Moribund Infants Research Articles

Extracorporeal membrane oxygenation: indications, technique and contemporary outcomes

### Learning objectives Extracorporeal membrane oxygenation (ECMO) is an advanced form of temporary life support, to aid respiratory and/or cardiac function. It has been used since the early 1970s and...

Mode of neonatal death in an Irish maternity centre.

Modes of neonatal dying vary among maternity centres, both within and between countries. There have been few reports concerning mode of dying from countries with low rates of termination of pregnancy, such as Ireland. We conducted a retrospective chart review of all neonatal deaths, between January 2010 and January 2013, within a single Irish maternity centre. The mode of dying was classified as one of (1) withholding life-sustaining treatment (LST), (2) withdrawal of LST in moribund infants, (3) withdrawal of LST for quality of life reasons or (4) death despite maximal intensive care treatment. There were a total of 64 deaths during the study period. Congenital abnormalities accounted for 47% of deaths and prematurity for 41% of deaths. Withholding LST was the most frequent mode of dying, occurring in 38% of all deaths. A total of 12% of neonatal deaths occurred despite maximal intensive care treatment. Congenital abnormalities were the most common cause of neonatal deaths. A high proportion followed LST being withheld, most likely a reflection of the low rates of medical termination in Ireland. Modes of dying in the neonatal period vary between maternity centres with culturally different backgrounds.

S2003 Decreased Expression of RAS Protein Activator Like 1 in Gastric Cancer

moribund infant mice, and wild-type controls. Genes of interest and cell lineage markers were examined by immunohistochemistry. Results: Line 1 transgenic male pups are born and nurse but lose weight and die by 2-3 days of age. Their intestines lack normal color gradation and contain hemoccult and fat positive black fecal matter. Uniform ectopic expression of the transgene in the infant small intestine villi is associated with premature crypt formation, early sucrase-isomaltase expression, and greatly reduced lactase activity. Females have patchy transgene expression and are slightly, but significantly, smaller than wild-type females at weaning. Flag-tag positive villi arise from crypts that lack lysozyme positive paneth cells and, as previously reported, have expanded goblet cell size and number in adult mice. Line 5 transgenic pups of both sexes are runted and few survive to weaning. Dying pups have features similar to line 1. Loss of paneth cells and expanded goblet cells also occur with high transgenic expression. Pups are normal sized in line 4 that has very patchy transgene expression, and in line 6 that has extensive but lower expression levels of VillinCdx2. Paneth cell loss occurs in line 4 crypts with two adjacent Flag positive villi, but are retained in line 6. Conclusions: High over-expression of Cdx2 in the small intestine is associated with decreased postnatal growth and high mortality. Over-expression of Cdx2 during embryogenesis promotes epithelial maturation with early crypt development, enhanced sucrase-isomaltase, and diminished lactase expression. Moreover, the level of Cdx2 expression can direct differentiation toward the goblet cell and away from the paneth cell lineages. We conclude that Cdx2 expression plays important roles directing intestinal epithelial maturation, differentiation, and lineage selection in addition to effects on gene expression, cell adhesion, and cell proliferation.

S2005 LRBA: A Link Between Inflammation and Carcinogenesis in the Gastrointestinal Tract

moribund infant mice, and wild-type controls. Genes of interest and cell lineage markers were examined by immunohistochemistry. Results: Line 1 transgenic male pups are born and nurse but lose weight and die by 2-3 days of age. Their intestines lack normal color gradation and contain hemoccult and fat positive black fecal matter. Uniform ectopic expression of the transgene in the infant small intestine villi is associated with premature crypt formation, early sucrase-isomaltase expression, and greatly reduced lactase activity. Females have patchy transgene expression and are slightly, but significantly, smaller than wild-type females at weaning. Flag-tag positive villi arise from crypts that lack lysozyme positive paneth cells and, as previously reported, have expanded goblet cell size and number in adult mice. Line 5 transgenic pups of both sexes are runted and few survive to weaning. Dying pups have features similar to line 1. Loss of paneth cells and expanded goblet cells also occur with high transgenic expression. Pups are normal sized in line 4 that has very patchy transgene expression, and in line 6 that has extensive but lower expression levels of VillinCdx2. Paneth cell loss occurs in line 4 crypts with two adjacent Flag positive villi, but are retained in line 6. Conclusions: High over-expression of Cdx2 in the small intestine is associated with decreased postnatal growth and high mortality. Over-expression of Cdx2 during embryogenesis promotes epithelial maturation with early crypt development, enhanced sucrase-isomaltase, and diminished lactase expression. Moreover, the level of Cdx2 expression can direct differentiation toward the goblet cell and away from the paneth cell lineages. We conclude that Cdx2 expression plays important roles directing intestinal epithelial maturation, differentiation, and lineage selection in addition to effects on gene expression, cell adhesion, and cell proliferation.

