Neonatal Intensive Care Nursery Research Articles

Evaluation of a prescreening blood donor program for prevention of perinatal transfusion-acquired cytomegalovirus (CMV) infection.

The purpose of this study was to evaluate the efficacy of a prescreened CMV seronegative blood donor group in preventing transfusion-acquired CMV infection in premature infants in the perinatal period. Group 0 donors with known CMV seronegative status were recruited to supply blood to the neonatal intensive care nurseries. One hundred and twenty-seven low birth weight infants born of CMV seronegative mothers remained seronegative when blood for transfusion was screened for CMV antibody. Twenty two infants shared six units of CMV seropositive blood due to technical errors or poor sensitivity of the test kit in the initial phase of the study. Fifteen of these patients were in the study group. One infant died of immaturity at four weeks of age and two of the remaining 14 showed asymptomatic CMV infection. Another infant who received granulocyte concentrates from CMV seropositive donors had symptomatic CMV infection. Throughout the 24 month study period, blood supply to the ICN was adequate and timely. The donor seroconversion rate was 0.7% per annum. Only one infant was exposed to the risk of CMV infection due to donor seroconversion. We conclude that the prescreening donor program is a sensible and efficient approach for providing CMV seronegative blood in neonatal transfusion therapy.

Malignant pneumomediastinum: Successful tube mediastinostomy in the neonate

Five critically ill neonates underwent tube mediastinostomy in the neonatal intensive care nursery for tension pneumomediastinum. All of the neonates showed immediate clinical improvement, with a decrease in peak airway pressure and elevation of arterial oxygen pressure levels. There were no complications directly attributable to the procedure. We believe that pneumomediastinum in association with severe hypoxia, metabolic acidosis, and high ventilation pressures indicates clinically significant tension in the mediastinum. This results in a decrease in systemic blood pressure and pulmonary venous return that is not amenable to conservative management. Needle aspiration is inadequate because of the dynamic nature of the air leak. Tube decompression of the mediastinum is the treatment of choice in these circumstances.

Using intuitive knowledge in the neonatal intensive care nursery

Schraeder, Barbara D. Ph.D., R.N.; Fischer, Dorothy K. R.N.C., M.S.N. Author Information

Parent Outreach in a Neonatal Intensive Care Nursery

Parent Outreach in a Neonatal Intensive Care Nursery

Issues in early identification of hearing loss.

In a general hospital, an early detection research program based on a high risk register and brain stem electric response audiometry (BERA) using click and frequency-specific stimuli identified 631 at-risk neonates from the well baby nursery and the neonatal intensive care nursery (ICN). BERA tests were done before discharge and four months later; comparison of outcomes revealed substantial discrepancies. From the follow-up test, 51 cases of mild to severe hearing loss were identified. Experience from the research program has raised some issues relevant for establishment of service programs. Evaluation of all babies (general nursery and ICN) is justified on the basis of yield but is resource consuming; strategies for minimizing work load are discussed. Risk factor criterion levels affect case loading and yield. Frequency-specific BERA identifies cases which would not be detected by click stimuli and which raise management questions. Deferral of testing to four months is feasible and desirable.

A Complete Computerized Program for Nutritional Management in the Neonatal Intensive Care Nursery

A computerized program in BASIC, which integrates the infant's fluid and nutritional requirements per gestational age and weight with the infant's postpartum age, was developed using the Apple II Plus microcomputer, dual floppy disks, and an Epson printer. Daily requirements of fluids, proteins, fat, CHO, vitamins, minerals, and trace elements are computed. For reference, the program displays the composition and indications for intravenous and hyperalimentation solutions, mature human milk, and 14 commercial formulas. Safety limits to prevent overload or deficient formulations are strategically displayed, warning the physician about possible complications and gradually orienting him toward achieving adequate nutritional balance in the patient. The nutritional intake, weight, and other important clinical variables are stored and retrieved for future evaluation. The flexibility of the program allows for modifications in intravenous and oral composition according to clinical requirements. The program improves the efficiency of the arduous daily formulation of nutritional needs, reduces the possibility of human error, facilitates the calculation process, diminishes time spent on the calculations, and increases the ease of nutritional data retrieval and the development of output programs.

