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The physical examination of the term newborn's cardiovascular system is reviewed detailing the normal and abnormal variants that can be found within the first few days after birth. The authors discuss the pathophysiologic changes that occur in the presence of congenital heart disease and how these changes affect the clinical presentation. The major common cardiac defects are described and discussed. Pulse oximetry screening is reviewed in detail indicating its value in the early detection of most cases of critical congenital heart disease. Finally, the reader is given several suggestions on diagnosis, stabilization, and when to refer to specialists.

Background. In 1990, the Florida Legislature established the Florida Healthy Kids Corporation to implement the concept of school enrollment-based health insurance coverage for children. The county school districts are used as a grouping mechanism to negotiate health insurance policies. The Florida Healthy Kids Corporation negotiates contracts with health maintenance organizations (HMOs) to assume financial risk and to provide health care services at each program site. In 1994, there were five sites with four different participating HMOs. Assessing quality of care is particularly important when contracting with HMOs because of the perception that financial and utilization review arrangements may restrict the enrollees' access to needed health care. One essential component of health care quality is the extent to which health care services are used in a manner consistent with the expected pattern of use for the population of enrolled children. The purpose of this study is to compare children's health care use across five different Florida Healthy Kids Program sites. Specifically, we compare the enrollees' actual health care use across HMO settings and program sites to the expected health care use based on the enrollees' case-mix. Methods. Each HMO provided child-specific health care use data including Physician's Current Procedural Terminologycodes and International Classification of Diseases,9th Revision codes. We used the Ambulatory Care Groups (ACGs) software to compare the children's actual health care use to the expected health care use at each site adjusted for case-mix. Several steps were then taken to determine if the children were receiving the anticipated number of health care visits based on their diagnoses. First, we divided the average number of encounters at each site by the group average across all of the sites, without adjusting for the case-mix of the enrollees. We then divided the average number of visits at each site by the expected number of visits based on the case-mix adjustment. A value of 1.00 means that the actual use and the expected use are identical. Values below 1 indicate underuse and values over 1 indicate overuse of health care services. Statistical comparisons of the actual versus expected average health care use across the five sites were performed by deriving the appropriate χ2 statistics. Results. A census of all children (N = 14 688) enrolled in the Florida Healthy Kids Program at each of the sites for 6 months or longer were included in the analysis. The average number of health care encounters across all sites for a 12-month time period was 2.98 ± 4.6 visits. After adjusting for the case-mix of the enrollees in each site using the ACG software, several of the five sites differed from one in a statistically significant way. However, these statistical assessments must be tempered with assessing the practical magnitude of the observed differences. Conclusions. The number of public and private efforts to insure children who are not eligible for Medicaid and whose parents cannot purchase private insurance has grown dramatically. These programs are vital for ensuring financial access to care for uninsured children. However, it is essential that such programs are not viewed as merely cost containment efforts. Assessing the degree to which children receive the health care services they need across multiple delivery settings is an essential yet challenging component of quality assurance. Generally, our analysis indicates that children in the Florida Healthy Kids Program are receiving the amount of health care expected based on their health care needs; which is one component of a high-quality health care program.

The 113th Congress of the United States begins in January 2013. With each new Congress, there are many changes, not only in the faces of the newly elected, but also in the membership of committees and the staff serving the members. As agendas for the session are set, there is a resurgence of conflicting priorities. In the past, when these conflicts were resolved, children were rarely at the top of the list. Given the numerous pressing national issues, both domestic and foreign, the same trend will likely occur.

Changes in our health care system proceed regardless of federal legislative activity. A significant component of reform affects specialty, high technology in-hospital care such as pediatric cardiology by attempting to focus on changing the emphasis toward a primary, outpatient model. This paper reviews some of the evolutionary events and processes affecting our health care delivery system. These events include: expanding high technology medicine; forces influencing regionalization of specialty care such as expansion of academic health centers; reimbursement sources and medical liability; and increasing control by major purchases of health care. Finally we review how the pediatric cardiologist and the practice of this specialty may evolve as a result of these events.

A multicenter, randomized, double-blind, placebo-controlled trial of synthetic surfactant therapy for premature infants with respiratory distress syndrome (RDS) and birth weights of 700 to 1350 gm demonstrated a reduction in severity of RDS, morbidity, and neonatal and 1-year mortality. Of the 419 infants who were entered in the study, 80% of the surviving infants in both the air placebo group (122) and the synthetic surfactant group (138) returned for the follow-up evaluation at 1-year adjusted age. The only significant difference observed at follow-up was a reduction in the incidence of mild cerebral palsy in the synthetic surfactant group (air placebo group, 8 of 122 (7%); synthetic surfactant group, 3 of 138 (2%); relative risk 0.306; 95% confidence interval 0.094, 0.999). No differences were observed between the air placebo and synthetic surfactant treatment groups with respect to health status of the infants, including the incidence of retinopathy of prematurity and neurodevelopmental delays. The difference in the overall incidence of impairment among the 1-year survivors in the air placebo group (43 of 122 (35%)) and in the synthetic surfactant group (40 of 138 (29%)) was not statistically significant. The results of this 1-year follow-up study show that rescue treatment with synthetic surfactant in infants weighing 700 to 1300 gm is not associated with adverse developmental consequences despite the improvement in survival.

