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Columbia University Medical Center New York, New York
Chad Andersen, MBBS
Neonatal Medicine
Women’s and Children’s Hospital Adelaide, Australia
Lauren Astrug, MD
Assistant Professor of Neonatology Department of Pediatrics Loyola University Chicago Chicago, Illinois
William E. Benitz, MD Professor of Neonatology Pediatric/Neonatal & Developmental Medicine Stanford University Stanford, California
Jatinder Bhatia, MD, FAAP Professor, Department of Pediatrics Chief, Division of Neonatology Director, Fellowship Program, NeonatalPerinatal Medicine
Director, Transport/ECMO/Nutrition Vice Chair, Clinical Research Medical College of Georgia Augusta University Augusta, Georgia
Shazia Bhombal, MD
Clinical Assistant Professor of Pediatrics Division of Neonatal and Developmental Medicine
Stanford University School of Medicine Palo Alto, California
Waldemar A. Carlo, MD
Edwin M. Dixon Professor of Pediatrics University of Alabama at Birmingham Director, Division of Neonatology Director, Newborn Nurseries Birmingham, Alabama
LIST OF CONTRIBUTORS
Maria Roberta Cilio, MD, PhD
Professeure Ordinaire de Neurologie Pediatrique Université catholique de Louvain Epileptologie pédiatrique et néonatale
Cliniques universitaires Saint-Luc
Adjunct Professor of Neurology and Pediatrics University of California, San Francisco
Erika Claud, MD
Professor
Pediatrics and Medicine
The University of Chicago Chicago, Illinois
Alain C. Cuna, MD
Neonatologist
Children’s Mercy Kansas City Assistant Professor of Pediatrics
University of Missouri-Kansas City Kansas City, Missouri
Vincent Duron, MD
Assistant Professor, Surgical Director of Critical Care
Pediatric Surgery
Morgan Stanley Children’s Hospital/ New York-Presbyterian New York, New York
Lin Fangming, MD, PhD Director of Pediatric Nephrology Columbia University New York, New York
Kirsten Glaser, MD
University Children’s Hospital University of Wuerzburg Wuerzburg, Germany
Pamela Isabel Good, MD
Neonatal-Perinatal Medicine Fellow Department of Pediatrics
Morgan Stanley Children’s Hospital of New York—Presbyterian
Columbia University Medical Center New York, New York
Cathy Hammerman, MD
Director Newborn Nurseries
Neonatology
Shaare Zedek Medical Center
Professor Pediatrics
Hebrew University Faculty of Medicine
Jerusalem, Israel
William W. Hay, Jr., MD
Professor of Pediatrics (Neonatology)
Scientific Director, Perinatal Research Center
University of Colorado School of Medicine
Anschutz Medical Campus
Scientific Director, Perinatal Research Center Aurora, Colorado
Kendra Hendrickson, MS, RD, CNSC, CSP
Clinical Dietitian II
Neonatal Intensive Care Unit
University of Colorado Hospital
Department of Nutrition
Aurora, Colorado
Stuart Brian Hooper, BSc(Hons), PhD
The Ritchie Centre
Hudson Institute of Medical Research
The Department of Obstetrics and Gynecolory
Monash University
Melbourne, Australia
Thomas A. Hooven, MD
Assistant Professor Pediatrics
Columbia University
New York, New York
Elie G. Abu Jawdeh, MD
Neonatal-Perinatal Medicine
Kentucky Children’s Hospital
University of Kentucky College of Medicine Lexington, Kentucky
Erik A. Jensen, MD
Department of Pediatrics
Division of Neonatology
The Children’s Hospital of Philadelphia
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Michael Kaplan, MB, ChB
Emeritus Director
Department of Neonatology
Shaare Zedek Medical Center
Professor of Pediatrics
Faculty of Medicine
Hebrew University
Jerusalem, Israel
Martin Keszler, MD
Professor of Pediatrics
Alpert Medical School of Brown University
Associate Director of NICU
Director of Respiratory Services
Women and Infants Hospital of Rhode Island
Providence, Rhode Island
Haresh Kirpalani, MB, MSc
Professor
Neonatology, Department of Pediatrics
The Children’s Hospital of Philadelphia Philadelphia, Pennsylvania
Emeritus Professor Clinical Epidemiology
McMaster University Hamilton, Canada
Ganga Krishnamurthy, MBBS
Assistant Professor of Pediatrics
Columbia University Medical Center Director, Neonatal Cardiac Care
Morgan Stanley Children’s Hospital of New York-Presbyterian
New York, New York
Satyan Lakshminrusimha, MBBS, MD, FAAP
Professor of Pediatrics
Chief, Division of Neonatology Director, Center for Developmental Biology of the Lung
University at Buffalo
The Women and Children’s Hospital of Buffalo Buffalo, New York
Abbot R. Laptook, MD
Professor of Pediatrics
Alpert Medical School of Brown University
Medical Director, Neonatal Intensive Care Unit
Staff Neonatologist
Women & Infants Hospital of Rhode Island
Providence, Rhode Island
Stéphanie Levasseur, MD, FRCPC
Assistant Professor of Pediatrics
Columbia University Medical Center
Morgan Stanley Children’s Hospital of New York-Presbyterian
New York, New York
Jack Lorenz, MD
Emeritus Professor of Pediatrics
Columbia University
College of Physicians & Surgeons
New York, New York
Shahab Noori, MD, MS, CBTI, RDCS
Fetal and Neonatal Institute
Division of Neonatology
Children’s Hospital Los Angeles
Department of Pediatrics
Keck School of Medicine
University of Southern California
Los Angeles, California
Camilia R. Martin MD, MS
Assistant Professor of Pediatrics
Harvard Medical School
Associate Director, NICU
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Richard J. Martin, MD
Case Western Reserve University School of Medicine
Columbia University Medical Center Director, Neonatal Intensive Care Unit
Morgan Stanley Children’s Hospital of New York-Presbyterian Director, Fellowship Training Program in Neonatal-Perinatal Medicine
New York Presbyterian Hospital, Columbia Campus
New York, New York
Ashley M. Reilly, PharmD
Clinical Pharmacy Specialist
Neonatal Intensive Care Unit/ Labor & Delivery
University of Colorado Hospital Department of Pharmacy
Aurora, Colorado
Calum T. Roberts Department of Paediatrics
Monash University
The Ritchie Centre
Hudson Institute of Medical Research
Monash Newborn
Monash Medical Centre
Melbourne, Australia
Tristan T. Sands, MD, PhD
Assistant Professor Neurology
Columbia University Medical Center
New York, New York
Istvan Seri, MD
Fetal and Neonatal Institute Division of Neonatology
Children’s Hospital Los Angeles Department of Pediatrics
Keck School of Medicine
University of Southern California Los Angeles, California
First Department of Pediatrics
Faculty of Medicine
Semmelweis University Budapest, Hungary
Michael Stark, BSc (Hons), MBChB, PhD
Associate Professor
Department of Neonatal Medicine
Women’s and Children’s Hospital
The Robinson Research Institute University of Adelaide Adelaide, Australia
Steven Stylianos, MD
Rudolph Schullinger Professor of Pediatric Surgery
Department of Surgery
Columbia University School of Physicians & Surgeons
Surgeon-in-Chief
Morgan Stanley Children’s Hospital
New York, New York
Arjan B. te Pas, MD, PhD Division of Neonatology
Department of Pediatrics
Leiden University Medical Center Leiden, The Netherlands
Payam Vali, MD
Assistant Professor of Clinical Pediatrics
University of California Davis Sacramento, California
Clyde J. Wright, MD
Section of Neonatology
Department of Pediatrics
University of Colorado School of Medicine and Children’s Hospital Colorado Aurora, Colorado
Tai-Wei Wu, MD
Fetal and Neonatal Institute
Division of Neonatology
Children’s Hospital Los Angeles Department of Pediatrics
Keck School of Medicine
University of Southern California Los Angeles, California
Ariela Zenilman, MD
Columbia University Medical Center New York, New York
PREFACE
This is the sixth edition of the Workbook in Practical Neonatology. There is no doubt that the practice of our discipline has changed in numerous ways since the first edition of this text was published in 1983. However, we remain passionately convinced that the study of neonatology is best conducted in a format similar to the dialogue between a learner and teacher as they “see” the patient. The dialogue is informed by the specific elements of acquired patient data that give some evidence for the status of the patient in supplement of the physical examination, and assessments for the daily plan of the patient are constructed. In each chapter, specific case studies are presented, followed by a series of questions that seek the reader to choose an intervention, and then the various approaches are discussed to bring the reader to identify the most appropriate plan of action.
