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PubMed2003

Neonatal hyperbilirubinemia and its association with thyroid hormone levels and urinary iodine excretion.

OBJECTIVE: To investigate, if, urinary iodine contents as a marker of iodine deficiency and hypothyroidism are associated with the incidence of neonatal hyperbilirubinemia. METHODS: One hundred neonates with total serum bilirubin > or = 15 mg/dl and with no known cause of jaundice were included in the study as a jaundice group. An equal number (n = 100) of non-jaundiced neonates (bilirubin < or = 14.9 mg/dl) with matching for age, gestation period and weight were enrolled in the study as a control group. RESULTS: Thirteen neonates (13%) in the study group had urinary iodine levels < 100 mg/dl as against only 2 (2%) in the control group (p < 0.05). Thirty-four (34/200-17%) neonates i.e. 17 each in the study and control groups had serum TSH > 5 mU/ml and hence an indirect indicator of iodine deficiency in the study population. The mean serum levels of total T3, T4 and TSH in the study neonates were 1.52 +/- 1.23 ng/ml, 15.8 +/- 12.0 micrograms/dl & 3.13 +/- 3.0 mU/ml respectively and did not differ significantly from the mean levels in the control group. Only one neonate in the study group had serum TSH > 20 mU/ml which was suggestive of hypothyroidism, but had normal T3 & T4. Seven neonates in the study group and 8 in the control group had low T4. There was no significant correlation between the maternal and neonatal urine iodine levels, thyroid functions and the bilirubin levels (p > 0.01). CONCLUSION: The jaundiced babies had lower urine oidine levels than the control population. Since, there was no significant difference in the levels of the thyroid hormones, no cause and effect relationship could be inferred between iodine deficiency and jaundice.

Bilirubin↗
PubMed1996

[What is the choice of training in neonatal intensive care? Analysis of wishes from 106 neonatologists].

BACKGROUND: Improvement of the care to the neonate relys on an increased number of pediatricians in nurseries and adequate neonatal resuscitation training. METHODS: A questionaire about the optimal modes of neonatal resuscitation training was sent to 132 pediatricians in charge of a neonatal unit or a neonatal intensive care unit. Response rate was 80.3%. RESULTS: The training program was targeted to be regional for the organization and for the evaluation. Nevertheless, 41% of answers also favored local evaluation. Duties in neonatal intensive care unit or transportation system, with differences among areas, were the proposed training choices. The pediatrician was considered to be the first person as an instructor and also as a learner in a multidisciplinary training program. Cooperation between primary and tertiary centers physicians was proposed as the best way for training. Proposed criteria for evaluating training efficacy included neonatal mortality and meconium aspiration syndrome rates. Government funding was suggested in 92% of answers. CONCLUSION: It seems necessary to perform a wide neonatal resuscitation training program. This multidisciplinary approach should be regional and follow the guidelines of the neonatal study group.

France↗
PubMed2004

Twins and triplets: the effect of plurality and growth on neonatal outcome compared with singleton infants.

OBJECTIVE: Information on outcome by gestational age from large numbers of twins and triplets is limited and is important for counseling and decision-making in obstetric practice. We reviewed one of the largest available neonatal databases to describe mortality and morbidity rates and growth in newborn infants from multiple gestations and compared these data with data for singletons. STUDY DESIGN: Data from a large prospectively recorded neonatal database that incorporated neonatal records from January 1997 to July 2002 were reviewed. We evaluated birth weight and neonatal mortality and morbidity rates that affected long-term outcome for each week of gestational age from 23 to 35 weeks of gestation for all nonanomolous inborn twins and triplets who were admitted to the neonatal intensive care unit and compared these data to all singletons who met similar criteria during the same time period. RESULTS: There were 12,302 twin and 2155 triplet births that met the entry criteria. The data for these newborn infants were compared with 36,931 singletons. Average birth weights at each gestational week were similar for all gestational ages until 29 weeks of gestation for triplets and 32 weeks of gestation for twins. After these gestational ages, the entire difference between twins and singletons was due to the weight of the smaller twin; the larger twins' mean weights were similar to singletons at all weeks that were studied. Birth order at each week also did not affect neonatal mortality rates, even when corrected for route of delivery and antenatal steroids. Neonatal morbidities associated with adverse long-term outcomes (intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis) were also not different between multiple infants and singletons. Intrauterine growth restriction (IUGR) was associated with increased mortality rates at all gestational ages, but in the absences of IUGR, discordance was not. CONCLUSION: Data on a large number of twins and triplets provide reassurance that neonatal outcome at all viable premature weeks of gestation are similar to singletons. Intrauterine growth restriction and prematurity are therefore the principal issues that drive neonatal mortality and morbidity rates in multiple gestations. These data are important for obstetric decision-making and patient counseling.