1447 COMPARATIVE METHODS OF EXTUBATION IN INFANTS

Atelectasis is a major cause of required reintubation in premature and sick newborns. Neonatal and anesthesia literature report up to 50% incidence of atelectasis in infants < 1.25kg., and 10%-25% in infants > 1.25 kg. Race, sex, time intubated and ventilator settings have not consistently predicted post-extubation atelectasis. Despite the lack of prospective studies comparing extubation methods, recommendations for bagging, suction and timing extubation with the respiratory cycle have been made. Our institution has undertaken a 12 month prospective study of all infants electively extubated in our Neonatal Intensive Care Nursery, excluding only infants with documented anomalies of the upper respiratory tract. Thus far 50 infants comprising 58 extubation episodes have been studied randomly divided into 5 groups: 1. extubation on patients' inspiration 2. extubation on expiration 3.extubation on inspiration with suction 4. extubation on expiration with suction 5. extubation with manual bagging. Radiographs were obtained on all infants 3 hours postextubation. Atelectasis occurlng > 3 hours post-extubation was felt to be unrelated to the method of extubation. The population was representative of a Level 3 ICN: 16(28%) infants were < 1.25 kg; 21(36%) infants were ≤ 30wks; 22(38%) were intubated ≥ 1 week; 34(59%) had HMD, 12(21%) had pneumonia/sepsis, and 12(21%) misc. (TTN, MAS asphyxia, etc.). Postextubation atelectasis occurred in 5(9%); 2 in group 2 and 1 in groups 3, 4, and 5. Preliminary results show a uniformly low incidence of postextubation atelectasis in our ICN, but do not suggest an optimal method of extubation.

1045 TRANSMISSION OF CYTOMEGALOVIRUS WITHIN A LARGE NEONATAL INTENSIVE CARE NURSERY

Acquired cytomegalovirus (CMV) infections are associated with significant morbidity and mortality for very low birthweight (LEW) infants, <1300gm, and infant-to-infant transmission has apparently occurred. Therefore, CMV acquisition by all infants hospitalized over 30 days was prospectively studied in a 60-bed neonatal intensive care nursery for 24 months. All newborn urines were cultured for CMV at birth and weekly until discharge. Sera from all LEW infants were assayed for IgG against CMV(EIA). All LEW infants lacking IgG against CMV (seronegative) received blood products from seronegative donors. Of 87 LEW infants born with IgG against CMV (seropositive), 7 acquired CMV while hospitalized. Of 71 LEW seronegative infants none acquired CMV (p<0.01 compared to seropositive infants). Infants with CMV viruria received no special isolation proceedures. No infant acquiring CMV received breast milk. EcoRI digestion of the DMAs of 13 CMV isolates from infants (acquired and congenital) during the last year showed no identical isolates. These results prove that transmission of CMV from infant to infant within a large neonatal intensive care unit occurs without significant frequency.

Endemic Serratia marcescens infection in a neonatal intensive care nursery associated with gastrointestinal colonization.

Serratia marcescens (SM) produced a prolonged outbreak in a neonatal intensive care unit of high level gastrointestinal colonization (10(9) SM/g feces) which in the early part of the outbreak predisposed to respiratory infection. The early outbreak featured a strain of SM carrying a 54 X 10(6) dalton conjugative plasmid which mediated resistance to gentamicin, tobramycin and beta-lactam agents. The second part of the outbreak involved primarily gastrointestinal colonization with SM strains that were plasmid-free. Acquisition of SM was related to very low birth weight (less than 1500 g). Among very low birth weight neonates, SM colonization was associated with pneumonia, patent ductus arteriosus, congestive heart failure and septicemia. Among neonates greater than 1500 g, SM colonization was associated with bronchopulmonary dysplasia, use of a respirator, patent ductus arteriosus and congestive heart failure. Respirator contamination, respiratory tract colonization and consequent pneumonia were reduced by more frequent changing of respirator tubing. Colonized sinks remained chronically colonized with multiresistant SM.