As true for the first edition, this book is designed to provide an opportunity to directly solve problems as you read through the clinical scenarios. The workbook format has four objectives: to allow you to evaluate your own knowledge for each problem presented; to permit you to identify areas of
knowledge in which you are deficient so that you may read up and enhance your armamentarium of knowledge; to keep you engaged and alert as you solve the problems presented and to have fun while learning.
We have recruited new authors to provide a fresh perspective on all the given areas. Each were chosen for their recognized expertise and status within the discipline, as has been the tradition since the first edition. Thus, the goal of the present edition is to provide new avenues from which to glean the available evidence, new insights into pathophysiology, and advances in treatment of critically ill neonates.
We wish to thank Angie Breckon from Elsevier for her outstanding guidance through the entire project. MCY wishes to thank his wife, Holly, children Andrew, Cait, Chris and Emily and grandchildren Isaac, Jacob, Gracie, and Charlotte for all their support. RAP wishes to thank his wife Helene, children Allison, Mitchell, Jessica and Gregory and grandchildren Lindsey, Eli, Willa, Jasper, Casey, Smith, Calla and Elliott for their love and support.
VIDEO TABLE OF CONTENTS
Video 16-1: Echocardiogram—Relationship of Ventricles and Great Vessels
Video 16-2: Fluoroscopic Image of Balloon Atraial Septostomy
Video 16-3: Echocardiogram—Ebstein’s Anomaly
Video 16-4: Echocardiogram—Stenotic Pulmonary Valve
Video 16-5: Fluoroscopic Image of Pulmonary Balloon Valvoplasty
Video 19-1: Benign Neonatal Seizure
A Physiologic Approach to Neonatal Resuscitation
Stuart B. Hooper, Arjan B. te Pas and Roberts Ca/um T. Roberts
INTRODUCTION
Neonatal resuscitation is commonly defined as the assistance given to infants immediately after birth as they transition to newborn life. From a physiologic perspective, this transition involves some of the most complex and profound changes that any human will likely encounter during their life. The airways that are filled with liquid during fetal life must be cleared to allow the entry of air and onset of pulmonary gas exchange, and major vascular shunts must close to separate the pulmonary and systemic circulations. It is truly an amazing feat of nature that the vast majority of infants transition through these changes with such apparent ease. As a result, it is easy to underestimate both the magnitude of the physiologic changes and the complexity and difficulty of rendering assistance to infants struggling to adapt to life after birth.
Very preterm infants commonly require assistance at birth because they are simply too immature to survive unassisted, but there is considerable debate about what assistance is required and how it should be provided. Nevertheless, a fundamental tenet of neonatal resuscitation is to recognize that at birth, newborn infants, particularly ery Rreterm infants, are not "mini adults" but are essen t ially exteriorized fetuses with liquid-filled airways. As such, the type of assistance given should be tailored to suit the infant's changing physiology and its specific needs at any moment in time. For instance, what is the logic of applying ventilation strategies that facilitate pulmonary gas exchange when the gas exchange regions of the lung are liquid filled and so no pulmonary gas exchange can occur? Although this is only a transient consideration for most infants, because the airways are rapidly cleared of liquid, it is a lingering consideration in very preterm infants who have problems aerating their lungs (te Pas et al, 2008).
A key component to a successful neonatal resuscitation is understanding the physiologic changes that occur after birth and having the capacity to monitor the infant as it progresses through these changes so that the right assistance can be provided at the right time. As such, rather than utilizing an algorithm-based approach for describing currently recommended strategies for neonatal resuscitation, we will discuss
the physiologic changes that occur at birth and highlight approaches that may best assist different subgroups of infants as their physiology changes. Many well-informed, recent publications have already detailed the currently recommended strategies for un_g_er aking neonatal resuscitation from a practical Rerspective (Weiner et al, 2018). We intend to take a d ifferent approach and will focus on the physiology. This is because currently recommended strategies for neonatal resuscitation will likely change as our understanding of the p t.siology improves and better strategies for facilitating the necess ry physiologic changes are identified. Indeed, much o f, the evidence underpinning current neonatal resuscitati 0 n guidelines is regarded as weak and/or absent SPerlman et al, 2015). The reasons for this are unclear, but it could be argued that a lack of scientific clarity regarding the physiology of transition is a major contributing factor. Nevertheless, in the following discussion, it will become evident that some of the emerging science is not consistent with current recommendations. This should not be misinterpreted as a recommendation for changing practice, but as the first important step in designing studies that will provide the required level of evidence needed to better guide practice.
ESTABLISHING PULMONARY VENTILATION
CASE1
You are called to the delivery room to resuscitate a late preterm infant born at 34 weeks' gestation by repeat cesarean section. The 1 min Apgar score is 2. You arrive at 90 sec of life. The infant is pale with a heart rate of 30 beats/min. The infant is receiving nCPAP with 100% oxygen, but only gasping intermittently. The Sao 2 reading on the pulse oximeter is 65%. The anesthesiologist has just begun chest compressions.
Exercise 1
Question
What is the next most appropriate next step in this infant's resuscitation, and what should have been done before you arrived?
Answer
Positive pressure ventilation should have been started immediately.
From a teleologic perspective, it is logical that the physiologic changes required for survival after birth are triggered by the one event that cannot occur in utero, lung aeration. Aerating the lung and establishing pulmonary ventilation triggers the physiologic changes that underpin the transition to newborn life (Hooper et al, 2015a). However, it is far too simplistic to assume that the primary benefit of “establishing pulmonary ventilation” is reestablishing oxygen and carbon dioxide exchange lost following umbilical cord clamping. Lung aeration not only triggers the switch to pulmonary gas exchange but also triggers a very large reduction in pulmonary vascular resistance (PVR), which initiates a series of cardiovascular changes that are also essential for survival after birth (see later). Positive pressure ventilation also enhances reabsorption of lung fluid.
CASE 1 CONTINUED
With initiation of positive pressure ventilation, the heart rate increases to 120/min and the saturation increases to 85% by 7 min of life. The infant is breathing regularly at 120 breaths/ min. Auscultation reveals fine rales and wet sounding rhonchi. You suspect the infant has a “wet lung syndrome.”
Exercise 2
Question
When is lung liquid reabsorbed? How did the mode of delivery influence the resorption of lung liquid?
Answer
Resorption of lung liquid begins antenatally and continues during labor and delivery. However, most lung liquid is reabsorbed postnatally when spontaneous or assisted ventilations begin. Infants delivered by cesarean section do not undergo the postural changes of vaginally delivered infants; those changes help to expel liquid from the lungs.