Birth Weight↗
PubMed2002

Evaluation of 6-year application of the enzymatic colorimetric phenylalanine assay in the setting of neonatal screening for phenylketonuria.

BACKGROUND: Most reports on phenylketonuria (PKU) screening focused solely on the result of the initial investigation of the neonatal screening sample. The aim of this study was to evaluate an enzymatic phenylalanine (Phe) determination in the whole context spanning from the initial investigation over the recall period, up to the confirmation or exclusion of the disease. METHODS: Phe of dried blood spot specimens was analysed colorimetrically in a microtitre-plate assay based on the L-phenylalanine dehydrogenase reaction coupled with an intermediate electron acceptor system. This assay was evaluated for analytical variables and for neonatal PKU screening in a total number of 423,773 neonates during a 6-year period. RESULTS: Method validation with respect to linearity, precision (within-run CVs 3.4-4.2%, between-run CVs 6.2-10.4%), and accuracy fulfilled all requirements for a screening method. Mean Phe (+/-SD) of 130,000 healthy neonates was 84 (+/-22) micromol/l with a cut-off point (mean+3 SD) of 150 micromol/l. From 423,773 neonates, hyperphenylalaninemia was confirmed in 155 cases and further differentiated into PKU (41 cases, 27%), BH(4) deficiency (3, 2%), non-PKU HPA (67, 43%), transient neonatal HPA (28, 18%), and secondary HPA (16, 10%). The number of false-positives (recall-rate) was 0.23%, and no false-negatives were noted. CONCLUSIONS: Detailed studies over a period of 6 years including more than 400,000 neonates clearly show that the enzymatic assay is a reliable and sensitive method for neonatal screening of PKU. The proven prevalence of non-PKU HPA in the German population disclosed by the assay was twice as high as compared to the "Guthrie test" used previously. The growing use and application of tandem mass spectrometry in neonatal screening will not derogate the usefulness of the enzymatic assay in PKU screening in the foreseeable future. Careful analysis of our screening results and monitoring of all pathological samples resulted in an evidence-based flow chart for a rational PKU screening.

Amino Acid Metabolism, Inborn Errors↗
PubMed1999

Long-term behavioral effects of repetitive pain in neonatal rat pups.

Human preterm neonates are subjected to repetitive pain during neonatal intensive care. We hypothesized that exposure to repetitive neonatal pain may cause permanent or long-term changes because of the developmental plasticity of the immature brain. Neonatal rat pups were stimulated one, two, or four times each day from P0 to P7 with either needle prick (noxious groups N1, N2, N4) or cotton tip rub (tactile groups T1, T2, T4). In groups N2, N4, T2, T4 stimuli were applied to separate paws at hourly intervals;each paw was stimulated only once a day. Identical rearing occurred from P7 to P22 days. Pain thresholds were measured on P16, P22, and P65 (hot-plate test), and testing for defensive withdrawal, alcohol preference, air-puff startle, and social discrimination tests occurred during adulthood. Adult rats were exposed to a hot plate at 62 degrees C for 20 s, then sacrificed and perfused at 0 and 30 min after exposure. Fos expression in the somatosensory cortex was measured by immunocytochemistry. Weight gain in the N2 group was greater than the T2 group on P16 (p < 0.05) and P22 (p < 0.005); no differences occurred in the other groups. Decreased pain latencies were noted in the N4 group [5.0 +/- 1.0 s vs. 6.2 +/- 1.4 s on P16 (p < 0.05); 3.9 +/- 0.5 s vs. 5.5 +/- 1.6 s on P22 (p < 0.005)], indicating effects of repetitive neonatal pain on subsequent development of the pain system. As adults, N4 group rats showed an increased preference for alcohol (55 +/- 18% vs. 32 +/- 21%; p = 0.004); increased latency in exploratory and defensive withdrawal behavior (p < 0.05); and a prolonged chemosensory memory in the social discrimination test (p < 0.05). No significant differences occurred in corticosterone and ACTH levels following air-puff startle or in pain thresholds at P65 between N4 and T4 groups. Fos expression at 30 min after hot-plate exposure was significantly greater in all areas of the somatosensory cortex in the T4 group compared with the N4 group (p < 0.05), whereas no differences occurred just after exposure. These data suggest that repetitive pain in neonatal rat pups may lead to an altered development of the pain system associated with decreased pain thresholds during development. Increased plasticity of the neonatal brain may allow these and other changes in brain development to increase their vulnerability to stress disorders and anxiety-mediated adult behavior. Similar behavioral changes have been observed during the later childhood of expreterm neonates who were exposed to prolonged periods of neonatal intensive care.

