Andrew Shennan

The follow-up records of 605 infants with birth weights of less than 1,500 g, with data available for 2 years after birth, were examined for evidence of abnormal pulmonary signs or symptoms. A total of 119 infants were identified and the neonatal oxygen requirements of these infants were compared with those of 486 infants who had normal pulmonary function. A requirement for oxygen at 28 days of life had a positive predictive value for abnormal pulmonary findings at the time of follow-up of only 38%, whereas 31% of those with normal pulmonary findings at the time of follow-up were still receiving oxygen at this age. The need for oxygen at 28 days was a good predictor of abnormal findings in infants of greater than or equal to 30 weeks' gestational age at birth but became increasingly less useful as gestational age decreased. It was found that, irrespective of gestational age at birth, the requirement for additional oxygen at 36 weeks' corrected postnatal gestational age was a better predictor of abnormal outcome, increasing the positive predictive value to 63%. The prediction of a normal outcome remained 90% for infants not receiving oxygen at this corrected gestational age.

With a randomized clinical trial, the possibility was assessed that a tracheal instillation of pulmonary surfactant prior to the first breath might prevent the development of some of the signs of neonatal respiratory distress syndrome. Of the 72 infants in the trial, all born at a gestational age of less than 30 weeks, 39 received 3 or 4 mL of surfactant, prepared from the lipids extracted from calf lung lavage. The treatment resulted in a significantly improved gas exchange during the first 72 hours of life. On the average, the arterial/alveolar PO2 ratio was 0.15 higher for the treated infants, and only about half as much extra oxygen had to be supplied. The respiratory support (peak inspiratory pressure X frequency) could be lowered significantly. Pulmonary interstitial emphysema occurred in 13 of the 33 control infants, but in only three of the 39 treated infants. Six of the control infants died in the neonatal period, but only one treated infant died. It is concluded that surfactant supplementation prior to the first breath is feasible and is of value as protection against the respiratory distress syndrome and the negative effects of hypoxia and ventilatory support.

BACKGROUND: Neonatal circumcision is a painful surgical procedure often performed without analgesia. We assessed the efficacy and safety of 5 percent lidocaine-prilocaine cream (Emla) in neonates undergoing circumcision. METHODS: We carried out a double-blind, randomized, controlled trial in 68 full-term male neonates: 38 were assigned to receive lidocaine-prilocaine cream, and 30 to receive placebo. One gram of lidocaine-prilocaine or placebo cream was applied to the penis under an occlusive dressing for 60 to 80 minutes before circumcision. Behavioral (facial activity and time spent crying) and physiologic (heart rate and blood pressure) responses were recorded during the procedure. Blood samples were obtained at various times after drug application for measurements of methemoglobin and plasma lidocaine, prilocaine, and o-toluidine (a metabolite of prilocaine). RESULTS: A total of 68 and 59 neonates were included in the safety and efficacy analyses, respectively. Demographic characteristics such as gestational age and birth weight did not differ between the lidocaine-prilocaine and placebo groups. During circumcision, the neonates in the lidocaine-prilocaine group had less facial activity (P= 0.01), spent less time crying (P<0.001), and had smaller increases in heart rate (P=0.007) than the neonates in the placebo group. Facial-activity scores were 12 to 49 percent lower during various steps of the procedure in the lidocaine-prilocaine group. As compared with neonates in the placebo group, infants in the lidocaine-prilocaine group cried less than half as much and had heart-rate increases of 10 beats per minute less. Blood methemoglobin concentrations (expressed as a percentage of the hemoglobin concentration) were similar (1.3 percent) in both groups. Lidocaine and prilocaine were detected in plasma in 23 (61 percent) and 21 (55 percent) of the infants treated with lidocaine-prilocaine cream, respectively. CONCLUSIONS: Lidocaine-prilocaine cream is efficacious and safe for the prevention of pain from circumcision in neonates.

OBJECTIVE AND METHODS: As the result of vigorous bubbling, infants receiving continuous positive airway pressure (CPAP) by an underwater seal (bubble CPAP) were observed to have vibrations of their chests at frequencies similar to high-frequency ventilation (HFV). We performed a randomized crossover study in 10 premature infants ready for extubation to test whether bubble CPAP contributes to gas exchange compared to conventional ventilator-derived CPAP. Measurements of tidal volume and minute volume were made using the Bear Cub neonatal volume monitor, and gas exchange was measured using an oxygen saturation monitor and a transcutaneous carbon dioxide (tcpCO2) monitor. RESULTS: There was a 39% reduction in minute volume (p < 0.001) and a 7% reduction in respiratory rate (p = 0.004) with no change in tcpCO2 or O2 saturation for infants supported with bubble versus ventilator-derived CPAP. CONCLUSIONS: The lack of difference in blood gas parameters associated with a decrease in the infant's minute volume and respiratory rate with bubble CPAP compared with ventilator-derived CPAP suggests that the chest vibrations produced with bubble CPAP may have contributed to gas exchange. Bubble CPAP may offer an effective and inexpensive option for providing respiratory support to premature infants.

Real-time ultrasound scans were performed on 66 low-birth-weight infants within the first six hours of life (mean, two hours), and then at 12, 24, 48, and 72 hours, and thereafter at weekly intervals. All of the infants were born in a perinatal unit. The incidence of intraventricular hemorrhage and subependymal hemorrhage was 31%. Eight of 20 infants had small hemorrhages (Papile, grades I and II); seven infants sustained grade III hemorrhages, and five infants sustained grade IV hemorrhages. All hemorrhages occurred in the first 72 hours of life; 25% were diagnosed with the first scan (ie, within the first six hours of life). The infants especially at risk were those less than 29 weeks' gestation. Five infants developed progressive posthemorrhagic ventriculomegaly that subsided spontaneously by age 8 weeks. The mortality in the study group was only 4.5%.