NEONATOLOGY TODAY News and Information for BC/BE Neonatologists and Perinatologists

Volume 5 / Issue 10 October 2010 Individualized Environments in the NICU IN THIS ISSUE

Individualized Environments in By Robert White, MD NICU – baby, parent, and caregiver – in ways the NICU that will be of demonstrable benefit to all. by Robert White, MD Page 1 In earlier days, hospital care was provided in Hypothesis 1: The optimal “microenvironment” for a newborn , even (especially) one who Following large wards. The images are familiar – long Vaginal rows of children with polio, soldiers with is ill, is skin-to-skin with mother. Delivery: A Frequently wounds, mothers in one ward, babies in an- Undiagnosed Problem other. Today, these images are replaced with The newborn’s brain is in the midst of an in- by Houchang D. Modanlou, MD private rooms, often rivaling the finest hotels in credibly active period of growth and develop- Page 6 amenities. Both business and patient-related ment during the third and “fourth trimesters.” outcome measures have led to this change Throughout this time, stimuli from the mother, DEPARTMENT which was resisted at first by both administra- both in and ex utero, are the biologically ex- tors and caregivers, but is now embraced by pected norm. From the pioneering work of Global Neonatology Today: A Harlow through concerns expressed early in Monthly Column nearly all as the optimal form of care. In par- ticular, the separation of mothers and babies, the history of intensive neonatal care1 to recent by Dharmapuri Vidyasagar, MD, FAAP, 2 FCCM previously the norm after a healthy birth, is now RCT work , a large body of evidence from the Page 5 seen as unnatural and unnecessary. fields of medicine, psychology, sociology, and anthropology establishes that in altricial mam- Medical News, Products & The NICU stands in distinct contrast to these mals, from rodents through primates to hu- Information changes throughout the rest of the hospital. mans, smell, taste, touch, kinesthetic, and Page 9 This did not arise because there was evidence auditory stimuli (especially maternal) promote that ill needed to be isolated from their brain development, while deprivation of the NEONATOLOGY TODAY mothers for extended periods of time, or that same stimuli cause long-term deficits in the they benefited from being in an open ward full newborn. It has been relatively easy to ignore Editorial and Subscription Offices this evidence since much of it appeared in lit- 16 Cove Rd, Ste. 200 of unnatural sensory stimuli. Nor was there Westerly, RI 02891 USA evidence that caregivers, with the responsibility erature not often read by medical personnel, www.NeonatologyToday.net to recognize and respond to those sights and much of the human work was done in non- sounds that signaled impending danger for acute settings, and because the remarkable Neonatology Today (NT) is a monthly resilience of babies allowed us to believe they newsletter for BC/BE neonatologists and their patients, benefited from NICU design that perinatologists that provides timely news was intended to be highly efficient, but which usually survived our profoundly unnatural NICU and information regarding the care of offered little respite from the cacophony of environment in relatively good shape. newborns and the diagnosis and treat- ment of premature and/or sick infants. stimuli. Recently, though, several studies document the © 2010 by Neonatology Today ISSN: value of parental presence in general and spe- 1932-7129 (print); 1932-7137 (online). Even so, open units have certain advantages – Published monthly. All rights reserved. one can see “everything and everyone,” which cifically, in skin-to-skin (STS) care for NICU may have social and medical value. In this patients. Scher et al3 demonstrated that STS Statements or opinions expressed in paper, we will explore ways in which the per- accelerated EEG signs of brain maturation in Neonatology Today reflect the views of 4 the authors and sponsors, and are not ceived advantages of open, ward-like units can preterm infants, while Milgrom et al showed necessarily the views of Neonatology be blended with environments that are indi- that training parents about the neurosensory Today. vidualized for the needs of each person in the needs of their babies enhanced white matter development. Fifer et al5 have recently shown Upcoming Meetings

Contemporary Management of Neonatal Pulmonary Disorders Conference Nov. 4-5, 2010; Tempe, AZ USA Do you or your colleagues have interesting research results, www.nalweb.com/cmnpdconference observations, human interest stories, reports of meetings, Hot Topics in Neonatology Dec. 5-7, 2010; Washington, DC USA etc. that you would like to share with the neonatology www.hottopics.org community? Submit your proposed article to The 24th Annual Gravens Conference on the Physical and Developmental Environments of the High Risk Infant [email protected] Jan. 26-27, 2011; Clearwater Beach, FL USA www.cme.hsc.usf.edu/events.html NEO: The Conference for Neonatology The final manuscript may be between Feb. 24-27, 2011; Orlando, FL USA 400-4,000 words, and www.neoconference.com contain pictures, graphs, Recruitment Ads charts and tables. Pages 2 and 11

Table 1: Private Rooms in the NICU reduce Length of Stay and BPD <30 Weeks Gestation Open Unit Private Rooms