Adrenocorticotropic Hormone↗
PubMedDate not supplied

4 million neonatal deaths: when? Where? Why?

The proportion of child deaths that occurs in the neonatal period (38% in 2000) is increasing, and the Millennium Development Goal for child survival cannot be met without substantial reductions in neonatal mortality. Every year an estimated 4 million babies die in the first 4 weeks of life (the neonatal period). A similar number are stillborn, and 0.5 million mothers die from pregnancy-related causes. Three-quarters of neonatal deaths happen in the first week--the highest risk of death is on the first day of life. Almost all (99%) neonatal deaths arise in low-income and middle-income countries, yet most epidemiological and other research focuses on the 1% of deaths in rich countries. The highest numbers of neonatal deaths are in south-central Asian countries and the highest rates are generally in sub-Saharan Africa. The countries in these regions (with some exceptions) have made little progress in reducing such deaths in the past 10-15 years. Globally, the main direct causes of neonatal death are estimated to be preterm birth (28%), severe infections (26%), and asphyxia (23%). Neonatal tetanus accounts for a smaller proportion of deaths (7%), but is easily preventable. Low birthweight is an important indirect cause of death. Maternal complications in labour carry a high risk of neonatal death, and poverty is strongly associated with an increased risk. Preventing deaths in newborn babies has not been a focus of child survival or safe motherhood programmes. While we neglect these challenges, 450 newborn children die every hour, mainly from preventable causes, which is unconscionable in the 21st century.

Adolescent↗
PubMed2003

Maternal methadone dose and neonatal withdrawal.

OBJECTIVE: The purpose of this study was to determine whether maternal methadone dosage correlates with neonatal withdrawal in a large heroin-addicted pregnant population. STUDY DESIGN: A retrospective review of all maternal/neonatal records of pregnancies that were maintained on methadone therapy in our institution was conducted. After in-hospital stabilization, women were given daily methadone therapy under direct surveillance, with liberal dosage increases according to maternal withdrawal symptoms. Neonatal withdrawal was assessed objectively by the neonatal abstinence score. The average methadone dose in the last 12 weeks of pregnancy and the last methadone dose before delivery (cutoffs of 40, 60, or 80 mg) were correlated to various objective measures of neonatal withdrawal. RESULTS: One hundred mother/neonate pairs on methadone therapy were identified. Women who received an average methadone dose of <80 mg (n=50 women) had a trend toward a higher incidence of illicit drug abuse before delivery than women who received doses of >/=80 mg (n=50 women; 48% vs 32%; P=.1). Women who received an average methadone dose of <80 mg had similar highest neonatal abstinence score, need for neonatal treatment for withdrawal, and duration of withdrawal compared with women whose condition was maintained with dosages of >/=80 mg (score, 11.1 vs 11.5; 68% vs 66%; and 13.3 vs 13.6 days, respectively; all P>.5). For all cutoffs that were used for high versus low dose and for both the average and last methadone dosage analyses, neonatal withdrawal was similar. CONCLUSION: The maternal methadone dosage does not correlate with neonatal withdrawal; therefore, maternal benefits of effective methadone dosing are not offset by neonatal harm.

