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Plasma vitamin A and E levels were inadequate in very low birth weight infants receiving a continuous infusion of a parenteral multivitamin preparation, 1.5 ml/kg per day, in dextrose-amino acid solution. A new delivery system using 2 ml/kg per day, infused for 6 hours from the first day of life, avoided loss during infusion and significantly improved plasma vitamin A and E levels during the first 28 days of life in very low birth weight infants.

Objective: Intraventricular hemorrhage in neonates with normally sized ventricles is overlooked when sonograms obtained via the anterior fontanelle fail to show a small amount of blood in the occipital horns of the lateral ventricle. Because visualization of the occipital horns is improved when sonograms are obtained via the posterior fontanelle, we studied the efficacy of posterior fontanelle sonography in establishing the diagnosis of intraventricular hemorrhage for 259 neonates., Materials and Methods: We compared cranial sonograms obtained via both the anterior and the posterior fontanelles for 34 infants who had intraventricular hemorrhage and whose mean age at birth was 28 weeks (range, 23-40 weeks) with sonograms for 225 neonates who did not have hemorrhage and whose mean age at birth was 31 weeks (range, 24-42 weeks). Sonograms were assessed for satisfactory visualization of the occipital horns of the lateral ventricles, for the characteristics of intraventricular hemorrhage, if present, and for ventricular size, assessed as normal or showing mild, moderate, or marked dilatation. The technique of posterior fontanelle sonography involves obtaining parasagittal views of the occipital horns of the lateral ventricles and coronal scans of the occipital horns at the level of the calcarine fissure. The data from the contrasting groups of neonates were analyzed with Student's t-test or 2 x 2 tables as appropriate. Five autopsies were done; two confirmed intraventricular hemorrhage, and three confirmed the absence of intraventricular hemorrhage., Results: Sonograms obtained via the posterior fontanelle were satisfactory for 92% of neonates born at less than 32 weeks' gestation and 88% of all neonates scanned. The mean age at birth of those with satisfactory sonograms obtained via the posterior fontanelle was 29 weeks (SD, 4 weeks); in comparison, a mean age at birth of 35 weeks (SD, 5 weeks) was associated with unsatisfactory sonograms (p < .0001). Intraventricular hemorrhage was detected via the posterior fontanelle but not via the anterior fontanelle on the initial diagnostic scan for 14 neonates. The ventricles were more likely to be normally sized when intraventricular hemorrhage was seen via the posterior fontanelle only (86%) than when intraventricular hemorrhage was seen via the anterior fontanelle as well (50%) (Fisher's exact test; p = .04)., Conclusion: Our results show that sonograms obtained via the posterior fontanelle increase the rate of detection of intraventricular hemorrhage in neonates with normally sized ventricles.

A simple filter paper technique is described for demonstrating and measuring insulin loss at the injection site in children with type 1 diabetes mellitus. Using this technique in a cohort of 19 children during a 7-day period, measurable fluid was demonstrated at the injection site in 68% of children at least once and was present following 23% of all injections. In nearly 80% of cases the insulin loss probably represented less than 1 unit but could on occasions be 2 units or more or up to 18% of the injected dose. Insulin losses were observed following injections given by children themselves and by parents. There was no significant relationship between insulin dose and insulin loss. Insulin losses at the injection site are frequent and, although usually small in amount, are a potential source of blood glucose variability.