LOS, ICU 43.1 days 32.4 days p=0.02 LOS, total 66.7 days 56.6 days p=0.04 mod/severe BPD 6.0% 1.6% OR 0.18 (0.4-0.8) Adapted from Ortenstrand, et al, 125:e278-85, 20102. that newborn infants learn to respond to an environmental stimulus most of the anticipated disadvantages can be overcome with good even when asleep, emphasizing the continuous, intense nature of the design. learning process in newborns. These studies confirm a much larger body of work in animals that demonstrates how important the exter- Universally, caregivers face the prospect of moving to a private-room nal environment, and especially parental interaction, is to the new- NICU with trepidation. This is true even after talking with their col- born. leagues in other private-room NICUs and in private-room pediatric and adult ICU facilities in their own institution. The greatest fear al- Hypothesis 2: The optimal “macroenvironment” for an ill newborn is ways relates to patient safety – even though we rely on monitors to a private room. alert us to problems the vast majority of the time, there is real comfort in being able to see the patients we are responsible for, and what is Private rooms can reduce unwanted noise and light stimuli, increase happening at their bedside. parental interaction6, and lead to reduced length of stay and chronic lung disease2 (Table 1). Concerns that safety might be compromised Fortunately, electronic communication devices have progressed to when infants are no longer in the direct line of sight of caregivers the point where a nurse is never really out of contact with his/her have been allayed in what are now dozens of private-room NICUs, as patients, his/her colleagues, other support areas in the hospital, or well as hundreds of pediatric and adult private-room ICUs. Open the outside world – in fact, far more information is now available to rooms with multiple patients cannot fully “insulate” babies from activ- the caregiver wherever he/she is. Challenges still exist; for example, ity at adjacent bedsides, even with the best design. alarms from devices that do not interface with the monitor system (e.g., ventilators, IV pumps) still must be transmitted in an auditory Perhaps most important is the concept of individualized environments mode. Nevertheless, caregivers in units who have moved from open – the appropriate environment for a newly born 23-week infant is to private-room design are generally happy about the change7,8. quite different from what will be optimal for that same infant 4 months later, or from what a full-term surgical infant might need. For exam- Other concerns about private-room design include a fear of isolation ple, in the latter two cases, the visual cortex is ready for external from colleagues, anticipation that travel distances for caregivers will stimuli such as facial expressions, whereas the 23-weeker doesn’t be increased, and that staffing needs will increase. All of these are even have blood supply to most of the retina. It is not possible in an very real issues, but can be addressed with good design strategies. open room design to accommodate the individual developmental needs of all of the babies all of the time, whereas this is much easier One of the major benefits of private patient rooms is that it allows in a private room – a factor that is all the more important for babies individualized environments for caregivers, too. In the past, caregiv- who are not in STS contact with their mothers for extended periods of ers, families, and patients all shared the same space, and most de- time. sign and operational features were intended to make that environ- ment optimal for babies. As a result, caregivers sacrificed their own Hypothesis 3: The optimal setting for family involvement with an ill needs to those of their patients – lights were turned down, radios newborn is, in most instances, a private room. turned off, conversations muted. Extensive literature on healthy workplaces has shown that access to daylight, bright lights at night, It is clear that most families prefer the private room setting. This is music, even pleasant scents create healthier, more pleasing envi- observed in before-and-after surveys, in patient satisfaction scores, ronments for the workforce. When babies and their families have and in units that have some beds in private rooms and some in open their own rooms, specific areas can be designed adjacent to but wards6. There are many reasons for this – families appreciate the separate from patient rooms that have an environment optimal for the privacy to bond with their infants, to receive unpleasant news, to ask needs of caregivers. questions of medical personnel, to “let their hair down.” They wel- come the sense of ownership and family space that a private room Design strategies for individualized environments in the NICU provides. They benefit from not being exposed to crises at adjacent bedsides, and from the lowered noise and activity levels. Single-family rooms (SFR) are the centerpiece of individualized envi- ronments for the NICU. They permit the optimal sensory macroenvi- Yet not all situations are best handled in private rooms. Multiple births ronment for an ill newborn, and make STS care easier for parents. is an obvious example where the ability to care for two or more in- They provide individualized space for families, and also permit spe- fants in a single room is advantageous. Nor do all families value pri- cialized areas to be developed for caregivers that do not encroach on vacy over community. Nils Bergman points out that in Africa, placing the infant’s space. a baby and its family in a private room would be considered solitary confinement. Even in the US, some parents would prefer to be in an The SFR must be large enough to meet the functions intended. open room to increase their opportunities for interaction with other There must be sufficient space around the bed (at least 4 feet clear- parents and caregivers. ance on either side and at the foot of the bed) for medical care to be provided, and enough room for a family member to provide STS care Hypothesis 4: The benefits of providing NICU care in a private room without interfering with equipment or storage areas at the bedside. In setting outweigh any perceived disadvantages for caregivers, and fact, the headwall should be designed so that it works well whether

NEONATOLOGY TODAY  www.NeonatologyToday.net  October 2010 3 the baby spends a majority of its time in STS tient care area for meals, access to nature, brain maturation after an 8-week trial of care or in an incubator, warmer, or crib. A and other medical and non-medical activities skin-to-skin contact on preterm infants. blueprint or mockup that shows only an in- that support an effective and satisfied team. Clin Neurophysiol 120:1812-8, 2009. fant bed in front of the headwall will almost 4. Milgrom J, Newnham C, Anderson P et certainly not be optimal for STS care, and Many more factors go into optimal NICU al: Early sensitivity training for parents will become a barrier to optimal care of the design, of course, but are outside of the of preterm infants: impact on the devel- infant from day one. scope of this article. Excellent resources are oping brain. Pediatr Res 67:330-5, readily available9-11. 2010. SFR units are larger than comparable open- 5. Fifer WP, Byrd DL, Kaku M et al: New- room units, so efficient care requires that Closing thoughts born infants learn during sleep. Proc Nat most supplies that will be utilized on a regu- Acad Science USA 107:10320-3, 2010. lar basis are stored at the bedside, either in Perhaps the best way to illustrate the value 6. Carter BS, Carter A, Bennett S: Fami- fixed or mobile (cart) devices. A sink and of individualized environments is to recall our lies’ views upon experiencing change in appropriate waste disposal containers must history with the use of breast milk and for- the neonatal intensive care unit envi- be present within each room; these are ide- mula. For a time early in our specialty, there ronment from the ‘baby barn’ to the pri- ally located near the entrance to the room. were suggestions that mother’s milk was vate room. J Perinatol 28:827-9, 2008. Whether already part of the hospital’s system inappropriate for the feeding of preterm in- 7. Stevens DC, Helseth CC, Khan MA et or not, electronic medical records should be fants and that infant formulae were better al: Neonatal intensive care nursery staff anticipated and a space allocated for a fixed options, partly because of their more desir- perceive enhanced workplace quality or portable computer workstation. able levels of protein and mineral intake, and with the single-family room design. J partly because they were so much easier to Perinatol 30:352-8, 2010. The family space in the SFR should also be store and deliver. Gradually, though, this 8. Smith TJ, Schoenbeck K, Clayton S: sufficient to permit parents to stay for ex- trend was reversed as it became apparent Staff perceptions of work quality of a tended periods in comfort. When these ar- that mother’s milk was the best source of neonatal intensive care unit before and eas (patient care, caregiver support, and basic enteral nutrition for infants of any ges- after transition from an open bay to a family) are adequately designed, the SFR tational age. Formulae have been improved private room design. Work 33:211-27, will be at least 175 square feet, and could to come closer to mother’s milk, although 2009. approach 300 square feet in an ideal setting. even now after much research it is clear that 9. White RD (ed.): The Sensory Environ- we cannot deliver the rich diversity of nutri- ment of the NICU: Scientific and Design- In addition to the family space within the ents, hormones, trace minerals, and other related Aspects. Clinics in Perinatology SFR, areas within the NICU should be allo- (some as yet undiscovered) bioactive sub- 31(2), Philadelphia, PA, WB Saunders, cated for parents to gather. Small, informal stances through any medium other than 2004. alcoves near patient rooms will be used mother’s milk. The same is true for environ- 10. White, RD, et al: Recommended Stan- more frequently and effectively than a large mental stimuli. We can improve the NICU at dards for the Newborn ICU. J Perinatol waiting room outside the main entrance of large and incubators in particular to provide 27:S4-19, 2007. the NICU, especially if they provide daylight, more suitable stimuli to infants, but they will 11. Institute for Patient and family-Centered coffee, and similar amenities for families never be better than a meager alternative to Care: http://www.ipfcc.org. under stress. Larger spaces outside of the direct and extended contact with the mother, patient care area can be dedicated to family either in quality or quantity of all the sensory NT support functions such as laundry, meals, stimuli. Designing individualized environ- education, and access to nature. This “stag- ments for the NICU means, first of all, creat- ing” of family support from the SFR to areas ing a culture where STS care is fostered, within the NICU and then areas outside of and then providing a space where the needs the NICU allows families to choose the level of each member of the NICU community can of privacy or community they need at a given be met without encroaching on the needs of time. others.

