Perinatal Medicine

676 Effect of Carboxyhemoglobin on Hemoglobinometers for Near-Patient Testing

A.K Gong, J.M. Steinke, and A.P. Shepherd, Departments of Pediatrics and Physiology, University of Texas Health Science Center, San Antonio, Texas

During a recent evaluation of two portable hemoglobinometers suitable for testing neonates, we noted disparate readings on certain quality-control (QC) materials that contained carboxyhemoglobin (HbCO) (Level 1, Multi-40 CO-Oximeter Controls Instrumentation Laboratory, Lexington, MA). Blood levels of HbCO increase both in neonatal hemolytic disorders and in carbon monoxide poisoning. We compared the HemoCue hemoglobinometer (HemoCue AB, Angelholm, Sweden) with the Hb-Quick (Avox Systems, Inc., San Antonio, TX) by taking repeated readings on controls. The co-oximeter (OSM3, Radiometer, Copenhagen, Denmark) was used as a reference instrument. The Level 1 control insert sheet listed an acceptable total hemoglobin range of 15.9-18.5 g/dL for the OSM3 (a mid-range value of 17.2, confirmed by OSM3). Repeated readings (n = 5) on the Hb-Quick agreed with the OSM3 averaging 17.46 ± 0.05SD; whereas the HemoCue's readings averaged 18.78 ± 0.15SD (1.58 g/dL higher). This Level 1 control contained 57.3% HbCO, so additional measurements on whole blood and Level 2 controls both before and after exposing them to CO. With CO equilibration, HbCO increased from 2.9 to 94.9% in Level 2 control and from 0.2 to 96.8% in whole blood.

The Hb-Quick and HemoCue both initially gave readings on Level 2 control that agreed with the insert sheet (14.45) and the OSM3 (14.3). Increased HbCO caused the HemoCue's readings to increase spuriously by 1.66 g/dL; readings on the Hb-Quick were not affected. Equilibrating whole blood with CO increased the Hb-Quick's average reading by 0.26 g/dL, but the HemoCue's reading increased by 1.24 g/dL. These findings indicate that the HemoCue should be used with caution if either QC materials or clinical blood samples contain significant fractions of HbCO. By contrast, the Hb-Quick gives accurate readings in the presence of high concentrations of HbCO.

677 the Use of Videoconferencing to Support Virtual Visitation in the Nicu

RL Boyd, J Bhatia, and WB Karp, Department of Pediatrics, Section of Neonatology, The Medical College of Georgia, Augusta, Ga.

Purpose: The availability of television-based analog telephone (POTS) videoconferencing equipment provided the impetus to explore ways in which such technology might support virtual visitation between an infant and health care providers in the NICU and families at home. A pilot project was conducted. Methods: Realtime, two-way interactive videoconferencing units (ViaTV Model VC105) were used throughout the project. Videoconferencing equipment was brought to the bedside of infants in the NICU and equipment was also brought home and installed by family members. Families whom the neonatologists felt might benefit from the technology were enrolled in the pilot study. Quantitative data were collected during each videoconference and included demographic information, measures of technology performance, and feelings and attitudes of family members. The data in this pilot project cover the time period, October 6, 1998 thru June 3, 1999, involving 36 videoconferences with 4 families. Results: The number of videoconferences held per family was 9 (range 3-16) and, on the average, families lived 66 miles from the NICU (range 25-92). The average length of the 36 videoconferences was 21 + 14.9 minutes (mean ± SD, range 5-55.) The mean birth weight of infants was 1389 grams (range 715-2465 gm) and the infants had a gestational age of 30 weeks (range 28 - 35). It took an average of 1.25 +0.61 times to technically establish the videoconference connection, with a baud rate of 23127 +1950.8. All videoconference occurrences were used for family visitation with the infant. In general, families felt very positive about videoconferencing with their infant. All staff and parents felt that the quality of the picture and sound were acceptable for this purpose. Conclusions: This pilot study shows that POTS videoconferencing may provide an alternate method of visitation in the NICU, especially when family members live at a distance. Further studies need to be done, particularly examining the affect of this technology on maternal-infant bonding.

678 Oral Baclofen Use for Hospitalized Infants with Perinatal Brain Injury

BS Carter, MM Perkins, RF Boedy and J Bhatia. Division of Neonatology, Departments of Pediatrics, Vanderbilt University, Nashville, TN and Medical College of Georgia, Augusta, GA.