Aims: To assess the impact, mortality, morbidity and economic costs, of respiratory distress syndrome severe enough to warrant ventilation in one year in New Zealand., Methods: Review of data from all five New Zealand regional neonatal intensive care units' participation in the international OSIRIS trial of exogenous surfactant (Exosurf) treatment for respiratory distress syndrome (involving 6700 infants in 21 countries), and extrapolation of these data to a full year., Results: There were 265 New Zealand infants entered in the OSIRIS trial; the mean birthweight was 1335 g and mean gestation 29 weeks; 61% of infants were less than 30 weeks gestation. Forty-seven infants (17.7%) died prior to discharge from hospital, 40 deaths being attributed to prematurity or respiratory distress syndrome. One hundred and two infants (38.5% of the cohort; 45% of surviving infants) were oxygen dependent and 36 infants (13.6%) were dead at 28 days of age. Thirty-four infants (12.8% of the cohort; 15% of surviving infants) were oxygen dependent and 40 infants (15%) were dead at the expected date of delivery. Infants were intubated for a mean 12.5 days, with surviving infants of less than 27 weeks gestation intubated for a disproportionately long period of time. Seventy-two infants (29% of the 246 infants examined) had an abnormality detected by cranial ultrasound scan at 1 or 6 weeks of age and in 23 (9%) this was a major abnormality. Of surviving infants 16 (7.5% of 213 examined) had a major abnormality on cranial ultrasound scan. Amongst infants at high risk for respiratory distress syndrome (gestation less than 30 weeks) 53% received antenatal steroids, compared with 22% in the OSIRIS trial overall. In a full year the cost of caring for infants with respiratory distress syndrome sufficiently severe enough to warrant ventilation is estimated to be NZ$12.5 million. The average cost of caring for a surviving infant was roughly NZ$52,500 and a nonsurviving infant was NZ$24,500., Conclusions: In a full year (total births 60,000) approximately 350 New Zealand infants may require ventilation for respiratory distress syndrome. Increasing the percentage of infants who receive antenatal steroids is likely to be extremely cost effective. In the era of antenatal steroids and exogenous surfactant, 85% of infants with respiratory distress syndrome requiring ventilation survive to discharge home and over 90% of survivors are likely to be healthy normal adults.

We wanted to identify the inhibitors of neutrophil elastase, quantify their activities in the upper airways of neonates, and relate these to the presence of active elastase and the likelihood of elastolytic injury occurring due to inhibitory capacity being overwhelmed. Activities of neutrophil elastase and its inhibitors were measured in tracheal aspirates from 17 infants, 10 of whom subsequently developed bronchopulmonary dysplasia. All aspirates contained immunologically detectable alpha 1-proteinase inhibitor (alpha 1-PI), but their inhibitory capacity against neutrophil elastase ranged from being undetectable to being in excess of the amount of alpha 1-PI detected immunologically. When the alpha 1-PI was removed from each of the aspirates, using a specific antibody, from 0-50% of the original activity remained, indicating the presence of another elastase inhibitor. Its properties were consistent with it being the low molecular mass, secretory leucoproteinase inhibitor (SLPI), also known as bronchial antileucoproteinase. The alpha 1-PI was from 0-100% active. Most of the inactive inhibitor was shown by western blotting to be complexed with elastase, with a small amount of cleaved material. There was no evidence of major oxidative inactivation. Free elastase was detected in only three of the aspirates; these had little or no detectable elastase inhibitory capacity, and most of their alpha 1-PI was complexed. Elastase load, comprising the sum of free and complexed elastase, correlated closely with myeloperoxidase activity, a recognized marker of inflammatory activity. Active SLPI levels showed a positive correlation with gestational age (r = 0.66). We conclude that most neutrophil elastase in the upper airways of ventilated infants is complexed.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective population-based study of chronic lung disease among all very low birthweight infants (birthweight 500-1499 g) born in New Zealand in 1986 is reported. Of 413 of these infants admitted to neonatal units, 355 (86%) survived to 28 days. An additional 50 infants were recorded as liveborn but died in the labour ward or other place of birth. Both observed survival and survival adjusted for birthweight, gestation and gender were significantly (P less than 0.05) better in larger centres. Oxygen requirement was assessed at 28 days of age, 36 weeks equivalent gestation and 84 days of age, when 38.6, 23.1 and 13.8% of infants, respectively, were being treated with oxygen. To examine the joint effects of predictor variables on oxygen requirement at each age, the data were analysed using multiple logistic regression methods. At 28 days, lower birthweight, shorter gestation, respiratory distress syndrome (all P less than 0.0001), and gender and hospital principally caring for the infant (both P less than 0.05) were significantly associated with treatment with oxygen. In comparison with other studies, New Zealand appears to have a relatively high rate of chronic lung disease. We speculate that a contributing factor may be the small size of some regional neonatal units.