Benzodiazepines↗
PubMed2006

A Quisling on neonatal jaundice.

BACKGROUND/METHODS: Nils Andreas Quisling was born in Telemark, Norway, in 1854 and became an obstetrician. In 1893 he published a monograph on neonatal jaundice. This monograph was studied and compared with other published sources from the same time period. RESULTS: Quisling discussed four theories on the cause of neonatal jaundice. "Suppression jaundice" held that jaundice was the result of suppressed liver function. "Haematogenous jaundice" claimed that bilirubin was formed from haemoglobin outside the liver, and had nothing to do with the liver. "Polycholia" held that neonatal jaundice was due to an increased secretion of all the constituents of bile. Quisling rejected these and supported the "hepatogenous" theory-jaundice was always a liver-related phenomenon. He described 50 cases of neonatal jaundice. The incidence of neonatal jaundice at the Kristiania Maternity Foundation was 26%. In Quisling's cases, gastrointestinal disturbances were common, and he felt this to be an under-reported complication of neonatal jaundice. He found that neonatal jaundice was often accompanied by fever. CONCLUSION: Gastrointestinal disturbances were causally involved in neonatal jaundice, resulting in impeded bile drainage. At the time of Quisling's study (1887), this "hepatogenous" theory of neonatal jaundice probably still had majority support in the European literature.

History, 19th Century↗
PubMed2006

Outbreak of methicillin-resistant Staphylococcus aureus colonization and infection in a neonatal intensive care unit epidemiologically linked to a healthcare worker with chronic otitis.

OBJECTIVE: To describe the investigation and interventions necessary to contain an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in a neonatal intensive care unit (NICU). DESIGN: Retrospective case finding that involved prospective performance of surveillance cultures for detection of MRSA and molecular typing of MRSA by repetitive-sequence polymerase chain reaction (rep-PCR). SETTING: Level III NICU in a tertiary care center. PARTICIPANTS: Three neonates in a NICU were identified with MRSA bloodstream infection on April 16, 2004. A point prevalence survey identified 6 additional colonized neonates (attack rate, 75% [9 of 12 neonates]). The outbreak strain was phenotypically unusual. INTERVENTIONS: Cohorting and mupirocin therapy were initiated for neonates who had acquired MRSA during the outbreak. Contact precautions were introduced in the NICU, and healthcare workers (HCWs) were retrained in cleaning and disinfection procedures and hand hygiene. Noncolonized neonates and newly admitted patients had surveillance cultures performed 3 times per week. RESULTS: Two new colonized neonates were identified 1 month later. HCW X, who had worked in the NICU since June 2003, was identified as having chronic otitis. MRSA was isolated from cultures of swab specimens from HCW X's ear canal and nares. HCW X was epidemiologically linked to the outbreak. Molecular typing (by rep-PCR) confirmed that the isolates from HCW X and from the neonates were more than 90% similar. Retrospective review of NICU isolates revealed that the outbreak strain was initially cultured from a neonate 2 months after HCW X began working on the unit. The epidemic strain was eradicated after removing HCW X from patient care in the NICU. CONCLUSION: An outbreak of MRSA colonization and infection in a NICU was epidemiologically linked to a HCW with chronic otitis externa and nasal colonization with MRSA. Eradication was not achieved until removal of HCW X from the NICU. Routine surveillance for MRSA may have allowed earlier recognition of the outbreak and is now standard practice in our NICU.

Bacteremia↗
PubMed2001

Plasma free fatty acids in neonates with congenital hypothyroidism.