Individualized environments for caregivers References start in the patient room with an ergonomically-designed space away from 1. Brimblecombe FSW, Richards MPM, but still near the immediate bedside for Roberton NRC: Separation and Special nurses to perform charting, consult with col- Care Baby Units. London, William leagues, or relax for a moment. Utilizing the Heinemann Medical Books Ltd., 1978. Robert White, MD same “staging” concept mentioned for fami- 2. Ortenstrand A, Westrup B, Brostrom EB Pediatrix Medical Group of Indiana lies, additional areas for caregivers to gather et al: The Stockholm neonatal family Memorial Hospital should be provided in the center of a cluster centered care study: effects on length 615 N. Michigan St. of patient rooms, allowing caregivers to col- of stay and infant morbidity. Pediatrics South Bend, IN 46601 laborate and socialize while still maintaining 125:e278-85, 2010. Tel: 574-647-7351 visual and electronic contact with their pa- 3. Scher MS, Ludington-Hoe S, Kaffashi, F tients’ rooms, and space outside of the pa- et al: Neurophysiologic assessment of email: [email protected]

The 24th Annual Gravens Conference on the Physical and Developmental Environment of the High Risk Infant, In collaboration with the March of Dimes

January 26-29, 2011 Sheraton Sand Key  Clearwater Beach, FL www.cme.hsc.usf.edu [email protected]

4 NEONATOLOGY TODAY  www.NeonatologyToday.net  October 2010 Global Neonatology Today: A Monthly Column

By Dharmapuri Vidyasagar, MD, FAAP, FCCM rica,. These levels are well below the 2010 target of 95% set at the United Nations General Assembly Special Session on HIV/AIDS in MILLENNIUM DEVELOPMENT GOAL (MDG #6) 2001.

The goal of MDG #6 is to combat HIV/AIDS, Malaria and other diseases, particularly Tuberculosis.

THE TARGETS “In summary, the Goal of MDG #6 in relation to prevention of HIV/AIDS is • To halt HIV/AIDS and begin to reverse the spread of HIV/AIDS by 2015. being met steadily. However, wide • To achieve universal access to treatment of HIV/AIDS for all those regional, gender differences exist. who need it by 2010. • To halt and begin to reverse the incidence of malaria and other major Populations in sub-Saharan Africa, and diseases by 2015. women and children in general, continue In this review we will address the status of the Goal of combating HIV/ to bear the brunt of the disease in many AIDS only. Next month, we will continue the review of MDG #6 focusing on Malaria and other diseases. ways.”

THE INDICATORS

The indicators used to measure the success of prevention of HIV/AIDS In spite of various new treatment modalities, for every two individuals are: treated, five are newly infected. Thus, there is a greater need for preven- 1. HIV prevalence among women - 15-24 years. tion and treatment. Increasing numbers of people are being treated 2. Condom use rate of the contraceptive prevalence rate. every year. Forty-two percent in 2008 compared to 33% in 2007 of 3. Knowledge of HIV/AIDS among 15-24 year old. those needing treatment, got treatment.

THE PROGRESS MADE Children also are taking a major brunt of HIV/AIDS. In addition to mother to infant transmission of disease, children orphaned by AIDS suffer more Target than the loss of parents. Estimated 17.5 million (<18 yr.) lost one or both parents to AIDS in 2008. As noted above the target is to halt and begin to reverse the spread of HIV/AID by 2015. The latest information shows that globally the spread In summary, the goal of MDG #6 in relation to prevention of HIV/AIDS is of HIV peaked in 1996 when an estimated 3.5 million people were newly being met steadily. However, wide regional and gender differences exist. infected. By 2008 the infection dropped to estimated 2.7 million. AIDS Populations in sub-Saharan Africa, and women and children in general, related mortality dropped from 2.2 million in 2004 to 2 million in 2008. continue to bear the brunt of the disease in many ways. There is a lot However, AIDS is still the major cause of death in the world today. more work to be done to meet the targets of HIV/AIDS-related targets of MDG #6. Thus, the spread of HIV appears to have stabilized, and deaths from AIDS has decreased. People with AIDS are living longer due to life sus- For more information: taining treatments although there are wide regional differences: http://who.int/topics/millennium_development_goals/diseases/en/index. html • In 2008, an estimated 33 million were living with HIV: 22 million of which were in sub-Saharan Africa. The Clock is Ticking! • In 2008, Sub-Saharan Africa accounted for 72% of all new HIV infec- tions. NT • Prevalence of AIDS continues to rise in Eastern Europe, Central Asia and as well as other parts of Asia. • Prevention is the first step to curb HIV infection. Dharmapuri Vidyasagar, MD, FAAP, FCCM University of Illinois at Chicago Though some progress has been made, comprehensive and well- Professor Emeritus Pediatrics informed knowledge of HIV among young people is still unacceptably Division of Neonatology low in most countries. Less than one third of young men, and less than Phone: +1.312.996.4185; Fax: +1.312.413.7901 one fifth of young women in developing countries claim such knowledge about HIV. According to surveys undertaken between 2003 and 2008, [email protected] the lowest levels (8%) are found among young women in Northern Af-

The 6th International Conference on Brain Monitoring and Neuroprotection in the Newborn

February 10-12, 2011 The Krasnapolsky  Amsterdam, The Netherlands www.cme.hsc.usf.edu [email protected]

