Pervasive gene flow despite strong and varied reproductive barriers in swordtails

One of the mechanisms that can lead to the formation of new species occurs through the evolution of reproductive barriers. However, recent research has demonstrated that hybridization has been pervasive across the tree of life even in the presence of strong barriers. Swordtail fishes (genus Xiphophorus) are an emerging model system for studying the interface between these barriers and hybridization. We document overlapping mechanisms that act as barriers between closely related species, X. birchmanni and X. cortezi, by combining genomic sequencing from natural hybrid populations, artificial crosses, behavioral assays, sperm performance, and developmental studies. We show that strong assortative mating plays a key role in maintaining subpopulations with distinct ancestry in natural hybrid populations. Lab experiments demonstrate that artificial F1 crosses experience dysfunction: crosses with X. birchmanni females were largely inviable and crosses with X. cortezi females had a heavily skewed sex ratio. Using F2 hybrids we identify several genomic regions that strongly impact hybrid viability. Strikingly, two of these regions underlie genetic incompatibilities in hybrids between X. birchmanni and its sister species X. malinche. Our results demonstrate that ancient hybridization has played a role in the origin of this shared genetic incompatibility. Moreover, ancestry mismatch at these incompatible regions has remarkably similar consequences for phenotypes and hybrid survival in X. cortezi × X. birchmanni hybrids as in X. malinche × X. birchmanni hybrids. Our findings identify varied reproductive barriers that shape genetic exchange between naturally hybridizing species and highlight the complex evolutionary outcomes of hybridization.

A lethal mitonuclear incompatibility in complex I of natural hybrids

The evolution of reproductive barriers is the first step in the formation of new species and can help us understand the diversification of life on Earth. These reproductive barriers often take the form of hybrid incompatibilities, in which alleles derived from two different species no longer interact properly in hybrids1-3. Theory predicts that hybrid incompatibilities may be more likely to arise at rapidly evolving genes4-6 and that incompatibilities involving multiple genes should be common7,8, but there has been sparse empirical data to evaluate these predictions. Here we describe a mitonuclear incompatibility involving three genes whose protein products are in physical contact within respiratory complex I of naturally hybridizing swordtail fish species. Individuals homozygous for mismatched protein combinations do not complete embryonic development or die as juveniles, whereas those heterozygous for the incompatibility have reduced complex I function and unbalanced representation of parental alleles in the mitochondrial proteome. We find that the effects of different genetic interactions on survival are non-additive, highlighting subtle complexity in the genetic architecture of hybrid incompatibilities. Finally, we document the evolutionary history of the genes involved, showing signals of accelerated evolution and evidence that an incompatibility has been transferred between species via hybridization.

Complex hybridization between deeply diverged fish species in a disturbed ecosystem

Over the past two decades researchers have documented the extent of natural hybridization between closely related species using genomic tools. Many species across the tree of life show evidence of past hybridization with their evolutionary relatives. In some cases, this hybridization is complex - involving gene flow between more than two species. While hybridization is common over evolutionary timescales, some researchers have proposed that it may be even more common in contemporary populations where anthropogenic disturbance has modified a myriad of aspects of the environments in which organisms live and reproduce. Here, we develop a flexible tool for local ancestry inference in hybrids derived from three source populations and describe a complex, recent hybridization event between distantly related swordtail fish lineages (Xiphophorus) and its potential links to anthropogenic disturbance.

Genomic insights into variation in thermotolerance between hybridizing swordtail fishes

Understanding how organisms adapt to changing environments is a core focus of research in evolutionary biology. One common mechanism is adaptive introgression, which has received increasing attention as a potential route to rapid adaptation in populations struggling in the face of ecological change, particularly global climate change. However, hybridization can also result in deleterious genetic interactions that may limit the benefits of adaptive introgression. Here, we used a combination of genome-wide quantitative trait locus mapping and differential gene expression analyses between the swordtail fish species Xiphophorus malinche and X. birchmanni to study the consequences of hybridization on thermotolerance. While these two species are adapted to different thermal environments, we document a complicated architecture of thermotolerance in hybrids. We identify a region of the genome that contributes to reduced thermotolerance in individuals heterozygous for X. malinche and X. birchmanni ancestry, as well as widespread misexpression in hybrids of genes that respond to thermal stress in the parental species, particularly in the circadian clock pathway. We also show that a previously mapped hybrid incompatibility between X. malinche and X. birchmanni contributes to reduced thermotolerance in hybrids. Together, our results highlight the challenges of understanding the impact of hybridization on complex ecological traits and its potential impact on adaptive introgression.

Bridging disciplines to advance elasmobranch conservation: applications of physiological ecology

A strength of physiological ecology is its incorporation of aspects of both species' ecology and physiology; this holistic approach is needed to address current and future anthropogenic stressors affecting elasmobranch fishes that range from overexploitation to the effects of climate change. For example, physiology is one of several key determinants of an organism's ecological niche (along with evolutionary constraints and ecological interactions). The fundamental role of physiology in niche determination led to the development of the field of physiological ecology. This approach considers physiological mechanisms in the context of the environment to understand mechanistic variations that beget ecological trends. Physiological ecology, as an integrative discipline, has recently experienced a resurgence with respect to conservation applications, largely in conjunction with technological advances that extended physiological work from the lab into the natural world. This is of critical importance for species such as elasmobranchs (sharks, skates and rays), which are an especially understudied and threatened group of vertebrates. In 2017, at the American Elasmobranch Society meeting in Austin, Texas, the symposium entitled `Applications of Physiological Ecology in Elasmobranch Research' provided a platform for researchers to showcase work in which ecological questions were examined through a physiological lens. Here, we highlight the research presented at this symposium, which emphasized the strength of linking physiological tools with ecological questions. We also demonstrate the applicability of using physiological ecology research as a method to approach conservation issues, and advocate for a more available framework whereby results are more easily accessible for their implementation into management practices.

A review of the anatomy of the upper airway in early infancy and its possible relevance to SIDS

BACKGROUND

Since the danger of prone sleeping in the first 6 months of life has been publicised, there has been a dramatic and consistent reduction in the incidence of sudden infant death syndrome (SIDS). However, unexpected infant deaths and apparent life-threatening events (ALTEs) continue to occur that are clearly not associated with known epidemiological risk factors.

AIMS

To review the unique features of the anatomy and function of the upper airway of the young infant which contribute to increased vulnerability to hypoxia in this age group. We discuss the clinical identification of those infants at risk of obstruction or restriction of the upper airway and the management of the 'at risk' infant.

CONCLUSIONS

In the era after the "back to sleep" campaigns, it is likely that an increasing proportion of cases of ALTEs and SIDS will be related to obstruction or limitation of upper airway size leading to sleep hypoxia/asphyxia. This type of problem may be anticipated by evaluation and investigation of infants with signs or a clinical history consistent with possible upper respiratory tract compromise, including micrognathia.

Neurodevelopmental outcome of infants treated with head cooling and mild hypothermia after perinatal asphyxia

OBJECTIVES

To determine the neurodevelopmental outcome of infants treated with head cooling with systemic hypothermia after hypoxic-ischemic encephalopathy.

