Computer-Assisted Newborn Intensive Care

(1)

Computer-Assisted

Newborn

Intensive

Care

Paul H. Perlstein, M.D., Neil K. Edwards, M.S., Harry D. Atherton, M.S., and James M.

Sutherland, M.D.

From the Newborn Dieision of the Department of Pediatrics, C‘nitersity of Cincinnati, and the Children c Hospital Research Foundation of the Cincinnati Childrens’ Hospital .%fedical Center, Cincinnati, Ohio

ABSTRACT. A minicomputer has been programmed to aid

in the intensive care of high-risk newborn babies. The

computer provides 24-hour on-line access to physiologic and

environmental data and controls the heating of infant incubators. The control algorithm limits fluctuations in the

incubator chamber and protects the infant against escape from neutral thermal conditions. The mortality rate for 105 infants cared for using the computerized system was signifi-cantly reduced when compared to that of 105 matched high-risk infants cared for using standard non-coniputer-assisted

techniques in the same nursery setting. Pediatrics,

57:494-5()2, 1976, HIGH-RISK INFANTS, COMPUTER USE,

ENvIRoN-MENTAL CONTROL.

Caring for sick high-risk infants has become

increasingly complex, requiring the simultaneous

solution of multiple diagnostic and therapeutic

equations. Applying computer technology to the

amelioration of problems encountered in

new-born intensive care units is inherently appealing.

In the following report, a study is described in

which an on-line computer was tested as an aid in

solving some well-defined problems arising in a

newborn intensive care nursery.

METHODS

In 1971, a computer was introduced into the

Intensive Care Nursery at the Cincinnati General

Hospital. The computer is programmed to

imple-ment an algorithm for controlling the

tempera-tures in standard convectively heated incubators.

The development of the algorithm was

promul-gated by the inability to incorporate many

advances in the understanding of neonatal

homeostasis into everyday patient care

activi-ties.’5

The algorithm is based on the same

assumptions that have guided incubator

develop-ment in the past. These assumptions include the

desirability of creating a “thermally neutral”

microclimate which keeps infants’ body

tempera-tures within a normal range and reduces

ther-mally induced metabolic work to a minimal

level.a614 In addition, the algorithm prevents

sudden temperature changes which might induce

apneic spells and bradycardia in susceptible

415 16 The algorithm also recognizes the

tendency for infants to become adapted to

ther-moneutral conditions and transitionally weans

them from a consistently warm incubator to the

less controlled temperate environment of the

modern air-conditioned nursery.5 ‘

Well-defined factors were used to construct the

algorithm. The computer is programmed to

main-(Received June 25; revision accepted for publication

September 5, 1975.)

Supported in part by grants from the Department of Health,

Education, and Welfare (MCR-390290) and the Crosley

Memorial Foundation.

ADDRESS FOR REPRINTS: (P.H.P.) University of

Cincin-nati College of Medicine, Z31 Bethesda Avenue, Room

(2)

ARTICLES 495

tam the infant’s skin temperature within a normal

range of 35.5 to 36.5 C.t6 Skin temperature is

measured with a surface thermistor attached with

tape to a single site. Ordinarily, the thermistor is

attached to an anterior abdominal wall surface

but it may also be attached to any other single

anterior, lateral or posterior trunk surface.

Changing the thermistor location is necessary so

that the thermistor does not become dislodged or

covered when the infant’s body position is

changed. The skin temperature is also limited in

its definition by virtue of the method of

ther-mistor attachment which causes variable

com-pression of the underlying superficial skin

vessels.

