- Neonatal-Perinatal Medicine
Clinical Professor, Pediatrics - Neonatal and Developmental Medicine
Medical Director, PICN, LPCH (2004 - Present)
Fellowship: Stanford University Neonatology Fellowship (1981) CA
Residency: UCSF Pediatric Department (1979) CA
Residency: UCSF Pediatric Department (1978) CA
Internship: UCSF Pediatric Department (1977) CA
Board Certification: American Board of Pediatrics, Neonatal-Perinatal Medicine (1981)
Board Certification: American Board of Pediatrics, Pediatrics (1981)
Medical Education: Columbia University College of Physicians and Surgeons (1976) NY
BA, Columbia College, NY (1972)
Community and International Work
Opportunities for Student Involvement
Mothers' Milk Bank of San José
Opportunities for Student Involvement
- Independent Studies (5)
Universal Level Designations for Hospitalized Pediatric Patients in Evacuation.
Children comprise approximately 22% of the population in the United States.1 In a widespread disaster such as a hurricane, pandemic, wildfire or major earthquake, children are at least proportionately affected to their share of the population, if not more so. They also have unique vulnerabilities including physical, mental, and developmental differences from adults, which make them more prone to adverse health effects of disasters.2-4 There are about 5000 pediatric critical care beds and 23 000 neonatal intensive care beds out of 900 000 total hospital beds in the United States.5 While no mechanism exists to consistently track pediatric acute care beds nationally (especially in real time), a previous study6 showed a 7% decline in pediatric medical-surgical beds between 2002 and 2011. This study also estimated there are about 30 000 acute care pediatric beds nationally. Finding appropriate hospital resources for the provision of care for pediatric disaster victims is an important concern for those charged with triaging patients in a major event.
View details for DOI 10.1542/hpeds.2021-006356
View details for PubMedID 35137099
Learning from Wildfire Disaster Experience in California NICUs.
Children (Basel, Switzerland)
2020; 7 (10)
Wildfires have been affecting California greatly, and vulnerable patients in neonatal intensive care units (NICUs) are not exempt. Our aim was to learn how personnel working in NICUs of California hospitals handled issues of neonatal transfer during wildfire disasters in recent years, with an ultimate goal to share lessons learned with healthcare teams on disaster preparedness. We identified California fires through newspaper articles and the CalFire.gov list. We determined which hospitals were affected and contacted members of the healthcare team through connections via the California Perinatal Quality Care Collaborative (CPQCC) database. We audio recorded interviews over phone or remote conferencing software or by written survey. We coded and analyzed transcripts and survey responses. While describing disaster preparedness, equipment (such as bassinets and backpacks), ambulance access/transport and documentation/charting were noted as important and essential. Teamwork, willingness to do other tasks that are not part of typical job descriptions, and unconventional strategies contribute to the success of keeping NICU babies safe when California wildfire strikes. Healthcare teams developed ingenious and surprising ways to evacuate NICU babies.
View details for DOI 10.3390/children7100155
View details for PubMedID 33019523
- The Neonatal Intensive Care Unit: From Aggressive Treatment to Care of the Dying, Insights from Art and Poetry CAMBRIDGE QUARTERLY OF HEALTHCARE ETHICS 2020; 29 (3): 354–60
- Sustainability of a Clinical Examination-Based Approach for Ascertainment of Early Onset Sepsis in Late Preterm and Term Neonates. The Journal of pediatrics 2020
California NICU disaster preparedness.
Journal of perinatology : official journal of the California Perinatal Association
NICU patients are disproportionately affected by any disaster due to their vulnerability and highly specialized care needs that require a multitude of resources. Research in disaster preparedness and its effect on NICU patients is limited.From March to May 2018, NICUs across California participated in a survey designed to assess their preparedness for a disaster.Of the 84 responding units, 99% were urban, 73% were nonprofit, and 65% were community NICUs. As for NICU participation in hospital training exercises for disaster preparedness, 10% did not participate in annual drills, 44% did once a year, 36% did twice a year, and 10% did more than two times per year.We showed that many NICUs had redundant systems in place and plans for various disasters; however, there is not consistent participation by NICUs in hospital training exercises for disaster preparedness.
View details for DOI 10.1038/s41372-020-0676-3
View details for PubMedID 32382117
Increased Carbon Monoxide Washout Rates in Newborn Infants.
BACKGROUND: Endogenous carbon monoxide (CO) production is primarily due to heme degradation, which also results in the equimolar production of bilirubin. Thus, estimates of total body CO production can serve as indices of total body bilirubin formation. The elimination rate of CO from a person's body (CO washout rate) after exposure to an elevated ambient CO concentration is determined by a variety of factors, and is very different between babies and adults.OBJECTIVE: We determined CO washout rates for babies using a simplified technique to measure total body CO excretion rates (VeCO).METHODS: Using a simplified technique, we measured the times to reach an approximate steady state after a change in ambient CO concentration (decay time constant) and CO washout rates in normal newborn infants using non-linear least squares curve fitting.RESULTS: We found a mean CO washout time of 18.7 ± 4.2 min and a CO equilibration (decay time) constant of 0.12 ± 0.04/min (0.08-0.21) for newborn infants.CONCLUSIONS: We confirm that CO washout rates for babies are much faster than those for adults. Therefore, measurements of carboxyhemoglobin (COHb) or end-tidal CO (ETCO), corrected for ambient CO, (COHbc and ETCOc, respectively) can be used as surrogates for VeCO and can provide accurate estimates of endogenous CO (VCO) and bilirubin production rates under normal environmental conditions. Such measurements can be used to identify infants with severe hyperbilirubinemia due to hemolysis and thus at high risk for bilirubin neurotoxicity.
View details for DOI 10.1159/000503635
View details for PubMedID 31634890
- Case 2: Infant with Early Direct Hyperbilirubinemia. NeoReviews 2019; 20 (6): e350–e352
Management of Chorioamnionitis-Exposed Infants in the Newborn Nursery Using a Clinical Examination-Based Approach.
BACKGROUND: Antibiotic use in well-appearing late preterm and term chorioamnionitis-exposed (CE) infants was reduced by 88% after the adoption of a care approach that was focused on clinical monitoring in the intensive care nursery to determine the need for antibiotics. However, this approach continued to separate mothers and infants. We aimed to reduce maternal-infant separation while continuing to use a clinical examination-based approach to identify early-onset sepsis (EOS) in CE infants.METHODS: Within a quality improvement framework, well-appearing CE infants ≥35 weeks' gestation were monitored clinically while in couplet care in the postpartum unit without laboratory testing or empirical antibiotics. Clinical monitoring included physician examination at birth and nurse examinations every 30 minutes for 2 hours and then every 4 hours until 24 hours of life. Infants who developed clinical signs of illness were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, and clinical outcomes were collected.RESULTS: Among 319 initially well-appearing CE infants, 15 (4.7%) received antibiotics, 23 (7.2%) underwent laboratory testing, and 295 (92.5%) remained with their mothers in couplet care throughout the birth hospitalization. One infant had group B Streptococcus EOS identified and treated at 24 hours of age based on new-onset tachypnea and had an uncomplicated course.CONCLUSIONS: Management of well-appearing CE infants by using a clinical examination-based approach during couplet care in the postpartum unit maintained low rates of laboratory testing and antibiotic use and markedly reduced mother-infant separation without adverse events. A framework for repeated clinical assessments is an essential component of identifying infants with EOS.
View details for PubMedID 30833294
- Triage by Resource Allocation for INpatients: A Novel Disaster Triage Tool for Hospitalized Pediatric Patients DISASTER MEDICINE AND PUBLIC HEALTH PREPAREDNESS 2018; 12 (6): 692–96
Chemical Contaminants in Raw and Pasteurized Human Milk
JOURNAL OF HUMAN LACTATION
2018; 34 (2): 340–49
Environmental contaminants ranging from legacy chemicals like p,p'-dichlorodiphenyltrichloroethane (DDT) to emerging chemicals like phthalates are ubiquitous. Research aims/questions: This research aims to examine the presence and co-occurrence of contaminants in human milk and effects of pasteurization on human milk chemical contaminants.We analyzed human milk donated by 21 women to a milk bank for 23 chemicals, including the persistent organic pollutants (POPs) polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), dichlorodiphenyltrichloroethane (DDT), and dichlorodiphenyldichloroethylene (DDE) isomers that are known to sequester in adipose tissue, along with the current-use and nonpersistent pesticides chlorpyrifos and permethrin, phthalates, and bisphenol A (BPA). Human milk was analyzed raw and pasteurized for these chemicals using gas chromatography-tandem mass spectrometry for the POPs and high-performance liquid chromatography-tandem mass spectrometry for non-POPs.Within the different chemical classes, PBDE47, PCB153, ppDDE, and MEHHP (phthalate metabolite) had the highest median concentrations and were observed in all samples. We also observed chlorpyrifos and BPA in all samples and permethrin in 90% of the samples tested. Only two chemicals, chlorpyrifos and permethrin, were susceptible to substantial degradation from pasteurization, a standard method for processing donated human milk.We detected 19 of 23 chemicals in all of our prepasteurized milk and 18 of 23 chemicals in all of our pasteurized milk. Pasteurization did not affect the presence of most of the chemicals. Future research should continue to explore human milk for potential chemical contamination and as a means to surveil exposures among women and children.