STUDY DESIGN

Infants >/=37 weeks' gestation, who had an umbilical artery pH </=7.09 or Apgar score </=6 at 5 minutes, plus clinical encephalopathy. Infants with major congenital abnormalities were excluded.

TRIAL DESIGN

Infants were allocated to either no cooling (rectal temperature = 37.0 +/- 0.2 degrees C, n = 15), or, sequentially, to head cooling accompanied by different levels of systemic hypothermia, including minimal cooling, rectal temperature 36.5 degrees C to 36 degrees C (n = 6), and mild cooling, to either 35.9 degrees C to 35.5 degrees C (n = 6), 35 +/- 0.5 degrees C (n = 6) or 34.5 +/- 0.5 degrees C (n = 7). Head cooling was accomplished by circulating cooled water through a coil of tubing wrapped around the head for up to 72 hours. Survivors were followed up with regular neurologic examination by a neonatologist until 18 months of age, then with blinded developmental testing using the revised Bayley Scales.

RESULTS

A total of 40 term infants were enrolled from 2 to 5 hours after birth. The control and the cooled groups were not significantly different for gestation, birth weight, Apgar score, and initial pH. There were 6 early neonatal deaths (3 normothermic and 3 cooled), and 1 death in infancy associated with severe spastic cerebral palsy in a normothermic infant. Six normothermic, 1 minimally cooled, and 4 mildly cooled infants had early stage 1 encephalopathy; all but 1 had a good outcome. Among infants with early stage 2 or 3 encephalopathy, an adverse outcome was found in 4 of 9 normothermic infants (44%) and 4 of 5 minimally cooled infants (80%), whereas in the combined mildly cooled groups, an adverse outcome was found in 4 of 15 infants (26%, odds ratio 0.46 [0.08, 2.56] vs normothermia).

CONCLUSIONS

The present study supports the safety of hypothermia, with no evidence of late adverse effects in any infant. Among infants with moderate to severe encephalopathy at enrollment, there was a tendency toward better outcome. These results emphasize the relatively wide range of outcomes using purely clinical criteria for enrollment. Therapeutic hypothermia should not be used outside of stringent, multicenter trials.

Delayed hypotension and subendocardial injury after repeated umbilical cord occlusion in near-term fetal lambs

OBJECTIVE

This study was undertaken to determine whether myocardial injury occurs after repeated intrauterine asphyxia.

STUDY DESIGN

Near-term fetal sheep with implanted instrumentation underwent either sham occlusions (n = 8) or repeated brief umbilical cord occlusions (n = 12) continued until the onset of severe (<20 mm Hg) or sustained hypotension. After 3 days of recovery, the fetal hearts were perfusion fixed.

RESULTS

Repeated umbilical cord occlusions led to a severe metabolic acidosis (pH, 6.84 +/- 0.09; lactate concentration, 14.1 +/- 1.5 mmol/L) with increasing hypotension during occlusions, which were terminated after 128 +/- 38 minutes. After the occlusions, the mean arterial pressure showed a delayed fall, which resolved after 12 hours. Ultrastructural examination showed evidence of subendocardial injury, with dilatation of sarcoplasmic reticulum, margination and clumping of nuclear chromatin, and mitochondrial swelling. The most severe morphologic changes, including electron-dense mitochondrial inclusions, were found in the fetuses with delayed recovery of the fetal heart rate after the final occlusion.

CONCLUSION

Subendocardial injury occurs after severe repeated intrauterine asphyxia in the late-gestation fetus, and this may contribute to cardiovascular compromise and the development of late decelerations.

Does early hospital discharge with home support of families with preterm infants affect breastfeeding success? A randomized trial

The aim of the present study was to determine if earlier discharge of preterm infants (<37 wk) from hospital is safe and if it affects breastfeeding rates. In a pilot observational study, premature infants received full oral (sucking) feeds for a mean (SD) 7.7 +/- 7.9 d before discharge. In the main study, 308 preterm infants were randomly assigned to either Early Discharge (148 infants) when fully orally fed but not yet gaining weight or Routine Discharge (160 infants) when fully orally fed and also gaining weight before discharge. A further 122 mothers declined randomization. The Early Discharge group was followed by Visiting Nurse Specialists who were available 24 h a day, while the Routine group was followed by the Home Care Nurses available on week days. There were no significant differences between the groups in birthweight or gestational age. The Early Discharge group were discharged 2.5 +/- 2 d after full oral feeding compared to 4.4 +/- 2.7 d for the Routine group (p < 0.001) and 6.1 +/- 5 d for those who declined. However, there was no significant difference between the Early and Routine groups for breastfeeding either at discharge (80 vs 83%), or 6 wk (55 vs 60%) or 6 mo after discharge (36 vs 36%), or for weight gain, or rates of re-hospitalization (8.8% vs 11.9% at 6 wk, p = 0.37).

CONCLUSION

Early discharge from hospital once a preterm infant can take full oral feeds does not alter later breastfeeding rates when adequate visiting nursing support is available.

CLINICAL REVIEW ARTICLE: Is changing the sleep environment enough? Current recommendations for SIDS

Sudden infant death syndrome (SIDS or cot death) was the major cause of post-neonatal infant death in many countries in the late 1970s and 1980s. There is now very strong evidence that public intervention campaigns targeting the prone sleeping position, which had been identified by epidemiological studies as a major risk factor, were followed by substantial falls in the rate of SIDS. In the present review we discuss the evidence on which current recommendations for the prevention of SIDS are based. The prone sleeping position is now clearly causally associated with SIDS. Further reductions in SIDS may be produced by recommending the back sleeping position as opposed to the side position. Maternal smoking in pregnancy and bed sharing by infants of mothers who smoke are also strongly associated with SIDS, but have been harder to influence. Paternal smoking has also been implicated, although the magnitude of the reported risk is small. Finally, breastfeeding, pacifier use and having the infant sharing the parents bedroom, but not the bed, may also reduce risk. Continued reductions in SIDS mortality will require innovative public health education to target these major risk factors, while building on the "back to sleep" approach.

Pregnancy outcome in women with reflux nephropathy and the inheritance of vesico-ureteric reflux

In women with reflux nephropathy, we investigated whether pre-existing hypertension and impaired renal function influence the rates of preeclampsia, renal function deterioration and preterm birth. The infants were investigated for vesico-ureteric reflux (VUR). A prospective audit of 54 pregnancies in 46 women with reflux nephropathy was performed. Preeclampsia complicated 24% of pregnancies and was increased in women with pre-existing hypertension (42%) compared with normotensive women (14%), (RR 3.0 (95% CI 1.1-7.8)). Nine (18%) women experienced deterioration in renal function during pregnancy Women with mild or moderate renal impairment were at increased risk of renal function deterioration (RR 12.7 (95% CI 1.6-98.5); RR 19.8 (95% CI 2.6-155)), respectively A third of infants were delivered preterm. The risk of preterm birth was increased if the mother had pre-existing hypertension (p = 0.01) or moderate renal impairment (p = 0.002). Seventeen (43%) of the 40 infants who underwent micturating cystourethrography had VUR, consistent with autosomal dominant inheritance with reduced penetrance. In reflux nephropathy, pre-existing hypertension was associated with an increased risk of preeclampsia and pre-existing renal impairment with deterioration in renal function. Infants of women with reflux nephropathy should be screened for VUR.