NEONATOLOGY TODAY  www.NeonatologyToday.net  October 2010 5 Subgaleal Hemorrhage Following Vacuum Extraction Vaginal Delivery: A Frequently Undiagnosed Problem

By Houchang D. Modanlou, MD transfusion was carried out without explanation are manually or electronically operated3. Both for a clinically significant drop in HCT. types of suction devices are equipped with gauges that monitor the amount of pressure Background This case clearly illustrates a lack of knowl- being generated. Release valves allow rapid edge and/or experience of some of our pedia- disengagement of the pressure as needed. At term gestation, in a nullipara woman, during tricians and neonatologists in the community the second stage of labor, for a duration of hospitals as well as the pediatric residents and These soft vacuum extractors have become approximately one hour, vacuum extractor was fellows in-training and neonatologists in the the predominant instrument used for operative used 9 times with several pup-offs. The obste- academic medical centers regarding the poten- vaginal delivery in the United States4. When trician failed and resorted to forceps application tial neonatal complications associated with compared with metal cup, soft cups are signifi- for the delivery of a 3465 g male infant. Rea- inappropriate application of vacuum extractor cantly more likely to fail to achieve vaginal de- sons for the application of vacuum extractor to effect delivery. For the past three decades livery however; they were associated with less were noted to be non-reassuring fetal heart the use of vacuum extractor has significantly neonatal scalp injury5. A list of modern vacuum rate tracings and maternal exhaustion. At de- increased in the United States. Indeed, its ap- devices can be found in a recent publication by livery, the infant was noted to be pale, flaccid plication has surpassed the use of obstetrical Ali and Norwitz 6. without any heart beat or respiratory efforts. forceps. Appropriate resuscitation was initiated follow- ing NRP guidelines. Apgar scores of 0, 0, 3, Subgaleal hemorrhage post vacuum extraction and 7 were assigned for 1, 5, 10 and 15 min- delivery may be of a rare occurrence, however, utes of life, respectively. Prior to the transport it may not be well apparent soon after birth but of the infant to a tertiary unit at a Children’s it may progress to become massive hemor- hospital for whole body cooling, a physical rhage and at times fatal. Pediatric medical staff examination in the NICU, revealed significant may not be familiar with potential complication head molding and the description of a large associated with vacuum extraction delivery. and fluctuating head mass written as caput Here, a description of vacuum, its application, succedaneum. At the Children’s Hospital, both and its potential neonatal complication is pro- the receiving pediatric resident and the neona- vided with the hope that more attention is paid tal fellow described failed vacuum applications to its complications Recognition of a clinically of six times, a “boggy” head again written as a significant SGH and the institution of an early large . A working diagnosis treatment may lessen neonatal morbidity and of hypoxic-ischemic encephalopathy (HIE) was mortality. entertained and whole body cooling was initi- ated, based on a nationally accepted protocol. Modern Vacuum Extractors After 72 hours, whole body cooling was dis- continued and detailed neurological evaluation Over the past three decades, vacuum extractor was carried out with EEG recordings and brain has progressively replaced forceps as the de- MRI. EEG was reported to be very abnormal livery instrument of choice for many obstetri- and MRI showed changes related to HIE but cians. without intracranial hemorrhage and the pres- ence of extracranial fluid collection. Despite The vacuum extractor consists of three main maximum efforts, the team of pediatric neu- parts: a cup that is designed to fit snugly rologist and neonatologist noted that infant’s against the top of the baby's head, a suction neurological condition was grave and not re- device that is capable of generating negative versible. After parental counseling, it was de- pressure, and plastic tubing that connects the cided to provide only palliative care. The infant cup to the suction device. eventually expired at 36 day of life. An autopsy was performed. Findings were consistent with Current vacuum instruments used in obstetrical the primary clinical diagnosis of HIE. Addition- practice are based on the original design by Figure 1. Some examples of modern vacuum ally, a large sero-sanguinous fluid collection Malmstrom in 1950‘s1,2. Malmstrom’s metal extractors: A. The Kiwi Omnicup; B. Soft was noted bellow the scalp aponeurosis with cup is a hollow hemisphere with incurved mar- vacuum hand-pump suction by an assistant; patchy calcification above the periosteum. gins, designed to be filled with artificial caput and C. Single handheld vacuum with succedaneum. A traction chain is passed operator hand-pump suction. Although during the entire hospitalization both through suction tubing, which is attached to a nursing and the medical staff repeatedly noted short metal pipe at the dome of the cup, and a Indication for Vacuum Application the “boggy” scalp, as well as the MRI report hand-pump is connected through a suction noted extra cranial fluid collection, it was re- bottle. The suction induces an artificial caput In the United States, 5 to 10% of all vaginal ferred to as resolving caput succedaneum. No succedaneum or within the cup to diagnosis of subgaleal hemorrhage (SGH) was deliveries are operative and are accomplished which a traction force is applied in concert with 6, 7 recorded descriptively or as a diagnosis. It with the use of vacuum and/or forceps . The uterine contractions. In the early 1970's, a soft rate of operative deliveries in some centers in should be noted that the infant’s hematocrit vacuum cup was introduced with several modi- (HCT) prior to transport was recorded to be Europe is ranging from 5.3 to 34.1% of all fications. Currently, available soft vacuums are 8 55.7%. By 24 hours of life, the HCT was re- births . Use of the vacuum for operative vagi- made of soft rubber, rigid plastic, soft silicone, nal deliveries has become more favorable. corded to be 31%. At that point packed RBC and rigid or soft polyethylene (Figure 1). These