AIRWAY LIQUID CLEARANCE BEFORE BIRTH AND DURING LABOR
Although there is some evidence to suggest that airway liquid clearance begins late in gestation before labor onset (Jain and Eaton, 2006), this is not a consistent finding, and the role of experimental artefacts is unclear with regard to the original observations (Harding and Hooper, 1996). Nevertheless, considering the capacity of the lung to clear airway liquid during labor and after birth (see later), whether small amounts of liquid are cleared before labor appear inconsequential. However, it is clear that airway liquid clearance can begin during labor and vaginal delivery (Olver et al, 2004). The release of adrenaline in response to the stress of labor activates Na1 channels located on the luminal surface of airway epithelial cells, which promotes Na1 reabsorption from the airways
into lung tissue (Olver et al, 1986). This reverses the osmotic gradient for liquid movement across the airway epithelium, leading to liquid reabsorption, rather than secretion as occurs in utero. However, Na1 reabsorption requires high levels of adrenaline, is relatively slow, only arises late in gestation, and so is not active in very preterm infants (Hooper et al, 2016). Similarly, as cesarean section delivery in the absence of labor avoids the stress of labor, this mechanism is unlikely to be activated in infants delivered by cesarean section without labor (Jain and Eaton, 2006).
Partial airway liquid clearance can also occur during labor as a result of induced postural changes before and during delivery of the head (te Pas et al, 2008). The fetus is forced into an exaggerated “fetal position” with the enhanced dorso–ventral flexion causing an increase in abdominal pressure and rostral displacement of the diaphragm (Harding et al, 1990). This increases intrathoracic pressures and forces liquid to leave the lungs via the trachea (Hooper and Harding, 1995; Harding and Hooper, 1996). As the fetal respiratory system is highly compliant, only small increases in intrathoracic pressure are needed for large reductions in airway liquid volumes (Hooper and Harding, 1995; Harding and Hooper, 1996). Although this mechanism is applicable to infants born vaginally, as per Na1 reabsorption, it is not readily applicable to infants born by cesarean section, particularly in the absence of labor.
Airway Liquid Clearance After Birth
Lung aeration has significant implications for respiratory function in the newborn period, and to better understand these consequences, the process of lung aeration can be divided into a series of phases that give rise to separate challenges (Hooper et al, 2016).
1. The first phase commences at birth with liquid-filled airways, and so the primary challenge is to clear the airways of liquid, which occurs across the distal airway wall.
2. Airway liquid is cleared from the airways into the surrounding lung tissue at a much greater rate (over minutes) than it is cleared from the tissue (over hours). As such, airway liquid accumulates within lung tissue for the first few hours after birth, forming “perivascular fluid cuffs,” expanding the chest wall and increasing interstitial tissue pressures, essentially making the lung edematous.
3. Airway liquid is gradually cleared from lung tissue via the circulation and lymphatics, after which lung function and mechanics stabilize.
Exercise 3
Question
What is the importance of spontaneous breathing (or positive pressure ventilation) on promoting the clearance of lung water?
Answer
To clear lung liquid from the airways and alveoli, positive pressure ventilation (either spontaneous or assisted) must begin. Ventilation moves the liquid through the airways to
the distal respiratory units, where it is absorbed into the lung interstitium and then into lymphatics.
As noted earlier, the majority of liquid remaining in the airway is cleared across the distal airway wall. For this to occur, the liquid must move distally through the airways before leaving the airways and entering the surrounding distal lung tissue (Hooper et al, 2016). This process has been observed in newborn rabbits using phase contrast x-ray imaging, showing that the air/liquid interface moves distally during each inspiration (Hooper et al, 2007; Siew et al, 2009b) (Fig. 1.1). As no further distal movement occurred between breaths, lung aeration and the creation of a functional residual capacity (FRC) occurs in a stepwise fashion, increasing with each successive inspiration (Fig. 1.1). This led to the recognition that hydrostatic pressure gradients (between airways and lung tissue) generated by inspiration are largely responsible for airway liquid clearance after birth (Hooper et al, 2007; Siew et al, 2009b). Importantly, this mechanism provides a rational explanation for why very preterm infants who have little or no capacity to reabsorb Na1 are still able to clear their airways of liquid. As the air/liquid interface can also move proximally between breaths, causing a reduction in FRC, it is possible that liquid can reenter the airways between breaths, necessitating its reclearance with the next inspiration (Hooper et al, 2007; Siew et al, 2009b).
Exercise 4 Question
During the transition to postnatal life, what are the factors that govern whether airway liquid clearance is fast or slow?
Answer
Variables that regulate the rate of resorption of liquid include:
A. The surface area of the lung
B. Airway resistance (liquid has a higher resistance than air)
C. Resistance to moving the liquid across the walls of the distal airways
D. Tightness of the epithelial barrier
The initial resistance to air entering the lungs at birth is governed by both the resistance to moving liquid through the airways and by the resistance to moving this liquid across the distal airway wall. As water has a much higher viscosity than air, the resistance to moving air into the lungs is much greater when the airways are liquid filled compared with a few moments later when they are air filled (te Pas et al, 2009a, 2016). Consequently, airway resistance decreases markedly during the initial phase of lung aeration, as progressively more of the airways aerate and the reduction follows an exponential function that is difficult to predict (te Pas et al, 2009a, 2016).
Fig. 1.1 Simultaneous plethysmograph recording and phase contrast x-ray images of a spontaneously breathing newborn rabbit during lung aeration. Upper panel: Plethysmograph recording showing 6 spontaneous breaths over a 10 sec period along with the gradual recruitment in FRC that occurs with each breath. Spontaneous breaths are the large increases in lung volume (indicated by an *) that decrease to a gradually increasing baseline (functional residual capacity: FRC). The reduction in lung volume after each breath is an artefact from the plethysmograph measurement. Bottom panel: Phase contrast x-ray images of the newborn rabbit’s chest, acquired at the time points indicated on the plethysmograph recording (indicated by an arrow and the corresponding letter for each image). Little to no aeration is present in image A, whereas a significant amount of aeration is present in image C, which was acquired approximately 10 seconds later.
On the other hand, little is known about the contribution that the resistance to liquid movement across the distal airway wall makes to the overall resistance to airway liquid clearance. Based on the volume of liquid that can be cleared during one inspiration (up to 3 mL/kg), and knowing the duration of inspiration (100–200 mSec), the liquid flux across the pulmonary epithelium can be as high as 15 to 30 mL/kg/sec or 0.9 to 1.8 L/kg/min. Although transient, this is surprisingly high for liquid movement across the relatively tight pulmonary epithelium (Egan et al, 1975). A large surface area is one obvious factor that allows the lung to clear liquid at this rate, but the “tightness” of the epithelial barrier likely resists water transfer.
The immature lungs of preterm infants have airways that are smaller in diameter and have few if any alveoli. As reducing the radius of a tube increases its resistance by the 4th power and as the absence of alveoli markedly reduces the lung’s surface area, the resistance to airway liquid clearance is higher in preterm infants than in term infants (te Pas et al, 2016). As a result, either the process of lung aeration will be much slower, or preterm infants will require larger inspiratory efforts or higher inflation pressures to overcome this higher resistance. This concept is at odds with current resuscitation guidelines that suggest using lower inflation pressures during the initiation of lung aeration in very preterm infants compared with term infants (Perlman et al, 2015). This recommendation is based on an extrapolation from studies in aerated lungs suggesting that higher pressures cause lung injury. However, considering it is the volume change and not the pressure per se that causes lung injury (Jobe et al, 2008) and that a liquid-filled lung is orders of magnitude less compliant than an air-filled lung (te Pas et al, 2009a), this recommendation may be flawed and requires further investigation.
Previous studies have demonstrated that the fetal pulmonary epithelium is relatively tight, which restricts the entry of even relatively small molecules into lung liquid during development (Egan et al, 1975). However, at birth these pore sizes markedly increase, which likely reduces the resistance to liquid movement across the epithelium in term newborns (Egan et al, 1975). However, it is unknown whether this occurs in preterm infants or whether it occurs to a greater degree due to the immaturity of the epithelium. Although this could reduce the resistance to liquid clearance, it may also contribute to the entry of plasma proteins into the lumen, which will interfere with surfactant function.
Exercise 5
Question
In the delivery room, how will I know when this infant’s lungs are optimally aerated?