Neonatal micrognathia is associated with small upper airways on radiographic measurement

In order to determine if infants with clinical micrognathia identified in the newborn period have smaller upper airways than do normal infants, and if their airway size is related to risk of later apnoea, respiration-timed upper airway radiographic measurements were performed in 21 asymptomatic neonates with clinical micrognathia. Their radiographic measurements were compared with those of a previously reported cohort of 35 normal infants. The micrognathic infants and a control group of 27 infants referred for parental anxiety were followed for 6 mo on home apnoea monitors. Sleep apnoea at home requiring stimulation by the parents occurred in 6 of 7 infants with micrognathia associated with craniofacial anomalies, 9 of 14 (64%) infants with isolated micrognathia, but only 1 of the 27 control infants (p < 0.001). Upper airway measurements at term of the infants with isolated micrognathia who later experienced apnoea were significantly smaller than either those of normal infants (p < 0.01) or of micrognathic infants who did not have apnoea requiring stimulation (p < 0.05). In conclusion, upper airway measurements on timed lateral radiographs in asymptomatic micrognathic infants at term (corrected age) revealed them to be smaller than those of normal infants. Narrower upper airways were associated with increased risk of subsequent apnoea requiring stimulation.

Cerebral hypothermia is not neuroprotective when started after postischemic seizures in fetal sheep

Prolonged cerebral hypothermia is neuroprotective if started within a few hours of hypoxia-ischemia. However, delayed seizure activity is one of the major clinical indicators of an adverse prognosis after perinatal asphyxia. The aim of this study was to determine whether head cooling delayed until after the onset of postasphyxial seizures may still be neuroprotective. Unanesthetized near-term fetal sheep in utero received 30 min of cerebral ischemia induced by bilateral carotid artery occlusion. Eight and one-half hours later, they received either cooling (n = 5) or sham cooling (n = 13) until 72 h after the insult. Intrauterine cooling, induced by circulating cold water through a coil around the fetal head, was titrated to reduce fetal extradural temperature from 39.4+/-0.1 degrees C to between 30 and 33 degrees C. Cerebral ischemia led to the delayed development of intense epileptiform activity from 6 to 8 h postinsult, followed by a marked secondary rise in cortical impedance (a measure of cytotoxic edema) and in carotid blood flow. Cerebral cooling markedly attenuated the secondary rise in impedance and reduced carotid blood flow (p < 0.001). After 5 d recovery, there was no significant difference in loss of parietal EEG activity relative to baseline in the hypothermia compared with the control group (-12.5+/-1.4 versus -15.2+/-1.2 dB, mean +/- SEM, NS) or in parasagittal cortical neuronal loss (82+/-9 versus 90+/-5%, NS). In conclusion, delayed prolonged head cooling begun after the onset of postischemic seizures was not neuroprotective. These data highlight the importance of intervention in the latent phase, after reperfusion but before the onset of secondary injury.

Antecedents of neonatal encephalopathy with fetal acidaemia at term

OBJECTIVE

To identify the relative contribution of antenatal hypoxia, obstetric catastrophe during labour and fetal monitoring practice to the occurrence of neonatal encephalopathy associated with acidaemia at term.

DESIGN

Prospective study.

SETTING

Tertiary referral hospital in Auckland, New Zealand.

SAMPLE

Twenty-two term babies born between January 1996 and October 1997 with umbilical artery pH < or = 7.09 (median 6.88) or 5 minute Apgar score < 7 (median 5.0), and moderate to severe encephalopathy within five hours of birth.

METHODS

Antenatal and intrapartum events and fetal heart rate monitoring practice were reviewed by an experienced obstetrician.

RESULTS

More than half the cases were associated with events beyond the control of the clinician: 5 of 22 (23%) had evidence of antenatal hypoxia and 5 of 22 (23%) experienced an obstetric catastrophe during labour. Use of continuous fetal monitoring techniques or the interpretation of fetal heart rate changes was suboptimal in 8 of 12 cases. Continuous monitoring was not performed at all in three cases. All pregnancies were of either low or medium risk; none had proteinuric hypertension and no case was breech, small for gestational age or had a gestational age > or = 42 weeks.

CONCLUSIONS

A significant proportion of babies with encephalopathy associated with acidaemia at term experienced either antenatal hypoxia or catastrophic events beyond the control of the clinician. Further improvements in obstetric care will require greater vigilance in low to medium risk pregnancies and improved fetal monitoring practice during both induction and labour.

Caffeine overdose in a premature infant: clinical course and pharmacokinetics

The elimination of caffeine was investigated in a 1860 g, 31 week gestation neonate, following the accidental administration of a 160 mg.kg-1 dose. The first serum concentration measured was 217.5 mg.l-1 at 36.5 h after dosing. Fitting of time-concentration data was performed using non-linear regression with MKMODEL. A first order elimination model was superior to a mixed order model. Parameter estimates were: clearance 0.01 l.h-1, volume of distribution 1.17 litres, elimination half-life 81 h. Toxic manifestations included hypertonia, sweating, tachycardia, cardiac failure, pulmonary oedema and metabolic disturbances (metabolic acidosis, hyperglycaemia and creatine kinase elevation). An unusual feature of this infant's illness course was gastric dilatation. These signs resolved by day 7 at a serum concentration of 60-70 mg.l-1. Caffeine clearance has traditionally been reported as either an absolute value or as directly proportional to body weight. The per kilogram model gives an erroneous impression that clearance is greatest in early childhood and then decreases with age until adult rates are reached in late adolescence. Age-related clearance values reported in the literature were reviewed using an allometric 3/4 power model. This size model demonstrates that clearance increases in infancy and reaches adult rates within the first three months of life.

Is urethral catheterization a successful alternative to suprapubic aspiration in neonates?

OBJECTIVE

To compare urine collection by urethral catheterization with suprapubic aspiration in a neonatal intensive care unit.

METHODOLOGY

All urine collections were documented, the collection methods attempted recorded and success rates calculated. The incidence of contaminated specimens was determined. The infants ranged in weight from 570 g to 4180 g and in gestation from 24 to 44 weeks.

RESULTS

Thirty-two out of 65 (49%) suprapubic aspirations were successful. Overall 33/42 (77%) of catheterizations were successful, 12/18 (67%) were successful when following an unsuccessful SPA. No SPA was contaminated compared to 7/22 (22%) of the catheter specimens. Urinary tract infection was present in 4/63 (6.3%) infants. There were no complications following catheterization.

CONCLUSIONS

Urethral catheterization is a useful and safe alternative to suprapubic aspiration, but suprapubic aspiration remains the method of first choice.

The successful containment of coxsackie B4 infection in a neonatal unit

This report describes the containment of a potential enterovirus epidemic in a neonatal intensive care unit. A case of neonatal enterovirus meningitis and myocarditis was identified. Polymerase chain reaction (PCR) was used to assist in appropriate cohorting of contacts. One further infant became cross-infected with Coxsackie B4. Serum PCR was accurate in detecting the infection in the early stages in this asymptomatic neonate. Neonatal enterovirus infection is relatively rare but has the potential to cause outbreaks in neonatal wards. PCR can be used to diagnose and monitor for cross infection.