Since the introduction of neonatal mass screening for congenital hypothyroidism (CH), numerous cases have been detected. It is of interest that even severely hypothyroid neonates rarely exhibit bradycardia, hypothermia, or inactivity, which have been recognized as typical signs of CH. Regarding neonates and young infants, few reported data are available on the effects of thyroid hormones on energy expenditure. Plasma free fatty acids (FFAs), markers for lipolysis, play essential roles in maintaining physiologic homeostasis. To study fuel utilization in CH neonates, we measured heart rates, plasma FFA, and thyroid hormones before and after levothryoxine (LT4) replacement therapy. Fifty-five screen-detected CH neonates and 29 age-matched normal neonates for controls were enrolled. The CH neonates were divided into two groups according to serum thyroid hormone levels: a mildly hypothyroid group (n = 37), serum thyrotropin (TSH) less than 100 microIU/mL and free thyroxine (FT4) 0.6 ng/dL or more; and a severely hypothyroid group (n = 18), TSH 100 microIU/mL or more and FT4 less than 0.6 ng/dL. Twenty-four of the 55 patients had their heart rates measured by electrocardiography. Fasting blood samples were taken from the subjects during physical movements. Serum levels of TSH, FT4, FFA, and other blood chemicals, measured on an autoanalyzer system in our hospital, were compared before and after LT4 substitution therapy. The following results were obtained. The mean plasma FFA values before LT4 replacement were 208.5 +/- 89.4 microEq/L in the mildly hypothyroid group, 228.5 +/- 114.7 microEq/L in the severely hypothyroid group, and 213.9 +/- 97.7 microEq/L in controls. No statistical differences were noted among the three values. Two months after LT4 replacement therapy, at the age of 3 months, plasma FFA concentrations significantly increased in both groups compared with those before the therapy. Control infants also showed a significant increase in plasma FFA concentrations from 1 to 3 months of age. There were no significant differences in plasma FFA concentrations among the three groups at the age of 3 months. No significant correlations were found between plasma FFA and serum thyroid hormones. From these results it is suggested that in neonates and young infants, thyroid hormones do not play major roles in mobilization of fats through the adrenergic regulation of lipolysis for energy supply. This may be one of the reasons for the unexpectedly mild signs and symptoms in the screen-detected hypothyroid neonates.

Congenital Hypothyroidism↗
PubMed2006

Neonatal animal models of opiate withdrawal.

The symptoms of opiate withdrawal in infants are defined as neonatal abstinence syndrome (NAS). NAS is a significant cause of morbidity in term and preterm infants. Factors, such as polysubstance abuse, inadequate prenatal care, nutritional deprivation, and the biology of the developing central nervous system contribute to the challenge of evaluating and treating opiate-induced alterations in the newborn. Although research on the effects of opiates in neonatal animal models is limited, the data from adult animal models have greatly contributed to understanding and treating opiate tolerance, addiction, and withdrawal in adult humans. Yet the limited neonatal data that are available indicate that the mechanisms involved in these processes in the newborn differ from those in adult animals, and that neonatal models of opiate withdrawal are needed to understand and develop effective treatment regimens for NAS. In this review, the behavioral and neurochemical evidence from the literature is presented and suggests that mechanisms responsible for opiate tolerance, dependence, and withdrawal differ between adult and neonatal models. Also reviewed are studies that have used neonatal rodent models, the authors' preliminary data based on the use of neonatal rat and mouse models of opiate withdrawal, and other neonatal models that have been proposed for the study of neonatal opiate withdrawal.

Age Factors↗
PubMed2005

Evaluation of WHO classification of hypothermia in sick extramural neonates as predictor of fatality.

The objective of this study is to correlate the severity of hypothermia in sick extramural neonates with fatality and physiological derangements. This is a prospective observational study carried out at the referral neonatal unit of a teaching hospital admitting extramural neonates. The subjects comprised of 100 extramural hypothermic neonates transported to the Referral neonatal unit. Neonates weighing more than 1000 g, with abdominal skin temperature less than 36.5 degrees C at admission were included in the study. Hypothermia was classified as per WHO recommendations. Clinical features including age, weight, gestational age, clinical diagnosis, vitals, place of delivery, details of transportation and capillary filling time were recorded at the time of admission. Oxygen saturation was recorded by a pulse oximeter. Samples for sepsis screen, blood culture and blood glucose were taken at admission. During the study it was observed that fatality was 39.3% in mildly hypothermic babies, 51.6% in moderately hypothermic babies and 80% in severely hypothermic babies. However, the presence of associated illness (birth asphyxia, neonatal sepsis and respiratory distress), physiological derangements (hypoxia, hypoglycemia and shock) and weight less than 2000 g were associated with more than 50% fatality even in mildly hypothermic babies. When moderate hypothermia was associated with hypoxia or shock, the fatality was 83.3% and 90.9% respectively. Similarly, mild hypothermia with hypoglycemia was associated with 71.4% fatality. The conclusion drawn from this study is that the WHO classification of severity of hypothermia correlates with the risk of fatality. However, it considers only body temperature to classify severity of hypothermia. The presence of associated illness (birth asphyxia, neonatal sepsis and respiratory distress), physiological derangements (hypoxia, hypoglycemia and shock) and weight less than 2000 g should be considered adverse factors in hypothermic neonates. Their presence should classify hypothermia in the next higher category of severity in WHO classification.