By world standards, the selenium status of the adult population of Christchurch, New Zealand is low. To determine the status of infants undergoing neonatal intensive care, plasma and red cell selenium and glutathione peroxidase levels were measured in infants admitted to the regional neonatal unit. Plasma levels in all newborn infants were one third to one half those in adults. Premature infants had levels significantly lower than those in cord blood from term infants, but their levels were not different from those of term infants admitted to the unit. There were no differences between adult and infant red cell levels. The premature infants remaining in the neonatal unit showed dramatic decreases in plasma selenium and glutathione peroxidase with age, with many infants having selenium levels of less than 0.13 mumol/L (10 micrograms/L). Low levels were seen in infants fed orally as well as those on parenteral nutrition. Thus, the low selenium status of New Zealanders is associated with particularly low selenium levels in premature infants. Because these infants have a high risk for oxidative diseases such as bronchopulmonary dysplasia (chronic lung disease) and retinopathy of prematurity, the possibility that these conditions are more serious in the New Zealand population needs to be assessed and consideration given to dietary supplementation.

Object: New Zealanders, because of a soil deficiency, have a low intake of selenium. To determine the impact of this on the infant population in Christchurch., Methods: we have measured red cell and plasma selenium and the selenoenzyme, glutathione peroxidase, in 70 infants less than 12 months old and related these to age and diet., Results: the infant population as a whole had mean plasma levels of selenium and glutathione peroxidase of 33 micrograms/L and 97 U/L compared with adult values of 74 micrograms/L and 150 U/L. Infant red cell levels of 0.30 mu g selenium and 9.0 U glutathione peroxidase per g haemoglobin were similar to those in adults. The selenium status of most breast fed infants after birth remained similar to that of cord blood. Mean plasma selenium and glutathione peroxidase levels in formula fed infants were about half those of breast fed infants, and their red cell selenium was also significantly lower. These did not increase until solids were introduced into the diet. The status of the infants reflected their diet, with the concentration of selenium in formulae being 3.9-5.2 micrograms/mL compared with a mean of 13.4 micrograms/mL in breast milk., Conclusions: since infants in more replete selenium areas show a gradual rise in blood selenium parameters after birth, this study suggests that formula fed and some breast fed infants in Christchurch receive an inadequate selenium intake. Consideration should be given to supplementing infant formulae and perhaps also the diet of pregnant and/or breast feeding mothers.

Ten point three percent of infants of birthweight less than 2000 g developed an inguinal hernia within one to three years of birth. This figure rose to 18.9% in those who were under 1500 g at birth. The high requirement for surgical repair and the rising survival figures for very low birthweight infants stresses the increasing numbers at risk from postoperative apnoea and bradycardia. The need for respiratory and cardiac monitoring following anaesthesia in low birthweight infants is emphasised.

A prospective study of incidence and prevalence of insulin-dependent diabetes mellitus in persons under 20 years was conducted over a 4-year period (1 February 1982-1 February 1986) for the Canterbury Hospital Board (total population 342,000) area in New Zealand. A central register for the area was established at the beginning of the study period. Degree of ascertainment was close to 100%. Average annual incidence was 11.7 persons per 100,000 (females: 10.6 per 100,000; males: 12.7 per 100,000) with no significant sex difference or temporal trends. Incidence peaks were seen for both sexes in the pubertal ages (females: 11 years; males: 13 years), with minor peaks occurring for both sexes in the pre-school ages. Age of onset was significantly younger in females than males. A seasonal variation in incidence was seen for males, with peaks in late autumn and mid-winter. 5.7% of the new diabetics had a first-degree relative with insulin-dependent diabetes mellitus. Islet cell cytoplasmic antibodies were detected in 68% of new diabetics and in 0% of age- and sex-matched healthy controls. Thyroid, gastric and adrenal auto-antibodies were seen more frequently in diabetics than in controls, but this difference was not significant. Prevalence of insulin-dependent diabetes on 1 February 1982 was 1.00 per 1000 and 1.05 per 1000 on 1 February 1986. The insulin-dependent diabetes mellitus incidence characteristics noted for the Canterbury Hospital Board area are similar to those reported for European and North American populations.

