We presented data showing a direct correlation of screening T4 values with birthweight in premature infants at this meeting three years ago.We opined that low T4 concentrations were due to decreased protein binding of T4. The next year,we reported data proving the speculation and showing lower binding was more than compensated for in term infants by increased TBG concentration. FT4 concentrations for term and VLBW infants were all within the normal adult range and the neonates had similar TSH concentrations indicating low T4 values were due to NTI. Further findings at 2 weeks in 5 of 32 VLBW infants suggest a Euthyroid Sick Syndrome. We compare clinical and hormonal values of these 5 with the remaining 27 infants in the tables.(cord v 2 wk- * p <.05 ** <.01) The FT4 method was validated by equilibrium dialysis.The correlation of immaturity and postnatal stress with the hormonal changes was also demonstrated by regression analyses. The values became normal in 3 of the 4 infants followed for 4 weeks. We believe the changes in hormonal values are due to a transient inhibitor of T4 binding unrelated to the diminished binding seen in both VLBW and term infants previously demonstrated. The putative transient inhibitor is associated with immaturity and stress.

In a population-based study of the approximately 15,000 births in New Hampshire, we have previously reported an increased risk of readmission to hospital (50%) and Emergency Room visits (70%) within the first two weeks of life for infants discharged at less than 48 hours of life. To address additional concerns regarding appropriate metabolic screening/hearing evaluation all 26 N.H. hospitals with maternity services were surveyed. Questionnaires were sent to Chiefs of Pediatrics and Nurse Managers and were returned by all. A second survey was sent to practicing physicians(pediatrician/family practioner) and 31.4% were returned.

Objectives: To supply normative data for screening thyroxine (T-4) and thyrotropin concentrations correlated with birth weight and age at screening of infants with birth weights ranging from 400 to 5500 gm, and to document the effects of screening of very low birth weight (VLBW) infants, because VLBW infants comprise 0.86% of surviving newborn infants and have very low total T-4 concentrations with normal or elevated free T-4 concentrations as a result of deficient protein binding of thyroid hormones.Study design. Both retrospective and prospectives studies were used. We conducted retrospective analyses of screening of T-4 and thyrotropin concentrations in 9,324 term, 18,946 low birth weight, and 3,450 VLBW infants in Massachusetts, and a prospective study of T-4 and thyrotropin concentrations in 48 VLBW infants at 2 weeks of age. Forty of the infants also had hormone measurements at 4 weeks, 29 at 8 weeks of age, and 24 had analysis of cord blood samples.Results: Median T-4 concentrations for each weight group (in 250 gm increments) increased progressively and significantly up to 2500 gm, Of the surviving VLBW infants, 1.5% had screening T-4 concentrations that were unmeasurably low (<3.9 nmol/L (0.3 mu g/dl)). The mean T-4 concentration varied with age at screening, increasing from cord blood concentrations to a peak at 1 to 3 days of age and thereafter decreasing to a nadir at about 2 weeks in both low birth weight and VLBW infants. In VLBW infants the mean concentrations return to the level of 1 to 3 days by 4 to 8 weeks of age. The incidence of screening thyrotropin concentrations greater than or equal to 40 mU/L correlates inversely with weight, The incidence of early, transient hypothyroidism in VLBW infants defined by this thyrotropin concentration was eight times that in term infants. Two infants had late-onset, transient hypothyroidism at 2 and 7 weeks, respectively.Conclusions: The normative data related to birth weight and age at screening allow proper interpretation of VLBW results for primary T-4 and primary thyrotropin screening programs, Screening of the concentrations of T-4 and thyrotropin in VLBW increases the number of secondary measurements of T-4 in a primary thyrotropin screening program and the number of secondary thyrotropin measurements in a primary T-4 screening program by 6% and 9%, respectively, We recommend screening analyses for VLBW infants in the latter part of the first week of life and again at 2 and 4 to 6 weeks of age. This protocol would increase the number of screening analyses by 1.6%.

There is concern that neonatal intensive care practice has resulted in an increased census of chronically ill infants. These infants may limit available acute tertiary care beds and cause staffing problems.We used our computer database to analyze epidemiologic characteristics of ICN admissions from 1976 through 1983. With well-established regionalized perinatal care, admission characteristics have remained relatively constant: 344 ± 45(S.D.)admissions/year, 54.2 ± 6.3% infant referrals, 31.8 ± 3.2% maternal-fetal referrals. There was no trend in the yearly distribution of admissions by birth weight or gestational age. There was no trend to increasing average length of stay (LOS) by year (14.7 days, range 13.4-17.1). Mortality and discharges to community hospitals have varied only slightly (10.7 ± 2.4%, 37.7 ± 3.2% respectively). Discharges directly home decreased from 44.6% to 22.8% while discharges to the pediatric ward increased 3.6% to 11.3% (1976 vs. 1983).Infants with LOS>28 days or to> 38 weeks corrected gestational age accounted for 6.1 ± 1.7% of admissions and 33 ± 9.8% of hospital days. Infants with LOS>12 weeks accounted for 2.3 ± 1.1% and 19.4 ± 10.1% of admissions and hospital days, respectively. While the percentages of hospital days represented by long term infants in 1983 were at the upper end of the ′76-′83 range, there was no trend even if pediatric ward LOS was included. We cannot show an increase in long term babies.

We report two female infants with postaxial polydactyly and hypopituitarism of differing etiologies. The first infant was born at term to a 26-year-old gravida 6 para 2 abortus 4 woman who noted markedly decreased fetal movement and intrauterine growth retardation. She was delivered from a breech presentation with posteriorly rotated simplified auricles, short nose, flat nasal bridge, microglossia, micrognathia, cleft posterior palate, short limbs with dislocated hips, postaxial polydactyly of hands and feet, bilateral simian creases, and 2-3 syndactyly of the toes. She died at 21 hours of age and autopsy revealed hypothalamic hamartoblastoma, bilateral hypoplastic renal ectopia, bilateral pulmonary hypoplasia, and a bifid epiglottis. Family history revealed that the mother's sister had died at 17 hours of age with remarkably similar dysmorphic features (no autopsy done), and this is the first report of apparent familial recurrence for Hall-Pallister syndrome. The second infant was born by cesarean section at 42 weeks with postaxial polydactyly of the left hand and primary panhypopituitarism. This pregnancy in a 21-year-old gravida 2, abortus 1 woman was complicated by extremely low maternal estriols. Size at birth and a cranial CT scan were normal, and the family history was negative for other individuals with hypopituitarism or polydactyly. Postaxial polydactyly may be associated with hypopituitarism, especially when associated with cleft palate, choanal atresia, congenital heart disease, and basal brain anomalies.

Physician preventable neonatal pulmonary disease was reviewed in all 250 infants admitted to the Dartmouth-Hitchcock Medical Center in calendar year 1976. Data were obtained from the delivering hospital's perinatal records, the neonatal course, and a monthly transport conference case review. All cases of Respiratory Distress Syndrome or Meconium Aspiration Syndrome were screened for inadequate fetal maturity or gestational age evaluation prior to delivery. Clinical, x-ray, and laboratory findings were used for diagnosis. All cases this year were transported, not inborn. Cost analysis comparing neonatal intensive care expense versus projected fetal maturity study expense for all New Hampshire pregnancies at risk supports performing the studies. The conclusion that approximately 10% of tertiary neonatal intensive care admissions in New Hampshire can be eliminated through adequate fetal gestational age evaluation is being presented to the New Hampshire Medical Society upon request.