Histologic dating of bruises in moribund infants and young children

It is generally held that leukocytes are found within bruised subcutaneous tissues within 4-12 h of injury as part of a standard cellular response to trauma. As a corollary, the absence of leukocytes is often cited as evidence of more recent injury. To investigate how long after injury it may be before a leukocyte response occurs selected bruises from three children aged 27, 11, and 3 months, respectively, were examined microscopically. All of the children had sustained lethal head trauma, with survival on life-support equipment for some time in hospital, and with bruises of at least 24-h duration confirmed by medical evaluation (at 30, 44, and 79 h from the time of initial medical evaluation to death). Histologic examination of selected lesions in all three cases revealed extravasation of red blood cells within subcutaneous tissues, but no leukocyte infiltration or other cellular reaction. Other bruises in these children exhibited a standard inflammatory response. This study has shown that selected bruises in three children were present for at least 30 h without a leukocyte infiltrate. Caution should, therefore, be exercised in assigning too rigid a time course to bruising in infants and young children based on a lack of a vital reaction, as the absence of leukocytes within soft tissues of bruised skin in these cases may not necessarily indicate that the injuries are recent. Variability in tissue response may also occur in different bruises in the same individual. Whether severe craniocerebral trauma played a role in delaying the cellular response in these particular injuries is unclear.

50 Years Ago in The Journal of Pediatrics: The value of transillumination in the diagnosis of hydraencephaly

Levin J. J Pediatr 1957;50:55-58 The author describes a newborn diagnosed in the first 2 months of life with hydraencepahly—a condition in which most of the cerebral cortex and white matter have been damaged, liquefied, and resorbed. Diagnosis of this child’s condition was prompted by macrocephaly and confirmed by a surgical burr hole, revealing a subdural membrane underneath which a probe could be passed without opposition to the other side. After surgery, an ordinary pen light was used to transilluminate the cranium and demonstrate the condition. The author points out the value of transillumination to diagnose hydraencephaly, which transilluminates well, and distinguishes such from hydrocephalus, in which transillumination is not manifest as often. Twenty years later in The Journal, transillumination using a Chun gun was described further to separate premature infants with hydrocephalus from those with “catch-up” head growth.1Vyhmeister N. Schneider S. Cha C. Cranial transillumination norms of the premature infant.J Pediatr. 1977; 91: 980-982Abstract Full Text PDF PubMed Scopus (6) Google Scholar Today we should recognize that transillumination, whether with a pen light, otoscope, or Chun gun, should be retired as a physical examination technique to diagnose these conditions. Ultrasonography will quickly identify hydrocephalus in newborns, as will computed tomography, yet computed tomography may not differentiate hydraencephaly from severe hydrocephalus. Brain magnetic resonance imaging will distinguish the remaining thin cortical rim in massive hydrocephalus from the fluid sac and lack of cortex in hydraencephaly. This distinction can be subtle but important, because the baby with severe hydrocephalus can improve after cerebrospinal fluid shunting procedures, unlike the moribund infant with hydraencephaly. Nevertheless, Levin’s report ironically points out what appears to be a timeless physical examination technique: measuring occipitofrontal circumference. Head circumference of 38.5 cm at 17 days of life was the herald for evaluation. As pediatricians, we often forget this “third anthropometric,” in deference to weight and height. Macrocephaly and microcephaly are early indicators of numerous neurologic conditions. Norms for head circumference are easy to remember, too. Boys and girls at term gestation are on average 35 and 34 cm, respectively, and then grow 2 cm/month in months 1 through 3, 1 cm/month in months 4 through 6, and .5 cm/month in months 7 through 12. In the third trimester, head circumference grows at 3 cm/month, and thus with subtraction the norms for many premature babies can be easily calculated. I would advocate that both parents and pediatricians boast not only of weight and height but also normal occiptofrontal circumference on newborns’ birth announcements. All hail head circumference!

