Full Term

Abstract: Background Nitric oxide is a major endogenous regulator of vascular tone. Inhaled nitric oxide gas has been investigated as a treatment for persistent pulmonary hypertension of the newborn. Objectives To determine whether treatment of hypoxaemic term and near-term newborn infants with inhaled nitric oxide (iNO) improves oxygenation and reduces the rates of death, the requirement for extracorporeal membrane oxygenation (ECMO), or affects long term neurodevelopmental outcomes. Search strategy Electronic and hand searching of pediatric/neonatal literature and personal data files. In addition we contacted the principal investigators of articles which have been published as abstracts to ascertain the necessary information. Selection criteria Randomized and quasi-randomized studies of inhaled nitric oxide in term and near term infants with hypoxic respiratory failure. Clinically relevant outcomes, including death, requirement for ECMO, and oxygenation. Data collection and analysis Trial reports were analysed for methodologic quality using the criteria of the Cochrane Neonatal Review Group. Results of mortality, oxygenation, short term clinical outcomes (particularly need for ECMO), and long term developmental outcomes were tabulated. Statistics: For categorical outcomes, typical estimates for relative risk and risk difference were calculated. For continuous variables, typical estimates for weighted mean difference were calculated. 95% confidence intervals were used. A fixed effect model was assumed for meta-analysis. Main results Fourteen eligible randomized controlled studies were found in term and near term infants with hypoxia. Seven of the trials compared iNO to control (placebo or standard care without iNO) in infants with moderate or severe severity of illness scores. Four of the trials compared iNO to control, but allowed back up treatment with iNO if the infants continued to satisfy the same criteria for severity of illness after a defined period of time. Two trials enrolled infants with moderate severity of illness score (OI or AaDO2) and randomized to immediate iNO treatment or iNO treatment only if they deteriorated to more severe criteria. One trial studied only infants with congenital diaphragmatic hernia (Ninos 1997) , and one trial enrolled both preterm and term infants (Mercier 1998), but reported the majority of the results separately for the two groups. Inhaled nitric oxide appears to improve outcome in hypoxaemic term and near term infants by reducing the incidence of the combined endpoint of death or need for ECMO. The reduction seems to be entirely a reduction in need for ECMO; mortality is not reduced. Oxygenation improves in approximately 50% of infants receiving nitric oxide. The Oxygenation Index decreases by a (weighted) mean of 15.1 within 30 to 60 minutes after commencing therapy and PaO2 increases by a mean of 53 mmHg. Whether infants have clear echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN) or not does not appear to affect outcome. The outcome of infants with diaphragmatic hernia was not improved; indeed there is a suggestion that outcome was slightly worsened. The incidence of disability, incidence of deafness and infant development scores are all similar between tested survivors who received nitric oxide or not. Authors' conclusions On the evidence presently available, it appears reasonable to use inhaled nitric oxide in an initial concentration of 20 ppm for term and near term infants with hypoxic respiratory failure who do not have a diaphragmatic hernia. Plain language summary Inhaled nitric oxide is safe and can help some full term babies suffering respiratory failure who have not responded to the usual methods of support. Inhaled nitric oxide can help some full term babies suffering respiratory failure who have not responded to the usual methods of support. Trials have shown that inhaled nitric oxide can increase the levels of oxygen in babies' blood and reduce the need for extracorporeal membrane oxygenation (ECMO), a highly technical and invasive therapy. Unfortunately, these benefits of inhaled nitric oxide care not seen in babies whose respiratory failure is due to a diaphragmatic hernia. Inhaled nitric oxide has not shown any short or longer term adverse effects.

Abstract: Extract: Pancreatic response to pancreozymin and secretin stimulations has been studied in premature and full term neonates. The following results have been obtained. (1) At birth premature neonates have a fairly well developed exocrine pancreatic function which is, however, lower than that of full term neonates. (2) One week after birth, exocrine pancreatic activity becomes higher in premature than in full term neonates. (3) Early administration of small amounts of starch stimulates pancreatic a-amylase (EC. 3.3.1.1) production. (4) A high protein diet stimulates increased production of both trypsin (EC. 3.4.4.4) and lipase (EC. 3.1.1.3), whereas a high fat diet alone has no effect on lipase secretion. Speculation: Exocrine pancreatic function is fairly well developed in premature neonates from 32-week gestation, although it is less developed at birth than it is in full term neonates and in older infants and children. After birth, the more rapid maturation of the exocrine pancreas function of premature neonates is probably related to the functional demands of a more rapid growth. The rates of maturation of secretion of a-amylase and trypsin increase proportionately to the starch and protein contents of the diet. The use of an appropriate diet therefore seems to be of great importance in regulating the secretions of the exocrine pancreas during the first month of life.