Asphyxia Neonatorum↗
PubMed2002

Use of plasma lactate to predict early mortality and adverse outcome after neonatal extracorporeal membrane oxygenation: a prospective cohort in early childhood.

OBJECTIVE: To examine the use of plasma lactate levels to predict mortality and neurodevelopmental outcome of neonates treated with extracorporeal membrane oxygenation. DESIGN: Prospective cohort study. SETTING: Two level III neonatal intensive care units in Canada and the United States. PATIENTS: Seventy-four neonates requiring extracorporeal membrane oxygenation in two neonatal intensive care units from 1994 to 1996. INTERVENTIONS: Differences in clinical and biochemical measurements, including serial lactate levels between three outcome groups (early deaths, adverse survivors, and normal survivors) were compared using analysis of variance. We also examined the predictive relationship between plasma lactate levels and the outcome at neonatal intensive care unit discharge and at 18-24 months postnatal age by backward, stepwise regression and Fisher's exact test. MEASUREMENTS AND MAIN RESULTS: Fifteen (20%) neonates died before neonatal intensive care unit discharge (early deaths), with seven additional deaths before follow-up, which are included in the adverse survivors group. Among 49 early childhood survivors (22 +/- 7 months), 27 were disabled or delayed with Mental and Performance Developmental Indices of 70 +/- 21 and 72 +/- 22, respectively. Early deaths had higher plasma lactate levels and were more acidemic than adverse and normal survivors, who were not different from each other (p <.05). Plasma lactate and the lowest arterial pH independently predicted 42% of the variance of the outcome ( p<.001). A peak lactate level of >or=25 mM predicted early mortality (sensitivity, 47%; specificity, 100%; positive and negative predictive values, 100% and 88%, respectively; p<.001), whereas a level of >or=15 mM predicted adverse outcome (sensitivity, 35%; specificity, 91%; positive and negative predictive values, 89% and 38%, respectively; p<.05). The predictability of plasma lactate was significantly improved in 45 neonates without congenital diaphragmatic hernia or lethal anomalies (sensitivity of 100% for early mortality, negative predictive value of 63% for adverse outcome). CONCLUSIONS In addition to assessing tissue oxygenation, plasma lactate may facilitate the decision-making process by providing early predictive information about the outcome of neonates treated with extracorporeal membrane oxygenation.

Analysis of Variance↗
PubMedDate not supplied

Improving the selective neonatal BCG program.

OBJECTIVES: The aim of the work was to develop and implement an improved selective neonatal Bacille-Calmette-Guerin (BCG) vaccine program in which neonates are systematically assessed, and those identified as at "high risk of being exposed to tuberculosis" are given neonatal BCG. DESIGN: Service models used in other parts of the country were assessed and their limitations and difficulties were carefully considered. Possible service models for local use were then considered. A selective neonatal BCG program involving universal neonatal screening was implemented. SAMPLE: A program was implemented offering BCG to high-risk neonates. RESULTS: As has been the case with other health trusts, developing a new neonatal BCG service met with obstacles and hurdles. Means of overcoming some of the difficulties are presented. Preliminary findings regarding the service model, including neonatal BCG uptake rates, were positive. CONCLUSION: A successful neonatal BCG program was implemented.

BCG Vaccine↗
PubMed1995

Neonatal intensive care cots: estimating the population based requirement in Trent, UK.