Congenital cardiac emergencies

Cardiac emergencies are rare in children in comparison to adults. The pathophysiology differs; ischaemic heart disease is virtually unknown, whereas most congenital cardiac emergencies occur secondary to structural heart disease. Of the myriad lesions many decompensate in the perinatal period, usually in association with arterial duct closure. Subsequent rapid haemodynamic deterioration may lead to a moribund infant in extremis at presentation and with more home deliveries and early discharges such infants may present not only to paediatricians, but to accident and emergency departments, GPs and community midwives.

End-of-Life After Birth: Death and Dying in a Neonatal Intensive Care Unit

In canonical modern bioethics, withholding and withdrawing medical interventions for dying patients are considered morally equivalent. However, electing not to administer cardiopulmonary resuscitation (CPR) struck us as easily distinguishable from withdrawing mechanical ventilation. Moreover, withdrawing mechanical ventilation from a moribund infant "feels" different from withdrawing mechanical ventilation from a hemodynamically stable child with a severe neurologic insult. Most previous descriptions of withdrawing and withholding intervention in the neonatal intensive care unit (NICU) have blurred many of these distinctions. We hypothesized that clarifying them would more accurately portray the process of end-of-life decision-making in the NICU. We reviewed the charts of all newborn infants who had birth weight >400 g and died in our hospital in 1988, 1993, and 1998 and extracted potential ethical issues (resuscitation, withdrawal, withholding, CPR, do-not-resuscitate orders, neurologic prognosis, ethics consult) surrounding each infant's death. Using traditional definitions, roughly half of all deaths in our NICU in 1993 and 1998 were associated with "withholding or withdrawing." In addition, by 1998, >40% of our NICU deaths could be labeled "active withdrawal," reflecting the extubation of infants regardless of their physiologic instability. This practice is growing over time. However, 2 important conclusions arise from our more richly elaborated descriptions of death in the NICU. First, when CPR was withheld, it most commonly occurred in the context of moribund infants who were already receiving ventilation and dopamine. Physiologically stable infants who were removed from mechanical ventilation for quality-of-life reasons accounted for only 3% of NICU deaths in 1988, 16% of NICU deaths in 1993, and 13% of NICU deaths in 1998. Moreover, virtually none of these active withdrawals took place in premature infants. Second, by 1998 infants, who died without CPR almost always had mechanical ventilation withdrawn. Finally, the median and average day of death for 100 nonsurvivors who received full intervention did not differ significantly from the 78 nonsurvivors for whom intervention was withheld. In our unit, a greater and greater percentage of doomed infants die without ever receiving chest compressions or epinephrine boluses. Rather, we have adopted a nuanced approach to withdrawing/withholding NICU intervention, providing what we hope is a humane approach to end-of-life decisions for doomed NICU infants. We suggest that ethical descriptions that reflect these nuances, distinguishing between withholding and withdrawing interventions from physiologically moribund infants or physiologically stable infants with morbid neurologic prognoses, provide a more accurate reflection of the circumstances of dying in the NICU.

Characterization of successful and failed autoresuscitation in human infants, including those dying of SIDS

Our purpose was to identify and further characterize physiologic mechanisms relevant to autoresuscitation from hypoxic apnea in infants dying suddenly and unexpectedly. We studied cardiorespiratory recordings of 24 infants (age range, 0.8-21 months) who died suddenly while being monitored at home. These recordings were analyzed for features indicated by studies in animal models to be characteristic of hypoxic gasping, and of recovery from bradycardia and apnea associated with gasping (e.g., autoresuscitation). Findings in 5 infants diagnosed as having sudden infant death syndrome were compared with 6 non-SIDS infants whose deaths resulted from other conditions. Additionally, we studied 15 healthy infants during sleep, using home monitor and other respiratory recording techniques, in order to obtain comparison data. We found in recordings from 23 of 24 subjects that hypoxic gasps with characteristic features occurred immediately preceding death. A unique pattern of complex, closely spaced gasps ("double" or "triple" gasps) was present in many subjects. Evidence of partially successful autoresuscitation closely following one or more gasps occurred in 11 subjects, while another 4 had evidence of complete autoresuscitation with return of normal heart rate and resolution of apnea on one or more occasions. Significant differences between SIDS infants and those dying from other causes included increased occurrence of complex gasps and decreased occurrence of partial or complete autoresuscitation in the SIDS infants. The non-SIDS cases were different from the SIDS cases in that only one had "double" gasps (n = 7), while none had "triple" gasps, as compared with 4 out of 5 SIDS cases with these patterns (P < 0.05, chi-square). Also, in contrast with the SIDS cases, more of the cases with specific postmortem diagnoses had evidence of partial (5 out of 6 cases) or complete (1 out of 6 cases) autoresuscitation (P < 0.05, chi-square). We conclude that partial or complete autoresuscitation by gasping is not uncommon in moribund infants during the first year of life. Failure of autoresuscitation mechanisms other than failure to initiate gasping may be characteristic of infants dying of SIDS. Some SIDS infants appear to be different from infants dying with other diagnoses with respect to efficacy and characteristics of hypoxic gasping.