6 NEONATOLOGY TODAY  www.NeonatologyToday.net  October 2010 During the past decade the number of vacuum Subgaleal Hemorrhage head will appear elongated (Figure 2) with con- deliveries overtook the number of forceps de- siderable molding of the skull bones. The lesion liveries performed9, 10. When compared with Scalp tissue may detach from the skull bone is fluctuating and gives the sensation of an old forceps-assisted deliveries, the vacuum has due to the effects of the applied suction or by leather pouch filled with fluid. The fluid will be been associated with a higher incidence of the tangential shearing of the scalp from the gravity dependent and accumulates on the de- neonatal complication and NICU admissions11. skull. The former is more common with exces- pendent aspects of the head. In severe cases of Operative vaginal delivery remains a valid op- sive negative cup pressure and/or traction or massive SGH, there can be elevation and dis- tion when problems arise in the second stage when the vacuum extractor cup is applied placement of the ear lobes and puffiness of the of labor. The most common indications are above the anterior fontanel. The latter may eyelids without superficial ecchymosis of the fetal compromise and failure to deliver sponta- occur with tangential pulling of the hair or overlying skin. Massive SGH is frequently asso- neously with maximum maternal efforts12. The combing of the hair in a hemophilic patient23, 24. ciated with hypovolemic shock, DIC, persistent Royal College of Australian and New Zealand Subgaleal hemorrhage occurs when emissary metabolic acidosis and death. Associated find- of Obstetricians and Gynaecologists gives two veins bridging the subgaleal space are dam- ings are low Apgar scores, pallor, tachycardia, indications for operative vaginal deliveries: aged and blood accumulates in the potential increased respiratory rate, hypotension and one, fetal compromise suspected or antici- space between the galea aponeurotica (epi- neonatal anemia21. pated; two, delay in the second stage of la- cranial aponeurosis) and the periosteum of the bor13. Similarly, the American College of Obste- skull bones (pericranium). Since the sub- Diagnosis and Management tricians and Gynecologists (ACOG) has pub- aponeurotic space has no containing mem- lished guidelines for the indications of vacuum branes or boundaries, the SGH may extend The occurrence of SGH after vacuum extrac- use for maternal and fetal reasons14,15. Fur- from the orbital ridges to the nape of the neck. tion ranges from 26 to 45 per 1000 vaginal thermore, ACOG made recommendations This condition is dangerous because of the deliveries15. The lesion may not be apparent regarding the fetal contraindication for vacuum large potential space for blood accumulation at birth21. In a prospective observational co- use as well as the application of cup pressure, with a volume of several hundred milliliters25. hort study Smit-Wu et al.28 found that vacuum traction, pressure release and discontinuation This blood loss can produce profound hypovo- extraction SGH occurred in term neonates of its application based on cup dislodgements, lemic shock, disseminated intravascular co- within 10 hours following birth. I believe that lack of progress and duration of its use. The agulation (DIC), unresponsive metabolic aci- SGH occurs more frequently than is reported in goal of operative vaginal delivery is to mimic dosis and death. The hemorrhage in the sub- the obstetrics and pediatric literature. This is spontaneous vaginal birth, thereby expediting galeal space is not instantaneous but is gradual most likely due to failure of diagnosis, partly delivery with a minimum of maternal or neona- and it may not be apparent or diagnosed at the because of its association with intracranial tal morbidity16. time of delivery or at the initial neonatal exami- hemorrhage. Lack of experience of the pediat- nation during the first few hours of life. It may ric residents, neonatal fellows, pediatricians Neonatal Complications not become clinically apparent until several and the neonatologists is due to their limited hours or up to a few days following delivery. time in neonatal care and delivery room atten- The most consistent finding post-vacuum ex- dance during their training may be another traction delivery is the presence of caput suc- Based on our experience, SGH may be initially reason for failure to diagnose SGH. cedaneum created by the suction pressure of confused with large caput succedaneum or the vacuum called chignon or exaggerated . Although a caput suc- In a recent article about pediatricians and the larger lesion with ecchymosis of the scalp tis- cedaneum, which is made of and tran- law in the AAP News, Goldsmith stated that sue. In either case, the lesion is due to exuda- sudation into the dermis, is commonly present general pediatricians face increased scrutiny in tion of fluid and, at times, extravasations of with a SGH, not surprisingly, the descriptions of the newborn nursery. He enumerated the ar- blood into scalp tissue. The edema is soft, su- caput succedaneum and its graphical presen- eas of concern to which pediatricians should perficial, and pitting in nature, and crosses sites tations in the leading textbooks of neonatol- pay attention. He listed communication issues of suture lines17, 18. Generally, the scalp edema ogy26, 27 and in the recent review article in the with parents, attendance at deliveries/ resolves by 24 hours however, the resolution of obstetrical literature6 are not very accurate. resuscitation, , genetic screening, the ecchymosis will take a few days. One textbook of neonatology26 describes “se- GBS testing, and missed diagnosis. What rum or blood or both accumulate above the Goldsmith did not mention in his commentary Other neonatal complications post vacuum- periosteum in the presenting part during labor” is the lack of knowledge about obstetrical his- assisted delivery are: scalp lacerations, sub- while another textbook27 and the review article6 tory, particularly problems related to labor and galeal hemorrhage (SGH), cephalohematoma, show hemorrhage associated with caput suc- delivery and the instrumentations to effect de- skull fracture, intracranial hemorrhage, subcon- cedaneum below aponeurosis. Above perios- livery, that pediatricians, pediatric residents, junctival and retinal , shoulder dysto- teum and below aponeurosis is the subgaleal neonatal fellows and the the neonatologists or cia, and neonatal hyperbilirubinemia as the space. Any hemorrhage in this space is SGH whoever presents himself/herself in the deliv- result of extravasated blood. On rare occasion and not caput succedaneum. ery room or to the newborn nursery have. In fetal and neonatal deaths have been report- the rush of attending to the delivery of a dis- ed19, 20, and 21. During the period of 1994 and The edema of caput succedaneum should re- tress newborn, important information may not 1998, FDA identified 12 deaths and 9 serious gress by the first 24 hours of life although the be verbally communicated between the obstet- complications following vacuum-assisted vagi- scalp ecchymosis will persist for a few days. rical healthcare providers and the neonatal nal deliveries19. The FDA cautioned and pro- Cephalohematoma, on the other hand, is a team. With the electronic medical records, the vided recommendations to healthcare provid- subperiostal hemorrhage, which may not be pediatric healthcare providers may not have ers about the use of vacuum extractors. It apparent at the time of delivery. Initially it is access to important obstetrical history. Knowl- stressed also the importance of notifying pe- tense in consistency and is limited to the indi- edge of an accurate obstetrical history, particu- diatricians that a vacuum device was used to vidual skull bone with which it is associated and larly of the labor and delivery process, is para- effect delivery and the neonate to be monitored does not cross the midline. Within 24 hours the mount for the pediatric healthcare providers to more closely for the first hours and days of life. lesion becomes soft and in a few days one can make correct diagnosis and anticipate possible During a 6 months period post-FDA advisory, palpate the calcified margin of the lesion. A per- problems in the newborn. Ross et al22 reported 10 neonatal deaths sistent fluctuating and boggy scalp lesion, cross- and several serious neonatal injuries after ing the suture lines, persisting after 24 hours of Subgaleal hemorrhage, as the result of an vacuum-assisted deliveries. life should suggest the diagnosis of SGH. The inappropriate use of vacuum extraction deliv-