STUDY OBJECTIVES: To estimate the population based requirement for neonatal intensive care (NIC) cots by investigating NIC utilisation in a large population based study. DESIGN AND SETTING: This was a two year, non-randomised, prospective cohort study of neonates receiving NIC in hospitals in the Trent Regional Health Authority (RHA). PARTICIPANTS: The main study considered the 2979 neonates born to Trent RHA residents who had begun high dependency care in Trent RHA or neighbouring health authorities between 1 April 1990 and 31 March 1992 and met any of the following criteria: (i) birth weight < 1500 g; (ii) gestation < 32 weeks; (iii) need for active respiratory support other than initial resuscitation; (iv) need for in utero or neonatal transfer to receive high dependency care; (v) severe asphyxial brain insult after delivery : and (vi) death. The analysis here is restricted to the 1730 neonates who received total parenteral nutrition or assisted ventilation, or both; that is, those who received NIC level 1 (ICL1) on at least one day. MEASUREMENT AND ANALYSIS: The treatment history of each neonate was converted into a time-line detailing the dates of beginning and stopping NIC, the dates of any transfers between units, and any gaps in NIC treatment. The duration of ICL1 was observed directly and that of intensive care level 2 (ICL20 was imputed from a model based upon round trip transfers. These were also recorded on the timeline. The time-lines were first used to derived the observed distribution of the utilisation of NIC cots in Trent RHA during the study. An extensive series of Monte Carlo simulations was then carried out in order; (i) to estimate cot requirements in smaller populations; (ii) to determine whether Trent RHA utilised its NIC cots in a manner that was clinically appropriate at the population based level; (iii) to perform a series of sensitivity analyses; and (iv) to compare results with an equivalent study carried out in the Northern RHA. MAIN RESULTS AND CONCLUSIONS: Trent RHA is reasonably representative of the greater population of England and Wales in terms of both the distribution of birth weight and of birth weight-specific neonatal mortality. Trent RHA did not seen to be underprovided for NIC cots or to be overusing these cots inappropriately. It therefore seems reasonable, if the assumptions of the analysis are borne carefully in mind, to treat these utilisation data as a rough guide to true population based need. NIC cot requirements depend critically upon the size of the served population - small populations are subject to greater random variability and require relatively more cots to ensure cot availability on an equivalent proportion of days. A neonatal unit should not therefore serve a population generating fewer than 5000 and 25 000 births per annum, the estimated population based provision which would ensure free cots on 29 out of 30 days falls gradually from 1.20 to 0.88 NIC cots per 1000 births per annum. A cooperative network of NICUs offers the opportunity to provide fewer cots per head of population while maintaining good access for most neonates referred to the service.

Bed Occupancy↗
PubMed1999

Auditory screening in neonates by means of transient evoked otoacoustic emissions: a report of 2,842 recordings.

The principal goal of an early identification program is to identify hearing impairment present at birth, in order to effect appropriate intervention as early as possible. Although recent research provides some evidence for the value of transient evoked otoacoustic emissions (TEOAEs) in neonate hearing screening, data are needed from large-scale clinical evaluations about the value of using TEOAEs for screening not only high-risk but also healthy neonates. A cohort of 1,421 neonates (2,842 ears) from the well-baby nursery was screened with TEOAEs in a 2-stage process. Neonates were referred from the first test prior to being discharged from the hospital. Those who failed were rescreened before the end of the first month. Those who did not pass the second-stage TEOAE screening were referred for diagnostic audiological evaluation for confirmation of hearing loss. Neonates transferred to a neonatal intensive care unit were not included in this study. Two neonates with bilateral sensorineural hearing loss of >40 dB hearing level were identified from this cohort. This study demonstrates the feasibility and the limitations of using TEOAEs as a universal hearing screening tool for all neonates. It confirms that the prevalence of hearing impairment in neonates has to be taken into account, even in a group of children without high-risk criteria. In France, a prevalence of 1.4 per 1,000 would represent 1,000 deaf children born every year, with reference to about 700,000 births per year. This study suggests that such universal screening programs would substantially increase the rate of early-identified infants with significant hearing impairment.

Acoustic Stimulation↗
PubMedDate not supplied

Validity and reliability of the neonatal skin condition score.