Answer
Heart rate, oxygen saturation and expired CO2
Heart rate and peripheral oxygen saturation levels, measured using a pulse oximeter and/or ECG leads, are commonly used to assess when neonatal resuscitation has
been “successful” (Dawson et al, 2010a, 2010b). The idea that an increasing heart rate is a sign of lung aeration is based on the concept that a low heart rate indicates a vagal-induced bradycardia in response to perinatal asphyxia (Dawes, 1968). As such, an increasing heart rate is assumed to reflect improved oxygenation following the onset of pulmonary gas exchange. However, it is now clear that an increase in heart rate can also occur after birth in the absence of an increase in oxygenation (Lang et al, 2015). In this instance, the increase in heart rate is secondary to an increase in PBF (in response to lung aeration), which increases venous return and left ventricular preload (Lang et al, 2015). Nevertheless, whether the increase in heart rate results from increased oxygenation or an increase in PBF, both only occur as a result of lung aeration.
An alternate indicator for lung aeration is the use of expired CO 2, which is closely related to the degree of lung aeration (Hooper et al, 2013). Indeed, it is such a sensitive indicator that it can detect breath-by-breath changes in lung aeration in parallel with the changing tidal volumes and increases much more quickly in response to lung aeration than an increase in both heart rate and oxygenation in infants (Hooper et al, 2013; Blank et al, 2014; Schmolzer et al, 2015). The close relationship between end-tidal expired CO 2 levels and tidal volumes is because CO 2 exchange is surface-area limited during lung aeration. As CO 2 has a high solubility, its diffusion across the pulmonary epithelium is very efficient and is not normally surface-area limited. As such, end-tidal CO 2 levels are commonly used to estimate pulmonary arterial blood P co 2 levels and can be used to calculate cardiac output (Trillo et al, 1994). However, when the lung is not fully aerated, the surface area available for gas exchange at end inspiration is dependent on the size of the tidal volume (Hooper et al, 2013). When tidal volumes are larger, the surface area for gas exchange increases, which increases the efficiency of CO 2 exchange.
Although CO2 monitoring in the delivery room is currently not routine, in combination with tidal-volume monitoring, it provides a reliable method for assessing the effectiveness of pulmonary ventilation immediately after birth. Indeed, considering that the dead space of the lower airways is 2 to 3mL/kg and that the pharynx is expandable (Crawshaw et al, 2017), it is possible to achieve significant tidal volumes (3–4 mL/kg) without gas entering the gas exchange regions of the lung. As such, the baby would appear to be ventilated, but oxygenation levels and heart rate would likely remain low. However, the absence of any expired CO2 would indicate that the gas exchange regions are not being ventilated. Some of the new respiratory function monitors include the ability to measure expired CO2 levels, although increasing dead-space volume is an issue, and are most effectively used in combination with tidal-volume monitoring. Alternatively, a colorimetric CO2 indicator, which changes color in response to expired CO2, can be used to indicate when gas exchange has commenced (Blank et al, 2014).
Exercise 6 Question
During resuscitation, what alternate resuscitation strategies might be used to improve uniform lung aeration and better ventilation in this infant?
Answer
Increase in positive end expiratory pressure (PEEP) or sustained lung inflation
Recognition that airway liquid clearance after birth results from the generation of hydrostatic pressure gradients (between airways and lung tissue) has provided opportunities for developing strategies that facilitate this process in very preterm infants. Indeed, in a simplistic sense, all that is required is to apply a gas pressure to the airways to overcome the high resistance of moving liquid through the airways and across the distal airway wall. This rationale is consistent with the current recommendations for using either intermittent positive pressure ventilation (iPPV) or continuous positive airway pressure (CPAP) in combination with the infant’s spontaneous breathing to assist preterm infants initiating pulmonary gas exchange after birth (Perlman et al, 2015; Weiner et al, 2018).
However, the big question is how much pressure should be applied? Indeed, if the applied pressure is too low, it will be insufficient to overcome the resistance required to move the liquid distally through the airways. If it is too high, then there is a risk of causing overinflation and lung injury in lung regions that have already aerated (Jobe et al, 2008). To add to the complexity, as the airway resistance dramatically decreases (by 100 fold) with airway liquid clearance, the pressures required to move the liquid at any given flow rate will also greatly reduce (te Pas et al, 2016). Considering the huge variability expected between individual infants at birth, particularly with the amount of liquid present in the airways and the level of inspiratory effort each will apply, stipulating a single set inflation pressure or CPAP level to assist preterm infants to aerate their lungs at birth ignores this complexity. Clearly the pressure required will be different in different infants and will change as the lung aerates. Although we now have a grasp of the complexities involved in facilitating lung aeration in very preterm infants, the challenge is to apply this knowledge in a useful and practical manner (Jobe, 2011).
During lung aeration, ideally the respiratory support applied should change in accordance with the change in resistance caused by airway liquid clearance. High airway pressures could be applied initially when the resistance is high, which decrease as the airway resistance decreases to avoid overinflation and lung injury. However, to decrease the applied pressure in synchrony with the decreasing resistance requires complex feedback information regarding the changing airway resistance. Although modern ventilators can measure airway resistance on a breath-by-breath basis, they are rarely used in the delivery room even if the infant is intubated. Instead, low-technology devices such as resuscitation bags or t-piece devices are more commonly used, mostly in
combination with noninvasive ventilation (Schmolzer et al, 2010; Schilleman et al, 2013). These provide little or no opportunity to measure airway resistance and provide little information on how to modify the required ventilation parameters as lung mechanics change unless it is combined with a respiratory function monitor. It seems counterintuitive that sophisticated ventilators and monitoring equipment are commonly used in the NICU once the lung has aerated and respiratory mechanics have stabilized, but they are not routinely used in the delivery room when respiratory mechanics are rapidly changing and respiratory function is very difficult to manage in a safe and effective way.
SUSTAINED INFLATION DURING RESUSCITATION
The movement of air into the lung at birth is primarily determined by airway resistance and the applied pressure gradient, as defined by F 5 DP/R; where F is flow, DP is the pressure gradient and R is airway resistance, which includes the resistance to moving liquid across the distal airway wall. As flow equals volume (V) divided by time (T), the factors determining the movement of air (inflation volume) into the lung can be defined as V 5 (DP 3 T)/R. As such, the main controllable factors determining inflation volume are the applied pressure gradient (DP) and time (T) over which the pressure is applied (inflation time). Although increasing the inflation pressure can overcome the high initial resistance, as the resistance decreases with lung aeration, there is a high risk of overinflating and injuring the lung if the pressure is not simultaneously reduced. Alternatively, increasing the inflation time using a slower, sustained inflation (SI) allows lower inflation pressures to be used. Although the initial flow of gas into the lung is slow, it rapidly increases as more of the airways aerate and the resistance decreases (te Pas et al, 2016). Theoretically, this approach has multiple advantages, as during a sustained inflation the lung’s end inflation volume is self-limiting and determined by the inflation pressure, which can be much lower than the pressure required to initially aerate the lung with a shorter inspiratory time.
As different lung regions aerate at different rates, a SI allows more lung regions to aerate during a single inflation (te Pas et al, 2009b, 2009a). This has important implications for lung injury, because during the subsequent inflation, air will rapidly flow into and expand aerated lung regions first due to the much lower airway resistance. Therefore if the inflation time is short (as occurs with iPPV), the entire tidal volume will only enter aerated regions, potentially causing overexpansion and injury in those regions with little further lung aeration (Siew et al, 2009a, 2011). Furthermore, as gas exchange only occurs when the distal gas exchange regions aerate, there is no reason to terminate the inflation to allow exhalation when these regions are liquid filled. These explanations underpin the rationale for providing a SI for the first inflation after birth, but the benefits described in animal studies have not been replicated in humans (van Vonderen et al, 2014a; Lista et al, 2015). Although the reasons are
unclear, in animal studies the SI was applied with an endotracheal tube, whereas in all human studies, the SI was applied noninvasively, usually with a face mask (including the SAIL trial). This is a major point of difference (see later), and studies that are restricted to comparing a SI with conventional ventilation in intubated infants may possibly reveal results that are as clear cut as the animal studies.