Studies of developmental outcome of neonatal intensive care unit graduates have generally been limited to the first 2 to 3 years of life, with outcome determined by psychometric tests. This study followed neonatal intensive care unit graduates born 1975 through 1983 (n = 457) into the public school system and compared their educational outcomes with those of newborn nursery graduates (n = 656). Outcomes were evaluated by placement in four academic categories: regular classroom, academic problems, speech/language impairment, and major impairment. Educational outcomes for children of both groups were essentially the same. Their placement in the four academic categories were equally affected by nonmedical variables, primarily income (below/above poverty level), race, and sex. Seventy percent of poverty-level children were in one of the three problem categories, compared with 40% of children above poverty level. Neither neonatal intensive care unit treatment nor low birth weight were major predictors of educational outcome. The only clear-cut neonatal intensive care unit effect occurred among children born with sensory or physical impairments. Therefore, in order to reduce poor educational outcomes, follow-up and intervention programs should be targeted primarily to children with diagnosable handicaps and from minority, low-income families.

One hundred forty-four newborn infants with pulmonary interstitial emphysema were stratified by weight and severity of illness, and randomly assigned to receive treatment with high-frequency jet ventilation (HFJV) or rapid-rate conventional mechanical ventilation (CV) with short inspiratory time. If criteria for treatment failure were met, crossover to the alternate ventilatory mode was permitted. Overall, 45 (61%) of 74 infants met treatment success criteria with HFJV compared with 26 (37%) of 70 treated with CV (p less than 0.01). Eighty-four percent of patients who crossed over from CV to HFJV initially responded to the new treatment, and 45% ultimately met success criteria on HFJV. In contrast, only 9% of those who crossed over from HFJV to CV responded well to CV (p less than 0.01), and the same 9% ultimately met success criteria (p less than 0.05). Therapy with HFJV resulted in improved ventilation at lower peak and mean airway pressures, as well as more rapid radiographic improvement of pulmonary interstitial emphysema, in comparison with rapid-rate CV. Survival by original assignment was identical. When survival resulting from rescue by the alternate therapy in crossover patients was excluded, the survival rate was 64.9% for HFJV, compared with 47.1% for CV (p less than 0.05). The incidence of chronic lung disease, intraventricular hemorrhage, patent ductus arteriosus, airway obstruction, and new air leak was similar in both groups. We conclude that HFJV, as used in this study, is safe and is more effective than rapid-rate CV in the treatment of newborn infants with pulmonary interstitial emphysema.

To determine whether a single prophylactic dose of synthetic surfactant would reduce mortality and morbidity rates, we performed a randomized, controlled trial of Exosurf Neonatal at 19 hospitals in the United States. The Exosurf preparation (5 ml/kg) was instilled into the endotracheal tube of premature infants weighing 700 to 1100 gm during mechanical ventilation, as soon as practical after birth. Control infants were treated with air (5 ml/kg). Dose administration was performed in secrecy by clinicians who did not reveal for 2 years what they had instilled. A total of 222 infants received air and 224 received the synthetic surfactant; 36 infants with congenital pneumonia or malformations were excluded from the primary efficacy analysis. By the age of 28 days, there were 44 deaths in the air group and 27 deaths in the surfactant group ( p =0.022). By the age of 1 year after term there were 61 deaths in the air group and 35 deaths in the surfactant group ( p =0.002). Although there was no reduction in the incidence of respiratory distress syndrome, a significant reduction in the number of deaths attributed to respiratory distress syndrome, a significant reduction in the incidence of pulmonary air leaks, and significantly lower requirements for oxygen and mean airway pressure indicated that lung disease was less severe in the Exosurf-treated infants. There were no significant differences in the incidence of complications such as bronchopulmonary dysplasia, intraventricular hemorrhage, patent ductus arteriosus, necrotizing enterocolitis, and infection. The results indicate that a single prophylactic dose of Exosurf, in high-risk premature infants treated soon after birth, reduces the number of deaths from respiratory distress syndrome and the overall mortality rate.

