Regional Neonatal Intensive Care Unit Research Articles

Gelatin Sign: Ultrasonographic Evidence of Cerebral Necrosis in Infants

Since its introduction, real-time ultrasonographic imaging of the neonatal brain has proven valuable in detecting a variety of pathologic and anatomic disturbances of the newborn brain.1-3 High resolution scanning heads, bedside technique, and video recording also allow study of the intracranial movement and responses to intrinsic and extrinsic forces. This paper reports six cases of infants with severe brain disease of widely different etiologies, in which abnormal response was found to cranial percussion, termed the "gelatin sign." MATERIALS AND METHODS A total of 506 consecutive real-time cranial ultrasound scans were obtained in 333 cases from a Level 3, regional neonatal intensive care unit. The scans were ordered by attending neonatologists to study the CNS in low birth weight infants and infants suspected of having intracranial disease.

Frequency and mechanism of neonatal thrombocytopenia

We performed a 1-year prospective study of 807 consecutive infants admitted to a regional neonatal intensive care unit to determine the frequency, natural history, mechanism(s), and cause of thrombocytopenia. Thrombocytopenia developed in 22% of the infants. The platelet count nadir usually occurred by day 4 and resolved by day 10. Possible mechanisms responsible for the thrombocytopenia were assessed by comparing mean platelet volume, platelet-associated IgG (PAIgG), and coagulation test results in those infants whose platelet count fell below 100 X 10(9)/L (n = 97) with values in age-, weight-, and disease-matched control infants without thrombocytopenia (n = 80). In some thrombocytopenic infants, 111In-labeled-platelet survival, an estimate of megakaryocyte number in bone marrow biopsy specimens obtained at autopsy, and response to platelet infusions were also assessed. The thrombocytopenia was caused by increased platelet destruction, as shown by short 111In-labeled-platelet survival (12 to 128 hours), a rising mean platelet volume during the first week of life, normal numbers of megakaryocytes, and a poorer than predicted response to platelet infusions. A potential cause for the thrombocytopenia could be found in the majority of infants: 52% had elevated levels of PAIgG, 21% had laboratory evidence of disseminated intravascular coagulation, and 12% had had exchange transfusions. In contrast, the control infants had normal coagulation assay results, and only 15% had elevated levels of PAIgG. Birth asphyxia was identified as an associated risk factor for thrombocytopenia. This study demonstrates that transient, destructive thrombocytopenia develops in a large proportion (22%) of infants admitted to a neonatal intensive care unit, and that birth asphyxia is an important risk factor.

COST OF NEONATAL INTENSIVE CARE FOR VERY-LOW-BIRTHWEIGHT INFANTS

A detailed costing of the Mersey regional neonatal intensive care unit was made for 1983 (at 1984 prices) for three levels of care; costs per inpatient day were £297, £138, and £71 for intensive, special, and nursery care, respectively. Regression of ungrouped patient-specific costs against birthweight showed the explanatory power of birthweight to be negligible. The average cost per very-low-birthweight (<1500 g) infant was £4490 for a survivor and £3446 for a non-survivor. A similar study elsewhere showed an almost six-fold difference in cost between survivors and non-survivors. It is postulated that medical management policy largely determines this difference and is crucial to any investigation of costefficiency.

Evaluation of strategy for testing thyroid function applied to hypothyroidism.

A strategy for testing thyroid function with discretionary assay of thyroid stimulating hormone (TSH) following initial measurement of total plasma thyroxine (tT4) was retrospectively evaluated in relation to the diagnosis of primary hypothyroidism. Over a two year period 14 641 tT4 assays were done and 6887 TSH assays, of which 29% were initiated in the laboratory. The percentage of raised TSH values (over 5 mU/1) was similar to those for clinician and pathologist initiated requests (23.2% and 23.6%). Some TSH requests (1620) were cancelled; when 212 of these were subsequently analysed the TSH value was raised in 5.7% The incidence of raised TSH values in 188 patients with a tT4 below 100 nmol/1 (7.8 micrograms/100 ml), in whom TSH was not requested, was 5.3% Most of these raised TSH results could be readily explained by information available to the requesting clinician but not given on the request form.

Evolution of neonatal intensive care in a district general hospital.