Exercise 7
Question
What are the adverse effects of higher levels of PEEP or sustained inflation during resuscitation?
Answer
High levels of PEEP or a prolonged sustained inflation can decrease venous return and reduce cardiac output.
Recent studies have suggested that a stepwise PEEP recruitment maneuver (up to 20 cmH2O) that extends over 2 to 3 minutes can achieve better postmaneuver lung mechanics than an SI (McCall et al, 2016). This suggestion is consistent with the concept that lung aeration is a function of applying an elevated pressure over an extended period, and the results show significant improvements in lung mechanics (Tingay et al, 2016, 2017). However, applying this maneuver ignores the cardiovascular consequences of applying high elevated airway pressures that increase intrathoracic pressures for an extended period. Simple physics dictates that as soon as intrathoracic pressures exceeds central venous pressure, then all venous return to the heart will cease and, as such, cardiac output must decrease (see later). Furthermore, in the aerated lung, high PEEP levels reduce PBF, and this effect on PBF is not completely reversed following the reduction in PEEP (Polglase et al, 2005). Although this adverse effect of increased intrathoracic pressure on PBF is applicable to both a sustained inflation and PEEP recruitment maneuver, a sustained inflation does not influence the time related increase in PBF, perhaps because sustained inflation is only 10 to 30 seconds long (Sobotka et al, 2011). However, the PEEP recruitment maneuver can take 2 to 3 minutes (Tingay et al, 2016, 2017), and it is unclear how it influences the increase in PBF at birth. There is also a need to be cautious of any rebound in cardiac output, as per a Valsalva maneuver that may occur post maneuver.
Whether a sustained inflation or a PEEP recruitment strategy is the most effective approach for aerating the lung remains unclear, and more studies are required. In particular, there is much debate about what is the most appropriate starting pressure and duration of the sustained inflation. However, evidence from animal studies indicate that these are not the correct starting points (McCall et al, 2016), particularly as a “one-size-fits-all” approach is unlikely to be successful in different infants (te Pas et al, 2009a, 2016). Targeting a set inflation volume instead of a fixed inflation time and using a ramped pressure increase, which is then held constant once gas starts to move into the lungs, may be more appropriate (Polglase et al, 2014; McCall et al, 2016; te Pas et al, 2016). Measurement of CO2 levels in the expired air
can then indicate whether a second inflation is needed. This approach is easy to implement in animals, but its application in humans will depend on the use of sophisticated approaches to monitor newborns immediately after birth (McCall et al, 2016).
CASE 1 CONTINUED
At 60 min of life the infant’s respiratory rate is 120/min. There is intermittent grunting. The inspiratory oxygen concentration is 100% to achieve a saturation of 90%.
Exercise 8
Question
Why is this infant tachypneic?
Answer
The increased water in the interstitium of the lung has reduced the infant’s lung compliance and reduced its inspiratory reserve volume by expanding the chest wall and flattening the diaphragm.
At birth, the liquid residing in the airways following the first breath is rapidly cleared into lung tissue, forming perivascular fluid cuffs (Bland et al, 1980). As liquid clearance from the tissue takes hours, the volume of liquid residing in the airways at birth must be accommodated within the lung’s interstitial tissue during this time (Bland et al, 1980; Miserocchi et al, 1994). This has consequences for respiratory function in the newborn period (Berger et al, 1996), including an increase in interstitial tissue pressure (Miserocchi et al, 1994). This in turn increases the potential for liquid to reenter the airways during expiration and expansion of the chest wall (Hooper et al, 2007; McGillick et al, 2017). Indeed, although the liquid has cleared from the airways, it remains within the thorax, forcing the chest wall to expand to accommodate both the liquid and the air that creates the newly formed FRC (Hooper et al, 2007; McGillick et al, 2017).
Exercise 9
Question
Assuming this infant’s lung water is increased, how can respiratory function be improved?
Answer
Increasing the positive end expiratory pressure
It is both fortuitous and necessary that the newborn’s chest wall is very compliant so that it can easily expand without further increasing interstitial tissue pressures and opposing FRC formation. This explains the importance of applying an end expiratory pressure on the airways during the immediate newborn period (Siew et al, 2009a). The positive airway pressure not only prevents the lung from collapsing but also opposes the elevated interstitial pressure and prevents liquid reentering the airways during expiration (Siew et al, 2009a). Phase contrast x-ray imaging in ventilated very preterm rabbits (Figs. 1.2 and 1.3) has clearly demonstrated that a FRC will not develop, largely due to liquid
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There are violent improbabilities here, but children like the book, and listen to it eagerly. The lesson of Christian love is taught by an old bedridden woman to various classes of children, among whom are some of the circus children, who have such a fascination for young readers.
51. Little Lives and a Great Love. By FLORENCE WILFORD. (Masters) 2s.6d.
Four tales designed to illustrate the text, ‘The love of Christ constraineth us,’ in a scale gradually ascending. Of the four, only the first is historical.
52. Helpful Sam. (Griffith, Farran, & Co.) 6d.
A very real and quaint young chimney sweep.
53. The Beautiful Face. By Mrs. MITCHELL. (Masters) 4s.6d.
A veritable child’s romance, not attempting to be historical, but graceful, tender, and bright enough to delight children.
54. Dandy. (S.P.C.K.) 6d.
A pleasant story of a lost dog.
55. Ben Sylvester’s Word. By C. M. YONGE. (Walter Smith) 3d. or 1s.
The value of truth in a witness. The murder in this has secured its popularity.
56. Little May and her friend Conscience. By Mrs. CUPPLES. (Nelson) 9d.
A debate with conscience.
57. Tim’s Basket. (Nelson) 6d.
Might cheer a crippled child.
58. Story of a Needle. By A.L.O.E. (Nelson) 1s.6d.
Autobiographical.
59. The Two Watches. By the Author of ‘Copsley Annals.’ (Nelson) 1s.
Didactic but lively.
60. Baby’s Prayerbook. By Mrs. SITWELL. (S.P.C.K.) 8d.
A tiny girl unconsciously leading her elder brother to a right course.
61. Wings and Stings. By A.L.O.E. (Nelson) 1s.
Once this was read to a class who delighted in it. Another year it fell flat, owing, perhaps, to the children having less imagination.
62. It’s his Way. By the Author of ‘Copsley Annals.’ (Nelson) 1s.
Very good for reading aloud.
63. Northope Cave. By MRS. SITWELL. (S.P.C.K.)
Seaside adventures, a brave little self-devoted fisher-boy among babies.
Most children are advanced enough at this age to prefer what is a little out of their own field; though here there will always be the differing tastes for adventure or character, and imaginative or matter-of-fact literature. What will fall flat with some will be appreciated by others; and, in general, what has been read to them is best liked. Explanations can be given, right intonations are explanatory in themselves, and foreign or unusual names are better understood.
64. Under the Lilacs. By LOUISA ALCOTT. (Sampson Low) 2s.
A stray boy and poodle, escaped from a circus, arrive in the middle of a doll’s feast held by a widow’s little girls. The house becomes their home, and the scenes are delightful, especially when the poor dog is lost and comes back minushis tail.
65. On Angels’ Wings. By the Hon. Mrs. GREENE. (Nelson) 5s.
Pathetic and tender. A deformed and sickly child in a German town has to part with her father on his summons to the war. Little Violet’s patience, the drolleries of her little friends, the kindness of the old
policeman, and the thoughtlessness of her young nurse go to children’s hearts.
66. The Abbey by the Sea. By Mrs. MOLESWORTH. (S.P.C.K.) 1s.
A furniture designer of evidently much cultivation with his little daughter by the sea-side. Perhaps too ideal, but refining.