View details for PubMedID 29601252
- Clinical Monitoring of Well-Appearing Infants Born to Mothers With Chorioamnionitis PEDIATRICS 2018; 141 (4)
Triage by Resource Allocation for INpatients: A Novel Disaster Triage Tool for Hospitalized Pediatric Patients.
Disaster medicine and public health preparedness
OBJECTIVE: To develop a disaster triage tool for the evacuation of hospitalized neonatal and pediatric populations.METHODS: We expanded an existing neonatal disaster triage tool for the evacuation of a children's hospital. We assessed inpatients using bedside visual assessments and chart review to categorize patients transport level based on local emergency medical services protocols and expert opinion. The tool was refined by using multiple Plan Do Study Act cycles. Primary outcome was the number of each level of transport required for hospital evacuation. Secondary outcome was improved efficiency of obtaining information about specific transport needs for evacuation.RESULTS: We evaluated 1382 patients both visually and through electronic chart review over 10 random days. Accordance between visual assessment and electronic chart review reached 96.3%. During a 2 hour statewide disaster drill, no hospital units completed self-assessed transport needs for their patients; a single nurse used Triage by Resource Allocation in INpatients to determine transportation needs in less than 1 hour. (Disaster Med Public Health Preparedness. 2018;page 1 of 5).
View details for PubMedID 29382399
Clinical Monitoring of Well-Appearing Infants Born to Mothers With Chorioamnionitis.
2018; 141 (4)
The risk of early-onset sepsis is low in well-appearing late-preterm and term infants even in the setting of chorioamnionitis. The empirical antibiotic strategies for chorioamnionitis-exposed infants that are recommended by national guidelines result in antibiotic exposure for numerous well-appearing, uninfected infants. We aimed to reduce unnecessary antibiotic use in chorioamnionitis-exposed infants through the implementation of a treatment approach that focused on clinical presentation to determine the need for antibiotics.Within a quality-improvement framework, a new treatment approach was implemented in March 2015. Well-appearing late-preterm and term infants who were exposed to chorioamnionitis were clinically monitored for at least 24 hours in a level II nursery; those who remained well appearing received no laboratory testing or antibiotics and were transferred to the level I nursery or discharged from the hospital. Newborns who became symptomatic were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, culture results, and clinical outcomes were collected.Among 277 well-appearing, chorioamnionitis-exposed infants, 32 (11.6%) received antibiotics during the first 15 months of the quality-improvement initiative. No cases of culture result-positive early-onset sepsis occurred. No infant required intubation or inotropic support. Only 48 of 277 (17%) patients had sepsis laboratory testing. The implementation of the new approach was associated with a 55% reduction (95% confidence interval 40%-65%) in antibiotic exposure across all infants ≥34 weeks' gestation born at our hospital.A management approach using clinical presentation to determine the need for antibiotics in chorioamnionitis-exposed infants was successful in reducing antibiotic exposure and was not associated with any clinically relevant delays in care or adverse outcomes.
View details for PubMedID 29599112
- Supplemental Feedings for High-Risk Preterm Infants. JAMA pediatrics 2016; 170 (11): 1112-?
Impact of Donor Milk Availability on Breast Milk Use and Necrotizing Enterocolitis Rates.
2016; 137 (3): 1-8
To examine the availability of donor human milk (DHM) in a population-based cohort and assess whether the availability of DHM was associated with rates of breast milk feeding at NICU discharge and rates of necrotizing enterocolitis (NEC).Individual patient clinical data for very low birth weight infants from the California Perinatal Quality Care Collaborative were linked to hospital-level data on DHM availability from the Mothers' Milk Bank of San José for 2007 to 2013. Trends of DHM availability were examined by level of NICU care. Hospitals that transitioned from not having DHM to having DHM availability during the study period were examined to assess changes in rates of breast milk feeding at NICU discharge and NEC.The availability of DHM increased from 27 to 55 hospitals during the study period. The availability increased for all levels of care including regional, community, and intermediate NICUs, with the highest increase occurring in regional NICUs. By 2013, 81.3% of premature infants cared for in regional NICUs had access to DHM. Of the 22 hospitals that had a clear transition to having availability of DHM, there was a 10% increase in breast milk feeding at NICU discharge and a concomitant 2.6% decrease in NEC rates.The availability of DHM has increased over time and has been associated with positive changes including increased breast milk feeding at NICU discharge and decrease in NEC rates.
View details for DOI 10.1542/peds.2015-3123
View details for PubMedID 26908696
DONOR HUMAN MILK AVAILABILITY PROMOTES BREAST MILK FEEDING AND LOWERS NECROTIZING ENTEROCOLITIS IN VERY LOW BIRTH WEIGHT INFANTS
LIPPINCOTT WILLIAMS & WILKINS. 2015: 176
View details for Web of Science ID 000346600700313
Storage of Leftover Unpasteurized and Pasteurized Human Milk
FEDERATION AMER SOC EXP BIOL. 2013
View details for Web of Science ID 000319883504433
Fortification of Donor Human Milk for Premature Infants
FEDERATION AMER SOC EXP BIOL. 2013
View details for Web of Science ID 000319883504354
Regional Disaster Planning for Neonatal Intensive Care
DISASTER MANAGEMENT: MEDICAL PREPAREDNESS, RESPONSE AND HOMELAND SECURITY
View details for Web of Science ID 000334643900006
Impact of an EMR-Based Daily Patient Update Letter on Communication and Parent Engagement in a Neonatal Intensive Care Unit.
Journal of participatory medicine
To evaluate the impact of using electronic medical record (EMR) data in the form of a daily patient update letter on communication and parent engagement in a level II neonatal intensive care unit (NICU).Parents of babies in a level II NICU were surveyed before and after the introduction of an EMR-generated daily patient update letter, Your Baby's Daily Update (YBDU).Following the introduction of the EMR-generated daily patient update letter, 89% of families reported using YBDU as an information source; 83% of these families found it "very useful", and 96% of them responded that they "always" liked receiving it. Rates of receiving information from the attending physician were not statistically significantly different pre- and post-implementation, 81% and 78%, respectively (p = 1). Though there was no statistically significant improvement in parents' knowledge of individual items regarding the care of their babies, a trend towards statistical significance existed for several items (p <.1), and parents reported feeling more competent to manage information related to the health status of their babies (p =.039).Implementation of an EMR-generated daily patient update letter is feasible, resulted in a trend towards improved communication, and improved at least one aspect of parent engagement-perceived competence to manage information in the NICU.
View details for PubMedID 23730532
Effect of Added Calcium, Phosphorus, and Infant Formula on Calcium and Phosphorus Dialyzability in Preterm Donor Human Milk
JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION
2012; 55 (4): 390-397
We studied the effect of preparing donor human milk (DHM) with commonly used nutritional additives on the dialyzability of calcium and phosphate. We hypothesized that the additives to DHM would decrease the dialyzability of calcium and phosphate when prepared according to hospital protocols.An in vitro system simulating premature infant digestion was developed to measure dialyzability of calcium and phosphate in DHM. Dialyzable calcium and phosphate were measured after in vitro digestion in DHM before and after preparation of DHM with the following additives according to hospital protocols: calcium glubionate, sodium potassium phosphate, calcium glubionate and sodium potassium phosphate added together, Similac human milk fortifier, Similac NeoSure, or Enfamil Enfacare.The percentage of dialyzable calcium in DHM with added calcium and calcium and phosphate together was greater than the percentage of dialyzable calcium in DHM with added powdered infant formulas (P<0.0001). Dialyzable calcium was greater in DHM with added calcium and with added calcium and phosphate than in all other treatment groups (P<0.0001). Dialyzable calcium in DHM without additives was not different from dialyzable calcium in DHM with added phosphate or with added powdered infant formulas. Dialyzable phosphate did not differ between the treatment groups.The addition of calcium alone or calcium and phosphate together increased calcium dialyzability in DHM significantly, whereas the addition of powdered human milk fortifier or formulas did not. The addition of calcium or calcium with phosphate together to DHM may provide the most dialyzable calcium.
View details for DOI 10.1097/MPG.0b013e318254ec07
View details for Web of Science ID 000309542600015
View details for PubMedID 22437472
Cultures of Holder-Pasteurized Donor Human Milk After Use in a Neonatal Intensive Care Unit
2012; 7 (4): 282-284
Current guidelines state that human milk, once thawed, should be kept in a refrigerator for only 24 hours. We cultured Holder-pasteurized donor human milk (DHM) after thawing and refrigeration under clinical conditions.Bottles of pasteurized DHM were thawed and used in a regional level 3 neonatal intensive care unit (NICU) in standard clinical fashion and kept refrigerated when not in use. Once no longer needed clinically, aliquots were cultured for bacteria.In total, 30 bottles were returned for culture; six were excluded from analysis because human milk fortifier had been added, and two had been left out of the refrigerator. The remaining 22 bottles were culture-negative after having been thawed for 7-122 hours.DHM without additives was culture-negative for 24 hours or longer after thawing and routine NICU handling. These data indicate that unfortified Holder-pasteurized DHM handled appropriately and refrigerated remains sterile for 24 hours after thawing and perhaps longer. Further study is needed to confirm this.