Neuroprotection with prolonged head cooling started before postischemic seizures in fetal sheep

OBJECTIVE

Cerebral hypothermia has been shown to reduce damage from experimental hy-poxia-ischemia if started shortly after reperfusion. However, in the newborn infant it may not be feasible to determine prognosis so soon after exposure to asphyxia. The aim of this study was to determine whether head cooling, delayed until shortly before the onset of postasphyxial seizure activity, is neuroprotective.

METHODS

Unanesthetized near-term fetal sheep in utero were subjected to 30 minutes of cerebral ischemia. Later, at 5.5 hours, they were randomized to either cooling (n = 7) or sham cooling (n = 10) for 72 hours. Intrauterine cooling was induced by circulating cold water through a coil around the fetal head. The water temperature was titrated to reduce fetal extradural temperature from 39.1 +/- 0.1 degreesC to between 30 degreesC and 33 degreesC, while maintaining esophageal temperature >37 degreesC.

RESULTS

Cerebral cooling suppressed the secondary rise in cortical impedance (a measure of cytotoxic edema), but did not prevent delayed seizures, 8 to 30 hours after ischemia. Transient metabolic changes including increased plasma lactate and glucose levels were seen with a moderate sustained rise in blood pressure. This severe cerebral insult resulted in depressed residual parietal electroencephalographic activity after 5 days recovery (-14.2 +/- 1.5 decibels), associated with a watershed distribution of neuronal loss (eg, 94 +/- 4% in parasagittal cortex and 77 +/- 4% in the lateral cortex). Hypothermia was associated with better recovery of electroencephalographic activity (-8.9% +/- 1.8 decibels) and substantially reduced neuronal loss in the parasagittal cortex (46 +/- 13%), the lateral cortex (9 +/- 4%), and other regions except the cornu ammonis sectors 1 and 2 of the hippocampus.

CONCLUSIONS

Delayed selective head cooling begun before the onset of postischemic seizures and continued for 3 days may have potential to significantly improve the outcome of moderate to severe hypoxic-ischemic encephalopathy.

The 'pharmacology' of neuronal rescue with cerebral hypothermia

The neuroprotective effects of hypothermia during cerebral ischaemia or asphyxia are well known. Although, in view of this, the possibility of a therapeutic role for hypothermia during or after resuscitation from such insults has been a long standing focus of research, early studies had limited and contradictory results. Clinically and experimentally severe perinatal asphyxial injury is associated with a latent phase after reperfusion, with initial recovery of cerebral energy metabolism but EEG suppression, followed by a secondary phase with seizures, cytotoxic edema, accumulation of cytotoxins, and cerebral energy failure from 6 to 15 h after birth. Recent studies have led to the hypothesis that changes in post-ischaemic cerebral temperature can critically modulate encephalopathic processes which are initiated during the primary phase of hypoxia-ischaemia, but which extend into the secondary phase of cerebral injury. This conceptual framework allows a better understanding of the 'pharmacological' parameters that determine effective hypothermic neuroprotection, including the timing of initiation of cooling, its duration and the depth of cooling attained. Moderate cerebral hypothermia initiated in the latent phase, between one and as late as 6 hours after reperfusion, and continued for a sufficient duration in relation to the severity of the cerebral injury, has been associated with potent, long-lasting neuroprotection in both adult and perinatal species. These encouraging results must be balanced against the adverse systemic effects of hypothermia. Randomised clinical trials are in progress to establish the safety and efficacy of prolonged cerebral hypothermia.

Selective head cooling in newborn infants after perinatal asphyxia: a safety study

AIMS

To determine the practicality and safety of head cooling with mild or minimal systemic hypothermia in term neonates with moderate to severe hypoxic-ischemic encephalopathy.

METHODS

Study group infants >/=37 weeks' gestation, who had an umbilical artery pH </=7. 09 or Apgars </=6 at 5 minutes, plus evidence of encephalopathy. Infants with major congenital abnormalities were excluded. TRAIL DESIGN: Infants were randomized to either no cooling (controls; rectal temperature = 37.0 +/- 0.2 degreesC, n = 10) or sequentially, either minimal systemic cooling (rectal temperature = 36.3 +/- 0.2 degreesC, n = 6) or mild systemic cooling (rectal temperature = 35.7 +/- 0.2 degreesC, n = 6). Head cooling was accomplished by circulating water at 10 degreesC through a coil of tubing wrapped around the head for up to 72 hours. All infants were warmed by servo-controlled overhead heaters to maintain the allocated rectal temperature. The rectal, fontanelle, and nasopharyngeal temperatures were continuously monitored.

RESULTS

From January 1996 to October 1997, 22 term infants were randomized from 2 to 5 hours after birth. All infants showed a metabolic acidosis at delivery, with similar umbilical artery pH in the control group (mean +/- standard deviation, 6.79 +/- 0.25), minimal cooling group (6.98 +/- 0.21), and mild cooling group (6.93 +/- 0.11), and depressed Apgar scores at 5 minutes in the control group (4.5 +/- 2), minimal cooling group, (4.7 +/- 2) and mild cooling group (6.0 +/- 1). In the mild-cooled infants, the nasopharyngeal temperature was 34.5 degreesC during cooling, 1.2 degreesC lower than the rectal temperature. This gradient narrowed to 0.5 degreesC after cooling was stopped. No adverse effects because of cooling were observed. No infants developed cardiac arrhythmias, hypotension, or bradycardia during cooling. Thrombocytopenia occurred in 2 out of 10 controls, 2 out of 6 minimal cooling infants, and 1 out of 6 mild cooling infants. Hypoglycemia (glucose <2.6 mM) was seen on at least one occasion in 2 out of 10 controls, 4 out of 6 minimal cooling infants, and 1 out of 6 mild cooling infants. Acute renal failure occurred in all infants. The metabolic acidosis present in all infants at the time of enrollment into the study progressively resolved despite cooling, even in the mild hypothermia group.

CONCLUSIONS

Mild selective head cooling combined with mild systemic hypothermia in term newborn infants after perinatal asphyxia is a safe and convenient method of quickly reducing cerebral temperature with an increased gradient between the surface of the scalp and core temperature. The safety of mild hypothermia with selective head cooling is in contrast with the historical evidence of adverse effects with greater depths of whole-body hypothermia. This safety study and the strong experimental evidence for improved cerebral outcome justify a multicenter trial of selective head cooling for neonatal encephalopathy in term infants.

Can preterm twins breast feed successfully?

AIM

To compare the success of singleton and twin preterm infants in establishing and maintaining breast feeding, and to evaluate the effectiveness of current programmes to promote breast feeding.

METHODS

All infants less than 37 weeks gestation discharged in one month from the special care baby unit at National Womens Hospital were studied. Data on the infants and their in hospital course was recorded from the neonatal records. The mothers were contacted by telephone 3 to 4 months after discharge, to elicit the subsequent breast feeding rates.