Before 1975 in Blackburn in the Premature Baby Unit monitoring facilities were limited. Ambient oxygen monitoring, blood gas analysis, and ventilation were not being performed. Gradually, special care was introduced and from 1978-80 all babies requiring intensive care and long term ventilatory care were transferred to the Regional Neonatal Intensive Care Unit. Not all babies with incipient or established respiratory failure, however, could be accepted, and those declined had unfavourable outcomes. In 1981 local intensive and ventilatory care was begun, and since then the survival of all babies has improved considerably. Our early neonatal mortality and neonatal mortality have fallen below the regional levels. In a district general hospital it is possible to achieve survival figures comparable with those of a regional centre.

INFECTION AND COLONISATION OF NEONATES BY HANSENULA ANOMALA

Over a 13-month period 52 neonates(10% of those admitted to the Mersey Regional Neonatal Intensive Care Unit) were found to be colonised with the ascosporagenous yeast Hansenula anomala. 8 babies became infected, all but 1 of whom were heavily colonised before infection. 7 of the 8 infected babies were of very low birth-weight (<1500 g). All 8 had multiple problems associated with low birth-weight and prematurity and were kept in the intensive care unit. 5 babies had fungaemia, 2 had fungaemia and ventriculitis, and 1 had ventriculitis only. In each case H anomala was the sole pathogen isolated. Anti- Hansenula antibodies developed in 5 babies within 3 months of infection. Infected babies were successfully treated with a combination of 5-flucytosine and amphotericin B. Despite extensive searches the babies appeared to be the only reservoir of the yeast.

Long-Term Morbidity of Infants With Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia occurred in 179 infants discharged from a regional neonatal intensive care unit between 1975 and 1982. Perinatal and outcome factors were compared for these study infants and a group of 112 controls matched for birth weight category and year of birth. There were multiple differences between study infants and controls in demographic, diagnostic, and therapeutic items, all of which were categorized as pulmonary items occurring before and after the development of bronchopulmonary dysplasia, and nonpulmonary items. The postdischarge death rate was 11.2% in infants and 0.9% in control infants (P less than .001). Ongoing morbidity was most marked in the areas of health history, physical examination, growth, and vision. Neurodevelopmental abnormalities and hearing abnormalities occurred slightly more frequently in study infants than in controls but not significantly so. Major developmental abnormalities were less frequent in this population than has been the case in other follow-up studies in this area. This group of infants requires close postdischarge observation because ongoing morbidity and postdischarge mortality, part of which may be preventable, are frequent.

Costs and outcomes in a regional neonatal intensive care unit

Costs and outcomes in a regional neonatal intensive care unit

Costs and outcomes in a regional neonatal intensive care unit.

At the Birmingham Maternity Hospital the mean cost of caring for surviving infants who require neonatal intensive care ranges from approximately pounds 2500 (for infants above 1500 g birthweight), to pounds 5500 (for infants 1000 to 1499 g birthweight), to pounds 10 000 (for infants less than 1000 g birthweight). The mean cost of caring for non-survivors is pounds 1000 or less, with little difference between the birthweight groups. These figures are based on the lengths of stay in three treatment regimens-intensive care, high dependency care, and special care-the average daily costs of which are estimated to be pounds 235, pounds 122, and pounds 43 respectively. The survival of very low birthweight infants (less than 1500 g) at this hospital has improved from 42% to 73% since the introduction of regional funding for neonatal intensive care. This increase in survival has been brought about without undue disability in the survivors.

Improving the Outcome of Pregnancy

PREVAILING perspectives on the care of pregnant women and their newborns (or perinatal care) too often start and stop with medical treatment of complicated pregnancies or premature births. Perinatal care is typically defined narrowly as being (1) hospital based and (2) centered around regional neonatal intensive care units (NICUs).1 This reductionist orientation minimizes the full range of maternal and infant care and ob

Chorangiosis. An Important Placental Sign of Neonatal Morbidity and Mortality

Chorangiosis is a placental change that has not been studied, to my knowledge, by investigators who publish in English. It occurs rarely in normal pregnancies. Each year, however, more than 30,000 neonates in the United States die within the first 28 days of life. Of 1,350 singleton newborns hospitalized in a regional neonatal intensive care unit, 74 (5%) had chorangiosis. One hundred thirty-four informational items of clinical, placental, and autopsy data were evaluated with a computer program written in Microsoft Basic. Depending on the gestational age of the population studied and the severity of the chorangiosis, the incidences of neonatal death and major congenital malformations were as high as 39% and 42%, respectively. Detailed findings introduce question of etiologic association with gestational diabetes, toxemia of pregnancy, and placental infection.