Abstract: . Recurrent apnoea occurred in 249 (1%) of the 25,154 live born babies during the 6 year study period. Only 18 were born at term and in these a cause was usually apparent. The incidence of recurrent apnoea increased with decreasing gestational age and was maximal at 30–31 weeks gestation (54%) falling to 7% at 34–35 weeks. The incidence in those <30 weeks gestation was probably underestimated due to the high mortality rate in this group in the earlier years of the study. With increased survival in 1978–79, the majority of survivors at those gestations developed apnoea. Apnoea usually commenced in the first 2 days of life (77%) and was unlikely to commence after 7 days. The lower the gestational age at birth the longer the apnoea continued; it usually ceased by full term. The predominant effect of gestational age on the incidence and duration of recurrent apnoea suggests that immaturity plays a major causative role. Perinatal insults which are more common in those of lowest gestation may contribute to its incidence and severity.

Abstract: Objective. In this study, we investigated prospectively the incidence of significant hyperbilirubinemia and demographic and laboratory characteristics and pattern of serum bilirubin levels of near-term newborns (35–37 weeks’ [245–265 days’] gestation) by comparing them with those of term newborns (38–42 weeks’ [266–294 days’] gestation) longitudinally in the first 7 days of life; we also aimed to determine the value of an early (6th-hour) serum bilirubin measurement in predicting the development of significant hyperbilirubinemia later during the first week of life in near-term newborns. Methods. Serum total bilirubin measurements were initially made at the 6th hour of life and repeated daily for the next 4 days, and a last measurement was performed on the 7th day (150th hour) in 219 term newborns (term group) and 146 near-term newborns (near-term group). Newborns with serum total bilirubin levels of ≥8 and ≥12 mg/dL on day 2, ≥12 and ≥15 mg/dL on day 3, and ≥14 and ≥17 mg/dL on days 4, 5, and 7 for birth weights 2000 to 2500 g and >2500 g, respectively, were defined to have significant hyperbilirubinemia, and phototherapy treatment was started. The predictive ability of the 6th-hour serum total bilirubin value in determining the development of significant hyperbilirubinemia in the near-term group was assessed on the basis of the placement of any of the first week’s serum bilirubin measurements in the ≥95th percentile of the study population. A Gaussian distribution curve, the 5th, 30th, 60th, and 95th percentiles, and 4 percentile tracks were obtained from mean serum total bilirubin values. On the basis of the percentile tracks with various sensitivity, specificity, and negative and positive predictive values, a nomogram demonstrating the 4 percentile tracks as risk-zone demarcators with divided risk zones was produced. Results. Twenty-three newborns (10.5%) in the term group and 37 newborns (25.3%) in the near-term group had significant hyperbilirubinemia and required phototherapy. When the daily mean serum bilirubin levels of the 2 groups were compared, the first 4 days’ values did not significantly differ between the 2 groups, whereas the 5th and 7th days’ values were significantly higher in the near-term group. There were significant differences between the 2 groups with respect to the incidence of significant hyperbilirubinemia, hematocrit, Apgar score, and mode of delivery. On the age-specific nomogram, the zone >95th percentile was labeled as high risk, and that Conclusions. Near-term newborns should not be treated as term newborns in the approach to management of hyperbilirubinemia, because infants of 35 to 37 weeks’ gestation had significantly lower birth weights, significantly higher serum total bilirubin levels on days 5 and 7, and were 2.4 times more likely to develop significant hyperbilirubinemia than those of 38 to 42 weeks’ gestation in the present study. In near-term newborns of 35 to 37 weeks’ (245 to 265 days’) gestation, the decision to diagnose and treat significant hyperbilirubinemia should be made on the basis of risk status (percentile distribution of the serum bilirubin values on postnatal age) rather than using birth-weight-based thresholds. A nomogram constructed from daily serum bilirubin values of each population, as we present herein, can be used in assessing the age (hour)-specific jaundice risk (high, intermediate, or low) of each near-term newborn.