RESULTS

Thirty of 33 preterm infants (29 to 36 weeks gestation) were breast fed at discharge from hospital: 93% of singletons, and 89% of twins. The twins were older and heavier at discharge (p < 0.004) due to their longer hospital stays (28.4 vs 16.3 days, p < 0.05). All but 2 infants progressed to exclusive breast feeding. There was a similar rate of decline in the rates of breast feeding in singletons and twins to 68% at 8-12 weeks and 49% at 12-16 weeks after birth.

CONCLUSIONS

Preterm twins can breast feed as successfully as preterm singleton infants; as with sufficient assistance and encouragement, their rates of breast feeding were comparable to those of term infants. Although the resources of this hospital do not allow preterm infants to become fully breast fed before discharge, the current programme at National Womens Hospital is effective in establishing successful breast feeding in these high risk infants.

Lymphatic dysplasia in a neonate with Noonan's syndrome

We present the case of a patient with Noonan's syndrome and massive nonimmune hydrops fetalis in whom lymphangiography was performed in the neonatal period. This demonstrated generalised lymphatic dysplasia, and we suggest a mechanism by which the lymphatic abnormalities in Noonan's syndrome may arise.

Changes in risk factors for hypoxic-ischaemic seizures in term infants

Term infants with seizures and evidence of perinatal asphyxia were prospectively identified in 1 city and 2 time periods: 1978-1981 and 1991. Infants with multiple congenital abnormalities, hypocalcaemia or infection were excluded. Although there was little change in the overall incidence of neonatal seizures between 1978-1981 (1.9 per 1,000) and 1991 (1.78 per 1,000, N.S.) there was a marked reduction in small for dates infants with seizures: 8 of 19 infants in 1978-1981 compared to none of 16 in 1991 (p < 0.005). In contrast, infants > or = 41 weeks continued to show a markedly increased risk for asphyxia (relative risk 4.48, 95% CI: 1.7-12.3). The mechanism of this improved outcome for small for gestational age infants is unknown, but speculatively may be due to improved obstetric monitoring techniques allowing early identification of compromised infants.

Dramatic neuronal rescue with prolonged selective head cooling after ischemia in fetal lambs

Hypothermia has been proposed as a neuroprotective strategy. However, short-term cooling after hypoxia-ischemia is effective only if started immediately during resuscitation. The aim of this study was to determine whether prolonged head cooling, delayed into the late postinsult period, improves outcome from severe ischemia. Unanesthetized near term fetal sheep were subject to 30 min of cerebral ischemia. 90 min later they were randomized to either cooling (n = 9) or sham cooling (n = 7) for 72 h. Intrauterine cooling was induced by a coil around the fetal head, leading initially to a fall in extradural temperature of 5-10 degrees C, and a fall in esophageal temperature of 1.5-3 degrees C. Cooling was associated with mild transient systemic metabolic effects, but not with hypotension or altered fetal heart rate. Cerebral cooling reduced secondary cortical cytotoxic edema (P < 0.001). After 5 d of recovery there was greater residual electroencephalogram activity (-5.2+/-1.6 vs. -15.5+/-1.5 dB, P < 0.001) and a dramatic reduction in the extent of cortical infarction and neuronal loss in all regions assessed (e.g., 40 vs. 99% in the parasagittal cortex, P < 0.001). Selective head cooling, maintained throughout the secondary phase of injury, is noninvasive and safe and shows potential for improving neonatal outcome after perinatal asphyxia.

Air entry in infant resuscitation: oral or nasal routes?

The current recommendation for resuscitation of infants is to blow air into both the nose and mouth. We have observed that mothers cannot cover both the nose and mouth of their infants. We compared postmortem tracheal and esophageal air entry by using the nose, combined nose and mouth, and mouth routes in eight infants. Air entry into the trachea occurred at lower pressures (P < 0.05) via a nose mask than via a combined nose and mouth mask or via a mouth mask. Air entry into the trachea occurred at lower pressures (P < 0.05) via the nose route in the neutral and extended neck positions compared with the flexed position. We were unable to demonstrate an effect of the route of air entry on esophageal air entry. The findings indicate that the nasal route of air entry is more effective than the combined nose and mouth or mouth routes and that neck flexion impedes air entry. We recommend that parents are taught to blow air into their infants' noses if the infant stops breathing.

Suppressive action of endogenous adenosine on ovine fetal nonshivering thermogenesis

Nonshivering thermogenesis is not initiated when the fetal sheep is cooled in utero but appears to require the removal of an inhibitor of placental origin at birth. To test whether adenosine is such an inhibitor, we examined the effect of the adenosine antagonist theophylline on the initiation of nonshivering thermogenesis during sequential cooling, ventilation, and umbilical cord occlusion in utero. Theophylline (18 mg/kg bolus and 0.6 mg.kg-1.min-1 thereafter) was infused for 90 min before and 90 min after cord occlusion. Theophylline enhanced the nonshivering thermogenic free fatty acid (FFA) and glycerol responses before cord occlusion, raising FFA concentrations 99% to 415 +/- 60 mueq/l (P < 0.01) and glycerol levels 87% to 526 +/- 135 mumol/l (P < 0.05). These FFA (P < 0.001) and glycerol (P < 0.05) concentrations were significantly greater than the corresponding period during the birth-simulation control. Umbilical cord occlusion did not alter FFA levels but induced a 41% rise in glycerol concentrations to 774 +/- 203 mumol/l (P < 0.05). The increases in nonshivering thermogenic indexes after the administration of the adenosine-receptor antagonist suggest that the quiescent state of ovine fetal brown adipose tissue may result, in part, from the tonic inhibitory actions of adenosine and that a decrease in adenosine concentrations enhances nonshivering thermogenesis. However, the further rise after umbilical cord occlusion suggests that at least one other inhibitor of placental origin inhibits nonshivering thermogenesis before birth.

Growth hormone increases breast milk volumes in mothers of preterm infants

AIMS

To determine the galactopoietic response to recombinant human growth hormone (hGH) in mothers of premature infants with inadequate lactation.

STUDY DESIGN

Prospective placebo-controlled, double-blind trial.

SUBJECTS

Twenty healthy mothers on no concurrent medication, with infants born between 26 and 34 weeks' gestation with insufficient milk production for their infants' needs.

INTERVENTIONS

Ten mothers received hGH, .2 IU/kg/day subcutaneously to a maximum of 16 IU/day, for 7 days, while 10 mothers received the same volume of placebo. One mother from each group withdrew from the study.

OUTCOME MEASURES

Maternal milk production and plasma concentrations of insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3), and growth hormone (GH) were determined before starting treatment and 1 day after stopping therapy. A nurse measured the amount of milk expressed (5 to 6 times daily) plus, if the infant was suckling, weighed the infant before and after feeding.

RESULTS

The mothers were enrolled 35 +/- 26 days after birth; at this time the infants weighed 1.89 +/- .64 kg. Milk production in hGH-treated mothers increased from 139 +/- 49 mL/day to 175 +/- 46 mL/day after 7 days of treatment (a rise of 31%). Placebo-treated mothers showed no significant change from 93 +/- 50 mL/day to 102 +/- 69 mL/day (a rise of 7.6%, not significant). Milk production increased in all treated mothers but decreased in 4 of 9 placebo mothers. Plasma concentrations of IGF-1 and IGFBP-3 increased in hGH-treated mothers but not placebo-treated mothers; there was no change in plasma GH levels in either group. No adverse effects were seen with hGH treatment in the mothers or infants.