Maternal attitudes to transfer before delivery

Abstract One hundred and one women provided, anonymously, retrospective information concerning their antenatal transfer from district general hospital to a central hospital housing the Regional Neonatal Intensive Care Unit. 94% consider their transfer to have been worthwhile, including 83% of those whose babies did not survive. 85% of those whose infants were born alive think that the transfer vitally enhanced their relationship with the child when compared with the alternative of postnatal transfer of the neonate. About half, however, have incorrectly attributed the successful outcome of the pregnancy to expertise and superior facilities at the central hospital. Because this may have an important effect upon the management of their future pregnancies, patients who have been transferred antenatally should be advised as to the eventual significance of this part of their management.

Neonatal Loss in the Intensive Care Nursery: Effects of Maternal Grieving and a Program for Intervention

This paper describes the reactions of 38 mothers whose infants died in a regional transport neonatal intensive care unit. Most described their infant's death as having a major impact on their functioning, although the impact had lessened by 9 months following the loss. In an attempt to help parents whose infant was about to die, a “neonatal hospice program” was implemented. Maternal report indicated that the program had increased staff involvement with families both during and following the infant's death and these additional contacts were described as helpful by most of the women interviewed.

Outcome for newborn babies declined admission to a regional neonatal intensive care unit.

Between July 1979 and June 1980 the regional neonatal intensive care unit (NICU) at St Mary's Hospital, Manchester, received 170 requests from maternity units for the transfer of ill newborn babies. Most of the babies were suffering from respiratory failure. The initial request was declined in 65 babies because of overcrowding or lack of facilities at the NICU (n = 59), or because transfer was not justified on medical grounds (n = 6). Forty-two of the 65 babies were compelled to remain in the maternity unit because they could not be accommodated at hospitals with facilities for ventilating newborn babies. The neonatal survival rate of babies with respiratory failure who were transferred to the NICU was 66% whereas the survival rate of similar babies who were declined transfer was 30%. Our findings support the efficacy of intensive care for ill babies with respiratory failure and suggest that such facilities need to be more widely developed.

Pathophysiology of intracranial haemorrhage in the newborn.

Intracranial haemorrhage accounts for a significant proportion of neonatal mortality. Most forms of intracranial haemorrhage occur more frequently in low birthweight infants, but there is no stage of maturity or nutritional Status at which any infant is free of risk of developing some form of intracranial haemorrhage during the perinatal period. The major focus of interest in this field in recent years has been the problem of intraventricular haemorrhage (IVH) in the preterm infant, particularly since the development of regional neonatal intensive care units (NICUs). Cerebellar haemorrhages have been recognized as another important form of pathology in low birthweight infants [41,62,67]. The preoccupation of perinatologists with intensive care of the low birthweight infant has to some extent caused a loss of interest in the classiclesions of subdural haemorrhage developing in association with birth trauma. Such forms of haemorrhage do however still occur with sufficient frequency to justify further discussion, particularly since the lesions are potentially preventable. In this review we will consider the pathophysiology of the major forms of intracranial haemorrhage which occur in the newborn, according to their site rather than on the basis of any prior assumption as to their cause. Curriculum vitae

Effects of Early Intervention and Stimulation on the Preterm Infant

To test the hypothesis that early intervention can enhance the development of high-risk preterm infants, a prescribed multimodal sensory enrichment program, within a regional neonatal intensive care unit, was designed and implemented. Twenty-eight appropriate-for-gestational age infants with birth weights between 1,200 and 1,800 gm were selected for study. To prevent control group contamination by the enrichment procedure the first 14 infants were designated as the control group, and the next 14 as the treatment group. Treated infants had significantly higher developmental status than control infants, as measured by the Bayley Scales of Infant Development, at six months past the maternal expected date of confinement (F = 14.98, P < .001, and F = 16.46, P < .001 for the mental and motor scales, respectively). Mean infant weight gain per day and mean total weight gain during the hospitalization were not significantly different for the two groups although the treatment group received significantly less calories per kilogram per day than the control group (F = 9.02 P < .006). Our data suggest that a prescribed intervention program for high-risk preterm infants appears to enhance the quality of development as measured at six months past the expected date of confinement. Further studies are necessary to determine the long-term value of early intervention and the apparent ability of infants receiving an enrichment program to utilize calories more efficiently than control infants.