If the infant’s skin temperature falls below 35.5

C, the incubator environmental temperature is

increased to more than 35.5 C. This is the only

time the infant is exposed to a heat-gaining

environment. The heat-gaining environment is

limited by setting a maximum allowable

incu-bator air temperature at 38 C. The 38 C

temper-ature was chosen to back up the thermostatically

controlled safety alarms and heater disconnect

features designed into the incubators to prevent

heating in excess of this level. Moreover, the

setting of a maximum upper incubator

tempera-ture limit provides an absolute limit to any rapid

and sudden temperature rise that might induce

apneic spells in susceptible infants.4

Metabolically neutral conditions were

estab-lished by relying on the data of Adamson and

Gandy.3 When an infant’s skin temperature is in

the normal 35.5 to 36.5 C range, the

environ-mental temperature is constrained to within 2

degrees C of the infant’s skin temperature. This is

accomplished by using the formula:

K (TS + TE) = Setpoint

In this formula, K is a constant set to the value

of 0.5, TS is the actual measured skin

tempera-hire, and TE is a computed environmental

temperature. Within defined temperature ranges,

the setpomt is the servocontrol reference

temper-ature used to trigger the decision to turn the

incubator heater on or off. The setpoint is initially

assigned a value of 35.5 C. This value assures that

within the normal skin temperature range of 35.5

to 36.5 C, the environmental temperature will

never fall below 34.5 C and therefore will not be

more than 2 degrees C below skin temperature.

When the infant’s skin temperature exceeds

36.5 C for more than five minutes, the assumption

that maintenance of a thermoneutral

environ-ment will benefit the infant is abandoned and the

setpoint value is shifted downward to allow

increasing gradients between the skin and

envi-ronmental temperatures to a maximum gradient

of 4 degrees C. This setting of setpoint values is

called the adaptive mode and is designed to

encourage reacquisition of homeothermic

capa-bilities prior to the baby’s transfer to an open

bassinet.

Since air temperature is the only variable

actually controllable in a convectively heated

single-thickness plexiglass-walled incubator, it is

necessary to compute the incubator

environ-mental temperature using the following

equa-tion:

TE = K1TA + K2 (TTW + TFW + TBW)

In this equation, TE is the computed

environ-mental temperature, K, is a constant equal to 0.5,

and TA is the measured midincubator chamber

air temperature. K2 is a constant equal to 0.167.

TTW is the temperature of the top wall, TFW

the temperature of the front wall, and TBW the

temperature of the back wall of the incubator. All

temperatures are measured and expressed in

degrees Centigrade. Since this equation defines

environmental temperature in terms only of the

convective and radiant components of heat loss,

its validity presumes that evaporative and

conductive heat losses are negligible. Conductive

heat loss is not a significant factor in a

conven-tional incubator. On the other hand, evaporative

heat loss may be significant in an unhumidified

convectively heated incubator; to minimize this

source of heat loss, a 70% relative humidity level

was maintained in all the controlled incubators.

Using this equation, it was established that

incu-bators in the study nursery have environmental

temperatures that are approximately 2 degrees C

less than the measured air temperatures. This is

approximately the same value determined for the

relationship between incubator air and

environ-mental temperatures independently reported by

Hey and Mount.’

The incubators controlled by the computer are

standard Air Shields Isolettes with either on:off or

proportional servocontrol electronic units. The

incubators are prepared by attaching Yellow

Springs Instrument Company thermistor probes

to the inside, top, back, and front walls of the

plexiglass chamber. A fourth thermistor is

suspended in the midincubator air stream and a

fifth measures the infant’s skin temperature.

These probes are plugged into an input box

attached to the incubator pedestal. The input box

connects to a multiplexer which, in turn,

trans-mits data to the computer. The decision to turn

the incubator on or off is transmitted back to the

at Viet Nam:AAP Sponsored on September 8, 2020

www.aappublications.org/news

(3)

FIc. 1. Preparation of computer-monitored and computer-controlled incubator.

incubator by way of electronics in the input box.