The State Children's Health Insurance Program (SCHIP) was enacted in 1997 to provide health insurance coverage for uninsured low-income children who do not meet Medicaid eligibility criteria. SCHIP was authorized for 10 years and was up for reauthorization in 2007. Because SCHIP is a capped grant and not an entitlement program, it has a fixed annual funding level and shortfalls were predicted to occur if federal funding was not expanded with the reauthorization. When faced with restricted funding in the past, states adopted different strategies to control the size of their SCHIP caseloads, including adjusting the processes by which families apply for and renew their coverage. The Congressional Budget Office estimated that federal funding would need to be increased by $7.8 billion over the next 5 years (2008–2012) to maintain current programs (Congressional Budget Office 2007). At the time of this writing, President Bush and Congress had reached an impasse over the amount by which SCHIP funding should be expanded, with the President twice vetoing reauthorization bills passed by Congress. As a temporary solution, federal SCHIP funding was extended through March 31, 2009 with the enactment of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (S. 2499). Motivating the national debate over SCHIP reauthorization are concerns about the appropriate income eligibility limit and crowd-out of employer-sponsored insurance. As a result, in addition to funding levels, SCHIP program eligibility is under examination. President Bush has emphasized refocusing “SCHIP on low-income, uninsured children below 200 percent of the Federal poverty level as the program was originally intended” (OMB 2007). In August 2007, the Centers for Medicare and Medicaid Services issued new guidance for providing coverage to children with family income above 250 percent of the federal poverty level (FPL). States must demonstrate that they have enrolled at least 95 percent of eligible children below 200 percent of the FPL in Medicaid or SCHIP and that employer-based coverage of low-income children has not decreased by more than two percentage points during the prior 5 years (CMS 2007). Consequently, states may reconsider how they conduct their eligibility determinations when children are due to renew their coverage. States can meet federal eligibility screening requirements by using existing information from state and federal agencies, thereby allowing families to self-declare income. In 2007, however, only 9 SCHIP programs and 11 Medicaid programs allowed self-declaration of income (Ross, Horn, and Marks 2008). All other states required documentation to verify income. Interviews of SCHIP administrators and descriptive analyses of state administrative data indicate that active redetermination procedures, which require families to submit documents to verify their eligibility, are a significant barrier to enrollee retention (Hill and Lutzky 2003). Retention is important because children who experience interruptions in health insurance coverage are more likely to have worse access to care and greater unmet health care needs (Szilagyi et al. 2000; Olson, Tang, and Newacheck 2005). A comparison of SCHIP renewal policies in four states found marked differences in retention based on the redetermination procedures used. Dick et al. (2002) analyzed SCHIP programs in Florida, Kansas, New York, and Oregon, using data from 2000 and 2001. Florida had a passive renewal process at the time, while the other states had active renewal processes. Under passive renewal, families whose children were in Florida's SCHIP, the Florida Healthy Kids Program (FHKP), received a letter notifying them about renewing their children's coverage. Families were asked to review the income information in the letter and report any changes to the FHKP. They also were asked to report changes in access to employer-sponsored health insurance for their children. Families who did not respond maintained their children's coverage if they continued to pay their premiums. The programs with active renewal processes required families to provide proof of income and complete renewal forms to continue coverage. Dick et al. (2002) found that 33–50 percent of children disenrolled at their first redetermination in the states with active renewal processes; in contrast, they found that 5 percent of children in the FHKP disenrolled at redetermination under the passive renewal process. More recent analyses of SCHIP enrollment patterns have used the renewal month as a control variable when examining the effect of premiums on enrollment and disenrollment behaviors (Kenney et al. 2007; Marton 2007), but none have explored the impact of a change in the renewal process on disenrollment. This study examines the impact of renewal policy changes on the risk of disenrollment in the FHKP. In addition, we examine whether the policy changes had a differential impact on children with different health status levels. We also control for sociodemographic characteristics that may influence parents' decisions to renew their children's coverage. Effective July 1, 2004, the passive renewal process for the FHKP was replaced with active redetermination. The active renewal process requires families to complete a Renewal Request Form annually supplemented with (1) proof of income and (2) information about their access to employer-sponsored family coverage and the cost of such coverage if it is available to them. If families do not provide all of the required documentation, their children are disenrolled from the program. This study extends the analysis by Dick et al. (2002) in three ways. First, we use multivariate survival analysis techniques which allow us to examine multiple factors that may influence children's disenrollment at redetermination. These factors include family income, rural or urban residence, and child age, gender, and health status. This was not possible in the Dick et al. (2002) analyses because of differences in data availability across the states. Second, we take into account program transition, so a child is not considered disenrolled until s/he leaves public health insurance altogether. Finally, we include long-term program enrollees instead of including only children who were newly enrolled during the observation period.

Objective. To assess the relative effects and the impact of perinatal and sociodemographic risk factors on long-term morbidity within a total birth population in Florida. Methods. School records for 339 171 children entering kindergarten in Florida public schools in the 1992–1993, 1993–1994, or 1994–1995 academic years were matched with Florida birth records from 1985 to 1990. Effects on long-term morbidity were assessed through a multivariate analysis of an educational outcome variable, defined as placement into 9 mutually exclusive categories in kindergarten. Of those categories, 7 were special education (SE) classifications determined by statewide standardized eligibility criteria, 1 was academic problems, and the reference category was regular classroom. Generalized logistic regression was used to simultaneously estimate the odds of placement in SE and academic problems. The impact of all risk factors was assessed via estimated attributable excess/deficit numbers, based on the multivariate analysis. Results. Educational outcome was significantly influenced by both perinatal and sociodemographic factors. Perinatal factors had greater adverse effects on the most severe SE types, with birth weight 10 times greater than that of very low birth weight, presence of a congenital anomaly, or prenatal care. Conclusions. Results are consistent with the hypothesis that adverse perinatal conditions result in severe educational disabilities, whereas less severe outcomes are influenced by sociodemographic factors. Overall, sociodemographic factors have a greater total impact on adverse educational outcomes than perinatal factors.

Objective. To determine the percentage of children who had insurance coverage in the 12 months preceding enrollment in a state-subsidized program; the percentage of parents who had access to employer-based family coverage; and the cost of the families' share of the premium per month. Methods. We randomly selected 930 families whose children were enrolled in the Florida Healthy Kids Program for a period of between 1 and 3 months and conducted telephone interviews with them in 1998 about their children's insurance coverage before program entry and their access to employer-based family coverage. There were 653 families in the final sample. Results. Only 5% of the children had employer-based coverage before program enrollment. However, 26% had access to family coverage through their employers with the family share of the premiums representing on average 13% of their incomes. Access to employer-based coverage varied significantly by family income. Conclusions. Throughout the development of the State Children's Health Insurance Program legislation, policy analysts expressed concern that families may crowd out or substitute a subsidized state plan for employer-based coverage. This substitution could result in fewer improvements in access to care and health status than were anticipated, because families are simply moving to a different form of health insurance. There is some degree of crowd out in the Healthy Kids Program. The economic burden to near-poor families to purchase employer-based coverage is significant. Some degree of substitution may need to be tolerated to ensure that children receive needed health insurance.