Clinical Predictability of Intraventricular Hemorrhage in Preterm Infants

Ninety-eight infants of less than 35 weeks' gestation, consecutively admitted to a regional neonatal intensive care unit, were followed prior to computerized tomography (CT) scan for clinical signs of subependymal and/or intraventricular hemorrhage. The presence or absence of intracerebral hemorrhage was confirmed by CT scan in all patients, and the severity of hemorrhage was quantitated as mild, moderate, or marked. Thirty-seven out of 98 infants (38%) demonstrated intracerebral hemorrhage on CT scan; 20 of 37 (54%) were predicted clinically. Clinical predictability was related to severity of hemorrhage as quantitated by CT scan. Clinical signs that were found helpful in predicting subependymal and/or intraventricular hemorrhage were fall in hematocrit, failure of rise in hematocrit with transfusion of packed red blood cells, tight fontanel, decrease in spontaneous activity, decreased tone, abnormal eye signs, and seizures.

Regional organisation of neonatal intensive care in the North-west

From January 1976 to July 1978, 234 ill neonates were transported to the regional neonatal intensive care unit (ICU) of St Mary's Hospital, Manchester, from 26 maternity hospitals three to 120 miles (4.8-193.1 km) away. Ninety per cent were transferred from 15 hospitals within a 30-mile (48.3 km) radius of the ICU. Most referring hospitals had more than 2000 births a year and offered good nursing supervision of high-risk neonates in conventional special care baby units (SCBUs). In 200 of the 234 babies respiratory symptoms precipitated referral, hyaline membrane disease being the most common final diagnosis. Altogether 143 babies received definitive mechanical ventilation, and most of them were ventilated in the ambulance en route to the ICU. The neonatal survival rates for all babies and for those who received mechanical ventilation were 61% and 45% respectively. Lethal inoperable malformations and tentorial tears accounted for 23 of the 92 deaths.A crisis-orientated referral service directed towards the treatment of babies with impending or actual respiratory failure needs close collaboration between the regional ICU and referring SCBUs, with parallel development of their facilities and skills. A complementary but distinct pattern of referral is necessary to cater for those high-risk but not critically ill babies who are born in hospitals that lack staff and facilities to provide the vigilant and anticipatory care that is so necessary.

Do we support parents of high-risk infants? A survey.

The establishment of regional neonatal intensive care units has reduced physical and mental handicaps in premature infants, but has caused emotional and psychological strain on parents because of frequently lengthy separation of mother and child. The study was undertaken to learn what is currently being done to support parents of high-risk infants. A questionnaire survey showed that prenatal screening was performed by only a few institutions. Not all nurseries employed full-time social workers. Such full-time status was no guarantee that all parents were interviewed and given support. Furthermore, requests for public health nurses to make predischarge and postdischarge home visits were not universally made.

1143 HYPOGLYCORRHACHIA ASSOCIATED WITH INTERCRANIAL HEMORRHAGE (ICH) IN THE NEWBORN

During 1977 four newborns who developed severe hypoglycorrhachia associated with ICH were seen at the Regional Neonatal Intensive Care Unit of the University of Florida. These infants represented 20% of all infants diagnosed as having ICH in our unit during the past year. CSF cultures were negative in each case. All hemorrhages were confirmed by CAT scan. As noted in the Table the hypoglycorrhachia occurred from 3-14 days after there was clinical evidence of the bleed. In each case the hypoglycorrhachia persisted for weeks. Two babies with frequent taps had 0 mg% CSF glucose for at least three days which was associated with the peak WBC and protein elevation. We feel the decreased CSF glucose in these infants was secondary to the ICH. Similar findings have also been noted in adults after ICH. The association of hypoglycorrhachia and ICH should be taken into account when caring for high risk infants.