Background: Infants with perinatal brain injury are known to be at risk for problems with abnormal neuromuscular tone and function which may affect successful oral feeding, posture and range of motion (ROM). Baclofen™, a gamma-aminobutyric acid agonist, impedes the release of excitatory neurotransmitters which result in spasticity. Purpose: To determine the potential efficacy and safety of oral (po) Baclofen™ in treating brain-injured infants with abnormal neuromotor exams while in the NICU. Methods: Baclofen™ was given po to 11 hospitalized infants (4 with hypoxic-ischemic encephalopathy, 7 with perinatal IVH) at a mean age of 10 weeks who were recovering in the NICU. Prior to treatment, infants receiving a therapeutic trial of Baclofen™ had neuromotor tone assessed on 2 occasions by a physical therapist (PT) using a standardized methodology (the Ashworth Scores). Treatment consisted of Baclofen™ starting at 0.5mg PO BID, advancing to a maximum dose of 2mg PO TID. Daily assessments were made to determine improvements in tone, ROM, oral feeding and ease of handling/care by nurses and parents. Net benefit was determined if Ashworth Scores improved over the course of a 1-2 week trial and no side-effects were encountered. Results: In 10 of the 11 infants treated, positive effects were seen, including decreased arching of the trunk, scissoring of the lower extremities, and upper extremity flexion or fisting; an ease of passive ROM, improved oral feeding, and/or a cessation of diazepam therapy. Baclofen™ was prescribed for long-term therapy in these 10 patients. In 1 patient Baclofen™ was discontinued because of late occuring weakness and mild sedation on outpatient follow-up. In only 1 patient was there no apparent benefit on a maximum dose of 6mg/day. Conclusion: Oral Baclofen may be a safe adjunct in the management of hypertonia and evolving spasticity in infants with perinatal brain injury. Controlled trials with longitudinal follow-up should be conducted to further evaluate safety and efficacy in both the inpatient and outpatient setting.

679 Does the Choice of Nipple Affect Oral Feeding Performance in Preterm Infants?

CE Scheel, C Lau, and RJ Schanler, Dep't Pediatrics, Baylor College of Medicine, Houston, TX

When preterm infants transition from tube to bottle feeding, a variety of nipples are used. For optimal feeding performance, caretakers select a nipple based on its characteristics and the infant's age and weight. As there are no criteria upon which to base the choice of nipples, the objectives of this study were to evaluate feeding performance using 3 commercial nipples. Methods: Oral feeding of 11 preterm infants (<30wks gestation) was monitored over time, at 1-2, 3-5, and 6-8 oral feedings/day. At each time, within 24 hours, 3 consecutive feedings were monitored, each with a different nipple (A, B, C) assigned randomly. In addition, caretakers were asked to identify the nipple they would have chosen at each session. Feeding performance was assessed as % overall transfer (ml consumed/ml ordered to be given), feeding efficiency (ml/min), and feeding duration (min). Results: The nipple effect at each stage of oral feeding on overall transfer (OT), efficiency, and duration of feeding (mean ± SD), and the % infants whose efficiency was optimized with the use of a specific nipple.

There was a 21% agreement between caretakers' choice of nipple and the one providing optimal efficiency. Conclusion: In the absence of well defined criteria to facilitate the selection of the optimal nipple, it appears that the use of Nipple B, overall, facilitated oral feeding in preterm infants born <30 weeks gestation. The observation that caretakers' selection was worse than random choice stresses the importance of acquiring a better understanding of the development of sucking in preterm infants in order to optimize their feeding performance.

680 Transfemoral Retrieval of Broken/Misplaced Broviac Catheters from Right Atrium in Neonates

T. Mercer, Y. Schoolov, A. Pramanik, R. Baier, C. Holland, E. Rivera, H. D'Agostino. Depts. of Pediatrics, Surgery & Radiology, LSU Health Sciences center, Shreveport, LA.

Critically ill infants that require parenteral nutrition may suffer breakage of Broviac catheters with migration of fragments into the heart.

Aim: To describe the technique of removal of broken & misplaced catheter fragments.

Method: A transfemoral approach is used. Broken catheter fragments are captured and removed with microsnares.