Objective. To determine the relationship between perinatal and sociodemographic factors in low birth weight and sick infants hospitalized at regional neonatal intensive care units (NICUs) and subsequent educational disabilities.Method. NICU graduates born between 1980 and 1987 at nine statewide regionalized level III centers were located in Florida elementary schools (kindergarten through third grade) during academic year 1992–1993 (n = 9943). Educational disability was operationalized as placement into eight mutually exclusive types of special education (SE) classifications determined by statewide standardized eligibility criteria: physically impaired, sensory impaired (SI), profoundly mentally handicapped, trainable mentally handicapped, educable mentally handicapped, specific learning disabilities, emotionally handicapped, and speech and language impaired (SLI). Logistic regression was used to estimate the odds of placement in SE for selected perinatal and sociodemographic variables.Results. Placement into SE ranged from .8% for SI to 9.9% for SLI. Placement was related to four perinatal factors (birth weight, transport, medical conditions [congenital anomalies, seizures or intraventricular hemorrhage] and ventilation), and five sociodemographic factors (child's sex, mother's marital status, mother's race, mother's educational level, and family income). Perinatal factors primarily were associated with placement in physically impaired, SI, profoundly mentally handicapped, and trainable mentally handicapped. Perinatal and sociodemographic factors both were associated with placement in educable mentally handicapped and specific learning disabilities whereas sociodemographic factors primarily were associated with placement in emotionally handicapped and SLI.Conclusions. Educational disabilities of NICU graduates are influenced differently by perinatal and sociodemographic variables. Researchers must take into account both sets of these variables to ascertain the long-term risk of educational disability for NICU graduates. Birth weight alone should not be used to assess NICU morbidity outcomes.

OBJECTIVES: The School Enrollment-Based Health Insurance program is designed to reduce financial barriers to children's health care use. This study sought to determine if any socioeconomic measures differed between enrollees with at least one health care encounter and those with no encounters. METHODS: Logistic regression was used to assess the impact of various predictors on the odds that a child would use health care services. RESULTS: Children receiving free insurance premiums were less likely to use health care than those receiving partial subsidy. African-American and Hispanic children were less likely than Whites to use health care. Age, sex, and months enrolled also influenced the likelihood of health care use. CONCLUSIONS: Financial and non-financial factors must be considered when developing children's health care programs.

Objective: To determine changes in survival patterns among very low-birth-weight ( Methods: The records of 12960 infants treated in nine perinatal intensive care centers in Florida were analyzed on the basis of survival (discharged alive from hospital) according to four independent variables: birth weight, race, sex, and transport status. Survival curves were generated using log linear regression techniques for each race by sex by transport status group. Results: Race, sex, and transport status correlated significantly with survival: survival percentages were higher among black infants, female infants, and infants transported to the perinatal intensive care centers than among white infants, male infants, and those admitted initially to the tertiary care centers. After 1985, 95% of neonates with birth weights between 1200 and 1500 g survived. In addition, survival of 500- to 550-g transported black male infants increased from zero to near 80% during the 13-year period; that of 500- to 550-g inborn white female infants rose from 35% to 70%. Conclusions: These results illustrate the value of taking into account race, sex, and transport status in efforts to understand the contribution that neonatal intensive care of extremely low-birth-weight infants makes to the lowering of infant mortality, and of using multivariable statistical procedures to generate predicted survival probabilities for different subpopulations. These probabilities can be applied to (1) predicting survival for specific subgroups of extremely low-birth-weight infants, and (2) helping physicians develop clinical guidelines for extending care to infants at the threshold of viability. (Arch Pediatr Adolesc Med. 1995;149:1311-1317)

Neonatal intensive care unit survivors (N = 494) from 10 tertiary care centers were evaluated over the first 4 to 5 years of life to determine the relative contributions of birth weight and sociodemographic factors to mental development. Six sociodemographic factors were studied: sex, race, family income, and mother's marital status, age, and educational level; the last five factors also are known to be associated with premature birth. Mental development was measured with the Bayley Scales of Infant Development (12 to 24 months) and the Stanford Binet Intelligence Test (4 to 5 years). Each factor's influence was assessed by multivariate analysis. Birth weight had limited long-term implications; at 4 to 5 years, only infants with birth weights less than 1000 gm had significantly lower scores than those in other birth weight categories. Sociodemographic variables had a greater impact on mental development, with age-dependent differences found between nonwhite and white children and between children with mothers of low, medium, and high educational levels.

According to the new federal diagnosis-related group (DRG) system, hospitals are reimbursed fixed sums based on discharge diagnoses, rather than variable sums that depend on specific goods and services consumed and number of days hospitalized. The government is now exploring DRGs as a potential mechanism for reimbursing physicians. In Florida, two DRG-type reimbursement systems were developed for neonatal and obstetrical hospitalizations in tertiary care settings, as departures from the federal DRG system. Called neonatal care groups (NCGs) and obstetrical care groups (OBCGs), both classification systems predicted hospital charges in these settings more accurately than did federal DRGs. The feasibility of a prospective pricing system for neonatologists and obstetricians based on NCGs and OBCGs was investigated. The data showed that neonatologists' charges had a high correlation with hospital charges (r = .90) and that increasing levels of intensity of care as defined by the NCGs were reflected by consistent increases in reimbursement to neonatologists. If the NCG system were to be applied, neonatologists would receive compensation equivalent to that which they currently earn according to the fee-for-service system. In contrast, obstetricians' charges bore almost no relationship to hospital charges. However, modest differences in obstetrician's charges did emerge as a reflection of number of complications, which are incorporated into the OBCG categories; this suggests that a reimbursement system based on hospital OBCG categories might be applied to obstetricians.

Five cyanotic newborn infants underwent cardiac catheterization between 8 and 36 hours of age with a tentative diagnosis of cyanotic congenital heart disease. All had normal cardiovascular anatomy. Cyanosis was the result of persistence of fetal cardiopulmonary circulation with right-to-left shunting across the ductus arteriosus. In all infants, cyanosis resolved spontaneously and the infants survived without sequelae. Admission chest roentgenograms of all infants showed marked hyperinflation of the lungs. Except for severe hypoxemia, the clinical presentation, chest films, and course of illness of these infants were consistent with transient tachypnea of the newborn. It is proposed that an increase in pulmonary vascular resistance, due to hyperinflation of the lungs, was the mechanism which reopened the fetal cardiopulmonary circulatory channels and produced hypoxemia, and that these infants suffered from a rare manifestation of a usually benign newborn respiratory condition. Further, given these pathophysiologic mechanisms, the use of continuous transpulmonary pressure gradients in the management of such infants would be contraindicated.