CONCLUSIONS

hGH therapy in mothers with lactational insufficiency can improve breast milk volumes.

Effect of radiant heat on head temperature gradient in term infants

AIMS

To test the hypothesis that external radiant heating might lead to significant fluctuations in superficial and core head temperatures in newborn infants.

METHODS

In an observation group of 14 term infants nursed under a radiant heater, servo-controlled to the abdominal skin, changes in rectal, core head, and scalp temperatures with heater activation were examined. In a further intervention group of six infants the effect of a reflective head shield on the fluctuations of scalp temperature was also tested.

RESULTS

In the observation group, when the heater had been off for 30 minutes, the rectal and scalp temperatures were 36.7 (SD 0.6) and 35.6 (0.6) degrees C, respectively, a difference of 1.2 (0.2) degrees C. After 30 minutes with the radiant heater on this fell to 0.2 (0.5) degrees C. The core head temperature, however, remained similar to the rectal temperature throughout. In the intervention group a reflective shield prevented the loss of the rectal-scalp gradient.

CONCLUSION

Overhead heater activation is associated with loss of the core to scalp temperature gradient, but no change in core head temperature in term infants. The clinical relevance of this superficial heating in vulnerable infants warrants further study.

Perinatal thermogenesis

The rapid initiation of thermogenesis is crucial for the survival of newborn infants. At birth the fetus must adapt to cooling, increased oxygenation and separation from the placenta. An experimental approach in the chronically instrumental fetal sheep of 'simulated birth in utero' allowed the evaluation of each of these stimuli sequentially. Cooling stimulated shivering, cardiovascular and endocrine responses but not nonshivering thermogenesis (NST). Ventilation of the cooled fetus with oxygen caused only modest NST which was not altered by an infusion of triiodothyronine. Occluding the umbilical cord was followed by a rapid substantial rise in NST which was maintained until the placental circulation was re-established. Thus the placenta is secreting factors into the fetal circulation which inhibit the ability of the brown adipose tissue to respond to either hormonal or neural stimuli. Placental prostaglandin E2 and probably adenosine are tonic inhibitors of thermogenesis in utero. Effective thermogenesis after birth requires the combination of separation from the placental inhibitors of lipolysis, increased oxygenation from breathing and the stimulation of cutaneous cold receptors.

Nasal route for infant resuscitation by mothers

In infants under 6 months of age air normally enters the trachea by the nose because the tongue fills the oral cavity, and the oral route is open only when the infant is making muscular efforts such as crying or gasping. The present recommendation for infant resuscitation is for the resuscitator's mouth to cover the mouth and nose of the baby. We set out to test whether this recommendation is feasible. We measured the dimensions of the faces of 28 babies aged between 2 and 4 months (the age when resuscitation is most often needed) and of the mouths of 25 of their mothers. Only 2 mothers would have been able to cover with their mouths the nose and closed mouth of 2 babies (not their own). The mannequins often used to teach adults to resuscitate infants are misleading because they present a wide open mouth, thus implying that that is the preferred route. We recommend that the nasal route of air entry be taught to parents for resuscitation of babies who have stopped breathing.

Family with partial monosomy 10p and trisomy 10p

We report on a family with an abnormality of 10p. The propositus has monosomy for the distal region of 10p and severe psychomotor delay, growth failure, congenital heart defect, multicystic kidney, grade V vesicoureteric reflux, and neurosensory hearing loss. The mother and the elder brother of the propositus carry a balanced reciprocal translocation (5q;10p)(q35.3;p12.3). A retarded and epileptic maternal aunt was found to have dup(10p). Study of the family history led to the successful obstetric management of a subsequent twin pregnancy in which an affected fetus with dup(10p) was identified and selectively terminated, while the other normal twin was delivered at term without problems.

A potential role for adenosine in the inhibition of nonshivering thermogenesis in the fetal sheep

Adenosine is released by the placenta into the fetal circulation and has potent antilipolytic properties in vitro. Nonshivering thermogenesis cannot be demonstrated by cooling fetal sheep in utero but can be induced by supplemental oxygenation and umbilical cord occlusion; this suggests the presence of inhibitor(s) of placental origin. To test whether circulating adenosine could be such an inhibitor, a series of experiments was carried out in nine fetal sheep at 136-145 d gestation. Birth was simulated in utero by sequentially cooling the fetus 2.49 +/- 0.23 degrees C with no change in the low levels of plasma FFA or glycerol; ventilating with O2 via an exteriorized tracheostomy tube and umbilical cord occlusion. Thermogenic indices rose markedly, and plasma FFA and glycerol concentrations peaked at 725 +/- 88 microEq/L (p < 0.01) and 771 +/- 154 mumol/L, (p < 0.001), respectively, O2 consumption rose to 20 +/- 2 mL/min/kg, and temperature increased 1.99 +/- 0.35 degrees C. The long-acting adenosine analog N6-(L-2-phenylisopropyl)-adenosine (PIA) was then infused (90 micrograms/kg bolus, then 300 micrograms/kg/h for 30 min); plasma FFA and glycerol decreased to 265 +/- 56 microEq/L (p < 0.003) and 477 +/- 102 mumol/L (p < 0.04), respectively; O2 consumption fell rapidly to 4.5 +/- 0.3 mL/min/kg (p < 0.01); temperature decreased 1.89 +/- 0.39 degrees C (p < 0.001); and fetal arterial BP decreased to 38 +/- 5 mm Hg (p < 0.004) in 30 min. A stepped dose-response study was performed in three fetal sheep.(ABSTRACT TRUNCATED AT 250 WORDS)

Antenatal diagnosis of urinary tract abnormalities by ultrasonography after 28 weeks' gestation: incidence and outcome

OBJECTIVE

The objective was to establish the likelihood that antenatal upper urinary tract dilatation identified after 28 weeks of gestation will progress to significant postnatal uropathy.

STUDY DESIGN

In 5 years, 3856 fetuses had ultrasonography after 28 weeks of gestation when the mothers were first seen in advanced pregnancy for delivery appointments or for other obstetric indications. Fetuses with urinary tract anomalies had ultrasonographic surveillance after 6 days and 6 weeks of life with further evaluation as necessary.

RESULTS

Renal tract anomalies were identified in 313 fetuses, and 55 infants had significant renal tract abnormalities. There were 7 deaths; 2 infants were anephric and 5 with hydronephrosis had lethal congenital abnormalities. Dilatation of the upper urinary tract was identified in 7.7% of the fetuses (298/3856) but was transient in 216 of them (72%). Follow-up of children with transient renal pelvis dilatation found only one with a history of urinary tract infection. Obstruction occurred in 23 infants (6.0/1000) and 16 required surgical correction. Vesicoureteric reflux was identified in 14 infants (3.6/1000) and resolved by age 2 years in 64%. Unilateral multicystic renal dysplasia occurred in 8 and posterior urethral valves occurred in 3 infants.

CONCLUSION

Antenatal ultrasonography after 28 weeks' gestation identified significant renal tract abnormalities with a frequency of 14.3 per 1000 births, permitting early treatment of the asymptomatic newborn and reducing later renal damage.