In Papua New Guinea, Plasmodium falciparum and P. vivax are common causes of acute malaria in children and P. malariae an uncommon cause. The increasing prevelance of chloroquine-resistant strains of P. falciparum in Papua New Guinea has prompted the search for alternatives to chloroquine as standard presumptive treatment. Sulfadoxine-pyrimethamine, either alone or in combination with a single dose of chloroquine, was compared with chloroquine alone for treatment of acute vivax malaria in children in Madang. Fever resolution was slowest in the group treated with sulfadoxine-pyrimethamine alone, and time to clearance of parasitemia was significantly longer in this group (P less than 0.001). Where possible, species identification should be undertaken in acute malaria and cases of P. vivax treated with chloroquine.

From January 1979 to December 1983, 178 infants with birthweight 501-1500 g were admitted to the neonatal unit at Christchurch Women's Hospital. One hundred and twenty-nine (72.5%) survived to discharge from the unit. Six infants died post discharge by 12 months of age. Fifty-six percent of surviving infants for whom records were available were admitted to hospital in the first year of life. Thirty infants could not be traced for follow-up. Ninety-three infants were assessed for functional abnormalities utilising medical records, neurological examination and developmental assessment. Thirteen infants (14%) had handicap: 7 (7.5%) with mild or moderate and 6 (6.5%) with major dysfunction. It is essential that neonatologists know the long term outcome for their neonatal intensive care practices and provision must be made for comprehensive follow-up of surviving very low birthweight infants.

Drug utilization has been audited prospectively for all infants cared for in a regional neonatal intensive care unit for a 3-month period. Twenty-five infants had a birthweight less than 1500 g and 54 had a birthweight greater than 1500 g. The total number of different drugs used was 76 and the mean number received was 8.6 with a range of 0-30. Infants with birthweights less than 1500 g received a mean of 14.5 drugs and infants with birthweights greater than 1500 g received a mean of 4.8 drugs. Almost two-thirds (63%) of doses were given orally, 20% intravenously and 10% via an umbilical artery catheter. Three drugs, one of which was received by 13% of infants, carried manufacturers' inserts advising against use in premature infants or the newborn.

Thirty-three infants with a birthweight of less than 1500 g were investigated retrospectively for the incidence and aetiology of thrombocytopenia occurring during the first week of life. The platelet count fell below 100 x 10(9)/l in 16 infants (48%). There was a moderately strong inverse correlation between the platelet count at its nadir during the first week or the first value below 100 x 10(9)/l and the percentage of blood volume transfused prior to this (r = -0.61; P less than 0.0001). When the platelet count was expressed as a percentage of the initial count the correlation was -0.74 (P less than 0.0001). The results were not affected by the elimination of the 10 infants with clinical conditions regarded as a probable cause of thrombocytopenia. The fitted least-squares regression line suggests that a transfusion equal to 10% of the blood volume on average reduced the platelet count by 19 x 10(9)/l or by 7% in these very low birthweight infants during the first week of life.

Much of the present knowledge of the status of malaria in Papua New Guinea stems from a few studies carried out in the past. In the present situation there are many areas of uncertainty not least the effects of poor acceptance of residual spraying programmes and the emergence of chloroquine-resistant falciparum malaria. New anti-malarials are being developed, new methods of vector control may become useful and immunization may soon become possible. In order to assess the impact of these measures it is essential that they are studied in an area with a well defined population and where the current epidemiological situation is known.