NEONATOLOGY TODAY  www.NeonatologyToday.net  October 2010 7 2. Malmstrom T. The vacuum extractor: an 18. Volpe JJ, Neurology of the Newborn. Third obstetrical instrument. Acta Obstet Gyne- Edition, 1995, Page 769, W.B. Saunders col Scand. 1957; 36:5-49. Company, Philadelphia. 3. Miksovsky P, Watson WJ. Obstetric vac- 19. Center for Devices and Radiological uum extraction: state of the art in the new Health. FDA Public Health Advisory: Need millennium. Obstet Gynecol Surv 2001; for CAUTION when using vacuum as- 56:736-51. sisted delivery devices. May 21, 1988. 4. Curtin SC, Park MM. Trends in the atten- 20. F Gary Cunningham et al., Editors. Wil- dant, place and timing of births, and the liams Obstetrics. Chapter 21: Forceps use of obstetric interventions; United delivery and vacuum extraction. 21st Edi- States, 1989-97. Natl Vital Stat Rep 1999; tion, Mc Graw Hill, New York, 2001. 47:1-12. 21. Modanlou HD. Neonatal Subgaleal hemor- 5. Johanson R, Menon V. Soft versus rigid rhage Following Vacuum Extraction Deliv- vacuum extractor cups for assisted vagi- ery. The Internet Journal of Pediatrics and nal delivery. Cochrane Database of Sys- Neonatology. 2005; Volume 5, Number 2. Figure 5. This is a picture of a 3-day-old tematic Reviews 2000, Issue 2. Art. No.: 22. Ross MG, Fresquez M, El-Haddad MA. term newborn infant following vacuum ex- CD000446. DOI: Impact of FDA advisory on reported traction delivery at a community hospital. 10.1002/14651858.CD000446. vacuum-assisted delivery and morbidity. J Vacuum was applied 6 times with several 6. Ali UA, Norwitz ER. Vacuum-Assisted Matern Fetal Med. 2000; 9: 321-326. pop-offs. Note generalized jaundice and Vaginal Delivery. Rev Obstet Gynecol. 23. Hamlin H. Subgaleal caused by elongated head with the evidence of gravity 2009; 2(1): 5-17. hair-pull. JAMA. 1968 Jul 29; 205(5):314. dependent extra cranial fluid. At the time of 7. Bofill JA, Rust OA, Perry KG Jr, Roberts 24. Falvo CE, San Filippo JA, Vartany A, admission to our NICU, 6 hours of life, in- WE, Martin RW, Morrison JC.Forceps and Osborn EH. Subgaleal hematoma from fant’s Hematocrit was 31%. Transfusion of vacuum delivery: a survey of North Ameri- hair combing. Pediatrics. 1981 Oct; 68(4): packed RBCs, 15 ml/Kg, was carried out can residency programs. Obstet Gynecol. 583-4. soon after admission. There was neither 1996 Oct; 88(4 Pt 1): 622-5. 25. Miksovsky P, Watson WJ. Obstetric vac- blood group incompatibility nor intracranial 8. Mangin M, Ramanah R, Aouar Z, Courtois uum extraction: state of the art in the new hemorrhage. At 4 years of age, the child is L, Collin A, Cossa S, Martin A, Maillet R, millennium. Obstet Gynecol Surv healthy. (Written signed permission from the Riethmuller D. Operative delivery data in 2001;56:736-51. child parents was obtained). France for 2007: results of a national sur- 26. Mangurten HH. Birth Injuries, in Martin RJ, vey within teaching hospitals. J Gynecol Fanaroff AA, and Walsh MC. Editors. ery, is associated with significant neonatal Obstet Biol Reprod (Paris). 2010 Apr; Fanaroff and Martin’s Neonatal-Perinatal morbidity and mortality. Early recognition of 39(2): 121-32. Medicine, Diseases of the Fetus and Infant. SGH and the institution of supportive care such 9. McQuivey RW. Vacuum-assisted delivery: 8th Edition, 2006, Volume One, Chapter as blood transfusion, volume support, and a review. J Matern Fetal Neonatal Med. 27, page 531. Mosby Elsevier, coagulation factors, in the presence of DIC, are 2004 Sep; 16(3): 171-80. Philadelphia. useful and indicated. Palliative treatment such 10. Putta LV and Spencer JP. Assisted Vagi- 27. Menkes JH. Perinatal Central Nervous as head wrapping has limited value. Early rec- nal Delivery Using the Vacuum Extractor. System Asphyxia and Trauma. In Taeusch, ognition and treatment of SGH is critical. Serial AM Fam Physician 2000; 62:1316-20. Ballard, and Avery, Editors Schaffer & observations for neonatal scalp changes, as 11. Kicklighter SD, Wolfe D, Perciaccante JV. Avery’s Diseases of the Newborn, Sixth described above, signs of pallor, anemia, Subgaleal hemorrhage with dural tear and Edition, 1991, page 407. W.B. Sauders metabolic acidosis and are rec- parietal-lobe herniation in association with Company, Phladelphia. ommended after vacuum-assisted deliveries. a vacuum extraction. J Perinatol. 2007 28. Smit-Wu MN, Moonen-Delarue DM, Dec;27(12):797-9. Benders MJ, Brussel W, Zondervan H, Summary 12. Yeomans ER. Operative vaginal delivery. Brus F. Onset of vacuum-related com- Obstet Gynecol. 2010 Mar; 115(3):645-53 plaints in neonates. Eur J Pediatr. 2006 The clinical feature of SGH is described in 13. The Royal College of Australian and New Jun; 165(6):374-9. order to help the reader to be vigilant about the Zealand of Obstetricicias and Gynaecolo- 29. Goldsmith JP. Pediatricians and the Law… rare occurrence of this serious complication gists, College Statement, C-Obs 16, No- General peds face increased scrutiny in with the application of vacuum extractor. The vember 2009. newborn nursery. AAP News, Volume 31, obstetrician should inform the neonatal health- 14. American College of Obstetricians and Number 6, June 2010. care providers that a vacuum extractor was Gynecologists. Delivery by vacuum ex- used to effect delivery. Neonatal staff should be traction. Washington, DC: ACOG Commit- NT educated about the correct anatomy and the tee on Obstetric Practice. Committee specific neonatal complications associated with Opinion. Number 208, September 1998. vacuum devices. Neonatal healthcare person- 15. American College of Obstetricians and nel should evaluate the infant frequently in Gynecologists. Operative vaginal delivery. order to timely diagnose and institute appropri- Washington, DC: ACOG; 2000. Practice ate therapy in order to avoid serious morbidity Bulletin No 17. and/or neonatal death. 16. Royal College of Obstetricians and Gy- naecologists (RCOG). Operative vaginal References delivery. London (UK): Royal College of Obstetricians and Gynaecologists Houchang D. Modanlou, MD 1. Malmstrom T. Vacuum Extractor-An Ob- (RCOG); 2005 Oct. 13 p. (Guideline; no. University of California, Irvine stetrical Instrument. Gothenberg, Sweden: 26). Northern Association of Obstetrics and 17. Potter EL, Craig JM. Pathology of the Address: Gynaecologists 1954, pp 1-32. Fetus & the Infant. Third Edition, 1975, 11 Shoreview page 104. Year Book Medical Publishers, Newport Coast, CA 92657 USA Inc., Chicago. [email protected]