Relationship between the fall in growth hormone secretion at birth and the onset of nonshivering thermogenesis is independent of beta adrenergic stimulation

At the time of birth, many rapid metabolic changes occur including the initiation of nonshivering thermogenesis and a rapid fall in growth hormone concentrations. To evaluate the interaction between these events 5 fetal sheep were studied at 135-144 days' gestation. The fetuses were first cooled 2.22 +/- 0.19 degrees C by circulating cold water through a coil placed around the fetal thorax and then ventilated with oxygen through an exteriorized tracheostomy tube to raise fetal arterial PO2 above 67.5 +/- 14.1 Torr. An hour later the beta adrenergic agonist isoproterenol was infused intravenously for 90 min. The fetuses were then separated from the placenta by occluding the umbilical cord. After 60 min the cooling and then the isoproterenol infusion were stopped and the responses monitored. Basal plasma free fatty acid (FFA 35 +/- 5 microEq L-1) and growth hormone (GH 141 +/- 12 ng mL-1) concentrations were not significantly altered by cooling alone, but oxygenation modestly increased plasma FFA to 237 +/- 55 microEq L-1 (P < 0.01) while GH concentrations fell to 58 +/- 27 ng mL-1 (P < 0.05). Isoproterenol administration did not significantly affect either FFA or GH concentrations. Occlusion of the umbilical cord caused a rapid nearly threefold increase in plasma FFA concentrations to 903 +/- 71 microEq L-1 (P < 0.01) and a fall in the same proportions in GH concentrations to 16 +/- 2 ng mL-1 (P < 0.005). Maximal fetal oxygen consumption was 24.2 +/- 4.4 mL kg-1 min-1. Cessation of cooling induced a significant fall in plasma FFA to 480 +/- 58 microEq L-1 (P < 0.01) and rise in GH concentrations to 46 +/- 5 ng mL-1 (P < 0.01). Following the withdrawal of isoproterenol, the fall in plasma FFA and rise in GH concentrations continued while the fetal oxygen uptake fell to 6.4 +/- 1.7 mliter kg-1 mL-1 (P < 0.01). During the study the variation in plasma GH was inversely correlated with changes in FFA concentrations (R = 0.77, P < 0.001). This study confirms that the major factors initiating nonshivering thermogenesis at birth are: sympathetic stimulation from cutaneous cooling, which was not significantly enhanced by isoproterenol; adequate oxygenation; and removal of placental inhibitor(s). The findings are in agreement with a causal relationship between the initiation of nonshivering thermogenesis and consequent rise in FFA concentrations and the rapid fall in circulating GH concentrations after birth in the lamb, independent of beta adrenergic stimulation.

Upper airway radiographs in infants with upper airway insufficiency

Upper airway measurements in nine infants considered to be at risk of upper airway insufficiency, six of whom presented after an apnoeic episode, were compared with measurements taken in two age groups of healthy infants. Paired, inspiratory and expiratory, lateral upper airway radiographs were obtained while the infants were awake and breathing quietly. The radiographs of all nine infants demonstrated narrowing in the oropharyngeal portion of the airway during inspiration and in six infants there was ballooning of the upper airway during expiration. Seven of the nine infants subsequently experienced recurrent apnoeic episodes which required vigorous stimulation to restore breathing. Experience suggests that respiratory phase timed radiographs are a useful adjunct to the evaluation of infants who are suspected of having upper airway dysfunction. They provide information regarding both the dimensions and compliance of the upper airway as well as the site of any restriction.

The persistence of anti-hepatitis B surface antibodies to three years of age: is a hepatitis B vaccine booster required?

AIMS

To evaluate the persistence of hepatitis B surface antibodies (anti-HBs) after immunisation in early infancy.

METHODS

The infants were born to low risk European mothers negative for hepatitis B surface antigen (HBsAg). All the children had received 3 doses of 20 micrograms of recombinant DNA hepatitis B vaccine.

RESULTS

One month after the third dose all 92 infants were seropositive. The GMT was 1190 mIU/mL and all but one infant had seroprotective titres above 10 mIU/mL. Three years after the vaccination 91% (59 of 65) children who returned for testing still had measurable anti-HBs titres. The GMT was 32 mIU/mL but 26% (17 of 65) had titres less than 10 mIU/ml. Only one child had serologic evidence of contact with the hepatitis B virus but did not develop the disease.

CONCLUSION

This vaccine is safe and effective for at least 3 years. The long term duration of protection from vaccination in early infancy requires further studies.

Withdrawal of placental prostaglandins permits thermogenic responses in fetal sheep brown adipose tissue

Significant nonshivering thermogenesis cannot be demonstrated in fetal sheep cooled in utero but can be induced by supplemental oxygenation and umbilical cord occlusion, which suggests the presence of inhibitor(s) of placental origin. To test the hypothesis that an ecosanoid could be such an inhibitor, we studied eight fetal sheep at 136-141 days gestation. Thermistors were placed in the fetal esophagus, a cooling tube was placed around the trunk, a tracheal cannula and carotid catheters were inserted, and a snare was placed loosely around the umbilical cord. After indomethacin infusion for 18 h, the fetuses were cooled by 2.13 +/- 0.13 degrees C by circulating cold water through the coil. Within 60 min plasma free fatty acid levels rose threefold to 245 +/- 82 mu eq/l (P < 0.01) and glycerol levels rose to 197 +/- 17 mumol/l (P < 0.01). Ventilation caused a further rise in thermogenic indexes, and fetal oxygen consumption rose to 19.9 +/- 1.2 ml.kg-1.min-1. In four fetuses we ceased cooling, which caused thermogenic indexes to fall and oxygen consumption to fall to 6.9 +/- 1.1 ml.kg-1.min-1. We continued to cool three fetuses and infused prostaglandin E2 into the fetuses for 60 min; thermogenic indexes and oxygen consumption fell rapidly on infusion and rose rapidly when infusion ceased. We suggest that placental prostaglandins inhibit brown adipose tissue thermogenesis before birth and that withdrawal after placental separation is one factor in the initiation of nonshivering thermogenesis at birth.

Modulation of growth hormone secretion by thermogenically derived free fatty acids in the perinatal lamb

To evaluate the hypothesis that the rapid fall in circulating GH concentrations at birth is secondary to the initiation of nonshivering thermogenesis and the consequent rise in FFA levels, a series of experiments was performed in late-gestation fetal sheep. By sequentially cooling the fetus by means of a coil placed around the fetal thorax, ventilating with oxygen via an exteriorized tracheostomy tube, and separating the fetus from the placenta by occluding the umbilical cord, nonshivering thermogenesis could be induced in utero. In the first protocol (n = 6) cooling alone had no effect on fetal plasma FFA levels, oxygenation elevated FFAs slightly from 64 +/- 7 mu Eq/liter to 183 +/- 29 mu Eq/liter, and cord occlusion caused a further marked rise (P less than 0.005) to 635 +/- 69 mu Eq/liter. Neither cooling nor ventilation affected fetal plasma GH concentrations which fell (P less than 0.001) from 160 +/- 17 ng/ml to 65 +/- 13 ng/ml upon cord occlusion. When the cord occluder was removed FFA levels fell (P less than 0.001) and GH concentrations rose (P less than 0.001) once more, and when the cord was again occluded FFA levels rose (P less than 0.001) and GH concentrations fell (P less than 0.001). In a second protocol nine fetuses were cooled, ventilated, and the umbilical cord occluded. Once more, plasma FFA levels rose (P less than 0.001) and GH concentrations fell (P less than 0.001); when thermogenesis was inhibited by the infusion of the adenosine agonist N6-(L-2-phenyl isopropyl)-adenosine, FFA levels fell from 725 +/- 88 mu Eq/liter to 265 +/- 56 mu Eq/liter and GH concentrations rose from 54 +/- 13 ng/ml to 323 +/- 73 ng/ml. In two further protocols the possibility that PIA was acting directly on GH secretion was excluded in six fetuses with low plasma FFA levels and in three fetuses with elevated plasma FFA levels secondary to a fatty acid emulsion infusion. These studies provide direct evidence that the pattern of change in plasma GH concentrations at birth in the sheep is determined in part by the rise in plasma FFAs of thermogenic origin.