View details for DOI 10.1089/bfm.2011.0055
View details for PubMedID 22424470
Extensive Subcutaneous Fat Necrosis of the Newborn Associated with Therapeutic Hypothermia
2012; 29 (1): 59-63
Subcutaneous fat necrosis of the newborn is a form of panniculitis that most often occurs in full-term infants with predisposing risk factors. Three neonates with hypoxic ischemic encephalopathy were treated with therapeutic hypothermia and developed extensive subcutaneous fat necrosis. All three infants developed extensive subcutaneous fat necrosis, involving the back, scalp, and arms. Mild, asymptomatic hypercalcemia was noted in one infant in the weeks following the subcutaneous fat necrosis. Hypothermia as a risk factor for subcutaneous fat necrosis is reviewed. Clinicians should be aware of subcutaneous fat necrosis as a possible risk factor and complication associated with asphyxiated newborns who may undergo therapeutic hypothermia. Future studies for therapeutic hypothermia should evaluate neonates for the development of subcutaneous fat necrosis.
View details for DOI 10.1111/j.1525-1470.2011.01374.x
View details for Web of Science ID 000299209300010
View details for PubMedID 21906137
- Feeding Premature Infants: Why, When, and What to Add to Human Milk JOURNAL OF PARENTERAL AND ENTERAL NUTRITION 2012; 36: 20S-24S
Ventricular Access Devices Are Safe and Effective in the Treatment of Posthemorrhagic Ventricular Dilatation prior to Shunt Placement
2012; 48 (1): 13-20
Intraventricular hemorrhage of prematurity (IVH) is a diagnosis that has become more frequent in recent years. Advances in medical care have led to survival of increasingly premature infants, as well as infants with more complex medical conditions. Treatment with a ventricular access device (VAD) was reported almost 3 decades ago; however, it is unclear how effective this treatment is in the current population of premature infants. At our institution (from 2004 to present), we treat posthemorrhagic hydrocephalus (PHH) with a VAD. In order to look at safety and efficacy, we retrospectively combed the medical records of premature children, admitted to Lucile Packard Children's Hospital from January 2005 to December 2009, and identified 310 premature children with IVH. Of these, 28 children required treatment for PHH with a VAD. There were no infections associated with placement of these devices and a very low rate of other complications, such as need for repositioning (7.41%) or replacement (3.75%). Our data show that treatment with a VAD is very safe, with few complications and can be used to treat PHH in this very complex infant population.
View details for DOI 10.1159/000337876
View details for PubMedID 22832699
Perioperative management of low birth weight infants for open-heart surgery
2011; 21 (5): 538-553
Infants of birth weight ≤2500 g are termed low birth weight (LBW). These children often have considerable morbidity from prematurity and intra-uterine growth restriction. Additionally, LBW infants have increased risk for cardiac and noncardiac congenital anomalies and may require surgery. Primary rather than palliative surgical repair of cardiac lesions has been preferred in recent years. However, LBW remains a risk factor for increased mortality and morbidity after open-heart surgery (OHS). There is a paucity of information about the anesthetic challenges presented by LBW infants undergoing OHS. This review summarizes the perioperative issues of relevance to anesthesiologists who manage these high-risk patients. Emphasis is placed on management concerns that are unique to LBW infants. Retrospective data from the authors' institution are provided for those aspects of anesthetic care that lack published studies. Successful outcome often requires substantial hospital resources and collaborative multi-disciplinary effort.
View details for DOI 10.1111/j.1460-9592.2011.03529.x
View details for PubMedID 21306474
Improved outcomes with a standardized feeding protocol for very low birth weight infants
JOURNAL OF PERINATOLOGY
2011; 31: S61-S67
The objective of this study was to evaluate the impact of a standardized enteral feeding protocol for very low birth weight (VLBW) infants on nutritional, clinical and growth outcomes.Retrospective analysis of VLBW cohorts 9 months before and after initiation of a standardized feeding protocol consisting of 6-8 days of trophic feedings, followed by an increase of 20 ml/kg/day. The primary outcome was days to reach full enteral feeds defined as 160 ml/kg/day. Secondary outcomes included rates of necrotizing enterocolitis and culture-proven sepsis, days of parenteral nutrition and growth end points.Data were analyzed on 147 VLBW infants who received enteral feedings, 83 before ('Before') and 64 subsequent to ('After') feeding protocol initiation. Extremely low birth weight (ELBW) infants in the After group attained enteral volumes of 120 ml/kg/day (43.9 days Before vs 32.8 days After, P=0.02) and 160 ml/kg/day (48.5 days Before vs 35.8 days After, P=0.02) significantly faster and received significantly fewer days of parenteral nutrition (46.2 days Before vs 31.3 days After, P=0.01). Necrotizing enterocolitis decreased in the After group among VLBW (15/83, 18% Before vs 2/64, 3% After, P=0.005) and ELBW infants (11/31, 35% Before vs 2/26, 8% After, P=0.01). Late-onset sepsis decreased significantly in the After group (26/83, 31% Before vs 6/64, 9% After, P=0.001). Excluding those with weight <3rd percentile at birth, the proportion with weight <3rd percentile at discharge decreased significantly after protocol initiation (35% Before vs 17% After, P=0.03).These data suggest that implementation of a standardized feeding protocol for VLBW infants results in earlier successful enteral feeding without increased rates of major morbidities.
View details for DOI 10.1038/jp.2010.185
View details for Web of Science ID 000289236900010
View details for PubMedID 21448207
Supplementation of Human Milk with Calcium, Phosphorus, and Post-Discharge Formula
FEDERATION AMER SOC EXP BIOL. 2011
View details for Web of Science ID 000310708403146
- Regional disaster planning for neonatology JOURNAL OF PERINATOLOGY 2010; 30 (11): 709-711
Understanding Neonatal Jaundice: A Perspective on Causation
PEDIATRICS AND NEONATOLOGY
2010; 51 (3): 143-148
Neonatal jaundice can be best understood as a balance between the production and elimination of bilirubin, with a multitude of factors and conditions affecting each of these processes. When an imbalance results because of an increase in circulating bilirubin (or the bilirubin load) to significantly high levels (severe hyperbilirubinemia), it may cause permanent neurologic sequelae (kernicterus). In most infants, an increase in bilirubin production (e.g., due to hemolysis) is the primary cause of severe hyperbilirubinemia, and thus reducing bilirubin production is a rational approach for its management. The situation can become critical in infants with an associated impaired bilirubin elimination mechanism as a result of a genetic deficiency and/or polymorphism. Combining information about bilirubin production and genetic information about bilirubin elimination with the tracking of bilirubin levels means that a relative assessment of jaundice risk might be feasible. Information on the level of bilirubin production and its rate of elimination may help to guide the clinical management of neonatal jaundice.
View details for PubMedID 20675237
Retrospective review of serological testing of potential human milk donors
ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION
2010; 95 (2): F118-F120
To estimate the prevalence of positive serology among potential donors to a human milk bank.Retrospective review of our experience with donor serological testing at our milk bank over a 6-year interval.Not-for-profit, regional human milk bank.Volunteer, unpaid potential donors of human milk.Serological testing for syphilis, HIV, hepatitis B, hepatitis C, human T cell lymphotropic virus type 1 (HTLV-1) and human T cell lymphotropic virus type 2 (HTLV-2).Results of serological screening tests performed on potential donors.Of 1091 potential donors, 3.3% were positive on screening serology, including 6 syphilis, 17 hepatitis B, 3 hepatitis C, 6 HTLV and 4 HIV.There is a significant incidence of positive serology among women interested in donating human milk. This implies that there may be significant risk associated with peer-to-peer distribution of human milk from unscreened donors.
View details for DOI 10.1136/adc.2008.156471
View details for PubMedID 20231217
DISASTER PLANNING - TRIAGING RESOURCE ALLOCATION IN NEONATOLOGY
BMJ PUBLISHING GROUP. 2010: 188
View details for Web of Science ID 000273638400311
Fentanyl Transdermal Analgesia During Pregnancy and Lactation
JOURNAL OF HUMAN LACTATION
2009; 25 (3): 359-361
This report describes an infant who was born to a mother with chronic pain treated with fentanyl 100 microg/h transdermal patch throughout her pregnancy and during lactation. On day of life 27, when the baby was feeding and gaining weight on maternal milk, samples of the baby's blood and maternal milk were sent for analysis. The mother's milk fentanyl level was 6.4 ng/ mL. The infant's blood fentanyl level was undetectable. This preliminary report suggests that fentanyl transdermal patch treatment might be a viable option for managing chronic pain during lactation.