Quantitative studies of erythrocyte and leukocyte methemoglobin reductase in neonatal methemoglobinemia were conducted. The prognostic value of such studies as indicators of the development of the mental retardation in certain cases of congenital methemoglobinemia is discussed.

Currently, accurate determination of body fluid compartments depends on the sodium bromide method (NaBr), an invasive measurement requiring venipuncture with infusion of a foreign substance. Impedance (Z) measurements may provide a practical noninvasive alternative for estimating fluid compartments in sick, premature neonates. To validate the impedance method, we compared it with the NaBr technique in nine anesthetized rabbits. Electrodes were placed for impedance measurement. Vascular catheters were inserted into the femoral artery and vein. Baseline impedance data were collected at 1.0 kHz and blood samples were drawn for NaBr standard assay. Using conventional assay techniques for determination of extracellular fluid volume (ECFV), we correlated NaBr data with impedance measurements. A linear relationship between ECFV by NaBr assay and the previously developed impedance equation rho L2/Z1.0 was established using regression analysis. A correlation value of r = .95 was obtained. These data suggest the potential for impedance to estimate ECFV.

The recent association of transient tricuspid insufficiency in newborn infants with ischemic papillary muscle necrosis prompted a detailed retrospective clinical and histologic analysis of autopsied infants who died within seven days of birth between 1973 and 1977. Infants with congenital heart disease, erythroblastosis fetalis, and known congenital viral infections were excluded. Thirty-one of 82 infants had at least one site of ischemic myocardial necrosis: 11 had lesions only in the right ventricle, 13 had lesions only in the left ventricle, and seven had bilateral lesions. The apical region of an anterior papillary muscle was the most common site. IMN occurred more commonly in older, larger infants. Asphyxia at birth, a murmur of atrioventricular valve insufficiency, and signs of congestive heart failure correlated well with the presence of IMN, but few other perinatal events predicted its occurrence. This report suggests that IMN is a common event in stressed infants who die early in life and probably is related to episodic hypoperfusion of the myocardium.

Sixty-two premature infants less than 2,000 gm birth weight received parenteral nutrition (PN) during periods of respiratory distress with feeding intolerance. Intrahepatic cholestasis (direct bilirubin ≥ 1.5 mg/dl) associated with PN developed in 14 or 23% of these infants. The mean time on PN to onset of cholestasis was 42 days, and the cholestasis persisted as long as the infants continued to receive PN. All five infants who had serial follow-up laboratory studies showed an eventual return of direct bilirubin levels to normal. The direct bilirubin level appeared to be the best clinically available test to monitor for the onset and to follow the resolution of this complication. The very low birth weight infants < 1,000 gm appeared to be at an increased risk of developing cholestasis with an incidence of 50%. However, there was no correlation between the length of time PN was administered to onset of cholestasis and the gestational age or birth weight of the infants. These tiny premature infants also received PN for significantly longer periods of time, and the longer the infusions were administered the greater was the risk of cholestasis developing.

This prospective longitudinal study was designed to evaluate the effects of a multidisciplinary infant development program (IDP) on the mental and physical development of low birth weight infants (

RECENTLY, we reported 14 term newborn infants affected by severe perinatal stress who subsequently manifested cyanosis, congestive heart failure and transient murmurs of tricuspid insufficiency.1 T...

Summary: Changes in cerebral blood flow in response to three states of acute acidosis, posthypoxic, lactic acid, and respiratory, were estimated by the microsphere technique. In all three states, the fraction of the systemic blood flow reaching the brain and the rate (ml/min) of blood flow to it increased. The increase in flow was linearly related both to the PaCO2 and to H+. Others have shown the flow rate to increase with hypercapnia, but the increase associated with an increase in hydrogen ion concentration while the PaCO2 was maintained at control levels does not appear to have been observed in mature animals.

Although group A and B streptococci have similar susceptibility to antimicrobics, group A streptococci are killed significantly faster at clinically relevant concentrations of penicillin or ampicillin. The addition of an aminocyclitol to either penicillin or ampicillin enhances the rate of killing of streptococci. Because the rate of killing of group B streptococci is significantly increased by the addition of gentamicin at concentrations of 0.1 μg and 0.5 μg/ml to either penicillin or ampicillin, the use of combined therapy may indeed be beneficial in the initial treatment of group B streptococcal meningitis. However, as meningeal inflammation subsides, gentamicin may not enter the central nervous system well enough to justify continued use. Combined therapy for the duration of treatment of penicillin-tolerant group B streptococci has been recommended on the basis of isolated case reports of relapse after single drug therapy. This approach is not supported by in vitro observations of no enhancement of the rate of killing of tolerant strains by the addition of gentamicin to penicillin. Thus, a final recommendation regarding the duration of combined therapy, and use with tolerant organisms, awaits further studies.