67. The Golden Thread. By Dr. NORMAN MCLEOD. (Isbister) 2s.6d.
This will also be found among the allegories, but it is, even as a mere story or romance, so charming to young listeners that it is here introduced.
68. Feats on the Fiord. By HARRIET MARTINEAU. (Routledge) 1s. and 1s.6d.(With 40 illustrations, 2s.)
Too lively and amusing to be out of date. Norwegian life is made perhaps rather too rose-coloured, but the adventures have a merit and interest apart from actual truth to nature.
69. The Ghost of Greythorn Manor. (Nelson) 6s.
May be useful where children or servants fear a haunted house.
70. Little Rosa. By Mrs. PRENTICE. (Nelson) 6d.
Fittest for the poor children to whom Father is a word of fear.
71. The Magpie’s Nest. (Nelson) 6d.
72. The Children on the Plains. (Nelson) 1s.6d.
Adventures on the Prairies with Red Indians; a good deal of religious talk.
73. Daughter of the Regiment. (Sunday School Union) 2s.
Children captured by Red Indians.
74. Leila, or the Island. By M. FRASER TYTLER. (Hatchards) 3s.6d.
Leila has always been an unfailing favourite. The second and third parts of her story are unequal to the first volume, which is
improbable enough, but such pretty and pleasant reading, and so sound-hearted, that it is quite a child’s classic.
75. Mr. Burke’s Nieces. (Cassell) 2s.
Confusion of identity between two children brought home from India, one of whom the Irish barrister believes to be his niece. It turns upon jealousy.
76. Little Hinges. (Cassell) 2s.6d.
A child’s disobedience in apparently a small matter leads to great family misfortunes. A sound lesson against ‘doing right in our own eyes.’
77. The Thorn Fortress. By M. BRAMSTON. (S.P.C.K.) 1s.
This will be classed among historical tales, as it belongs to the period of the Thirty Years’ War, but the interest is sufficient to win children quite ignorant of the history of the period. The inhabitants of a village in the track of the armies have a refuge in the forest, impregnably fenced with thorn bushes. The adventures of a little maiden, who falls into the hands of the marauders, and wins their heart by her innocent sweetness, are enjoyed by all readers and hearers.
78. Max Krömer. By HESBA STRETTON. (R.T.S.) 1s.6d.
The Siege of Strasburg from a child’s point of view.
79. Lost in Egypt. By Miss M. L. WHATELY. (R.T.S.) 4s.
The adventures of the little daughter of an English engineer, suddenly left an orphan in a remote place, and abandoned by the servants. She is adopted by a peasant woman, and afterwards has experience of several Egyptian houses before she is recovered by her English grandmother. Here and there it is lengthy, and some conversations might be spared, but it has been listened to and read with great interest.
80. The Blue Ribbons. By ANNA HARRIET DRURY. (Kerby) 3s.6d.
Founded on the anecdote of Marie Antoinette acting fairy to the child she met in the wood.
81. Hans Brinker, or the Silver Skates. By MARY M. DODGE. (Sampson Low) 1s.
Delightful scenes of Dutch winter life.
82. The Oak Staircase. By M. and C. LEE. (Griffith, Farran, & Co.) 3s.6d.
This is the best for reading aloud of the three historical tales by these ladies. It begins with a child wedding in the days of Charles II. The little bride (a Countess) is sent to school at Taunton, where the mistress, a Huguenot, is enthusiastic in Monmouth’s cause, and the poor girls are among ‘the maids of Taunton.’ The young husband intercedes, but goes into banishment with the Jacobites, and his wife has in after times to procure his pardon, after which they begin their married life. The book has been found very attractive to children.
83. The White Chapel. By ESMÉ STUART. (S.P.C.K.) 2s.
A dreamy child’s adventure, very prettily told, connecting the little white curtained bed with the white chantry chapel in a cathedral.
84. The Carved Cartoon. By AUSTIN CLARE. (S.P.C.K.) 4s.
This has been much enjoyed when read aloud to somewhat intelligent Sunday-school children in the country, and Londoners always like it. The title is unfortunate, for a cartoon cannot be carved, and what is meant is a copy of a cartoon made by Grinling Gibbons, whose adventures in the Plague and Fire of London are made very interesting.
85. Ivo and Verena. (Masters) 2s.
A beautiful little Fouqué-like tale of early Christianity in the North.
86. Peggy and other Tales. By FLORENCE MONTGOMERY. (Cassell) 2s.
This may be useful where temperance tales are required, though we rather wonder at the father who chose such a subject to amuse his little children.
87. The Ambition of Kate Hicks. (S.P.C.K.) 4d.
Useful for girls going out to service.
88. The Grey House on the Hill. By the Hon. Mrs. GREENE. (Nelson) 2s.6d.
A lonely page-boy falsely accused.
89. I must keep the Chimes going. By Miss ELLIOT. (Seeley) 1s. 6d.
A very beautiful story of a girl in a hard place, but with a cheerful spirit.
90. Friarswood Post Office. By C. M. YONGE. (Walter Smith) 2s. 6d.
A history of a workhouse lad, founded on fact.
91. The Pink Silk Handkerchief. (Walter Smith) 2d.
A useful tale of deceit and vanity.
92. The Girls of Flaxby. By C. R. COLERIDGE. (Walter Smith) 2s.
Pupil-teachers shown in a manner useful to them and still more so to those who have to deal with them.
93. Lads and Lasses of Langley. By C. M. YONGE. 2s. (See No. 28.)
Stories of village life, chiefly for the elder children; curiosity and a few other follies shown up.
94. Polly Spanker’s Green Feather. By Mrs. WALFORD. (S.P.C.K.) 4d.
Droll disaster with finery.
95. Sowing and Sewing. By C. M. YONGE. (W. Smith) 1s.6d.
An endeavour practically to illustrate the Parable of the Sower.
96. Stories of Youth and Childhood. (Walter Smith) 2s.
These first appeared in the ‘Magazine for the Young,’ and are very good. Phœbe, who is sent to the hospital, is our special favourite.
97. Copsley Annals. By Miss ELLIOT. (Seeley) 1s.6d.
These are unusually interesting. The supposed ghost, which turns out to be a clock whirring, excites breathless interest. The last story is better fitted for mothers than children.
98. The House of the Little Wizard. (Hatchards) 3s.6d.
99. Goldhanger Woods. By M. AND C. LEE. (National Society) 2s.
This calls itself a child’s romance, and has some exciting adventures.
100. My Great Aunt’s Cat. (S.P.C.K.) 2d.
A droll and wholesome warning against false excuses.
101. Uncle Ivan. By M. BRAMSTON. (National Society) 2s.6d.
Two sisters have to guard the papers of their uncle, a political exile, against spies. Very amusing for rather advanced readers such as pupil teachers.
102. Wild Thyme. (S.P.C.K.) 4d.
103. Susan Pascoe’s Temptation. (S.P.C.K.) 4d.
The first of these is very touching, the second its continuation and a good lesson.
104. Self Conquest. By FLORENCE WILFORD. (S.P.C.K.) 1s.
Another rescue from a circus.
105. Marty and the Mite Boxes. (Shaw) 3s.6d.
An American story of contributions to a church, and the exertions of a rough little set of choir boys.
106. Little Jeanneton’s Work. By C. A. JONES. (Wells Gardner, Darton, & Co.) 3s.6d.
A little shepherdess whom the young lady of the château nearly spoils by making her Arcadian. Very prettily illustrated.
107. A Peep behind the Scenes. By Mrs. WALTON. (R.T.S.) 3s.6d.
This is an American story of a self-willed child, which children like very much. She chooses during her mother’s absence from home to board with people of her own selection, and gets into very comical predicaments.
109. A Little Step-daughter. By the Author of the ‘Atelier du Lys.’ (National Society) 3s.6d.
A child stolen by smugglers in the wild districts of Southern France in the time of Louis XV., taken care of by a woman who feeds silkworms. Very interesting.