8 NEONATOLOGY TODAY  www.NeonatologyToday.net  October 2010 Medical News, Products and Information

Use of 3D MRI is Helpful Tool for Displaying With a 3D MRI, a practitioner can obtain fetus,” says Laurie Panesar, MD, Assistant Fetal Anatomy volumetric, high resolution images that can Professor of Pediatrics in the Division of be manipulated to view in any plane de- Pediatric Cardiology. “By detecting these Three-dimensional MRI is an emerging and sired, obviating the need for redundant 2D types of problems prenatally, we can better images and potentially decreasing the over- prepare for the baby’s birth and also better useful technique for displaying fetal anat- all exam time. “With the right image quality, prepare the parents about what to expect omy and diagnosing problems in the womb that means less time in the magnet for the when their baby is born.” in a wide spectrum of clinical applications, mom, improving workflow, and improving according to Jeffrey C. Hellinger, MD, a patient satisfaction,” he explained. Thomas Biancaniello, MD, Chief of Pediatric pediatric imaging specialist at SBUMC Cardiology, adds that 3D MRI is beneficial (Stony Brook University Medical Center). Ultrasound and the newer 3D ultrasound for imaging the fetus because “the diagnos- remains the “principle obstetrical imaging tician may have little control of the views “Through enhanced visualization, 3D MRI modality. It is readily performed in outpa- obtained by fetal echocardiography be- improves one’s understanding and ability to tient and inpatient settings at minimal in- cause of the fetal position.” display fetal anatomy. With a better under- convenience to the mother, yielding reliable standing and display of anatomy, it en- information for immediate clinical counsel- “Three-D MRI has been shown to be useful hances exam interpretation and communi- ing and management,” Dr. Hellinger writes in infants, older children, and teenagers cation,” said Dr. Hellinger, who details the in the Applied Radiology article. However, with congenital heart disease, as it allows uses and advantages of the technique in Dr. Hellinger writes that MRI “offers superior visualization of structures that are out of the “Fetal MRI in the Third Dimension,” a review spatial resolution and structural detail, af- range of more conventional imaging,” he published in the July-August issue of Ap- fording comprehensive anatomical displays explains. plied Radiology, the journal for radiologists, from single acquisitions.” and available online. According to Catherine Kier, MD, Chief of “MRI is often requested to provide more Pediatric Pulmonology, Allergy and Immu- “I joined Stony Brook to help advance pedi- definitive anatomical understanding and nology, and Director, Cystic Fibrosis Center, atric imaging, beginning with select imaging diagnosis for abnormalities identified on the 3D MRI plays into the importance of early protocols, and this is one of them,” said Dr. screening ultrasound, as well as to assess diagnosis, which is critical regarding long- Hellinger, who came to SBUMC around the for concomitant abnormalities. The literature term pediatric patient outcomes. June 2010 launch of Stony Brook Long Is- has also advocated its use for anatomical land Children’s Hospital, the only dedicated screening in the setting of congenital heart “Congenital pulmonary abnormalities like children’s hospital east of the Nassau/ disease and predisposed families.” diaphragmatic hernia and cystic lung le- Queens border. sions can be diagnosed with state-of-the-art The 3D MRI has numerous uses at SBUMC fetal imaging like 3D MRI. This in combina- Stuart E. Mirvis, MD, Editor-in-Chief of Ap- for pediatric imaging. Physicians practicing tion with subspecialty collaboration and plied Radiology, comments on the piece, in various subspecialties, such as Maternal- comprehensive services will lead to excel- writing “Our cover story this month is quite Fetal Medicine, Pediatric Cardiology, and lent patient outcomes.” likely the first article of its kind. It is an ex- Pediatric Pulmonology, Allergy and Immu- cellent review of 3D Fetal MRI tech- nology, are beginning to use the imaging Dr. Hellinger’s article contains striking fetal niques…The article does more than illus- modality. images taken with 3D MRI. He and co- trate several flashy pictures that can be author Monica Epelman, MD, of the De- generated on 3D workstations and instead “Ultrasound serves as the standard test to partment of Radiology at The Children’s shows clinical radiologists, who may not be evaluate non-cardiac fetal anatomy, and Hospital of Pennsylvania, conclude the arti- as familiar with this technology, that not only MRI imaging for fetal, placental, and uterine cle on 3D fetal MRI stating, “Successful can it be done, but there are very beneficial abnormalities can be useful in confirming or utilization requires optimized image quality emerging applications.” clarifying possible abnormalities that ultra- and understanding of advanced visualiza- sound detects. But because of our inability tion techniques. Continued evidence-based Three-D sequences, which are available to control fetal movement in utero, the investigation is required to determine the with fetal MRI at SBUMC, has distinct ad- shorter time taken to get 3D MRI images of impact of 3-dimensional fetal MRI on fetal vantages for the pregnant mother, Dr. fetuses gives us a better chance of getting diagnosis and management.” Hellinger points out. Because the fetus is useful fetal images than standard 2D MRI,” moving frequently during a typical 20-24 says Paul, Ogburn, MD, Director, Maternal- week exam, 2D MRI necessitates obtaining Fetal Medicine. Prenatal Pesticide Exposures Linked to multiple images in multiple planes. “That Attention Disorders in Preschool Children translates to a fairly long exam, an average “Three-D imaging can act as an adjunct to of 30 minutes to 45 minutes. For any patient add to our understanding of congenital Exposure to organophosphate (OP) pesti- an MRI can be discomforting, let alone heart defects and also of any other congeni- cides before birth can increase susceptibility someone who is pregnant.” tal abnormalities that may be present in the to attention disorders such as attention deficit/