These electronics cause simulation of a 30 C

temperature for a heater on command, or 40 C

temperature for a heater off command. This

simulated temperature is passed from the input

box to the skin thermistor input jack on the

incubator’s electronics module. This preparation

is illustrated in Figure 1. By setting the incubator

for servocontrol operation, the Isolette

electron-ics can be used without modification to turn the

incubator heater on or off as a slave to the

external computer logic. In the event of a

computer failure, additional circuitry

automati-cally transfers heater control away from the

computer-connected pathways to the local single

skin temperature servocontrol logic. The

incuba-tors are all set to deliver maximum humidity to

the infant chambers. In the Isolettes that were

used, this maximum (measured with a Yellow

Springs Instrument Company Dew Point Sensor)

is about 70%.

Heart and respiratory rate monitors, alarm, and

display equipment in the nursery also serve as

data preprocessing units for the computer. A

graphic cathode ray computer terminal

(Tek-tronik 1040) is installed in the nursery for display

of all monitored and computed data. These data

are provided at the patient station either as

graphic eight-hour summaries or in tabular form.

The nursery personnel can communicate with the

computer or engineering staff by using the

type-writer keyboard of the terminal.

At present, the algorithm is programmed into a

PDP 1 1 /20 minicomputer (Digital Equipment

Corporation). The minicomputer is located in the

Newborn Division Office area, approximately

one-eighth mile from the nursery. Data are

trans-mitted to and from the nursery by way of private

transmission lines rented from the telephone

company.

SUBJECTS

Any infant born in the Cincinnati General

Hospital and admitted to the Newborn Intensive

Care Nursery between 1971 and 1975 was eligible

for this study. Inclusion as a study subject was

contingent on the infant’s admission at a time

when a prepared and empty study incubator was

available. If a study incubator was not available,

the baby was placed in a routinely prepared

incubator and was assigned to a pool of potential

control infants. There were 107 infants cared for

in the computer-assisted management group.

Two of these babies were excluded from analysis.

One of these excluded babies was an infant born

live following a therapeutic abortion attempt at

22 weeks’ gestation. This baby died three hours

after admission to the nursery. The other

excluded infant had Potter’s syndrome with

hypo-plastic lungs and kidneys. The remaining 105

infants were each matched for sex, race, and

birthweight (using 500-gm increments) with an

infant in the routinely cared for pool of infants.

Without exception, each control infant was the

first matching infant admitted to the nursery

following the admission of the paired study

subject. This selection process presumed that a

natural randomization exists in the ordering of

births in the population. Although the possible

invalidity of this presumption was recognized, the

method of selecting a control population was

sustained in order to establish consistency in the

methodology. Moreover, since each control infant

was selected by virtue of being admitted to the

nursery as soon as possible after the admission

time of the paired study infant, it was hoped to

diminish the unanticipated effects of minor

time-related changes in nursery procedures and

personnel on infant survival. The control subjects,

though identified retrospectively, were selected

without foreknowledge of their survival outcome.

The clinical characteristics of the 105 pairs of

infants are summarized in Table 1. The study and

control groups were similar by comparison of

birthweights, gestation, and five-minute Apgar

(4)

I I Computer Assisted Care ( N‘ 51 10

- 9-

8-

7- 6-

5- 4- 3-2

I I

‘

I

---I I

.. ‘\. .\N’NNN.J

10

- 9-

8-

7-6

5- 4-

3-2

Routine Core C N46

I

\NNNNNNk\\NNNNN

I I I I I

2000 1800 1600 1400 200 000 800 600

.N’’.NN” NN’”N

FIG. 2. Survival of infants with RDS by birthweight and type of care.