110. Alone in Crowds. By ANNETTE LYSTER. (S.P.C.K.) 3s.
A youth bred up by his father on a desert island from early infancy. When rescued and brought home he is utterly astray and perplexed in England.
111. The Giant Killer. By A.L.O.E. (Nelson) 3s.
This is rather stilted, but has been much enjoyed by elder children. It is much better than the second part ‘The Roby Family.’ As a rule, this lady’s books are very religious, without Church teaching, and a little too stiff in language, but useful.
112. Bear and Forbear. (Cassell) 2s.
An excellent tale of an Edinburgh newspaper boy.
113. Rhoda’s Reward. By Mrs. MARSHALL. (Cassell) 1s.
A young girl who overcomes a strong temptation.
114. For Half-a-Crown. By ESMÉ STUART. (National Society) 3s.
This is the price of a poor Italian baby bought out of the slums of Portsmouth, and bred up to be a very spirited and interesting little person.
115. Three Stories for Working Girls. (S.P.C.K.) 1s.
This, like ‘Kate Temple’s Mate,’ is chiefly fitted for the rough girls of factories.
BOYS.
Boys are here treated as separate subjects. The mild tales that girls will read simply to pass away the time are ineffective with them. Many will not read at all. Those who will read require something either solid, droll, or exciting. There are lads who will study books of real information with all their might, and will take up pursuits of science, or enter into poetry. This, however, comes (if at all) at the age when school is over and labour has begun, so that intellectual occupation is not the task but the refreshment. The solid, therefore, is not attempted in the present list. What it aims at giving is such a choice of books as boys will listen to with interest, or if they read in quieter moments, or in illness, may find so amusing as not to be tempted to think that nothing diverting or stimulating is to be found beyond the Penny Dreadful. If their taste can be kept unsullied during the time of growth, there is more hope for it afterwards.
The books here mentioned are all suitable for circulation in any general library, but are placed separately as an answer to the oftasked question, ‘Do you know of anything my boys willread?’
Many well-intentioned and really pretty books are omitted, even though written for boys, because they do not seem to hit off the peculiar taste of that large class. Others are omitted because, though there is little harm in them, and we should not object to seeing a lad reading them, if of his own catering, yet parish libraries
and school rewards give a kind of recommendation to a book which makes it needful that it should be beyond censure. For instance, that exciting and entrancing tale, ‘King Solomon’s Mines,’ is marred by the falsehoods told to the natives, and (more injuriously perhaps) by the constant reference to bad language on the part of the naval lieutenant, in a style to confirm boys in their notion of its being a manly fashion. Its successor, ‘The Phantom City,’ has none of these defects. Be it remembered that this catalogue is only intended to suggest and assist, not to exclude, and likewise that the works therein are not merely suited to lads, for though girls will often greatly prefer a book about the other sex, boys almost universally disdain books about girls.
We need only name this first and best of all desert island tales, which ought to be read as an English classic by all young people— not boys alone.
117. The Swiss Family Robinson. (Warne), 1s. 6d., (Cassell), 5s., (Marcus Ward), 2s.6d., 3s.
It is a curious fact that this book was written by the tutor of Baron Humboldt and his brothers. It certainly encouraged a considerable spirit of adventure, and perhaps was partly inspired by the pupils’ interest in it as it proceeded. The second edition here mentioned is well illustrated, and is a fresh translation, more accurate perhaps, but scarcely so inviting to the childish English reader as the first more freely abridged version. The adventures are unfortunately more charming than possible in either naval or scientific eyes.
118. Masterman Ready. By Captain MARRYAT. (Warne) 5s.
The outcome of a sailor’s disgust at the Swiss family’s raft of tubs and other impossibilities. Written with the ability of a distinguished novelist, and exercising over the children the fascination of the two preceding tales.
119. The Island Queen. By R. M. BALLANTYNE. (Nisbet) 3s.6d.
Here a young lady is by general consent elected to be queen of a shipwrecked crew. Mr. Ballantyne’s tales of adventure are perfectly safe from the moral point of view, and always have a religious tone, but when any matter brings forward points of difference, the tone is not that of the Church. Happily, however, there is seldom room for any such difficulty.
120. The Young Crusoe. By Mrs. HOFLAND. (Nelson) 1s.6d.
The best of this once popular author’s stories republished.
121. The Fate of the ‘Black Swan.’ By F. FRANKFORT MOORE. (S.P.C.K.) 3s.
A search in New Guinea for a missing brother.
122. The Fortunes of Hassan. (S.P.C.K.) 2s.6d.
Hassan is a dog who sees a good deal of the fortunes of war in Bulgaria.
123. The Good Ship ‘Barbara.’ By S. W. SADLER, R.N. (S.P.C.K.) 3s. 6d.
Two brothers, one in the navy, the other in the merchant service, see a good deal of the coast of Africa. The introduction of an ‘unattached’ and helpless missionary is the only weak point.
124. Ned in the Blockhouse. (Cassell) 2s.6d.
125. Ned in the Woods. (Cassell) 2s.6d.
126. Ned on the River. (Cassell) 2s.6d.
127. The Camp Fire and the Wigwam. (Cassell) 2s.6d.
128. The Lost Trail. (Cassell) 2s.6d.
129. Footsteps in the Forest. (Cassell) 2s.6d.
American, Fenimore Cooper-like adventures, but without the love or the somewhat stilted language. There is an admirable Red Indian hero, a Christian, who appears in all difficulties. Boys revel in these books, which seem to have an unusual attraction for them. The three first form the ‘Boy Pioneer Series,’ the three last the ‘Log Cabin Series.’ Many of the real pioneers of Kentucky are introduced.
130. Lost in the Backwoods. By Mrs. TRAILL. (Nelson) 3s.6d.
Adventures in a Canadian forest of fifty or sixty years ago. Well worthy of its republication.
131. The French Prisoners. By BERBY. (Macmillan) 4s.6d.
The friendship that springs up between some German boys and their French captives, well told.
132. Treasure Island. By R. L. STEVENSON. (Cassell) 5s.
So exciting and engrossing that it must be mentioned, but bringing the reader into rough company, among a good many horrors.
133. Tom Brown’s School Days. By T. HUGHES. (Macmillan) 2s. or 6d.
The life is so fresh and wholesome in spirit that, though the sphere is so different from that of the elementary school-boy, his tone may be raised by it.
134. Ascott Hope’s Tales.
These are too numerous and have too many different publishers for enumeration, but all are lively and wholesome tales of boyhood mostly in school life, and are good to lend and give.
135. The Crofton Boys. By HARRIET MARTINEAU. (Routledge) 1s. and 1s.6d.(With 40 illustrations, 2s.)
A very attractive story of a brave little boy at school, who loses his foot by an accident, and resolutely conceals the name of the
perpetrator.
136. Follow the Leader. By TALBOT B. REED. (Cassell) 5s.
Another public-school story, sound and spirited, and likely to interest. People sometimes learn best from what does not profess to be about their own life.
137. In Quest of Gold on the Whanga Falls. By C. H. JOHNSTONE. (Cassell) 3s.6d.
Exciting Australian adventures. It is to be hoped they will not inspire the gold fever, for which, however, ‘True Gold’ (see No. 602) may be an antidote.
138. The Boy with an Idea. By Mrs. EILOART. (Warne) 2s.6d.
An inventive genius, always getting into exquisitely droll predicaments, some of which are quite fit to do duty at a penny reading.
139. Twenty Thousand Leagues under the Sea. By JULES VERNE. Two parts. (Low) Cloth 3s.6d., boards, 2 parts, 1s.each.
140. The Mysterious Island. Three parts. (Low) Cloth 2s., boards 1s.each.
141. The Earth to the Moon and a Trip round it. (Low) Cloth 2s., boards 1s.each.
142. Five Weeks in a Balloon. (Low) Cloth 2s., boards 1s.
143. Dr. Ox’s Experiment. (Low) Cloth 2s., boards 1s.
144. The Steam House. (Low) Two parts. Cloth 2s., boards 1s. each.
Jules Verne is a modern Baron Munchausen with an air of science and a Frenchman’s ironical gravity. To some he is perfectly enchanting, but there are soberer minds who are bewildered as to whether the wonders they read of are meant for truth or fiction, and
dislike him accordingly. We have only mentioned a small selection of his translated works, but all are perfectly safe, for he is a religious, sound-hearted man. ‘Dr. Ox’s Experiment’ is short enough for a penny reading among intelligent people.