Studies were carried out on premature infants in the neonatal intensive care unit to determine the effect of feeding of lactobacilli on colonization of the gastrointestinal tract by antibiotic-resistant gram-negative enteric organisms. Thirty premature infants were matched by birth weight and gestational age, randomized and fed double blind either lactobacilli-containing formula or non-lactobacilli-containing formula within 72 hours of delivery. The two study groups were screened weekly by culture for stool lactobacilli, for gram-negative bacteria and for antibiotic resistance of these bacteria. Lactobacilli were cultured from the stools of 13 of 15 patients receiving lactobacilli and from 3 of 15 patients not receiving lactobacilli (P less than 0.001). Gram-negative enteric organisms were isolated during 40 of the 86 weeks (47%) of hospitalization for patients receiving lactobacilli and during 28 of 57 weeks (49%) for patients not receiving lactobacilli. There was no significant difference between the study groups in the number of resistant organisms or in the proportion of resistant organisms per gram-negative enteric isolates (4 of 40 vs. 0 of 28). These results suggest that facultative gram-negative enteric bacterial colonization, with either total or aminoglycoside-resistant strains, is not decreased by oral feedings of Lactobacillus acidophilus in premature infants.

Aspiration is common in the intubated human neonate. Thus, the ventilatory and blood gas responses to citric acid and saline instillation into different airway sites were studied in ten awake, unanesthetised lambs, breathing spontaneously via a tracheostomy tube. With a system of balloons, 1 ml of saline or citric acid was placed selectively into the midtrachea, the laryngeal area, or the lower trachea (lower tr). Changes in minute ventilation (VE), after a 30 sec baseline period, were measured 30 sec and 1 and 2 min after the challenge. Arterial blood gas changes were measured at 30 sec and 2 min. Major increases in VE were seen only when saline or citric acid was instilled into the lower tr, the citric acid responses exceeding saline ones. The arterial oxygen tension (PaO2) fell after lower tr saline, whereas the arterial CO2 tension (Pa) fell with midtracheal saline instillation. A rise in pH and a fall in Pa accompanied citric acid given into the lower tr. An initial rise in PaO2 after citric acid into the lower tr was followed by a return to baseline despite hyperventilation. The ventilatory and blood gas changes with saline and citric acid depend on the site of airway instillation. Pediatr Pulmonol 1987; 3:45–50.

Antimicrobial sensitivity, synergy, and timed-killing assays were determined for 20 strains of group B streptococci isolated from cultures of blood and cerebrospinal fluid (CSF) of infected neonates. The mean minimal inhibitory concentrations by the tube-dilution method were as follows: penicillin, 0.02 microgram/ml; ampicillin, 0.05 microgram/ml; and gentamicin, 4.5 micrograms/ml. No synergy was detected with any combination of penicillin or ampicillin and gentamicin by the checkerboard titration method. Killing kinetics were determined for combinations of penicillin or ampicillin and gentamicin at low concentrations of these antibiotics comparable to those attained in the CSF following systemic administration of these antibiotics. Addition of 0.1 microgram and 0.5 microgram of gentamicin/ml to penicillin or ampicillin significantly accelerated the killing of group B streptococci. Despite the "poor" permeation of gentamicin into the CSF, the accelerated killing of streptococci at low concentrations of this antibiotic provides a rationale for the initial use of a combination of penicillin or ampicillin and gentamicin in the treatment of group B streptococcal meningitis.

A case of an aneurysm of an anomalous right subclavian artery following retrograde catheterization of the right brachial artery is described. This complication was not recognized until the patient presented with symptoms related to a superior mediastinal mass. After appropriate studies were performed operative intervention was successful in establishing a patent subclavian artery.

Survival for low-birth-weight infants has traditionally been analyzed by birth weight categories spanning considerable ranges of weight. We developed a finer description of survival rates to allow estimation of survival percentages for infants of any specific birth weight between 500 and 2500 gm. Our sample consisted of 16,183 infants treated in tertiary neonatal intensive care between 1980 and 1987. Their survival data were analyzed by 50 gm increments between 500 and 2500 gm, and a continuous survival curve was constructed by log linear regression methods. Mortality differences between males and females and blacks and whites were analyzed. Survival for females was higher than males between 500 and 1500 gm and higher for blacks than whites between 650 and 1500 gm. Between 1500 and 2500 gm, no significant effects of birth weight, race, or sex were observed, with survival remaining stable at approximately 95% across all combinations of variables.

The objective of this research was to determine the oxygen consumption of newborn infants with respiratory distress syndrome in the first 4 days of life. Serial determinations of oxygen consumption were made in 14 infants with respiratory distress syndrome receiving positive end-expiratory pressures. The mean (+/- SE) oxygen consumption determined at 24, 48, 72, and 96 h postnatal age were 8.3 +/- 0.9, 6.5 +/- 0.8, 5.5 +/- 0.5, and 5.3 +/- 0.6 ml/min/kg, respectively. The level of oxygen consumption at 24 h postnatal age was significantly greater than the levels determined at 48, 72, and 96 h (p less than 0.03). The oxygen levels found at 72 and 96 h of age were comparable to those determined for healthy preterm infants. A linear regression of serial oxygen consumption and weight loss yielded a 'fair' (r = 0.5) correlation with a significant inference (p less than 0.01).

Evaluations were done at 21 months post-conceptual age on 134 LBW infants discharged from the Regional Neonatal Intensive Care Center between 1974-1976. A 60% return of those assigned for evaluation (all infants with birth weights less than 1500 grams and 20% of infants with birth weights between 1500 and 2500 grams) was achieved. The evaluation tools were the Bayley Scales of Infant Development with mental and physical developmental quotients (MDQ;PDQ), neurological and general evaluations. The only group that was significantly different from the other groups was those less than 1000 grams, where 6 of 16 in this group were estimated to be mentally defective. Three of the 6 defective babies had birth weights less than 750 grams. No differences were evident due to race and sex. It would appear that the babies at major risk for serious handicap are the very LBW babies and they continue to provide a perplexing problem for those involved with the care of small infants.