View details for DOI 10.1177/0890334409333475
View details for PubMedID 19286842
- Response to ??Deception and the Principle of Double Effect?? Camb Q Healthc Ethics 2009; 18: 101
- Response to "Deception and the Principle of Double Effect" by Amnon Goldworth (CQ Vol. 17, No. 4) The Role of Intention CAMBRIDGE QUARTERLY OF HEALTHCARE ETHICS 2009; 18 (1): 101-102
- Current issues in human milk banking. NeoReviews 2007; 8: e289
- The extremely premature infant at the crossroad. Ethical Dilemmas in Pediatrics 2006
Once-daily gentamicin dosing in newborn infants
1999; 103 (6): 1228-1234
We developed a simplified gentamicin dosing protocol for all neonates using a loading dose and once-daily dosing that would have an equal or lower incidence of toxicity and an equal or improved effectiveness compared with a regimen with no loading dose that included use of divided daily dosing.All neonatal intensive care unit patients with a postnatal age =7 days and started on gentamicin therapy at the discretion of the attending neonatologist were evaluated in this comparative cohort study. All peak and trough serum drug levels (SDL), pertinent demographic data, and markers of potential nephrotoxicity, ototoxicity, and cure were tracked prospectively during 132 consecutive, nonrandomized courses of therapy on a new gentamicin protocol. These were compared with data retrieved retrospectively throughout 103 consecutive, nonrandomized courses of therapy in a control group.Initial measured peak SDL were higher (7.8 +/- 1.1 microgram/mL vs 6.1 +/- 1.0 microgram/mL) and trough SDL were lower (0.9 +/- 0.2 microgram/mL vs 2.7 +/- 0.6 microgram/mL) in the protocol term subset, compared with the control term subset (gestational age, >/=37 weeks; weight, >/=2500 g). One hundred percent of the initial and maintenance peak SDL in term protocol neonates were 5 to 12 micrograms/mL; compared with 84% of the initial and 61% of maintenance peak SDL in the term control group. One hundred percent of the initial and maintenance trough SDL were in the desired range of <2 micrograms/mL in term protocol neonates; compared with 70% of the initial and 94% of maintenance trough SDL in the term control group. No significant differences were found in any SDL in low birth weight neonates (gestational age <37 weeks or weight <2500 g and >1500 g) in the protocol compared with the control group. The very low birth weight (weight <1500 g) protocol neonates had a significantly higher mean initial trough SDL (2.3 +/- 0.7 micrograms/mL vs 1.5 +/- 0.6 micrograms/mL) and a lower incidence of initial trough SDL <2.0 micrograms/mL (30% vs 95%) than very low birth weight neonates in the control group. No differences were seen between groups in incidence of significant rise in serum creatinine or failure of hearing screen.A loading dose followed by once-daily dosing was shown to result in SDL in the safe and therapeutic range in all term neonates in this study. In low birth weight neonates, this regimen resulted in peak and trough SDL throughout therapy that were similar to those observed in the control group. Delaying the initiation of maintenance once-daily dosing until 36 to 48 hours after the loading dose would be expected to result in a higher incidence of initial trough SDL in target range for very low birth weight neonates.
View details for PubMedID 10353934
Multicenter controlled clinical trial of high-frequency jet ventilation in preterm infants with uncomplicated respiratory distress syndrome
1996 Annual Meeting of the Pediatric-Academic-Societies
AMER ACAD PEDIATRICS. 1997: 593–99
To test the hypothesis that high-frequency jet ventilation (HFJV) will reduce the incidence and/or severity of bronchopulmonary dysplasia (BPD) and acute airleak in premature infants who, despite surfactant administration, require mechanical ventilation for respiratory distress syndrome.Multicenter, randomized, controlled clinical trial of HFJV and conventional ventilation (CV). Patients were to remain on assigned therapy for 14 days or until extubation, whichever came first. Crossover from CV to HFJV was allowed if bilateral pulmonary interstitial emphysema or bronchopleural fistula developed. Patients could cross over to the other ventilatory mode if failure criteria were met. The optimal lung volume strategy was mandated for HFJV by protocol to provide alveolar recruitment and optimize lung volume and ventilation/perfusion matching, while minimizing pressure amplitude and O2 requirements. CV management was not controlled by protocol.Eight tertiary neonatal intensive care units.Preterm infants with birth weights between 700 and 1500 g and gestational age <36 weeks who required mechanical ventilation with FIO2 >0.30 at 2 to 12 hours after surfactant administration, received surfactant by 8 hours of age, were <20 hours old, and had been ventilated for <12 hours. Outcome Measures. Primary outcome variables were BPD at 28 days and 36 weeks of postconceptional age. Secondary outcome variables were survival, gas exchange, airway pressures, airleak, intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), and other nonpulmonary complications.A total of 130 patients were included in the final analysis; 65 were randomized to HFJV and 65 to CV. The groups were of comparable birth weight, gestational age, severity of illness, postnatal age, and other demographics. The incidence of BPD at 36 weeks of postconceptional age was significantly lower in babies randomized to HFJV compared with CV (20.0% vs 40.4%). The need for home oxygen was also significantly lower in infants receiving HFJV compared with CV (5.5% vs 23.1%). Survival, incidence of BPD at 28 days, retinopathy of prematurity, airleak, pulmonary hemorrhage, grade I-II IVH, and other complications were similar. In retrospect, it was noted that the traditional HFJV strategy emphasizing low airway pressures (HF-LO) rather than the prescribed optimal volume strategy (HF-OPT) was used in 29/65 HFJV infants. This presented a unique opportunity to examine the effects of different HFJV strategies on gas exchange, airway pressures, and outcomes. HF-OPT was defined as increase in positive end-expiratory pressure (PEEP) by >/=1 cm H2O from pre-HFJV baseline and/or use of PEEP of >/=7 cm H2O. Severe neuroimaging abnormalities (PVL and/or grade III-IV IVH) were not different between the CV and HFJV infants. However, there was a significantly lower incidence of severe IVH/PVL in HFJV infants treated with HF-OPT compared with CV and HF-LO. Oxygenation was similar between CV and HFJV groups as a whole, but HF-OPT infants had better oxygenation compared with the other two groups. There were no differences in PaCO2 between CV and HFJV, but the PaCO2 was lower for HF-LO compared with the other two groups. The peak inspiratory pressure and DeltaP (peak inspiratory pressure-PEEP) were lower for HFJV infants compared with CV infants.HFJV reduces the incidence of BPD at 36 weeks and the need for home oxygen in premature infants with uncomplicated RDS, but does not reduce the risk of acute airleak. There is no increase in adverse outcomes compared with CV. HF-OPT improves oxygenation, decreases exposure to hypocarbia, and reduces the risk of grade III-IV IVH and/or PVL.
View details for Web of Science ID A1997XZ07900002
View details for PubMedID 9310511
Once daily gentamicin dosing in the neonatal intensive care unit.
NATURE PUBLISHING GROUP. 1996: 1343–43
View details for Web of Science ID A1996UD23801344
Once daily gentamicin dosing in the neonatal intensive care unit
LIPPINCOTT WILLIAMS & WILKINS. 1996: A192–A192
View details for Web of Science ID A1996TP69001027
Retrospective analysis of risks associated with an umbilical artery catheter system for continuous monitoring of arterial oxygen tension.
Journal of perinatology
1995; 15 (3): 195-198
We reviewed retrospectively the incidence of complications encountered with two different umbilical artery catheters (UACs): a silicone-rubber end-hole catheter and an electrode-tipped, side-hole catheter for continuous, invasive monitoring of arterial oxygen tension (PaO2). During calendar year 1989, there were 457 admissions to the neonatal intensive care unit: 168 patients had placement of a UAC. Two of these were admitted only briefly for cardiac catheterization and were eliminated from analysis. One patient had both types of catheters placed sequentially. Thus the data on 166 patients with 51 PaO2 monitors and 116 silicone-rubber UACs were evaluated. The patients who had a PaO2 monitor UAC had a lower mean birth weight than those in the other group (1621 +/- 1043 gm vs 1972 +/- 1048 gm; p = 0.0473). The catheter life span was not different between the groups, with a range of 1 to 16 days for PaO2 monitors and 1 to 27 days for silicone-rubber UACs. Inability to withdraw blood, poor blood pressure tracing, or both conditions resulted in catheter removal for 5 of 51 PaO2 monitor UACs and 4 of 116 end-hole UACs. The incidence of these problems did not differ significantly between the two groups. There were no cases of thromboembolic complications in the patients who had a PaO2 monitor UAC, whereas two of the silicone-rubber UACs were removed because of perfusion problems in the lower limbs, which resolved with decannulation. We conclude that the use of the PaO2 monitor UAC allows for continuous, invasive monitoring of PaO2 without any significant increase in risk compared with that for the silicone-rubber end-hole UAC.
View details for PubMedID 7666267
A modified newborn intensive care unit environment may shorten hospital stay.