Results: BG was born at 31 weeks gestation, weighing 2165 grams, had repair of esophageal atresia with tracheoesophageal fistula at 1 day of age. A 2.7 Fr. Broviac catheter was placed via the right femoral vein with its tip at the level of L2. At the age of 41 days, thrombosis of the catheter was treated with urokinase instillations with apparent restoration of catheter patency. Swelling of the right thigh was noted the following day. A chest X-ray revealed breakage of the catheter and a broken fragment of of 2.5 cm into the right atrium. The broken fragment was lassoed with 1.2 cm snare, folded in a catheter sheath and successfully removed. The infant was discharged at two and half months, and is remaining well on long-term follow up.

DJ, born at 26 weeks, weight 920 grams, developed meningitis, BPD, pneumonia secondary to G-E reflux and feeding intolerance. Hence at the age of 3 months, a 2.7 Fr. Broviac catheter was placed in the left femoral vein to administer intravenous nutrition. A month later a chest X-ray taken showed that the catheter was broken and the tip had migrated into the right atrium. The broken catheter fragment was removed using a 4mm microsnare. The baby was discharged at the age of 5 months.

Conclusion: Broken fragments from Broviac catheters that migrate to the heart are succesfully removed using microsnares.

681 the Pitfalls of Newborn Hearing Screening in a Primarily Medicaid Population

M GAYLORD, T CHATTAWAY, K LORCH, C STANFORD, v LORCH, DEPARTMENT OF PEDIATRICS, UNIVERSITY OF TENNESSEE MEDICAL CENTER AT KNOXVILLE, KNOXVILLE, TN.

Universal hearing screening (UHS) of newborns (NB) ≥36 wks. in a primarily Medicaid (M) population is fraught with difficulty. From 1/1/94 to 4/99, 12,059 NB were delivered in our University Hospital (80% Medicaid) and 9,532 HS (automated BAER, A-ABR) were performed on NB prior to discharge. 201 NB were omitted and 2,326 were not tested secondary to pediatrician's request. Of those tested, 568 (5.9%) failed and 241 (44%) were retested at 1 mo. 327 NB (57.9%) did not return despite phone and letter follow-up. Of the 241 retests, 41 (17%) failed again (26 [63%] conductive loss, 15 [36%] sensori-neural hearing loss, SNHL). Of the SNHL 26% was unilateral.

Using similar percentages and extrapolating the 327 no shows, another 19 SNHL could be estimated for a rate of 3.7/1000 births (as seen in previous studies).

Newborn hearing screening in an 80% Medicaid practice, despite traditional follow-up methodology, is associated with a high non-return rate. Successful rescreening will depend on alternative follow-up strategies.

682 Impact of Parental Visitation Policies on Parents and Nurses in the Neonatal Intensive Care Unit

WJ Kowalski, M L Lawson, and D G Oelberg, Department of Pediatrics, Eastern Virginia Medical School and Children's Hospital of The King's Daughters, Norfolk, VA.

Aim: Open visitation policies in neonatal intensive care units (NICU's) have been shown to decrease parental stress and improve family bonding, but they require increased time and effort from nursing staff. We sought to determine how such policies impact nurses, parents and the parent-nurse relationship. Methods: Qualitative interviews were conducted with 19 nurses and 6 parents in the NICU. Subjects were asked to describe important issues - including restricted visitation during shift changes - relating to the visitation policy. Results: Nursing responses to parent visitation could be categorized in 3 ways: 1) holding and bonding are important (33%); 2) parents demand nurses' time - reducing job efficiency (33%); and 3) bonding is important, and parents demand nurses' time (33%). In all, 68% of nurses mentioned having at least some problems with visiting parents. Half (54%) of those nurses also expressed problems with sibling visitation. None of the nurses supported decreased time for visitation; however, 63% stated that absence of parents during shift change provided some relief for nurses. An astounding 81% of parents expressed positive feelings about leaving during shift change. Parents stated that they used shift change to “take a break”, eat or run errands. Only 1 of 6 parents expressed complaint about excessive lengths or frequencies of shift changes. Sixty-three percent of parents stated that exceptions should be made to the visitation policy for sick babies, children and one-time visitors, although 40% of these parents expressed frustration with policy inconsistencies. Nurses also maintained conflicting beliefs about flexibility. Although the majority (75%) of nurses stated that inconsistencies impede job efficiency, half of these nurses also supported the need for flexibility in selected situations. Conclusions: Open visitation policies in the NICU should: 1) include scheduled breaks for parents and nurses, and 2) support flexibility in policy enforcement. Restricted parent visitation during nursing shift changes provides stress relief for both nurses and parents. Policies detailing the determination of exceptions may reduce the stress caused by inconsistencies while concurrently accommodating special needs.

