SUMMARY Lung function was measured at 30 minutes and again at 2 hours after birth in 12 infants delivered vaginally, in 15 infants delivered by elective caesarean section under general anaesthesia (GA), and in 15 delivered under epidural anaesthesia (EDA). Umbilical arterial blood was analysed for pH and for concentrations of catecholamines and cortisol. No important differences in gestational age, birthweight, Apgar scores, or haematocrit were found among the three groups. Tidal volume and minute ventilation measured 30 minutes after birth were lower in infants delivered by caesarean section than in those delivered vaginally and at 2 hours the tidal volume was still lower in the babies delivered by caesarean section than in those delivered vaginally. Dynamic compliance was lower at 30 minutes in the group that had a caesarean section than in the vaginal group, and this difference was significant at two hours. Tidal volume, minute ventilation, and dynamic compliance in the GA and EDA groups did not differ. The catecholamine and cortisol concentrations at birth were higher in the vaginal group than in the group delivered by caesarean section. Two hours after birth there was a significant correlation (r= 084) between the catecholamine concentrations of the infants born vaginally and lung compliance. The lower dynamic lung compliance in infants delivered by elective caesarean section might be explained by delayed absorption of liquid in the lung due to lack of catecholamine surge. PatientsAll the infants in the study were born at term in uncomplicated deliveries, and their mothers had normal pregnancies. Their development, assessed according to a modified Dubowitz score, was appropriate for gestational age, but infants with an umbilical arterial pH <7-24 at birth were excluded.

The immediate postnatal metabolic adaptation and sympatho-adrenal activation were studied in infants delivered vaginally or by elective caesarean section. Vaginally delivered infants showed high catecholamine levels at birth compared to infants born by caesarean section under epidural or general anaesthesia. Umbilical arterial glucose levels were significantly higher in the vaginal group than in both caesarean section groups. At 30 min, all groups showed a marked decrease with several infants showing asymptomatic hypoglycaemia in the caesarean section group. C-peptide levels showed no difference at birth but later became significantly higher in the vaginal group. Although the levels of free fatty acids and glycerol were low at birth, they were significantly higher in the vaginal group. In all groups they increased substantially with time. Considering the marked differences in catecholamine levels, the differences in metabolic adaptation were unexpectedly small. This implies an attenuated metabolic response to sympatho-adrenal stimulation in the newborn.

Jdnsson B, Katz-Salamon M, Faxelius G, Broberger U, Lagercrantz H. Neonatal care of very-lowbirthweight infants in special-care units and neonatal intensive-care units in Stockholm. Early nasal continuous positive airway pressure versus mechanical ventilation: gains and losses. Acta Paediatr 1997; Suppl419: 4-10. Stockholm. ISSN 0803-5326.Very-low-birthweight (VLBW) infants are usually intubated at birth and mechanically ventilated at neonatal intensive-care units (NICUs). The objectives of this study were to evaluate the use of early nasal continuous positive airway pressure (NCPAP) in a regional cohort and to determine to what extent VLBW infants need transfer to a regional NICU from special-care units (SCUs) that primarily use early NCPAP for respiratory care. We compared the outcome for infants at SCUs and NICUs in Stockholm County, Sweden, from 1988 to 1993. All infants with birthweights of less than 1501 g were included in this study (n = 687). Fifty-nine per cent of the infants (400/687) were supported using only supplemental oxygen or NCPAP. Of these, 170 (25%) received only supplemental oxygen and 230 (34%) were supported only by NCPAP. A total of 350 (5 1%) infants received early NCPAP. Of these infants, 120 (34%) later required mechanical ventilation. Only 167 (24%) infants received mechanical ventilation from the beginning. Failure of NCPAP was significantly associated with the presence of respiratory distress syndrome. A total of 161/412 (39%) infants were transferred from SCUs to NICUs. Of infants =s 26 weeks' gestation and infants > 26 weeks, 71% and 34% were transferred, respectively. Total mortality was 16%. The mortality for transfers was 20% compared to an overall mortality in SCU and NICU infants of 9% and 15%, respectively. The overall incidence of intraventricular haemorrhage (IVH), grade 111-IV was 8%, perivenmcular leucomalacia (PVL) grade I-IV was 7%, retinopathy of prematurity (ROP) requiring cryotherapy was 4.3% and chronic lung disease (CLD) was 14%. There were significant differences in the incidence of IVH, PVL, CLD and ROP between SCU and NICU infants in matched gestational age groups. In conclusion, infants with a gestational age of 27 weeks or more may often be adequately cared for at SCUs without mechanical ventilation by using early NCPAP. However, infants with a gestational age of 26 weeks or less should be transferred to tertiary-care centres preferably before birth, because they will often require mechanical ventilation. 0 Continuous positive airway pressure, mechanical ventilation, pretenn infants H Lagercrantz,

We investigated colonization with Ureaplasma urealyticum (Uu) in infants <30 weeks gestation and assessed the relationship to other risk factors influencing respiratory morbidity, plus the effect of treatment with erythromycin. Ventilated preterm infants [n = 155; median GA 26 (23-29) weeks] were cultured for Uu in endotracheal aspirate and nasopharynx. Colonized infants were randomly assigned to treatment with erythromycin 40 mg/kg/d, intravenously or orally. The rate of colonization was 29/155 (19%) and the Uu-colonized infants had lower mean gestational ages than the culture-negative infants (25 vs 26 weeks). For the colonized infants PROM (48% vs 12%), chorioamnionitis in the mother (46% vs 17%) and vaginal delivery (71% vs 29%) were more common. More colonized infants needed supplemental oxygen at 36 weeks' postconceptual age (p < 0.05). Erythromycin treatment was effective in reducing colonization with negative control cultures in 12/14 (86%) of treated infants. No significant differences were found between the colonized treated infants (n = 14) and those not treated (n = 14) in time with supplemental oxygen. Oxygen requirement at 36 weeks was related to lower gestational age, late appearance of PDA, late onset sepsis and signs of chorioamnionitis in the mother. We conclude that the Uu colonization is related to increasing immaturity, the presence of prolonged rupture of membranes, signs of chorioamnionitis and vaginal delivery. Treatment with erythromycin reduced colonization but did not significantly alter length of time with supplemental oxygen.

Children born small for gestational age (SGA) and children having very low birth weight, less than 1500 g, are claimed to be at risk of developmental problems, even when obvious pathology and disability are absent. In this study, sensorimotor and cognitive development of 14 medically healthy, very-low-birth-weight and small-for-gestational-age children were investigated. The children were born at the Karolinska Hospital between 1979 and 1981. At the time of the assessment, the children were aged 8.7-11.2 years. The assessment instruments included the Wechsler Intelligence Scale for Children, a modified version of the Bruininks-Oseretsky Test of Motor Proficiency, as well as selected subtests from the Halstead-Reitan Neuropsychological Battery and from the Southern California Tests of Sensory Integration. Information was also obtained from obstetric, neonatal and pediatric records, which included early developmental assessments. As a control group, 14 children were recruited and matched for age, sex and socio-economic background. The very-low-birth-weight-small-for-gestational-age group scored significantly lower on measures of visuospatial ability, non-verbal reasoning, strategy formation and gross-motor coordination. The group differences were largely attributable to the subnormal performance of eight of the very-low-birth-weight-small-for-gestational-age children. These children, who also tended to be born earliest (less than 33 weeks), had a high incidence of behavioral and educational problems. These findings are consistent with the view that the very preterm infant develops a different neurobehavioral organization than a full-term infant. Developmental deficits may become increasingly evident in the early school years.