Journal of perinatology
1994; 14 (5): 422-427
Premature infants with birth weights from 1121 to 2000 gm were assigned randomly to two groups. Experimental group infants were placed on a microprocessor-controlled cradle that provided levels of motion and sound analogous to those of the third-trimester intrauterine environment. Periods of motion totaling 50% of the time were randomized on and off; motion speed was reduced 35% during a 12-hour night period. A uterine souffle sound was generated continuously but varied in pulse rate and volume with the motion and speed of the bed. Experimental group infants (n = 20) were placed on the cradle under a radiant warmer as soon as their condition was stable clinically. Control group infants (n = 18) were usually placed initially under a radiant warmer and transferred to an incubator when their condition was stable. Otherwise, both groups received standard newborn intensive care unit care. The mean length of hospital stay was significantly shorter for experimental group infants than for control group infants after controlling for gestational age and weight on entry to the study. Experimental group infants began nippling earlier and stopped requiring gavage feedings sooner. Experimental group infants had a decreased incidence of apnea. Blinded Brazelton Neonatal Behavioral Assessment Scale scores for the Orientation and Range of State cluster scales were significantly better for experimental group infants. A retrospective contrast group of preterm infants who met study criteria had an average length of stay similar to that of the control group infants. These data support the hypothesis that appropriate levels and kinds of stimulation may facilitate the maturation of preterm infants.
View details for PubMedID 7830161
Experience with double-lumen umbilical venous catheters in the low-birth-weight neonate.
Journal of perinatology
1994; 14 (4): 280-284
Reliable vascular access can be problematic in sick low-birth-weight neonates. Umbilical venous catheters are one form of vascular access that can be used in this population. A retrospective review of experience with umbilical venous catheters in our neonatal intensive care unit from January 1989 through December 1991 was conducted. This included 128 patients: 70 with single-lumen (Gesco Umbilicath II) and 58 with double-lumen (Becton-Dickinson Careflow) catheters. Birth weight, gestational age, catheter life span, complications, and number of punctures for peripheral intravenous lines were analyzed. The mean birth weight, gestational age, and catheter life span did not differ significantly between catheter types. The incidence of catheter-related sepsis did not differ significantly (two single-lumen, three double-lumen) and occurred only in neonates with a catheter life span greater than 10 days. The number of intravenous punctures was significantly decreased in those neonates with double-lumen umbilical venous catheters (p < 0.0001). We conclude that in sick low-birth-weight infants the use of double-lumen umbilical venous catheters entails no greater risk than the use of a single-lumen umbilical venous catheter and may reduce iatrogenic stress associated with the starting of peripheral intravenous lines.
View details for PubMedID 7965222
ADHESION OF PERCUTANEOUSLY INSERTED SILASTIC CENTRAL VENOUS LINES TO THE VEIN WALL-ASSOCIATED WITH MALASSEZIA-FURFUR INFECTION
JOURNAL OF PARENTERAL AND ENTERAL NUTRITION
1993; 17 (5): 458-460
Percutaneously inserted Silastic central venous catheters have been used for prolonged infusion of parenteral nutrition in neonates. Malassezia furfur infection has been associated with intravenous fat emulsions infused through central venous lines. In this paper, we report two premature infants whose Silastic catheters were adhered to the vein wall with associated M furfur infection.
View details for Web of Science ID A1993LY89300014
View details for PubMedID 8289414
Overestimation of neonatal PO2 by collection of arterial blood gas values with the butterfly infusion set.
Journal of perinatology
1993; 13 (3): 255-?
View details for PubMedID 8345393
TRISOMY-22 WITH CONGENITAL DIAPHRAGMATIC-HERNIA AND ABSENCE OF CORPUS-CALLOSUM IN A LIVEBORN PREMATURE-INFANT
AMERICAN JOURNAL OF MEDICAL GENETICS
1992; 44 (4): 437-438
We report on a liveborn premature male with trisomy 22 who had multiple congenital anomalies, including congenital diaphragmatic hernia and absence of corpus callosum. He died of pulmonary hypoplasia associated with diaphragmatic hernia within 12 hours of age. Chromosome analysis by multiple banding techniques based on lymphocyte culture confirmed that he had trisomy 22. This may be the first report of congenital diaphragmatic hernia and isolated absence of corpus callosum associated with trisomy 22.
View details for Web of Science ID A1992JV04900009
View details for PubMedID 1442883
- MULTIPLE-LUMEN UMBILICAL VENOUS CATHETERS JOURNAL OF PEDIATRICS 1992; 121 (3): 499-499
EFFECT OF VASCULAR PUNCTURE ON BLOOD-GASES IN THE NEWBORN
1991; 10 (4): 287-290
Continuous monitoring methods have shown changes of oxygenation in neonates during various procedures. However, actual changes in blood gases during vascular punctures have not been reported. We studied the effect of vascular puncture on arterial blood gases during routine venipuncture in 17 neonates who had indwelling arterial catheters. Arterial blood gases were analyzed before, during, and following recovery from venipuncture. Ventilator settings were not changed during the study, though oxygen concentration (FiO2) was adjusted as indicated by continuous PO2 or saturation monitors. During venipuncture, there was a significant fall in PaCO2 from 38 +/- 5 to 32 +/- 7 mmHg (P less than 0.0001) and in PaO2 from 75 +/- 21 to 58 +/- 23 mmHg (P less than 0.0001). Following venipuncture, both values returned to baseline. The results of this study imply that blood gases obtained by intermittent arterial sticks may provide data that do not accurately reflect the neonates' respiratory status.
View details for Web of Science ID A1991FU22100010
View details for PubMedID 1896238
NEONATAL HYPERBILIRUBINEMIA AT HIGH-ALTITUDE
AMERICAN JOURNAL OF DISEASES OF CHILDREN
1989; 143 (8): 983-987
A previous retrospective study showed an increased frequency of neonatal hyperbilirubinemia at high altitude in Colorado. In a prospective study we found that 39% of newborns at 3100 m altitude vs 16% at 1600 m exhibited hyperbilirubinemia, defined as a day 3 serum bilirubin level of 205 mumol/L or higher. Increased bilirubin production at 3100 m vs 1600 m was shown by increased levels of corrected carboxyhemoglobin. This finding was supported by increased erythropoietin and bilirubin values in cord blood and increased hematocrit values at day 3 among infants at 3100 m vs 1600 m. The sustained elevation in bilirubin for breast-fed vs formula-fed infants at 1600 m was observed for both feeding types at 3100 m. The findings suggested that there is a hematologic response to decreased oxygen availability at high altitude, resulting in increased bilirubin production accompanied by delayed bilirubin clearance.
View details for Web of Science ID A1989AJ49000033
View details for PubMedID 2756976
EFFECT OF BOOSTER BLOOD-TRANSFUSIONS ON OXYGEN UTILIZATION IN INFANTS WITH BRONCHOPULMONARY DYSPLASIA
JOURNAL OF PEDIATRICS
1988; 113 (4): 722-726
To assess the impact of booster transfusions on oxygen utilization in infants with bronchopulmonary dysplasia, we noninvasively measured oxygen consumption (VO2) and the variables of systemic oxygen transport (SOT) before and 24 hours after transfusion therapy in 10 oxygen-dependent infants with bronchopulmonary dysplasia. The infants had been born with a mean gestational age of 27.6 weeks and a mean birth weight of 0.88 kg. Study weight averaged 1.24 +/- 0.35 kg, and study age averaged 5.5 +/- 2.4 weeks. Requirements for fractional concentration of inspired oxygen averaged 0.41 +/- 0.15 to maintain an oxygen saturation of 0.93 +/- 0.02. The VO2 was measured by means of a commercially available analyzer through a flow-through circuit and pump connected to a hood or in line with the ventilator. Cardiac output was calculated by means of pulsed Doppler ultrasonography. Oxygen saturation was measured by means of transcutaneous pulse oximetry. The coefficient of oxygen utilization was calculated as VO2/SOT. Transfusion consisted of packed erythrocytes (10 ml/kg). Oxygen utilization fell in all subjects after transfusion (p less than 0.01), but it fell more substantially in subjects with higher coefficients of oxygen utilization (r = -0.80, p less than 0.01), suggesting a physiologic benefit in selected patients, particularly those with higher levels of oxygen utilization. There was also a significant increase in overall systemic oxygen transport (p less than 0.01) and decrease in VO2 (p less than 0.02). Hemoglobin levels alone did not correlate with overall systemic oxygen transport, VO2, or level of oxygen use before transfusion, and thus did not predict which subjects would have a physiologic benefit from transfusion as reflected by falls in oxygen utilization.