683 Complications during Prophylactic Surfactant Administration to Very-Low-Birth-Weight Infants

GT Mandy, AA Moïse, TN Hansen*, SE Hegemier, EO Smith, AL Gest, JM Adams, G Sitler, L Evey Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, TX. ^†Department of Pediatrics, Ohio State University and Children's Hospital, Columbus, OH

There is limited information regarding complications during surfactant administration. As part of a large clinical trial the complications of prophylactic surfactant administration were observed.

276 doses of surfactant (Survanta) were administered prophylactically to 100 very-low-birth-weight infants (birthweight 1243 ± 303 g, gestation 29 ± lwk). Heart rate changes, oxygen saturation, loss of chest wall movement, ventilator adjustments and reflux of surfactant into the endotracheal tube were monitored. McNemar's test was used for statistics.

Bradycardic episodes (heart rate <90/min) were rare, 1.2% of administration events. Desaturations (below 90%) were frequent, in 47.3% of administration events. In 44% of these episodes the oxygen saturation dropped to <80%. In 36.3% of administration events loss of chest wall movement was observed. 42.7% of administration events required FiO2 increase averaging 18% higher than prior administration. In addition 52.5% of the administration events required an increase of the peak inspiratory pressure (PIP). Different degrees of reflux of surfactant were common in 39.3% of the administration events. Patients tolerated the first dose with significantly less complication when the first dose was compared to each additional dose. (* p<0.001, ** p<0.005, *** p<0.05) Although reflux of surfactant tended to be more frequent at the first dose, this tendency was not significant (NS).

Complications during surfactant administration frequently happen. We speculate that prior to surfactant administration increase of the FiO2 by 20% will prevent the majority of desaturations. These observations do not contraindicate giving additional doses. Supported by Ross Laboratories.

684 Nasal Airway Obstruction after Exposure to Valproic Acid in Utero

G Nguyen, L Pettit, D Suskind-Liu, B Barkemeyer, Departments of Pediatrics and Otorhinolaryngology, LSU Health Sciences Center, New Orleans, LA.

Multiple minor and major congenital anomalies have been described in infants due to the teratogenic effects of valproic acid in utero. Typical facial features of fetal valproate syndrome include tall, narrow forehead, infraorbital grooves, flat nasal bridge, broad nasal root, anteverted nares, shallow philtrum, and long upper lip with thin vermilion border. The most frequently reported major congenital malformations are neural tube defects, congenital heart defects, oral clefts, genital abnormalities, and limb defects. We describe an infant exposed to valproic acid in utero with typical facial features of fetal valproate syndrome who developed respiratory distress shortly after birth due to severe upper airway obstruction at the level of the anterior nares. Endotracheal intubation was initially required with subsequent surgical placement of nasal stents to establish an adequate airway. To our knowledge, this is the only reported case of nasal airway obstruction in association with fetal valproate syndrome.

685 Comparison of the Crib and Berlin Scores for Predicting Neonatal Mortality and Short Term Morbidity

NS Chouhan, C Dore, SA Roberts.(intr. by AA Hutchison)Departments of Pediatrics, University of Kentucky, Lexington, KY, Hammersmith & Wythenshawe Hospitals, UK.

Background: The CRIB score and the new Berlin score are used to predict neonatal mortality at 12 hours of age and at birth respectively. This retrospective study compared the CRIB and Berlin scores in the post surfactant era. In addition the scores were evaluated after inclusion of intra uterine growth retardation (IUGR).

Methods: Data for the CRIB and Berlin scores were collected from the charts of 47 neonates admitted to the NICU in August 1997. The scores were compared for 22 neonates who died and 25 who survived. Short term morbidity parameters were: length of stay, intraventricular hemorrhage and chronic lung disease.