EXTRACORPOREAL MEMBRANE OXYGENATION 2001: The Odyssey Continues

Extracorporeal membrane oxygenation was established as a standard of care by demonstrating its ability to save lives in moribund infants. The designs of early studies provided no living cohorts of similarly ill patients by which to measure accurately other (and perhaps to many more important) outcomes of interest: long-term neurodevelopmental outcomes or cost. Prospective cohort studies of neurodevelopmental outcomes post-ECMO demonstrate: (1) because ECMO, as used, saves lives, there will be an increase in the absolute number of handicapped children surviving; (2) there is little evidence that ECMO creates a relative increase in the percent of handicapped children surviving severe respiratory failure. The high direct costs of an ECMO program are measured and well publicized. When such costs are compared with similar therapies in other fields (in such terms as cost per survivor), the cost of ECMO does not seem to be an outlier. Trials of newer therapies, such as iNO, show the capacity to decrease the use of ECMO but have failed to demonstrate either cost-effectiveness or better long-term outcomes. It has not been shown that either society or individual patients have benefited from the decreased need for ECMO.

Extracorporeal membrane oxygenation and neonatal respiratory failure: Experience from the extracorporeal life support organization

Extracorporeal membrane oxygenation (ECMO) has rescued moribund infants with respiratory failure from a variety of causes. We report the experience from 58 United States and 7 overseas ECMO centers between 1980 and 1989. Voluntarily submitted data forms provided details of diagnosis, clinical condition, ECMO indications, morbidity, and mortality. Of 3,528 infants with a predicted mortality > 80% treated with ECMO, 83% survived. Entry diagnoses and aggregate survival were: meconium aspiration syndrome (MAS) 1,356 (93%), persistent pulmonary hypertension of the newborn (PPHN) 480 (83%); congenital diaphragmatic hernia (CDH) 585 (62%); hyaline membrane disease (HMD) 532 (84%); sepsis 416 (77%); and other 185 (77%). ECMO indications were a-AdO 2 > 600 for 6 to 8 hours (22%), oxygenation index > 40 for 4 hours (18%), acute deterioration (14%), maximal therapy failure (34%), and barotrauma (1%). Annual survival improved over 9 years except for CDH, which decreased from 70% (1987) to 56% (1989) P < .01). Survivors differed from non-survivors ( P < .05) by birth weight ( > 2 kg), gestational age ( > 37 weeks), entry diagnosis (MAS, PPHN, HMD, sepsis v CDH), inborn versus outborn, pre-ECMO pH, and ECMO duration. Technical complications in 25% of patients and medical complications in 75% adversely affected survival. Annual sepsis survival improved to 75% (1989) but had significantly greater complication rates ( P < .05) than other diagnoses. Multicenter data yield information not available from single institution experience. Although entry criteria and conventional therapy continue to evolve, ECMO currently improves survival from an estimated 20% to 83% overall. Individual prognosis depends on entry diagnosis, clinical condition, and complications.