View details for Web of Science ID A1988Q533800020
View details for PubMedID 3171797
EFFECT OF ALTITUDE ON NEONATAL BILIRUBIN PRODUCTION
WILLIAMS & WILKINS. 1987: A357
View details for Web of Science ID A1987G700501099
INCREASED IMMUNOREACTIVE ERYTHROPOIETIN IN CORD PLASMA AND NEONATAL BILIRUBIN PRODUCTION IN NORMAL TERM INFANTS AFTER LABOR
OBSTETRICS AND GYNECOLOGY
1986; 67 (1): 69-73
The purpose of this investigation was to compare immunoreactive erythropoietin levels in umbilical cord plasma and neonatal bilirubin production in infants born of normal women who delivered with or without labor. Two groups of term (38 to 42 weeks) singleton pregnancies were compared: 1) those delivered by repeat elective cesarean section without prior labor (N = 17), and 2) those delivered vaginally or by cesarean section after labor (N = 24). None of the infants was asphyxiated, and there was no difference in Apgar scores between the no-labor and labor groups. The cord plasma erythropoietin levels were lower in the infants of women who had repeat elective cesarean section without labor than in those whose mothers had labor before delivery (Wilcoxon rank sum test, P less than .025). The median erythropoietin for the no-labor group was 22.9 mU/mL compared with 38.8 mU/mL for the labor group. The pulmonary excretion rate of carbon monoxide (VeCO), an index of bilirubin production, for the no-labor group was 14.3 +/- 6.2 SD microL/kg per hour compared with 18.0 +/- 4.9 SD microL/kg per hour for the labor group (P less than .05). The hemoglobin concentration for the no-labor group was 16.0 +/- 1.5 SD g/dL compared with 17.7 +/- 2.2 SD g/dL for the labor group (P less than .05). The VeCO correlated with the hemoglobin concentration (N = 32, r = 0.37, P less than .05). The results of the present study suggest that labor is normally associated with increases in the cord plasma erythropoietin level.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1986AWU2300013
View details for PubMedID 3940341
USE OF SODIUM-NITROPRUSSIDE IN NEONATES - EFFICACY AND SAFETY
JOURNAL OF PEDIATRICS
1985; 106 (1): 102-110
Sodium nitroprusside was administered to 58 neonates, including 11 with severe respiratory distress syndrome, 15 with persistent pulmonary hypertension of the newborn, 28 with clinical shock, three with systemic hypertension, and two with pulmonary hypoplasia, all refractory to conventional intensive therapy. Nitroprusside was infused at 0.2 to 6.0 micrograms/kg/min for periods of 10 minutes to 126 hours. Infants with severe respiratory distress syndrome had increased PaO2 and decreased PaCO2 or peak inspiratory pressure, and nearly all (82%) survived. Infants with persistent pulmonary hypertension of the newborn had variable responses; improvement did not correlate with survival, but survival (47%) was identical to that in an earlier series of infants given tolazoline. Infants in shock had improved perfusion, urine output, and serum bicarbonate levels, and these responses were significantly related to survival. Hypertension was controlled in all three hypertensive infants. Adverse effects were very uncommon. Toxic effects were not observed. Sodium nitroprusside is effective and can be used safely in circulatory disorders in the neonate.
View details for Web of Science ID A1985AAH1500023
View details for PubMedID 3917495
BILIRUBINEMIA IN OLDER VERY LOW BIRTH-WEIGHT INFANTS
SLACK INC. 1985: A136
View details for Web of Science ID A1985TY84700801
INCREASED IMMUNOREACTIVE ERYTHROPOIETIN IN CORD PLASMA AND NEONATAL BILIRUBIN PRODUCTION IN NORMAL TERM INFANTS AFTER LABOR
SLACK INC. 1985: A144–A144
View details for Web of Science ID A1985TY84700846
BILIRUBIN PRODUCTION AFTER SUPPLEMENTAL ORAL VITAMIN-E THERAPY IN PRETERM INFANTS
JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION
1985; 4 (1): 38-44
The purpose of this investigation was to determine the influence of early vitamin E supplementation on the rate of heme catabolism (bilirubin production) in healthy preterm infants. Bilirubin production was estimated from the concentration of carbon monoxide in "end-tidal" gas. Serum vitamin E, hemoglobin, and bilirubin levels were determined by standard techniques. Thirty infants received supplementation with vitamin E or placebo in a double-blind, randomized fashion. Infants were studied on day 1 of life prior to therapy, and on days 3 and 7 postnatally. Results showed that in both placebo-supplemented and vitamin E-supplemented groups, vitamin E levels were significantly higher on days 3 and 7 compared with day 1. Bilirubin production was not significantly different on day 3 compared with day 1 in either group, but was significantly lower in both groups by day 7 compared with day 1. There were no significant differences in hemoglobin and serum bilirubin levels between the two groups at any point in time. In conclusion, although vitamin E supplementation significantly raises vitamin E levels, placebo-supplemented premature infants also achieve vitamin E sufficiency and a decrease in bilirubin production by day 7 of age.
View details for Web of Science ID A1985ABS3400008
View details for PubMedID 3981366
- USE OF NONINVASIVE TESTS TO PREDICT SIGNIFICANT JAUNDICE IN FULL-TERM INFANTS - PRELIMINARY STUDIES PEDIATRICS 1985; 75 (2): 278-280
NEONATAL BILIRUBIN PRODUCTION ESTIMATED FROM END-TIDAL CARBON-MONOXIDE CONCENTRATION
JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION
1984; 3 (1): 77-80
The relationship between the pulmonary excretion rate of carbon monoxide (VECO) and the concentration of CO, in a sample of breath, drawn through a nasopharyngeal catheter at end-expiration, was assessed in 25 studies of nine preterm and 14 term infants. The VECO and this approximate end-tidal sample of CO (ETCO) correlated significantly over a wide range of CO elimination rates: VECO = 10.45 ETCO + 2.25 (n = 25, r = 0.95). The ETCO correctly predicted elevations in VECO greater than 2 SD of the mean VECO for normal infants (13.9 +/- 3.5 microliter/kg/h), with 90% sensitivity and 73% specificity (p less than 0.01). Three subjects with Rh isoimmune hemolytic disease were easily identified by the ETCO as well as the VECO. The ETCO is a simple, noninvasive measurement for rapidly identifying infants with significant hemolytic disease.
View details for Web of Science ID A1984RW76000017
View details for PubMedID 6537974
- LATERAL DECUBITUS POSITION AND PULMONARY INTERSTITIAL EMPHYSEMA - REPLY JOURNAL OF PEDIATRICS 1984; 105 (5): 847–48
Pulmonary excretion of carbon monoxide in the human infant as an index of bilirubin production. IIc. Evidence for the possible association of cord blood erythropoietin levels and postnatal bilirubin production in infants of mothers with abnormalities of gestational glucose metabolism.
American journal of perinatology
1984; 1 (2): 177-181
A total of 20 infants who had levels of erythropoietin (Ep), the major hormone regulating erythropoiesis, measured in their cord blood also had determinations of the pulmonary excretion rate of CO (VECO) performed, as an index of total bilirubin production. They were either infants of normal mothers or those of mothers with diabetes, gestational diabetes, and missed abnormalities of gestational glucose metabolism. The mean VECO (13.0 +/- 3.5 mu 1/kg/hr) and the mean Ep (20.0 +/- 9.7 SD mU/ml) of the infants with normal mothers (n = 9) were not different from the means previously established by our laboratories (13.9 +/- 3.5 SD mu 1/kg/hr, n = 20; and 23.7 +/- 12.8 SD mU/ml, n = 30, respectively); they were significantly lower than those of the infants of the abnormal mothers in this study. The 5 infants who had a cord blood Ep level greater than 50 mU/ml had a higher mean VECO, 27.8 +/- 7.1 mu 1/kg/hr, compared with 17.2 +/- 4.9 SD mu 1/kg/hr, of the six infants with cord blood Ep levels that were within 2 SD of the previously established normal mean cord blood Ep level (p less than .025). These data suggest that increased cord blood Ep levels and postnatal bilirubin production in infants whose mothers had abnormalities of gestational glucose metabolism are associated phenomena. Since polycythemia did not occur in these infants, ineffective erythropoiesis or mild, compensated hemolysis remains a likely cause of the increased total bilirubin production. In some cases, perinatal hypoxic stress may have affected the Ep response.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for PubMedID 6518065
- LATERAL DECUBITUS POSITION AS THERAPY FOR PERSISTENT FOCAL PULMONARY INTERSTITIAL EMPHYSEMA IN NEONATES - A PRELIMINARY-REPORT JOURNAL OF PEDIATRICS 1984; 104 (3): 441-443
- SURVIVAL AND MORBIDITY OF OUR SMALLEST BABIES - IS THERE A LIMIT TO NEONATAL CARE PEDIATRICS 1984; 73 (3): 415-416
USE OF THE DECUBITUS POSITION TO TREAT PULMONARY INTERSTITIAL EMPHYSEMA (PIE)
SLACK INC. 1983: A138–A138
View details for Web of Science ID A1983PU88600818
CORRELATION OF END-TIDAL CO (ETCO) AND THE PULMONARY EXCRETION RATE OF CO (VECO)
SLACK INC. 1983: A138
View details for Web of Science ID A1983PU88600820
MATERNAL BETA-ADRENERGIC TOCOLYSIS AND NEONATAL BILIRUBIN PRODUCTION
AMERICAN JOURNAL OF DISEASES OF CHILDREN
1983; 137 (1): 58-60
The potential for beta-adrenergic drugs to increase total bilirubin formation via cyclic adenosine monophosphate-mediated stimulation of hepatic microsomal heme oxygenase in the human neonate was evaluated. The pulmonary excretion rate of endogenously produced carbon monoxide (VeCO), an index of total bilirubin formation (TBF), was measured in 18 preterm neonates whose mothers received beta-adrenergic drugs for tocolysis and in 18 preterm neonates whose mothers were untreated. The mean VeCO of the neonates in the former group (17.2 +/- 7.3 microL/kg/hr) was the same as that in the latter group (17.4 +/- 6.2 microL/kg/hr); both values were elevated when compared with the mean VeCO of 20 term newborns (13.9 +/- 3.5 microL/kg/hr). Our findings indicate that TBF is not significantly increased in neonates whose mothers received beta-adrenergic drugs before delivery.