Results: The groups did not differ in birthweight, gestational age or Apgar scores. The CRIB scores were:10.81±5.38 in babies who died vs 2.92±3.9S in survivors(unpaired t-test; P=0.000). The Berlin scores were:22.36±10.85 in babies who died vs 16.76±6.59 in survivors(P=0.04).The CRIB score prediction of neonatal mortality had a sensitivity of 77.3% and a specificity of 84% as assessed by logistic regression analysis. The Berlin score had a sensitivity of 54% and a specificity of 80%. Using receiver operating characteristic analysis, the CRIB score value for area under curve(AUC) was 0.89 vs 0.67 for Berlin score. With the addition of IUGR to the CRIB score the prediction of mortality had a sensitivity 86.4% with an AUC of 0.92. Short term morbidity could not be predicted.

Conclusion: The CRIB score performed at 12 hours of age is a better tool for predicting neonatal mortality than is the Berlin score performed at birth.

686 Title: the Influence of Late Apnea, Bradycardia, And/Or Desaturation (Episode) on Anticipated Discharge in Preterm Infants

Objective: To determine the length of stay from the last episode interrupting anticipated discharge.

Study Design: For the study period of January - September 1999 there were 896 admissions to the Neonatal Intensive Care Unit and Intermediate Care Units. 289 patients were less than 2000 grams at birth and of these 42 met criteria for the study which included < 34 weeks gestation, birth weight <2000 grams, PO / GT feeds, open crib, PO meds. Exclusions from study included tracheostomies, VP shunts, seizure disorders, and if episodes were triggered by a procedure.

Results: Gestational ages ranged from 24 to 32 weeks. The mean birth weight was 1167 grams and the mean length of stay was 65.3 days (range 27-115 days). The mean post-conceptual age (PCA) at last episode was 37.3 weeks (range of 32 to 45.8 weeks). The mean PCA at discharge was 38 weeks (range of 33.1 to 46.4 weeks). 19% of the patients failed a trial of methylxanthine and were restarted. Of the 42 patients, 92.9% were discharged home on apnea monitors and 88.1% on methylxanthines. The mean length of stay after late episode was 5.2 days with a range of 1 to 14 days. The mean number of days on a home monitor was 100 with the range being 11 to 220 days.

Conclusion: Proposed discharge was disrupted due to late episodes in 15% of preterm infants (< 2000 grams / < 34 weeks gestation). This group had a wide range of PCA. Physician management of discharge after last episode varies. Late episodes were associated with high utilization of home monitoring and methylxanthines. Duration of home monitoring is variable. No patients were readmitted for episodes after discharge.

687 a Hidden Morbidity of “Successful” Early Discharge

CM MASSEY, PG RADMACHER, DH ADAMKIN, DEPARTMENT OF PEDIATRICS, UNIVERSITY OF LOUISVILLE, LOUISVILLE, KY

PURPOSE: To evaluate hyperbilirubinemia after early discharge (Ed/c:<48 hrs.) in normal newborns. METHODS: Retrospective review of medical charts of normal infants, born at Norton Hospital (NH, Louisville, KY) between 1/1/94-12/31/98 and admitted to Kosair Children's Hospital (KCH, Louisville, KY) for jaundice (JND) within 7 days of d/c. Lab results for serum bilirubin (BR) were evaluated. RESULTS: We previously reported that Ed/c increased risk for hospital admission with JND when compared to later d/c (Rd/c:>48 hrs.) (J Invest Med 1999;47:129A). There were 44 infants admitted to KCH for JND: 36 (82%) in the Ed/c group and 8(19%) in the Rd/c group (p<0.001). There were no statistical differences between groups regarding the proportions of primigravidas, breast-feeding mothers, age at hospital admission or length of hospital stay (data not shown).

CONCLUSIONS: 1. Infants discharged early are at ~4 times higher risk for hospital readmission for JND than infants with later d/c. 2. Of infants admitted for JND, ~20% had BR>25 mg/dL (all breast-fed and Ed/c), necessitating exchange transfusion in 1 infant with Coombs (+) hemolytic disease. 3. Community health care providers may need to see breast-feeding mother-infant dyads within 48 hrs. of d/c and to continue to monitor them until lactation is safely established. Women who plan to breast feed need thorough lactation counseling prenatally and should be able to demonstrate adequate knowledge about the signs/symptoms of hyperbilirubinemia and lactation impairment/insufficiency prior to discharge.