OBJECTIVE: To demonstrate the validity and reliability of the Neonatal Skin Condition Scale (NSCS) used in the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the National Association of Neonatal Nurses (NANN) neonatal skin care evidence-based practice project. SETTING: NICU and well-baby units in 27 hospitals located throughout the United States. PARTICIPANTS: Site coordinators (N = 27) and neonates (N = 1,006) observed during both the pre and postimplementation phases of the original neonatal skin care project. METHOD: To assess reliability, two consecutive NSCS assessments on a single infant were analyzed. Site coordinators were contacted after the original project was concluded. Sites indicating that a single nurse scored all infant skin observations provided data that were used to evaluate intrarater reliability. Sites using more than one nurse to score skin observations provided data that were used to assess interrater reliability. To assess validity, the following variables were used from the original data set: the Neonatal Skin Condition Scale (NSCS), with three subscales for dryness, erythema, and breakdown; birth weight in grams; number of skin score observations for each infant; and the prevalence of infection, defined as a positive blood culture. RESULTS: For intrarater reliability, 16 sites used a single nurse for all NSCS assessments; total NSCS assessments 475. For interrater reliability, 11 sites used multiple raters; total assessments 531. The NSCS demonstrated adequate reliability for each of the three subscales and for the total score, with the percent agreement between scores ranging from 68.7% to 85.4% (intrarater) and 65.9% to 89% (interrater); all Kappas were significant at p < .001 and were in the moderate range for reliability. The validity of the NSCS was demonstrated by the findings that smaller infants were 6 times more likely to have erythema (chi2(6) = 109.55, p < .0001), and approximately twice as likely to have the most severe breakdown (chi2(6) = 108.01, p < .0001). Infants with more observations (longer length of stay) had higher skin scores (odds ratio = 1.21, p < .0001), and an increased probability of infection was noted for infants with higher skin scores (odds ratio = 2.25, p < .0001). CONCLUSIONS: The Neonatal Skin Condition Score (NSCS) is reliable when used by single and multiple raters to assess neonatal skin condition, even across weight groups and racial groups. Validity of the NSCS was demonstrated by confirmation of the relationship of the skin condition scores with birth weight, number of observations, and prevalence of infection.

Evidence-Based Medicine↗
PubMed2001

Review of 49 neonates with acquired fungal sepsis: further characterization.

BACKGROUND: Neonatal acquired fungal sepsis (AFS) is a risky condition that warrants every effort for early diagnosis and management. METHODS: We retrospectively reviewed the medical charts of all 4445 neonatal intensive care unit (NICU) admissions in the past 10 years and detected 49 neonates with AFS. We then compared their data with those of 49 matched control neonates who did not have AFS. The following details were collected: gestational, perinatal and neonatal courses; bacterial sepsis; antibacterial therapy; laboratory and imaging investigations; and antifungal therapy and its complications. RESULTS: The incidence of AFS was.4 to 2 cases per 1000 live-births and 3.8% to 12.9% of very low birth weight (VLBW) infants. Compared with 1989 through 1992, between 1993 and 1995 the rate of AFS in VLBW neonates significantly increased (3. 8%-5.6% --> 9.6%-12.9%), along with a significant increase of NICU admission rate (369-410 --> 496-510 admissions/year). Compared with controls, AFS neonates had significantly longer hospitalizations, higher rates of mechanical ventilation, umbilical vein catheterization, and previous treatment with broad-spectrum antibacterial agents (amikacin, vancomycin, ceftazidime, or imipenem). At the onset of AFS, 42.8% of patients had hyperthermia and 40.9% had normal white blood cell count. Causative fungi were as follows: Candida albicans-42.8% of cases, Candida parapsilosis-26.5%, and Candida tropicalis-20.4%. Fungal dissemination was rare, complications of antifungal therapy were infrequent, and no deaths occurred. CONCLUSIONS: First, non-albicans Candida have become more frequent in neonatal AFS. Second, mechanical ventilation and antibacterial agents are significant risk factors for AFS. Third, hyperthermia is a frequent presenting sign of AFS. Fourth, a normal white blood cell count does not rule out AFS. Fifth, meningeal involvement in neonatal AFS should be ruled out before initiation of antifungal therapy. Sixth, the policy of empiric antifungal therapy for AFS should be considered on an individual NICU basis.newborn infant, fungal sepsis, clinical signs, risk factors.

Abdomen↗