View details for Web of Science ID A1983PV55800013
View details for PubMedID 6128920
USE OF END-TIDAL CARBON-MONOXIDE TO CORRECT END-TIDAL HYDROGEN IN NEONATES
JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION
1983; 2 (4): 659-662
We evaluated the usefulness of end-tidal CO (ETCO) as an internal standard for reducing the error in end-tidal H2 (ETH2) measurements due to contamination of repeated breath samples with nonalveolar gas. Triplicate end-tidal samples were drawn from 12 healthy premature infants in small (less than 1 cc) increments through a posterior nasopharyngeal catheter at end-expiration, determined from the infant's chest wall movement. CO and H2 determinations were made on each sample by a reduction gas detector capable of determining CO and H2 concentrations to +/- 0.001 and 0.010 ppm, respectively. Respiratory breath samples were corrected for ambient CO and H2 concentrations. Since the alveolar gas fraction has the highest CO concentration of all tidal gases, the end-tidal sample with the highest CO peak was assumed to be most representative of uncontaminated alveolar gas. The other samples were "corrected" using a factor that was the ratio of the patient's highest CO peak to the given sample's CO value. The use of ETCO to correct ETH2 from samples deliberately contaminated with ambient air can significantly reduce the variability of ETH2 values. However, such correction is probably not necessary when comparing groups of infants using a standard collection technique. For individual infants, correction may reveal more marked short-term fluctuations in true alveolar H2 concentration.
View details for Web of Science ID A1983RM46200015
View details for PubMedID 6644447
BREATH HYDROGEN ANALYSIS - A REVIEW OF THE METHODOLOGIES AND CLINICAL-APPLICATIONS
JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION
1983; 2 (3): 525-533
Hydrogen gas (H2) is a product of the fermentation of dietary carbohydrate (CHO) by bacteria in the lumen of the gastrointestinal tract in man. Thus, H2 is actually an exogenously produced gas, which either is passed as flatus, or diffuses into the body and is exhaled. In the adult, a fairly constant fraction is expired, providing a reliable indicator of total colonic H2 production. Breath H2 analysis currently represents a useful clinical means of testing adults and older children for the malabsorption of CHO. Noninvasive and easy procedures for the collection of expired air have encouraged their increasingly widespread use in pediatrics. Evidence to date suggests that breath H2 analysis may provide the best available method for estimating semiquantitatively the degree of CHO malabsorption. The association of the results of breath H2 analysis with other clinical measures of CHO digestion and absorption is expected, but discrepancies can also be anticipated based on the nature of this particular trace gas method. The interpretation of the results of breath H2 analysis in neonates and young infants remains especially problematic because of confounding variables which are difficult to control and are measured infrequently.
View details for Web of Science ID A1983RC94400022
View details for PubMedID 6620060
Total bilirubin production in infants of Chinese, Japanese, and Korean ancestry.
Taiwan yi xue hui za zhi. Journal of the Formosan Medical Association
1982; 81 (12): 1524-1529
View details for PubMedID 6963338
A SENSITIVE ANALYTICAL APPARATUS FOR MEASURING HYDROGEN PRODUCTION-RATES .2. APPLICATION TO STUDIES IN HUMAN INFANTS
JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION
1982; 1 (2): 233-237
We estimated hydrogen (H2) production by determining simultaneously the end-tidal concentration (ETH2) and the direct pulmonary excretion rate (VeH2) in normal-sized, healthy, term and preterm neonates between 2 days and 7 weeks of life who were receiving all their calories enterally as breast milk or a proprietary formula. We found that there was no peak or pattern in H2 production during the first 3 postprandial hours (mean VeH2 = 1.00 +/- 0.97 SD ml/kg/h; mean ETH2 = 40.3 +/- 33.1 SD ppm). Frequently, there was marked short-term variability of the ETH2 in a given infant (coefficient of variation = 13.4% +/- 18.7%). H2 production was elevated in normal neonates without signs of malabsorption. We found that VeH2 correlated with ETH2 using both nasopharyngeal catheter (r = 0.63; p less than 0.001) and nasal prong (r = 0.71; p less than 0.001) collection techniques. We conclude that breath hydrogen determinations in neonates are not readily comparable to similar studies in older patients. Longitudinal studies of individual infants may reveal changes in breath H2 excretion of sufficient magnitude to be distinguishable from moment-to-moment variations, and correlatable with certain intercurrent clinical problems affecting intestinal H2 production or pulmonary H2 excretion. However, interpretation of breath H2 determinations in human infants will be difficult.
View details for Web of Science ID A1982PB96500014
View details for PubMedID 7186035
MATERNAL BETA-ADRENERGIC TOCOLYSIS AND NEONATAL BILIRUBIN PRODUCTION
SLACK INC. 1982: A143
View details for Web of Science ID A1982MX91200844
Trace gas analysis in bilirubin metabolism: a technical review and current state of the art.
Advances in pediatrics
1982; 29: 129-149
View details for PubMedID 6891175
PAIRED DETERMINATIONS OF BLOOD CARBOXYHEMOGLOBIN CONCENTRATION AND CARBON-MONOXIDE EXCRETION RATE IN TERM AND PRETERM INFANTS
JOURNAL OF LABORATORY AND CLINICAL MEDICINE
1982; 100 (5): 745-755
Paired determinations of COHb and VeCO were performed on 30 term infants (38 to 42 weeks' gestation) and 26 preterm infants (28 to 37 weeks' gestation) during the first week of life. All subjects were breathing room air at the time of the study. Values of COHb were corrected for RAco by linear regression of COHb (percent saturation) vs RAco (ppm). Regression coefficients for term and preterm infants with no history of pulmonary impairment were nearly identical (COHb = 0.175 RAco + 0.45, r = 0.77, n = 25 for term infants; COHb = 0.168 RAco + 0.51, r = 0.82, n = 9 for preterm infants) and agreed well with theoretical values. For the group of term infants, linear regression of Veco (microliter/kg/hr) vs. COHbc, where COHbc = COHb - 0.17 RAco, resulted in VEco = 23.4 COHbc + 4.02, r = 0.75, n = 30. The corresponding relationship for preterm infants with no history of pulmonary impairment was VEco = 24.7 COHbc + 3.85, r = 0.61, n = 13. For a subpopulation of preterm infants with a history of pulmonary dysfunction, the correlation decreased significantly, with VEco = 4.34 COHbc + 17.6, r = 0.097, n = 11. These results demonstrate that (1) COHbc is a reasonable index of VEco and consequently of the heme catabolic rate in both term and preterm infants with no clinical history of pulmonary dysfunction and (2) inference of VEco from COHbc may be misleading in certain cases without a consideration of the factors relating these two variables.
View details for Web of Science ID A1982PN66000009
View details for PubMedID 7130831
- MACROSOMIA - CAUSES AND CONSEQUENCES JOURNAL OF PEDIATRICS 1982; 100 (4): 515-520
- BREATH HYDROGEN IN PRETERM INFANTS - CORRELATION WITH CHANGES IN BACTERIAL-COLONIZATION OF THE GASTROINTESTINAL-TRACT JOURNAL OF PEDIATRICS 1982; 101 (4): 607-610
FAVORABLE RESULTS OF NEONATAL INTENSIVE-CARE FOR VERY LOW-BIRTH-WEIGHT INFANTS
1982; 69 (5): 621-625
From 1961 to 1976, 229 infants with birth weights ranging from 751 to 1,000 gm were admitted to the Stanford University Hospital Intensive Care Nursery. The overall neonatal mortality for these infants was 63% (144/229), and there were ten late deaths. Before 1967, no infant in this group who required mechanical ventilation survived; thereafter, 30% (34/114) of the ventilated patients survived. Of the 75 long-term survivors 60 participated in a high-risk infant follow-up program; these included 23 infants who had received mechanical ventilation. The mean birth weight of these infants was 928 +/- 67 (SD) gm. Seventeen children (28%) had significant morbidity: seven (12%) with severe handicaps and ten (17%) with moderate handicaps. During this same period, seven infants weighing less than 750 gm at birth were also observed. The three infants who had not required ventilatory support thrived; the other four infants had required respirators and were significantly handicapped. More recently, neonatal mortality for infants with birth weights from 751 to 1,000 gm has improved: for 1977 to 1980, it was 28% (33/118). Furthermore, neonatal mortality for ventilated infants in this weight group was 27% (26/95). These data indicate an improved prognosis for very low-birth-weight infants, even with ventilatory support.