TABLE I

ARTICLES 497

CLINICAL CHARACTERISTICS OF STUDY GROUPS

Characteristic

T otal Pairs All infants With RDS

All Infants With RDS

>

799 gin

Computer (No. = 105)

Routine

(No. = 105) P

Computer (No. = 51)

Routine

(No. = 46) P#{176}

Computer Routine

(No. = 42) (No. = 39) P#{176}

Birthweight (gm) 1,521

±

57 1,548 ± 60 NS 1,310 ± 60 1,231 ± 64 NS 1,442

±

53 1,345 ± 50 NS

Gestation (wk) 31

±

7 32

±

5 NS 30

±

5 30

±

5 NS 31 ± 4 31 ± 5 NS

Five-minute Apgar 6.1 6.2 NSt 5.8 5.5 NSt 5.9 5.9 NSt

#{176}NS= not significantly different at P = .05. tUsing Wilcoxin-White Ranks Test.

Infants in the control group received the same

general care as the study infants. All the control

infants were attached to standard heart rate and

respiratory rate signal conditioners and alarm

monitors. Small oscilloscopes were used to display

electrocardiograms and respiratory wave forms.

Air Shields incubators of various types were used

to house most of the control infants. Some of these

incubators were heated in response to air

temper-ature thermostats and some to standard skin

temperature referenced on:off or proportional

servocontrol logic. A relative humidity level of

60% to 70% is routinely maintained in all closed

incubators in the study nursery. Four of the

control group infants were cared for in open

radiantly heated cribs. Although this variation in

type of incubator care results in a somewhat

heterogenous control population, it nonetheless

reflects the real-life eclectic use of various

tech-niques in caring for babies admitted to the

nursery during the study period. All four of the

infants cared for in open cribs weighed over 1,400

gm at birth.

For part of the data analysis, infants were

excluded based on whether or not they had

respiratory distress syndrome (RDS). To be

included in the groupings of infants with RDS, a

baby either had to have recorded autopsy

confir-mation that hyaline membranes were present in

the lungs, or a clinical syndrome supported by

documented descriptions of retractions, grunting,

and respiratory acidosis persisting for more than

24 hours without coincident meconium

aspira-tion, pneumonia, or heart failure. None of the

ccs

\\NN\’ \\N\\ \\\N\NN\\

Birth Weight in Grams #{149}Lived

a Died

(5)

TABLE II

RELATIONSHIPS BETWEEN TYPE OF CARE AND MORTALITY

To tal Group Infants Withot

‘

it RDS Infants Wi th RDS

Birtluveight Type of Care No. Live Dead

x

P No. Live Dead

_x

P No. Live Dead

x2

_P

IComputer

< 800 gm Routine 14

14 1 2

13

12 NS#{176} 7

1 2

4 5

NS

7 1 6 NS

(Computer

>

799 gm Routine 91 91

80

66

11

25 6.787 <.01

49 52 43 44 6 8 NS 42 39 37 21 5

18 11.667 <.001 IComputer All 105

os

81 68 24 37 54 59 44 46 10 13 NS 51 46 37 22 14

24 6.204 <.02 #{176}NS= not significantly different at P = .05.

infants with RDS were cared for in radiantly

heated open cribs. The subject and control groups

created by this division of the 105 pair population

were not dissimilar in mean birthweight,

gesta-tion, or Apgar scores (Table I).

RESULTS

Of the 105 infants in the computer-assisted

group, 81 lived and 24 died. This is a greater

survival rate (x2 = 3.905; P

<

.05) than tabulated

for the 105 infants in the routinely cared for

control group of whom 68 lived and 37 died. In

the 105 pairs, there were 14 pairs of infants

weighing less than 800 gm at birth. Only one of

the 14 computer-assisted infants and two of the 14

control infants survived. When these 14 pairs

were eliminated from the 105 pair total

popula-tion, 91 study pairs remained. Of the 91

computer-assisted babies weighing more than 799

gm, 80 lived and 1 1 died which is a greater

difference in survival (x2 = 6.787; P

<

.01) when

compared to the 66 live and 25 dead infants

weighing more than 799 gm in the control

group.