We have reported (Bucciarelli et al., Pediatrics, in press) 14 newborns stressed by acute birth hypoxia (and/or hypoglycemia) who developed congestive heart failure, tricuspid insufficiency, and electrocardiographic evidence of myocardial ischemia. Two infants died, each showing tricuspid papillary muscle infarction at autopsy. Subsequently, 13 more stressed newborns, clinically suggesting MD with TTI, have had determinations made of total CPK. Ten had a final clinical diagnosis of MD with TTI. In 9, total CPK was elevated (mean 874 IU/1), in 6 of whom the CPK-MB fraction was elevated to a degree consistent with acute myocardial infarction (mean 185 IU/1). Four of the 10 having MD with TTI died; 2 of these had elevated CPK-MB and papillary muscle infarction; 2 had normal CPK-MB and no infarction at autopsy. Three of the 13 studied had other final diagnosis; (1 with persistent fetal circulation, 2 with congenital heart disease). All had lower mean CPK (107 IU/1) and all had CPK-MB fractions

The recent association of transient tricuspid insufficiency of the newborn with papillary muscle necrosis prompted a detailed retrospective clinical and histologic analysis of all autopsied infants to find sites of myocardial necrosis. In a four year period, 19 of 80 autopsied infants who died within 7 days of birth were found to have one or more sites of significant myocardial damage. None of the 80 had congential heart disease. 10/19 pregnancies were classified as high risk. All were singleton births. Of 9/19 monitored during labor, 7 had abnormal monitor patterns. Seven infants had tricuspid insufficiency (TI) murmurs and one had the murmur of mitral insufficiency (MI). All those with the TI murmurs had distinct necrotic foci in the tricuspid valve papillary muscles. The infant with the MI murmur had moderate to severe damage of the mitral valve papillary muscles. Six of seven with TI murmurs were term infants. Thirteen of 19 had suffered asphyxia, 6 of them had had massive aspiration of meconium stained amniotic fluid. Six of nineteen infants had creatine phosphokinase studies and 5 of 6 had significant elevation of the MB fraction. The occurrence of a severe asphyxial episode or abnormal monitor pattern associated with the development of TI or MI murmurs and elevated CPK-MB fraction suggests that the infant has suffered a papillary muscle or other myocardial necrosis.

Although Ct is recognized as a common etiologic agent in infant pneumonia, its role in pulmonary infection of premature infants has received little attention. Eight premature high risk babies hospitalized in our intensive care nursery over a 9 month period were documented to have Ct pneumonitis by standard McCoy cell tissue culture of endotracheal tube aspirates (7 patients) or nasopbaryngeal swab (1 patient). All patients had negative CMV urine cultures. Birthweights ranged from 610-2200 g. and gestational ages from 26-34 weeks. Six patients were born vaginally and 2 by Caesarean section. Age ranges at time of Ct isolation was 8-83 days (mean 29 days). All patients were cultured during an acute worsening of their respiratory status; 7 showed acute changes on chest X-ray. Seven patients were treated with erythromycin for 3 weeks; the remaining patient died prior to Ct identification. Five patients died of respiratory failure, 1 patient is at home on oxygen therapy for chronic lung disease and 2 patients have no residual lung disease. During this same time period, there were 8 infants of similar gestational age, birthweight, chronological age and mode of delivery whose endotracheal aspirate culture was negative for Ct. All these infants have survived. Chlamydia trachomatis appears to be associated with severe pulmonary disease in premature infants. Ct pneumonitis should be considered in a premature high risk infant with worsening respiratory status.

High-frequency ventilation has become a valuable tool in the management of neonates with severe pulmonary disease. Along with reports of clinical successes, have come reports of serious complications, primarily mucous obstruction of the airways and necrotizing tracheitis. Airway histopathology from four infanta who died after prolonged (ave., 8 days), high-frequency jet ventilation (HFJV) with the Mallinkrodt Bunnell Life-Pulse Jet Ventilator were compared to 12 matched control infants who died after conventional mechanical ventilation (CMV). Each of the four HFJV treated infants was matched to three CMV treated infants for birth weight, gestational age, date of birth and duration of mechanical ventilation. The 4-point, 9-variable, histologic scoring system of Ophoven et al. was used to score histologic changes at the level of the larynx, mid-trachea, carina, and right and left main bronchi. Total injury scores and patterns of acute and chronic injuries were compared using the Wilcoxon rank-sum test for nonparametnc measurements. We found no statistically significant differences in total injury scores, or in patterns of acute or chronic injury at the levels of the larynx, trachea, carina, and right and left bronchi. Our results are in contrast with previously published data. The differences may be related to improved humidification systems provided by the most recent generation of jet ventilators.

Aspiration is common and often complicates recovery from ventilator therapy in the neonate. The object of this study was to examine the upper airway sites which determine the respiratory responses to an irritant challenge. Twelve lambs were studied awake at a mean postnatal age of 26 days and with a mean weight of 6.7kg. Via a tracheostomy (Ty) and system of balloons, it was possible to instill selectively 1 ml of S, or CA, onto firstly only the mid-tracheal area (MT), secondly only the laryngeal area (LA) and thirdly only the lower tracheal area (LT). During the studies spontaneous breathing occurred via an endotracheal tube placed in the Ty. Minute ventilation (VE), recorded as changes from baseline, was measured at 30 seconds (s), 1 and 2 minutes (m), after the challenge. Arterial blood gas changes were measured at 30s and 2m. Significant increases in VE resulted only when either S or CA were given into the LT. The mean CA increase at 30s was significantly greater than the S one (587 v 78 ml/kg/min). A lesser difference persisted at 1 and 2 m. After LT S PaO2, fell at 30s (-8mmHg) and at 2 m (-9mnHg). At 30s and 2m LT CA resulted in a rise in pH (0.08; 0.02), ll in PaCO2 (-7mmHg; -4mmHg) and no changes in BE. At 30s an 2m LA CA caused a fall in PaO2 (-14mmHg; -10mmHg) while LT CA caused a rise in PaO2 at 30s (16mmHg) and a fall at 2m (-3mmHg). The response to an irritant challenge in the airway consistently resulted in increased ventilation only when the lower tracheal site was stimulated but delayed hypoxemia occurred. The laryngeal site VE response was inconsistent but associated with significant hypoxemia. The mid-tracheal site response was minimal.