Coarctation of the aorta in the newborn: a clinical study.

The clinical findings and presentation in nine consecutive neonates in whom coarctation of the aorta was diagnosed over a period of two years were reviewed. Coarctation of the aorta constituted 16% of all infants with congenital cardiovascular malformations admitted to the Neonatal Intensive Care Nursery. The mean age on admission was 8.3 days. The admission findings included absent femoral pulses, 5; feeble femoral pulses, 4; differential blood pressure between upper and lower extremities, 9; congestive heart failure, 8; hypertension, 2; and failure to thrive, 1. Five of the infants died owing to refractory congestive heart failure at the mean age of 10.2 days. It is emphasized that palpation of the femoral pulse should be a routine examination in the neonatal period in order to detect coarctation of the aorta and that surgical intervention may be considered in cases refractory to medical management.

Persistent pulmonary hypertension of the newborn. Trends in incidence, diagnosis, and management.

Persistent pulmonary hypertension of the newborn ( PPHN ) has become a more commonly recognized problem in neonatal intensive care nurseries. In 62 neonates, 27 from 1980 and 35 from 1981, we compared classification, methods of diagnosis, modes of therapy, and survival. Thirty neonates (48%) had primary and 32 (52%) had secondary PPHN . Overall survival was 71% with significant differences in primary v secondary PPHN . Survival was also higher in 1981 than 1980 and was related to earlier diagnosis and to the more rapid initiation of therapy.

Noise Pollution in the Neonatal Intensive Care Nursery

Noise Pollution in the Neonatal Intensive Care Nursery

Nosocomial Klebsiella pneumoniae infection: clinical and hygienic measures in a neonatal intensive care unit.

An outbreak in a neonatal intensive care nursery of severe infections caused by Klebsiella pneumoniae type K-17 has been studied. Over a 9-month period 20 epidemiologically linked cases of severe septicemia, meningitis and pneumonia were diagnosed. The specific epidemic strain could be identified. After introduction of a policy of hygienic measures the nosocomial infection could be eradicated although colonization still occurred. Thorough handwashing before and after the nursing care of each infant, individual gowning and disposable gloves in the care of infants below 1 500 g were important. The changing bacterial ecology of a neonatal unit should be followed closely by weekly routine throat cultures as well as by cultures of incubators and ventilation equipment. The present investigation has shown the importance of this procedure, which is mandatory for appropriate choice of antimicrobial agents when treating infections in critically ill or very low birth weight infants in the neonatal intensive care unit. Prophylactic antimicrobial treatment is not indicated. Control of K. pneumoniae nosocomial infections can only be achieved by maintaining a high standard of hygiene in the neonatal care.

Neonatal hypotension: two years’experience in a neonatal intensive care nursery

Routine measurement of blood pressure in high risk neonates admitted to the intensive care nursery during a 2 year period resulted in detection of 18 infants with persistent hypotension requiring definitive treatment. The perinatal events in these babies were compared to those in a control group of infants. No single well defined factor responsible for neonatal hypotension could be found in the antenatal period or during labour. However 14 of the 18 babies were asphyxiated at the time of admission compared to 6 of 18 controls (p less than 0.02). Seventeen of 18 babies were preterm. Treatment consisted of maintenance of ventilation, oxygenation and acid-base status, volume expansion when indicated and inotropic agents. Nine of the 18 hypotensive babies died compared to 1 of 18 controls. Failure to respond within a few hours of commencement of treatment indicated poor prognosis.