When the original 105 infants in each group

were divided on the basis of whether each infant

did or did not have RDS, 51 mfants with RDS

were found within the computer-assisted and 46

within the control group. When these 51

computer-assisted and 46 control RDS infants

were excluded from an analysis of the original 105

infant pairs, there were 54 computer-assisted and

59 control infants remaining. There was no

signif-icant difference between the survival of the

groups without infants with RDS. On the other

hand, of the 51 computer-assisted infants with

RDS,

37

survived and 14 died. This survival rate is

significantly higher

(x2

= 6.204; P

<

.02) than

that calculated for the 46 RDS babies in the

routine care control group, 22 of whom lived and

24 of whom died. The distribution of these infants

by weight groups is summarized in Figure 2.

Excluding all infants weighing less than 800 gm

from the analysis of infants with RDS resulted in a

computer-assisted care population group of 42

infants and a routine care control population of

39 infants. Only 5 (12%) of the 42

computer-assisted infants died, whereas 18 (46%) of the 39

routinely cared for babies died. This difference in

survival between the two groups of infants with

RDS weighing more than 799 gm at birth is highly

significant

(x2

= 11.667; P

<

.001).

Because of the degree of significance achieved

in this comparison of grouped infants with RDS

weighing more than 799 gm at birth, further

comparisons were made in order to determine if

the method of selecting the control group of

routinely cared for infants inadvertently resulted

in a control group that did not fairly represent the

expected mortality rates of the total study nursery

population. Because the reliability of data on

total nursery survival rates was questionable prior

to 1974, only infants admitted to the study

nursery in 1974 were used for this check on the

control population. In 1974, a total of 46 babies

with RDS and weighing more than 799 gm at

birth were cared for using non-computer-assisted

routine management methods.

Of these 46 infants, 15 died. When these 46

babies are compared to the 39 study control

group of routinely cared for babies of whom 18

died, there is no significant difference in the

mortality rates of the matched study control and

the unmatched general population of infants.

Moreover, like the 39 matched study control

infants, the 46 routinely cared for infants in the

nursery population had a significantly higher

mortality rate when compared to the

computer-assisted care study babies

(x2

= 5.359; P

<

.02).

(6)

COMPUTER ASSISTED #{149}& y -12.8+ .16X r.5795 p( .01 (25d.f.)

ROUTINE CARE O &- y-l6.8+ .l8X r.6478 p( .01 (25d.f.)

.

+10-

+5-0

.

#{149}0

0 0

#{149}#{149}

0

.

0 0

0--5

-I0

-IS

-.

.

00

.

0

.

0

0 0

0#{149} 0

Computer Assisted N=27

0

Routine Core

N=27

Mean±SE. Meon±S.E. P’

I I 0

Birthweight(gms) 1917±119 1954±101 NLS

Gestation (wks) 34.1 ±6 34.8±.7 NS.

5minAPGAR 7.0 8.0 (.05

7doy weight

loss (%) 44 ± 1.0 4.6t 1.2 NS.

Calories/kg/day 52±4 66±4 (.02

**

1

*N.S.-Not Significant

**Using WILCOXIN-WHITE Ranks Test

I I I I

30

40

50

60

70

80

90

00

110

ARTICLES 499

K

CALORIC

INTAKE

/kg/day

FIG. 3. Weight change as related to caloric intake.

studied were reviewed to tabulate weight changes

during the first seven days and caloric intake

during the first six days of life. The 28 infants in

the computer-assisted care study group lost a

mean of 4.4

±

1% of their birthweight which is

not significantly different from the 4.6

±

1.2%

weight loss recorded for the 27 routinely cared for

control infants. On the other hand, the control

infants had a mean 66

±

4 cal/kg/day intake

which is significantly greater than the 52

±

4

cal/kg/day taken in by the study group of babies

(P

<

.02). These groups were not dissimilar in

mean birthweights, gestations, or five-minute

Apgar scores. This information is summarized in

Figure 3, which also includes the significant

correlations established for both groups in

relating weight changes to caloric intakes.

