues to pose a challenge in the selection of patients for surgical ligation of the ductus and for appropriate timing of the operation. The exciting possibility of pharmacologic closure of the ductus with indomethacin inhibition of prostaglandin synthesis was first suggested by Sharpe.' Support for this hypothesis was detailed in two reports of indomethacin-induced PDA closure in premature infants with RDS.- :~ A recent update of the combined experience of these two West Coast centers is even more encouraging considering the extremely high incidence of successful pharmacologic treatment and the relatively low associated morbidity. ~ We present our less favorable experience with indomethacin therapy in premature infants with RDS and PDA and briefly examine some of the possible reasons for the discrepancy in results.

Management of premature infants with patent ductus arteriosus: D. A. Murphy, E. Outerbridge, L. Stern, G. M. Karn, W. Jegier, and J. Rosales. J. Thorac. Cardiovasc. Surg. 67:221–228 (February), 1974

Management of premature infants with patent ductus arteriosus: D. A. Murphy, E. Outerbridge, L. Stern, G. M. Karn, W. Jegier, and J. Rosales. J. Thorac. Cardiovasc. Surg. 67:221–228 (February), 1974

Management of premature infants with patent ductus arteriosus

The majority of premature infants with patent ductus arteriosus will undergo spontaneous closure of this structure regardless of whether pulmonary disease has been present (40 out of 57). Excluding the 5 infants with more complex associated congenital heart disease, 15 of 52 required surgery. Of the 37 infants not requiring surgery, 26 had definite spontaneous closure of the ducts. (Four were lost to follow-up, but the ducts are presumed closed.) Six infants in this group died, and in 2 the patent ductus arteriosus was the direct cause of death. Although surgery can be lifesaving, the selection of patients ideally must be made over a period of time. This is usually possible except in extreme cases. Even though division of the duct is associated with a low operative mortality rate, the late mortality (50 per cent) and the morbidity rates are high. Nevertheless, this risk should not be a contraindication to surgery, since most of the operated infants clearly would have died without ligation of the duct.

Management of premature infants in the tropics as practised in a premature nursery.

Though there are many problems such as nutrition, taking care of the sick and organization of M. C. H. services demanding our immediate attention, in countries llke ours, lhe care of premature infants also is significantly important. A programme of easily adaptable methods in the management of premature infants in the economically under-developed countries is essential. To show the importance of this need, a study of the incidence of prematurity and the type of care that has been evolved to meet the growing needs in this direction are presented. This study was carried out in the premature nursery of the Institute of Pediatrics and Child Health, King George Hospital, Visakhapatnam.