Prematurity and the obstetrician: A regional neonatal intensive care nursery is not enough

Modem-day perinatal care has resulted in dramatically improved outcomes of premature infants, particularly those weighing 750 to 1,500 gm or of 27 to 32 weeks' gestational age. Assuming that the birth is not traumatic, the infant asphyxiated, or made hypothermic at birth, the chances of the very small premature baby developing normally are great. The delivery of an infant of ≤32 weeks' gestational age or weighing < 1,500 gm should occur at a perinatal center when possible.

Limited value of nephelometry in monitoring the administration of intravenous fat in neonates.

To evaluate the usefulness of nephelometry in predicting hyperlipidemia in neonates receiving intravenous fat (IVF), 23 infants in our neonatal intensive care nursery had simultaneous measurements of the serum IVF level (as determined by nephelometry), triglyceride, cholesterol, and free fatty acid/albumin molar ratio. There was a positive correlation between the serum IVF level and triglycerides, but the IVF level did not reliably predict elevated triglycerides, cholesterol, or free fatty acid-albumin molar ratio. Thus, neonates receiving IVF emulsions cannot be monitored by nephelometry alone. Adequate monitoring requires measurement of specific lipid fractions.

The prevalence of Clostridium difficile and toxin in a nursery population: A comparison between patients with necrotizing enterocolitis and an asymptomatic group

During a period when certain neonates in our nursery developed necrotizing enterocolitis, we studied stool specimens from a population of symptomatic and asymptomatic patients for the presence of Clostridium difficile and its toxin. The presence of the organism among nursery personnel and in the nursery environment was also evaluated. Results showed that five symptomatic neonates and 17 asymptomatic neonates in a population of 37 patients studied in our neonatal intensive care and intermediate care nurseries had positive stool cultures for C. difficile. Toxin was detected in stool from four of five symptomatic patients and was present at dilutions of greater than 1/125 in stool from six asymptomatic patients who were culture positive for C difficile. The organism was not found in stool samples from any nursery personnel but was recovered from the hand culture of a nursery worker and from the inanimate environment. Although our findings support the notion of nosocomial spread of C difficile, we were unable to clearly implicate the organism as the cause of necrotizing enterocolitis in our nursery.

Modifying Practices to Promote Family‐Centered Care in the Neonatal Intensive Care Nursery

ABSTRACT: The Alternative Birth Center (ABC) practice and outcomes at Mount Zion Hospital are described and compared to those in the regular labor and delivery area. In the ABC there were fewer cesareans, better Apgar scores at 1 and 5 minutes, less use of analgesia and anesthesia, but no significant difference in admissions of babies to the newborn intensive care nursery. The ABC has helped to make more flexible some of the newborn procedures. Several case histories are presented which illustrate ways that such care can be provided while responding appropriately to parents’concerns.

A New Cytomegalovirus Syndrome?

There have been several observations, some unpublished, of acquired cytomegalovirus (CMV) infection in small infants associated with pneumonitis and respiratory distress. These reports have received little attention because of the high frequency of inapparent CMV infection and the relative infrequency of confirmed disease acquired in early infancy. In this issue of theJournal(p 482), Ballard and her co-workers at the Mount Zion Hospital in San Francisco report an experience that began in July 1975, when they discovered three infants with CMV in their neonatal intensive care nursery. This led to a weekly survey of infants who had been in the nursery for more than 28 days. These findings are worthy of note. They isolated CMV from 16 of the 51 infants, an astounding 31.3%! To add to the interest, they found that 14 of the 16 virus-positive infants had symptoms that were remarkably similar. These included an unusual gray

Follow-up of preschool age survivors of neonatal intensive care.

High risk birth status is related to a number of subsequent deficits in development. Factors such as maternal education and economic status of the family are hypothesized to affect the development of high risk children. In this study preschool aged survivors (n = 18) of a neonatal intensive care nursery were compared to a randomly selected control sample (n = 18) on measures of intelligence, receptive language, and visual motor integration. No significant effects were found for birth status alone. A significant interaction between level of maternal education and birth status was found on the measure of intelligence.