November 4-5, 2010; Tempe Mission Palms, Tempe, Arizona Contact: Cathy Martinez (602)277-4161 x 11  Fax: (602) 265-2011  E-mail: [email protected] www.nalweb.com/cmnpdconference

NEONATOLOGY TODAY  www.NeonatologyToday.net  October 2010 9 hyperactivity disorder (ADHD), according to By measuring prenatal exposures and focus- Health and Human Services. EHP is an new research published in the journal Envi- ing on participants likely to have higher expo- open-access journal, and all EHP content is ronmental Health Perspectives (EHP). The sures to OP pesticides than the general available free online at www.ehponline.org. new study is part of a growing body of re- population, this study complements research search indicating that exposure to OP pesti- published in the June 2010 issue of the jour- Source: Environmental Health Perspectives cides can adversely affect brain develop- nal Pediatrics. In that study, Maryse (NIEHS) ment. Bouchard and colleagues measured the same six OP metabolites in 1,139 children OP pesticides target the nervous systems of aged 8 to 15 years selected from the general insects by affecting the activity of neuro- US population. They found associations be- transmitters including acetylcholine, which in tween OP exposure and ADHD even though humans plays a critical role in brain devel- those children had lower average exposures NEONATOLOGY TODAY opment and is involved in attention and than did the children in the CHAMACOS © 2010 by Neonatology Today short-term memory. Exposure to OP com- study. ISSN: 1932-7129 (print); 1932-7137 (online). pounds may also disrupt DNA replication and Published monthly. All rights reserved. the growth of nerve axons and dendrites. The authors of the EHP study suggest that Infants and young children are much more research should continue to investigate Publishing Management vulnerable to OP exposures than adults are whether genetic differences in OP metabo- Tony Carlson, Founder & Senior Editor because their ability to produce the enzyme lism affect susceptibility to developmental [email protected] that detoxifies OP pesticides is still develop- disorders, including ADHD. They state that Richard Koulbanis, Publisher & Editor-in-Chief ing. “given that attention problems of children [email protected] interfere with learning and social develop- John W. Moore, MD, MPH, Medical Editor/ Editorial Board Mothers participating in the study were re- ment, finding potential causes that can be [email protected] cruited during by the Center for remediated are of great public health impor- the Health Assessment of Mothers and Chil- tance.” A companion article, also released Editorial Board: Dilip R. Bhatt, MD; Barry D. dren of Salinas (CHAMACOS). The Mexican- today in EHP, explores potential genetic Chandler, MD; Anthony C. Chang, MD; K. K. American women lived in the Salinas Valley, mechanisms behind effects associated with Diwakar, MD; Philippe S. Friedlich, MD; Lucky an area of intensive agriculture where more OP exposure. Jain, MD; Patrick McNamara, MD; David A. than 235,000 kg of pesticides are applied Munson, MD; Michael A. Posencheg, MD; annually. The researchers analyzed six OP The authors of “Organophosphate Pesticide DeWayne Pursley, MD, MPH; Joseph Schulman, metabolites in urine samples collected from Exposure and Attention in Young Mexican- MD, MS; Alan R. Spitzer, MD; Dharmapuri Vidysagar, MD; Leonard E. Weisman, MD; the mothers during pregnancy and from their American Children” are Amy R. Marks, Kim Stephen Welty, MD; T.F. Yeh, MD children several times after birth. The pres- Harley, Asa Bradman, Katherine Kogut, ence of these metabolites indicated expo- Dana Boyd Barr, Caroline Johnson, Norma FREE Subscription - Qualified Professionals sure to OP pesticides used in the Salinas Calderon, and Brenda Eskenazi. This re- Neonatology Today is available free to qualified Valley, such as chlorpyrifos, diazinon, and search was funded by grants from the Na- medical professionals worldwide in neonatology oxydemeton-methyl. tional Institute of Environmental Health Sci- and perinatology. International editions available in ences, the US Environmental Protection electronic PDF file only; North American edition The children’s behavior was assessed at the Agency, and the National Institute for available in print. Send an email to: ages of 3 and a half years (n = 331) and 5 Occupational Health and Safety. [email protected]. Include your name, title(s), organization, address, phone, fax and email. years (n = 323) using reports from the moth- The article is available at ers and standardized psychological tests. http://ehponline.org/article/info:doi/10.1289/e Sponsorships and Recruitment Advertising hp.1002056. For information on sponsorships or recruitment The results indicated that as the concentration advertising call Tony Carlson at 301.279.2005 or of OP metabolites in the urine of pregnant The authors of the companion paper, “PON1 send an email to [email protected] women increased, so did the likelihood that and Neurodevelopment in Children Exposed their children’s test scores would be consis- to Organophosphate Pesticides in Utero,” Meetings, Conferences and Symposiums tent with a clinical diagnosis of ADHD. The are Brenda Eskenazi, Karen Huen, Amy List your meeting on the Neonatology Today web- association was stronger at age 5 years than Marks, Kim G. Harley, Asa Bradman, Dana site; send an email to: [email protected]. Include the meeting name, dates, location, URL at 3 and a half and was more pronounced in Boyd Barr, and Nina Holland. This research and contact name. boys than in girls. Prenatal exposures had a was funded by grants from the National Insti- greater association than did exposures after tute of Environmental Health Sciences and Corporate Offices birth: A tenfold increase in levels of meas- the US Environmental Protection Agency. 824 Elmcroft Blvd. ured pesticide metabolites in the mother’s The article is available at Rockville, MD 20850 USA urine during pregnancy correlated to about a http://ehponline.org/article/info:doi/10.1289/e Tel:+1.301.279.2005; Fax: +1.240.465.0692 500% increase in the likelihood of attention hp.1002234. issues in their 5-year-olds; whereas, a ten- Editorial and Subscription Offices fold increase in levels of metabolites in the EHP is published by the National Institute of 16 Cove Road, Ste. 200 children’s urine at 5 years of age corre- Environmental Health Sciences, National Westerly, RI 02891 USA sponded to a 30% higher likelihood. Institutes of Health, US Department of www.NeonatologyToday.net

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10 NEONATOLOGY TODAY  www.NeonatologyToday.net  October 2010

Do you or your colleagues have interesting research results, observations, human interest stories, reports of meetings, etc. that you would like to share with the neonatology community?

Submit your proposed article to [email protected]

The final manuscript may be between 400-4,000 words, and contain pictures, graphs, charts and tables.

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