View details for Web of Science ID A1982NN58700022
View details for PubMedID 7079021
EVIDENCE FOR THE POSSIBLE RELATIONSHIP OF NEONATAL SKINFOLD THICKNESS TO MATERNAL GLUCOSE-METABOLISM DURING THE 3RD TRIMESTER
JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION
1982; 1 (1): 59-62
Forty-eight infants, including 14 premature infants who were appropriate size for gestational age (AGA), 10 full-term AGA infants, 18 full-term infants who were large for gestational age (LGA), and six premature LGA infants of diabetic mothers (IDMs), had measurements of skinfold thickness (SFT) in the first 72 h of life. For the 24 LGA infants, there was a significant positive correlation between maternal glycohemoglobin (Hb AIc) in the post-partum period and SFT (r = 0.42, p less than 0.05). Our observations in this study support those of others, demonstrating that SFT increases with increasing gestational age. In addition, they support the hypothesis that, in diabetic pregnancies, or pregnancies associated with an elevated Hb AIc, a reflection of the time-integrated blood glucose level over the weeks preceding parturition, fetal hyperglycemia and hyperinsulinemia stimulate increased triglyceride synthesis in adipose cells and lead to an increase in fetal subcutaneous fat.
View details for Web of Science ID A1982PB96400012
View details for PubMedID 6193261
PULMONARY EXCRETION RATES OF CARBON-MONOXIDE USING A MODIFIED TECHNIQUE - DIFFERENCES BETWEEN PREMATURE AND FULL-TERM INFANTS
BIOLOGY OF THE NEONATE
1982; 41 (5-6): 289-293
The pathophysiology of the exaggerated hyperbilirubinemia in premature infants remains unclear. The relative contribution of bilirubin production may be estimated by measuring the pulmonary excretion rate of carbon monoxide (VeCO). We found that the mean VeCO of premature infants, 16.7 +/- 5.0 microliters/kg/h, was significantly elevated (p less than 0.05) compared with the mean VeCO of full-term infants, 13.9 +/- 3.5 microliters/kg/h. Premature infants who required phototherapy had a significantly (p less than 0.05) higher mean VeCO than those who did not. The VeCO did not correlate with gestational age, implying that factors which associate frequently but variably with gestational age may have an important influence on heme catabolism.
View details for Web of Science ID A1982NV61400012
View details for PubMedID 7104416
THE PULMONARY EXCRETION RATE OF CARBON-MONOXIDE (VECO) AND THE BLOOD CARBOXYHEMOGLOBIN LEVEL (COHB) IN PREMATURES AND NORMAL TERMS
NATURE PUBLISHING GROUP. 1981: 655–55
View details for Web of Science ID A1981LG15501292
THE RELATIONSHIP OF NEONATAL SKINFOLD THICKNESS TO MATERNAL GLUCOSE-METABOLISM DURING THE 3RD TRIMESTER
SLACK INC. 1981: A128
View details for Web of Science ID A1981KY10800761
OUTCOME OF VERY LOW-BIRTH-WEIGHT (VLBW) INFANTS
NATURE PUBLISHING GROUP. 1981: 655
View details for Web of Science ID A1981LG15501293
DELAYED CLEARANCE OF BILIRUBIN IN INFANTS OF DIABETIC MOTHERS
SLACK INC. 1981: A141
View details for Web of Science ID A1981KY10800838
BIRTH-WEIGHT AND NEONATAL BILIRUBIN PRODUCTION RELATED TO MATERNAL GLUCOSE-HOMEOSTASIS
SLACK INC. 1981: A139
View details for Web of Science ID A1981KY10800827
RELATIONSHIP OF THE PULMONARY EXCRETION RATE OF CO (VECO) AND THE BLOOD CARBOXYHEMOGLOBIN LEVEL (COHB) IN PREMATURES AND TERMS
NATURE PUBLISHING GROUP. 1981: 655
View details for Web of Science ID A1981LG15501291
- PULMONARY EXCRETION OF CARBON-MONOXIDE AS AN INDEX OF BILIRUBIN PRODUCTION .2A. EVIDENCE FOR POSSIBLE DELAYED CLEARANCE OF BILIRUBIN IN INFANTS OF DIABETIC MOTHERS JOURNAL OF PEDIATRICS 1981; 98 (5): 822-824
- PULMONARY EXCRETION OF CARBON-MONOXIDE IN THE HUMAN INFANT AS AN INDEX OF BILIRUBIN PRODUCTION .26. EVIDENCE FOR THE POSSIBLE EFFECT OF MATERNAL PRENATAL GLUCOSE-METABOLISM ON POSTNATAL BILIRUBIN PRODUCTION IN A MIXED POPULATION OF INFANTS EUROPEAN JOURNAL OF PEDIATRICS 1981; 137 (3): 255-259
A DOUBLE-BLIND-STUDY OF THE EFFECTS OF ORAL INDOMETHACIN IN PRETERM INFANTS WITH PATENT DUCTUS-ARTERIOSUS WHO FAILED MEDICAL-MANAGEMENT
1981; 1 (3): 245-249
Over a two year period, 52 infants were found to have clinical signs of patent ductus arteriosus (PDA). Twenty-seven responded to fluid restriction and furosemide; the remaining 25 infants entered the Indomethacin (IN) study protocol. Their mean (+/- SE) gestational age was 29.3 (+/- 0.6) weeks and birth weight was 1,142 (+/- 80) gm. Either a placebo or IN (0.25 mg/kg) orally was given for two doses, 24 hours apart; if no response occurred, the patient was crossed over to the opposite medication. Using Chi-square analysis, a significant response rate to IN was found. There were no significant differences in birth weights, gestational ages, or fluid intake between responders and nonresponders. However, both responders and nonresponders required a prolonged ventilator course, suggesting factors other than PDA causing prolonged ventilatory requirements in these babies.
View details for Web of Science ID A1981LQ63100009
View details for PubMedID 7346744
- LATE MORBIDITY AMONG SURVIVORS OF RESPIRATORY-FAILURE TREATED WITH TOLAZOLINE JOURNAL OF PEDIATRICS 1980; 97 (4): 644-647
3-YEAR OUTCOME OF SURVIVORS OF RESPIRATORY-FAILURE TREATED WITH TOLAZOLINE
SLACK INC. 1980: A122
View details for Web of Science ID A1980JB49200719
A DOUBLE-BLIND-STUDY OF THE EFFECTS OF ORAL INDOMETHACIN (IN) IN PRETERM INFANTS WITH PATENT DUCTUS-ARTERIOSUS (PDA) WHO FAILED MEDICAL-MANAGEMENT
NATURE PUBLISHING GROUP. 1980: 607–
View details for Web of Science ID A1980JL99401087
INFRARED RADIANT WARMERS EFFECTIVE FOR MAINTAINING BODY-TEMPERATURE OF CRITICALLY ILL PREMATURES UNDER ROUTINE NICU CONDITIONS
WILLIAMS & WILKINS. 1979: 493
View details for Web of Science ID A1979GS68101002
CRYOGLOBULINS-3 - FURTHER STUDIES ON NATURE, INCIDENCE, CLINICAL, DIAGNOSTIC, PROGNOSTIC, AND IMMUNOPATHOLOGIC SIGNIFICANCE OF CRYOPROTEINS IN RENAL-DISEASE
QUARTERLY JOURNAL OF MEDICINE
1975; 44 (174): 285-307
Serial serum samples from a large number of patients with immunologic renal disease, normal healthy controls, acute infections as well as non-immunological renal disease were studied for the presence, nature and properties of cryoproteins, and these correlated with serial renal functional, morphologic, immunohistologic and clinical fingings as well as serologic observations. A high incidence of cryoproteins were found in renal disease thought to be mediated by immune complexes. Cryoprecipitates were not detected in the other patients. The presence of fibrinogen in a serum cryoprecipitate was always associated with rapidly progressive disease and poor prognosis. An association between the detection of cryoproteins and the clinical and morphological activity of disease was observed. Persistence of cryoproteinemia was associated with progression and apparent disappearance with resolution or progression to end stage renal disease. In patients with hematuria or proteinuria of questionable significance cryoprotein detection was always associated with immune complex nephritis. Renal transplantation in the presence of cryoproteinemia was associated with recurrent nephritis in the graft. Cryoproteins were found to have biologic properties attributable to antigen-antibody complexes, to contain immune complexes of antigen and antibody and to have serologic factors concentrated. The detection of serum cryoglobulins was found to be a better index of clinical and morphologic activity of immune complex renal disease than was serum complement. As in our previous studies, these proteins appear to be of diagnostic and prognostic value in renal disease and provide a method of antigen identification in these disorders.
View details for Web of Science ID A1975AF55000007
View details for PubMedID 1101284