The in vitro pyrimethamine sensitivity of 20 Plasmodium falciparum isolates from Papua New Guinea children was determined. The children were treated with sulphadoxine-pyrimethamine and six were found to have clinically resistant malaria. The P. falciparum isolated from these subjects were more resistant to pyrimethamine in vitro than 13 of the isolates from sensitive cases. These results suggest that pyrimethamine sensitivity alone may be a good indicator of in vitro response to sulphadoxine-pyrimethamine.

Chloroquine-resistant Plasmodium falciparum malaria is increasing in prevelance in Papua New Guinea and alternative therapies for acute malaria are being sought. A trial of sulfadoxine-pyrimethamine for the treatment of acute falciparum malaria in children has been carried out in Madang, Papau New Guinea. Eighty-five children were treated with sulfadoxine-pyrimethamine, either alone or in combination with a single 10 mg/kg dose of chloroquine. Of 78 children completing 28-days follow-up, treatment failures occurred in 15 (19.2%) and of these, 8 (10.3%), are believed to be sulfadoxine-pyrimethamine resistant; the others remain equivocal. There was no advantage in this study in combining a single dose of chloroquine with sulfadoxine-pyrimethamine; indeed, this combination was associated with an increased incidence of vomiting. It is argued that sulfadoxine-pyrimethamine should not become the standard presumptive treatment for acute malaria in Papua New Guinea.

Drugs ingested by a lactating mother would be expected to appear in human milk to some extent and be ingested by a breast-feeding infant. Drugs pass from maternal plasma into milk by passive diffusion and are distributed within the aqueous, protein and lipid phases of milk. Distribution into milk will be affected by physiochemical characteristics of the drug: acid-base characteristics, relative protein binding in plasma and milk, and lipid solubility, as well as milk composition. The milk-to-plasma concentration ratio is the most commonly quoted index of drug distribution into human milk. However, calculation of the daily infant dose of drug ingested in milk, and from this the dose in milk relative to the maternal dose on a weight-adjusted basis, is a more relevant indicator of infant exposure to a drug. This is particularly true for drugs with a high volume of distribution, for which only a small proportion of the mother's dose is contained within the plasma and available for distribution into milk. A better indication of infant exposure to a drug is the steady-state plasma drug concentration in a breast-feeding infant, the major determinants of which are the dose rate (via milk) and the oral availability and clearance in the infant. Although in neonates the rate of absorption may be different from adults, there is little evidence that its extent is significantly different. Clearance, however, is impaired in very young infants, particularly if premature. The decreased clearance would result in a proportional increase in steady-state plasma concentrations in the breast-feeding infant. Consideration of the dose ingested in milk and the approximate clearance in infants of different ages allows estimation of likely steady-state plasma concentrations in breast-feeding infants. From these considerations, recommendations regarding the safety of drugs during breast-feeding can be made. Drugs which are very toxic or have dose-independent toxicity should be considered separately. Recommendations regarding 'social' drugs such as nicotine, alcohol, caffeine and theobromine are particularly difficult, as doses are uncontrolled and vary variable.

An eight-year-old girl with severe acquired aplastic anaemia received a bone marrow transplant from her 11-year-old brother. The bone marrow graft is firmly established, but the patient has mild chronic graft versus host disease affecting liver and skin. The indications for bone marrow transplantation in aplastic anaemia are discussed.

Following the Sheldon report (UK 1971) the proportion of newborn infants admitted to neonatal units in England and Wales rose to 20% of live births. Admission policies in Christchurch have followed Sheldon's recommendations and by 1981, 37% of all infants born in Christchurch Women's Hospital were admitted to the neonatal unit. Admission criteria were reviewed in 1982 with the result that most infants with a birth weight greater than 2.5 kg are no longer admitted to the unit. In addition an intermediate nursery was opened to admit healthy but low birth weight (1.8 to 2.5 kg) infants together with their mothers. In 1983 only 9.7% of inborn infants were admitted to the neonatal unit. Data relating to the operation of the intermediate nursery are presented.