CONCLUSIONS

The results indicate that a computer can be

employed successfully as a tool in an intensive

care nursery. Improved infant survival is the

measure of success used in arriving at this

conclu-sion. Infants weighing more than 799 gm at birth

and particularly infants who developed RDS were

the major contributors to the statistical difference

in survival between computer-assisted and

routinely cared for infants.

The conclusion does not pretend to a clear

understanding of why this computer application

contributed to the demonstrated reduction in

infant mortality. On the other hand, infants cared

for in computer-connected incubators had less of

a seven-day weight loss for calories given than did

the routinely cared for control infants. This is

interpreted as support for the hypothesis that by

minimization of metabolic stress, computer

control over environmental heating played a role

in the enhancement of survival.

Although mean weight losses were not

dissimi-lar, the infants in the computer-assisted care

group did not have as great a caloric intake as did

(7)

:

ENU

35

30 -I 1

-U

I

f

I

1 I

Fl

3 00

4’#{248}#{248}

Se#{248} 6’#{248}#{248}7’Ge 8 00 9 ee 10 00 T

E r’i

P S

HR

RR 100

0-APNEA

) 10 SEC

BRADYCARD IA

I

3 00 400

I j I I I

I

I I I

I

‘

I

I I I

I

S 00 600 700 800 9#{216}#{216}10 00

LO HR-tOO

LO PR- 15

PULSE

r1Fr’::T

FIG. 4. Computer-generated eight-hour summary of skin, midincubator air, computed

environ-niental temperatures (in degrees C), heart rate, and respiratory rate sampled every 15 minutes.

At bottom of summary, apneic spells longer than ten seconds in duration and episodes of

bradycardia (heart rate falls to less than 80% of finning niean heart rate) are summarized in

histograiiis of nuniber of occurrences during each 15-minute sampling period.

the

routinely

cared

for infants.

The

caloric

intake

was not controlled in this study and the difference

reflects the calories administered as guided by the

clinical condition of each baby and, for the

nonintravenously administered calories, the

in-fant’s acceptance of formula feedings. The lower

mean five-minute Apgar score of study infants,

when compared to the mean Apgar score of

control infants, may indicate that study infants

were actually sicker than control infants and

therefore did not feed as well. Another

explana-tion for the different caloric intakes is related to

the possibility that the tightly constrained

computer-controlled incubator environment

might have been soporific for the contained infant

when compared to the more stimulating,

unsta-ble, and ever-changing environment in routinely

controlled incubators. This possibility requires

further investigation.

The study infants also differed from the control

infants with respect to the manner in which

moni tored physiologic and environmental data

were displayed and recorded. The

computer-generated displays are both graphic and tabular

and

include

heart

rate,

respiratory

rate,

skin

teni perature, air tem perature, environmental temperature, and body impedance trends over

eight-hour periods of time. The frequencies of

episodes of apnea and bradycardia are included as

histograms on these summary displays. Hard copies of the displayed information are available

to the health provider. An example of one of these

displays is shown in Figure 4. The impact of this readily accessible information on infant survival

cannot be separated from the impact of incubator

control. On the other hand, patient care was

clearly modified by the availability of these

summaries which, through interpretation of

unusual trends, led to the discovery and repair of

maladjusted or malfunctioning equipment,

modi-fication or discontinuance of procedures, and,

frequently, verification or questioning of a

din-ical impression of a monitored infant’s progress.

Among the most frequent equipment failures

discovered was the malfunctioning of water heating systems supplying humidity to positive-pressure devices and head hoods. Feeding was the

procedure most often modified because of its

clear relationship to periodic apneic spells

(8)

impres-ARTICLES 501 sion of subtle infant deterioration when supported

by

the

display

of

an

increasing

incidence

of

bradycardia and apnea led to more confident

searches

for

the

cause

of the

deterioration.

The

method

of information

display,

therefore,

must be

considered to have played a role in the type of patient care delivered. Clearer definition of this role will have to await the results of more tightly controlled studies using this system.