Reversible umbilical cord occlusion: effects on thermogenesis in utero

The initiation of thermogenesis at birth is an important adaptation for survival. We examined the sequential effects of cooling, increased oxygenation, and repeated episodes of umbilical cord occlusion on nonshivering thermogenesis in six fetal sheep at 139 to 145 d of gestation. The fetal sheep were cooled by circulating cold water through a coil placed around the trunk for 4 h. The fetal core temperature fell 2.47 +/- 0.24 degrees C in the first 60 min of cooling with minimal changes in plasma FFA and glycerol levels. After fetal arterial O2 tension was increased above 6.65 kPa by ventilation, fetal temperature and thermogenic indices rose significantly in 60 min. After occlusion of the umbilical cord by a reversible occluder cuff, plasma FFA levels rapidly increased to 635 +/- 69 muEq/L (p less than 0.005) by 30 min, fetal temperature increased a further 0.96 +/- 0.20 degrees C (p less than 0.001) and fetal O2 consumption peaked at 25.3 +/- 4.9 mL.min-1.kg-1. Release of cord occlusion caused a rapid fall in FFA to 149 +/- 23 muEq/L (p less than 0.005) and a fall in fetal core temperature of 0.90 +/- 0.13 degrees C (p less than 0.001) in 30 min. After irreversibly snaring the umbilical cord, the plasma FFA rose to 611 +/- 83 muEq/L (p less than 0.005) and the fetal temperature rose 0.78 +/- 0.09 degrees C (p less than 0.02). The effects on thermogenesis of interrupting and reestablishing placental flow are rapid and reversible and suggest the presence of placental inhibitors of brown adipose tissue thermogenesis.

Breast feeding preterm infants

Breast feeding is the optimal way to feed infants but may be difficult in preterm infants. In a study of 43 mothers with 49 preterm infants admitted to a neonatal unit during a 10 week period-84% (36 of 43) wished to breast feed and 92% (33 of 36) of these mothers left hospital breast feeding. Their infants were from 30 to 36.5 weeks gestation, weighing a mean 2590 (SD 530) g and were in hospital 16 (11) days. Only three mothers who wished to breast feed failed to do so. The 10 bottle fed infants were smaller, younger and remained longer in hospital. The majority of mothers (88%) who were discharged breast feeding were still successfully breast feeding their preterm infants three months later. This is in marked contrast to a previous study of mothers, of full term infants, where there was a marked decrease in breast feeding by three months. The mothercraft teaching described is an effective method of providing preterm infants and their mothers with the advantages of breast feeding.

The endocrine control of the onset of thermogenesis at birth

The experimental studies in the fetal sheep demonstrate that the central hypothalamic mechanisms for responding to a cold stress have differentiated well before birth. There are several major determinants of the initiation of maximal thermogenesis at birth. These are cutaneous cooling, oxygenation and separation from the placenta. Firstly the stimulation of cutaneous cold receptors regulates sympathetic nervous system activity, primarily local noradrenaline release from sympathetic nerve termini to the brown adipocyte adrenoreceptors. Circulating catecholamines, the euthyroid state and other hormones also play a role. Secondly an increase in oxygen delivery to brown adipose tissue through increased oxygen content and increased blood flow is required. Finally, our observations suggest that separation from the placenta is necessary for maximal nonshivering thermogenesis. The effects on thermogenesis of interrupting and reestablishing placental flow are rapid and reversible. Umbilical cord occlusion is the signal for a rapid increase in thermogenesis, while the release of cord occlusion is followed by an equally rapid fall in thermogenesis. This strongly suggests the presence of a placental inhibitor of brown adipose tissue thermogenesis. The problem of the regulation of growth and recruitment of brown adipose tissue in the fetus despite the lack of thermal stress in utero may be resolved by this evidence for an inhibitory factor of thermogenesis produced by the placenta. The withdrawal of the inhibitor at birth by separation from the placenta will allow the rapid initiation of thermogenesis in response to sympathetic nervous system stimulation of the brown adipose tissue.

Upper airway measurements during inspiration and expiration in infants

Accurate measurements of the upper airway of the infant are important but are difficult to obtain reliably because of the normal variation that occurs during respiration. X-ray films of the lateral upper airway were obtained during inspiration and expiration in healthy infants, by using as a timing device a respiration monitor which was wired to the x-ray machine and was attached to the abdominal wall of the infant. Cephalometric measurements were made of 44 "normal" full-term neonates and 29 infants at 6 weeks of age. Despite significant differences in head circumference between the sexes, only the nasion to sella length was significantly longer in the boys (P less than .01). The lateral upper airway measurements were independent of weight, head circumference, and sex in the neonates and infants at 6 weeks of age but were significantly smaller during inspiration than expiration (P less than .01). The measurements progressively increased from the middle to the posterior airway space at both ages. The middle airway space behind the caudal end of the hard palate was smaller during inspiration at 6 weeks of age compared to the neonate (P less than .01). During expiration, the posterior airway space was larger at 6 weeks compared to the neonate (P less than .01). The method described in this report enables reliable roentgenographic measurements to be made of the upper airway of the infant; normal values for the changes during inspiration and expiration are provided. This may assist in the evaluation of infants with suspected upper airway obstruction.

Prenatal cranial haemorrhages in 47 Pacific Islander infants: is traditional massage the cause?

Intracranial haemorrhage is usually a very rare occurrence in the fetus before the onset of labour but we have identified major, mostly subdural, prenatal intracranial haemorrhages in 47 infants of immigrant Pacific Islander parentage. Forty-four infants have been stillborn and the numbers from 1983 to 1986 were sufficient to account for the stillbirth rate for Pacific Islanders in Auckland being approximately 60% higher than rates for Europeans or Maoris. Two of three liveborn infants survived with neurological sequelae. Similar haemorrhages may be the cause of a congenital hydrocephalus in Pacific Islanders. A bleeding disorder can be excluded in most cases, as can trauma from accidents or assaults. Trauma during attempts at cephalic version of breech presentations by traditional methods could explain why 53% of deliveries were breech and other pathological and clinical features. Advice at antenatal clinics about possible dangers of traditional massage has coincided with a reduction in the incidence of haemorrhages since 1986.