Effect of Extracorporeal Membrane Oxygenation on Leukocyte Function in Neonates

The impact of extracorporeal membrane oxygenation (ECMO) on neonatal leukocyte content and function was examined in six patients. Patients were treated with ECMO for a mean of 134 h (range 44-246 h). Absolute neutrophil counts decreased from 14679 +/- 2291/mm3 to 7791 +/- 1672/mm3 after 2 h of ECMO. However, neutrophil phagocytosis and oxidative burst remained unchanged during the first 48 h of bypass. Monocyte counts also decreased during bypass, and at times were undetectable in 50% of patients. Monocyte HLA-DR content was decreased compared to normal cord blood prior to initiation of ECMO, and remained low throughout ECMO. However, the content increased significantly after termination of bypass. Plasma C3a levels increased transiently, paralleled by an increase in neutrophil CR3 expression. While moribund infants had some impairment of host defenses prior to ECMO, there was no further impact of ECMO per se on the parameters measured, other than transient complement activation and decreased monocyte counts.

Selective use of extracorporeal membrane oxygenation in the management of congenital diaphragmatic hernia

Extracorporeal membrane oxygenation (ECMO) provides lung rest for moribund infants with congenital diaphragmatic hernia (CDH) after deterioration from a "honeymoon" period. This suggests that unstable pulmonary hypertension determines demise more than pulmonary hypoplasia. We avoided treating overwhelming pulmonary hypoplasia by using ECMO only if the premoribund condition had been marked by evidence of adequate lung parenchyma as a best preductal PO2 greater than 100 torr and PCO2 less than 50 torr with maximal therapy. Twenty-six CDH infants with respiratory distress within 4 hours survived operation. Five were not ECMO candidates, with best PO2 33 +/- 9, PCO2 157 +/- 30 torr, and died. Seven honeymoon infants, with best PO2 325 +/- 80, PCO2 27 +/- 5, survived without ECMO. Fourteen additional infants had honeymoon 26 +/- 13 hours with PO2 256 +/- 48, PCO2 30 +/- 8 followed by a-AdO2 gradients 600 torr x 16 +/- 4.5 hours despite maximal therapy. All 14 were treated with ECMO for 48 to 210 hours. Arterial blood gas values at initiation were PO2 34 +/- 6, PCO2 59 +/- 19, and pH 7.22 +/- 0.2. Right-to-left shunting due to pulmonary hypertension was documented by oximetry and two-dimensional echo/Doppler examination. Twelve of 14 (86%) ECMO-treated infants survived with normal arterial blood gas values on room air, no right-to-left shunting, and no gross neurologic sequellae to date. Two of 14 died. Improvement on ECMO was marked by positive hyperoxia response and decreased right-to-left shunting.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital diaphragmatic hernia

Posterolateral congenital diaphragmatic hernia (Bochdalek's hernia, CDH) that presents in the neonatal period is often manifest as life-threatening respiratory distress due to mechanical compression of the cardiopulmonary system by herniated viscera. Most patients can be supported through surgical reduction and repair with standard neonatal techniques. Postoperatively, many develop severe, refractory persistent pulmonary hypertension of the newborn (PPHN) after a variable period of adequate oxygenation. Despite aggressive ventilatory and pharmacologic maneuvers, a significant number of these infants develop fatal hypoxia and acidosis. At our institution, extracorporeal membrane oxygenation (ECMO) has been used as a therapy of last resort in 12 moribund infants with PPHN and respiratory failure after repair of CDH. There were 7 survivors. All long-term survivors [6] were totally weaned from ventilatory support; all met the criteria for nonsurvival as defined by Bohn et al. [2]. Eight patients (4 survivors) had no PaO2 greater than 100 torr postoperatively. ECMO can relieve the hypoxic and metabolic stimuli that aggravate pulmonary hypertension and provide cardiopulmonary support. It is the treatment of choice for infants who are deteriorating in the face of maximum conventional therapy after surgical correction. Lesions that were formerly denoted nonsurvivable can be effectively treated. It is urged that this therapy be used whenever necessary to sustain the life of an infant who has survived operation, regardless of whether the patient has demonstrated a “honeymoon” period, PaO2 greater than 100 torr, or any other factor conventionally thought to delineate survivable from nonsurvivable lesions. Such practices may exclude patients with survivable lesions from life-saving therapy.

Newborn transport in metropolitan Sydney: experience with a newborn intensive care unit based regional transport service.