Therefore, the only firm conclusion resulting from the present study is that this particular application of computer technology has enhanced the survival of infants admitted to the study nursery. This does not guarantee that application

in other nurseries, with differing physical and technical resources and dealing with differing patient care problems than the described system,

would result in a similar enhancement of survival.

This experience, however, may help to encourage those who are prepared to initiate other studies into a computer’s capability to assist in the management of problems arising in the complex setting of newborn intensive care units.

REFERENCES

1. Hey EN, Mount LE: Heat losses from babies in incuba-tors. Arch Dis Child 42:75, 1967.

2. Hex’ EN, Mount LE: Temperature control in incul)ators.

Lancet 2:202, 1966.

3. Adamson K, Candy JS: The influence of thermal factors

upon oxygen consumption of newborn human

infants. J Pediatr 66:495, 1965.

4. Perlstein PH, Edwards NK, Sutherland JM: Apnea in

premature infants and incubator air temperature changes. N Engi J Med 282:461, 1970.

5. Glass L, Silverman WA, Sinclair JC: Effect of the thermal environment on cold resistance and growth of sI1all infants after the first week of life. Pediatrics

41:1033, 1968.

6. Silverman \VA, Fertig J\V, Berger AP: The influence of

the thermal environnient upon the survival of newly born premature infants. Pediatrics 22:876,

1958.

7. Buetow KC, Klein SW: Effect of Illaintellance of

“nor-mal skin temperature on survival of infants of low birth weight. Pediatrics 34:163, 1964.

8. Day RL, Caliguiri L, Kamenski C, et a!: Body

tempera-ture and survival of premature infants. Pediatrics

34:171, 1964.

9. Adamsons K Jr: The role of thermal factors in fetal and neonatal life. Pediatr Clin North Am 13:599, 1966.

10. Oliver TK Jr: Temperature regulation and heat

prodiic-tion in the newborn. Pediatr Clir, North Am 12:765, 1965.

1 1. Candy GM, Adamsons K Jr. Cunningham N, et a!:

Thermal environment and acid-base homeostasis in

hunian infants during the first few hours of life.

J Clin Invest 43:751, 1964.

12. Bruck K: Temperature regulation in the newborn infant. Biol Neonate 3:65, 1961.

13. Scopes JW: Metabolic rate and temperature control in

the human body. Br Med Bull 22:88, 1966.

14. Silverman WA, Parke PC: Keep him warm. Am J Nurs

65:81, 1965.

15. Perlstein PH, Edwaras NK, Atherton HD, Sutherland JM: An environmental trigger to cardiac instability

in the neonate. Read before the meeting of the

Americal Pediatric Society, Atlantic City, New

Jersey, May 1972.

16. Sinclair JC: The premature baby who “forgets to

breathe.” N Engl J Med 282:508, 1970.

17. Perlstein PH, Hersh C, Glueck CJ, Sutherland JM: Adaptation to cold in the first three days of life.

Pediatrics 54:41 1, 1974.

ACKNOWLEDGMENTS

\Ve are indebted to Ms. Laurine Cochran and the Nursing

Staff in the Newborn Nurseries at the Cincinnati General Hospital, Ms. Barbara Barnes and the Staff in the Children’s

Hospital Medical Center Newborn Special Care Unit, and

the many Fellows, housestaff members, medical students, and other colleagues who constructively and critically

cOntril)uted to development of this program. We gratefully acknowledge the technical assistance provided by Ken Evans, Sheila Hoffman, Marta Stegman, and Nada Huron.

(9)

1976;57;494

Pediatrics

Paul H. Perlstein, Neil K. Edwards, Harry D. Atherton and James M. Sutherland

Computer-Assisted Newborn Intensive Care

Services

Updated Information &

http://pediatrics.aappublications.org/content/57/4/494

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

(10)