"Inadvertent PEEP" develops during high frequency ventilation. This effect is not as well recognized using a conventional ventilator at high frequencies. A neonatal lung model with respiratory compliance of 3.3 ml/cm H2O and a pressure tap to measure alveolar pressure (Palv) was ventilated with a Baby Bird through a 2.5 mm ID neonatal ET tube at 20 to 100 breaths per minute (BPM) using a variety of I:E ratios, peak pressures, and end expiratory pressures. Proximal airway pressure (Paw) was measured at the ET tube adaptor. End tidal Palv increased as frequency, peak pressure and I:E ratios were increased even if the ventilator was set at zero PEEP. This inadvertent increase in Palv was not detected by the proximal airway pressure monitor even though the "Inadvertent PEEP" (Palv-Paw) was as great as 9.8 cmH2O at 100 BPM. "inadvertent PEEP" is the result of insufficient expiratory time at high ventilator rates, and its magnitude is decreased by increasing expiratory time.

There is limited developmental outcome data available on near term infants requiring intensive care. To assess the impact on larger infants requiring such care, a 20% random sample of infants >2500 grams discharged from the University of Florida Regional Neonatal Intensive Care Center (RNICC) between 1975-1976 were evaluated at 21 months post conceptual age. The Bayley Scales of Infant Development's mental and physical development quotients (MDQ/PDQ) and physical and neurological exams were the outcome assessment measures administered utilizing a blind experimental design. Mean gestational age was 39 weeks and mean hospital stay was 7 days. No statistical differences were found by race or sex of the infants. Those infants who were transferred to the RNICC had MDQ and PDQ significantly lower than those born inhouse. Since only sick infants in this weight group are transported, the lower MDQ and PDQ may be just a reflection of the initial disease.

• High-frequency jet ventilation in neonates has been associated with airway damage ranging from focal necrosis to complete airway obstruction with mucus and severe necrotizing tracheobronchitis. However, studies have lacked consistent criteria for assessment, and jet ventilation systems have varied widely. We compared autopsy and histopathologic findings in six neonates who died after prolonged jet ventilatory support with findings in six matched controls who died after receiving conventional ventilatory support. Jet ventilation consisted of a pressure-limited, time-cycled, flow-interrupter–type system. The airways of all patients were assessed by the histopathologic scoring system of Ophoven et al. No differences were observed between neonates who received jet ventilation or conventional ventilation. We believe that the risk of airway damage should not preclude the use of jet ventilation, although further monitoring is imperative. (AJDC1989;143:228-232)

The vasodilating effects of the post-synaptic, vascular dopamine receptor (DA1) agonist, fenoldopam (Fen) on the systemic and renal vascular beds have been widely investigated. The effect of Fen on the pulmonary vascular bed is not well known. Using an isolated, in situ, salt perfused, isogravimetric rat lung preparation, we devised an experiment in which we infused Fen into the isolated lung during normotensive pulmonary artery pressure (PAP), during prostaglandin (PGF2α) induced pulmonary hypertension, and after DA1 blockade with SCH 23390, during a hypertensive state. Four Sprague-Dawley rats were studied. For all experiments, PAP and LAP were directly measured while flow (Q) was maintained at a constant rate, (Q ≥ 0.03 ml/kg/min). PVR was calculated, PVR = (PAP - LAP)/Q. ΔPAP and ΔPVR for all experimental conditions were evaluated by normal distribution analysis with a null hypothesis stating that PAP=0 and PVR=0. The null hypothesis is rejected at p

The outputs of a Healthdyne Jet (HJ) and a Baby Bird (BB) ventilator were compared by ventilating a neonatal lung model with physiological resistance and compliance. We measured alveolar pressure (Palv), change in lung volume ( ΔLV) and tidal volume (VT) over the frequency (f) range of each ventilator (80-900 BPM and 20-100 BPM respectively) using a variety of I:E ratios, peak pressures, end expiratory pressures, and flow rates. The relationships of Palv, LV and VT to f were similar in both ventilators. Palv and LV increased similarly by increasing frequency. This effect was magnified by increasing I:E ratio or flow rate. VT decreased in both ventilators according to a hyperbolic relationship (x·y=constant). A conventional and jet ventilator have very similar mechanical output and pressure and volume relationships over their frequency ranges. This similarity derives in part from similarity of design and in part from interaction between the ventilator and the ventilated object.

Beginning January, 1983, a comprehensive hearing screening program for all infants less than 28 days of age was initiated. 487 infants at risk for hearing impairment were screened using a list of 20 risk criteria. Infants are classified as high risk when they meet one or more of the risk criteria. Testing involves Behavorial Observation Audiometry (BOA), Tympanography (Tymp) and Auditory Brainstem Response (ABR). Hearing impairment was diagnosed when the infant failed BOA, or ABR on two occasions. Any infant who failed Tymp received otologic exam to rule out middle ear disease. To date 440 infants were classified at high risk and 214 have been tested. 8 (3.8%) have been diagnosed as hearing impaired. The most frequent risk factors to appear in the 8 hearing impaired infants were a birthweight

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.