ABSTRACT. The effect of skilled transport on the condition of 100 infants referred for intensive care and the factors affecting their survival were analysed. Infants with respiratory failure who were not moribund showed significant increases in pH (P &lt; 0.01) and arterial/alveolar P02 ratio (P &lt; 0.001) with assisted ventilation. Less severely ill infants were transported without significant change in pH and blood gas status. Hypoxaemia (17%), hyperoxaemia (24%) and hyperglycaemia (14%) were not uncommon on admission to the newborn intensive care unit.Survival rate did not decrease significantly with decreasing birth weight or gestation. Factors significantly more common in infants who died were one minute Apgar score 0–3 (P &lt; 0.05), and pH &lt; 7.25 (P &lt; 0.05) and PaCO2 &gt; 60 mmHg (P &lt; 0.005) on admission to the NICU. Infants mechanically ventilated before transport did not have a significantly higher mortality rate than those ventilated after admission, though moribund infants and those with untreated early onset bacterial pneumonia had high mortality rates.Pre‐transfer events were responsible for the death of 8 (38%) of the 21 infants who died and perhaps contributed to the death from intraventricular haemorrhage of a further 5 infants (24%).

Prostaglandin E1 Infusion in the Hypoplastic Left Heart Syndrome

Aortic infusion of prostaglandin E1 in a moribund infant resulted in marked clinical improvement. Appropriate studies were conducted and the diagnosis of hypoplastic left heart syndrome was made. Although the outcome was unaltered, the improved clinical condition allowed us to exclude potentially curable defects such as aortic coarctation and interruption.

Subdiaphragmatic total anomalous pulmonary venous drainage: Report of a successful surgical correction

The seventh reported case of successful surgical correction of total anomalous pulmonary venous drainage with subdiaphragmatic obstruction is presented. Angiographic confirmation of the diagnosis and identification of the site of obstruction was obtained prior to operation. Adequate investigation in a moribund infant was facilitated by the use of intermittent positive pressure ventilation. Surgical correction was achieved by anastomosis of the common pulmonary vein to the left atrium followed by ligation of the anomalous connection to the portal system. Early investigation of these critically ill infants is advocated, since without surgical intervention, the prognosis is hopeless.

Evaluation of a disposable plastic, low volume, pumpless oxygenator as a lung substitute

A simple, disposable plastic device, with a total priming volume as low as 30 ml. (20 ml. per kilogram) has been tested as a lung substitute for prolonged periods. Primed with saline, it is interposed between a single femoral artery and vein, with cardiac action as the sole pumping mechanism. Asphyxiated puppies have been maintained for eight hours. Preliminary studies on moribund infants with the respiratory distress syndrome indicate sufficiently good chemical results to warrant further trial.

A review of the management of intussusception in a pediatric center (1938-1958). Three hundred eighty-two consecutive cases.

Introduction Among patients admitted to a pediatric hospital with intussusception all degrees of severity of this disease are seen, from children with unexplained abdominal pain of short duration, to moribund infants who die before effective therapy can be instituted. Current reports have assessed the effectiveness of barium enema reduction in intussusception. 5,15,21,24,30 Other recent articles attest to the fact that intestinal resection may be performed in cases of irreducible or infarcted intussusception with a steadily decreasing mortality. 2,3,17,23 These two subjects seem pertinent to cases falling at the two extremes in the spectrum of disease severity; i.e., hydrostatic pressure reduction is applicable in the early, uncomplicated cases of intussusception, while resection becomes necessary in neglected or unusually malignant ones. The present study attempts to relate these currently prominent aspects of this disease to the general clinical problem of intussusception as seen in a pediatric center. A summary of the experience

EFFECT OF PENICILLIN IN THE TREATMENT OF INFANTILE CONGENITAL SYPHILIS

IN THE year that has elapsed since our preliminary note,¹122 additional cases of manifest congenital syphilis in children under 2 years of age have been treated by the university groups at New Orleans, Philadelphia, Baltimore and Galveston. This brings the total number now suitable for analysis to 191. Among these are 84 Negro boys, 84 Negro girls, 10 white boys and 13 white girls. The mean age at start of treatment was 164 days, with range from 11 days to 23 months. Pretreatment studies have been adequate for all, and no therapy other than intramuscular injection of penicillin has been employed. Total dosages have ranged from 770 to 150,000 units per kilogram of body weight; the smaller of these represents the amount received by a moribund infant of 5 weeks who died during the first day of treatment. The smallest total dosage received by any infant who completed