145. Ben Sylvester’s Word. (See No. 55.)
146. Frank’s Debt. By C. M. YONGE. (Walter Smith) 3d.
The dull rude lad raised by better surroundings.
147. The Little Duke. (See No. 488.)
148. The Caged Lion. (See No. 410.) 6s.
149. Harry and Archie. (See No. 254.)
150. Pickle and his Page Boy. (See No. 30.)
151. For Fortune and Glory, a Story of the Soudan War. By LEWIS HOUGH. (Cassell) 5s.
A somewhat wild story, involving adventures with an old semimadman who has turned Mahometan, but with a very graphic description of life in the English army.
152. On Board the ‘Esmeralda.’ By J. HUTCHESON. (Cassell) 3s.6d.
No harm in it, though the Squeers establishment at the beginning might have been spared.
153. Jackanapes. By J. H. EWING. (S.P.C.K.) 1s.
This beautiful story wins the attention of boys, but those who read it to them find it advisable to skip the unnecessary incident of the elopement.
154. Mutiny on the ‘Albatross.’ By F. FRANKFORT MOORE. (S.P.C.K.) 3s.6d.
Exactly fulfilling the boy’s description, ‘A pretty book with plenty of killing.’
155. Nimrod Nunn. (S.P.C.K.) 2s.
A village waif becomes a brave soldier, and is killed in Egypt.
156. Pirates’ Creek. By S. W. SADLER. (S.P.C.K.) 3s.
157. Tales by W. H. Kingston.
There are so many of these, and brought out by so many publishers (S.P.C.K.), (Griffith, Farran, & Co.), (Warne), (Shaw), (Nisbet), (Routledge), that it is hardly possible to collect or enumerate them, and one description answers for all. They are full of adventure, well studied from travels and geography, perfectly safe and innocent, with more incident than character, and very useful for those who love adventurous tales.
158. Tales by R. M. Ballantyne.
These also are too numerous for individual mention. They teach much as to manners, geography, &c., and there is a conscientious, religious tone about both authors, but Mr. Ballantyne’s are apt to be rather confused where any Church matter comes in question.
159. A Hero: Philip’s Book. By the Author of ‘John Halifax.’ (Routledge) 1s.
A very striking picture of moral versusphysical courage.
160. Straight to the Mark. By the Rev. T. S. MILLINGTON. (R.T.S.) 5s.
A good schoolboy tale.
161. Paul Howard’s Captivity. (Griffith, Farran, & Co.) 1s.6d.
A boy who propitiated his Chinese captors by his knowledge of watches.
162. Will’s Voyages. By F. F. MOORE. (S.P.C.K.) 3s.6d.
163. The ‘Great Orion.’ By F. F. MOORE. (S.P.C.K.) 3s.
164. The Adventurous Voyage of the ‘Polly.’ By S. W. SADLER. (S.P.C.K.) 3s.
165. Scapegrace Dick. (See No. 460.)
166. In the Land of the Moose, the Bear, and the Beaver. By ACHILLES DAUNT. (Nelson) 3s.6d.
167. In the Bush and on the Trail. (Nelson) 3s.6d.
Both these are beautifully got up, and will make the boy who gets either of them for a prize happy at the moment, and sure to imbibe some real knowledge of the places named and animals described.
168. Yussuf the Guide. By G. MANVILLE FENN. (Blackie) 5s.
Travels in Asia Minor. Full of adventures and often very droll.
169. Devon Boys. By G. MANVILLE FENN. (Blackie) 6s.
An excellent set of seaside adventures near Barnstaple in the old smuggling times.
170. The Final Reckoning. By G. A. HENTY. (Blackie) 5s.
Bush life in Australia in the convict times.
171. Beyond the Himalayas. By JOHN GEDDIE. (Nelson) 3s.6d.
172. Lake Regions of Central Africa. By JOHN GEDDIE. (Nelson) 3s. 6d.
173. The Castaways in the Wilds of Borneo. By MAYNE REID. (Nelson) 3s.6d.
174. Frank Redcliffe. (Nelson) 3s.6d.
Adventures in South America.
175. Mark Willis. (Nelson) 1s.6d.
Adventures of a sailor boy.
All these are interesting tales of enterprise conveying much useful geographical information, and wholesomely sound and amusing.
DRAWING-ROOM STORIES.
The stories under this head are chosen for their unusual excellence, but they deal in general with a way of life, with pursuits, allusions, and temptations, so much out of the line of the ordinary clients of the parish library that we do not recommend them for that purpose, although they would do no harm but decidedly good, so far as they were understood, and, where readers of a superior degree are included, would be excellent.
176. The Langdales of Langdale End. By ELEANOR LLOYD. (Marcus Ward) 3s.6d.
A lively, clever set of children, slightly over-independent of their parents. They get into a scrape by secretiveness about their pleasures, and their discussions of their clergyman might not be edifying to some readers.
177. Hermy, the Story of a Little Girl. By Mrs. MOLESWORTH. (Routledge) 2s.6d.
A pleasant nursery tale.
178. Miss Fenwick’s Failures. By ESMÉ STUART. (Blackie) 2s.6d.
A governess’s troubles with naughty children.
179. A York and a Lancaster Rose. By ANNIE KEARY. (Macmillan) 6s.
One Rose is a professor’s daughter, the other is a carpenter’s. They come into connection at the soup kitchen of a Sisterhood, much to their mutual benefit. The trials of the professor’s daughter are those of a large intellectual family in a London house, where inclination often has to be silently sacrificed.
180. Laneton Parsonage. By ELIZABETH SEWELL. (Longmans) 1s.
The catechism illustrated practically by three periods of the lives of a clergyman’s daughters—at home, at school, and after the return from school.
181. Sweet William. By Mrs. ERSKINE. (S.P.C.K.) 1s.6d.
An engaging little girl, devoted to her butterfly-hunting brothers, but waking to high and deep aspirations, which find their first fulfilment in the discovery of an old cottage woman’s lost son.
182. Grumble. By Mrs. ERSKINE. (S.P.C.K.) 1s.
The pinch of agricultural depression felt but not understood in the nursery drives a little damsel to try to mend matters by wishingin a fairy ring.
183. The Birthday. By Lady HARRIET HOWARD. (Masters) 3s.6d.
A charming set of children in high life, simple, natural, and wholesome, a favourite of many years’ standing.
184. The White Gipsy. By ANNETTE LYSTER. (S.P.C.K.) 3s.
A child picked up by gipsies after a railway accident, and bred up among them till recovered by his mother.
185. Decima’s Promise. By AGNES GIBERNE. (Nisbet) 3s.6d.
This is made to a servant girl not to reveal an accident to a young child of which both alike are guilty. It results in the poor child’s idiocy, and thus would be a wholesome warning to nurses, but Decima’s other troubles are rather out of their beat.
186. In the Marsh. By BESSIE CURTEIS. (S.P.C.K.) 2s.
A very clever portrait of life on the Sussex coast, as seen by some young folks quartered in a farmhouse.
187. Rosamond Ferrars. By M. BRAMSTON. (S.P.C.K.) 2s.6d.
A girl hardened by want of home life introduced into a good and happy home where the key of life is given to her.
188. The Little Brown Girl. By ESMÉ STUART. (S.P.C.K.) 2s.6d.
An orphan unkindly treated by children who are prejudiced against her, and nearly frighten her to death.
189. The Runaway. (Macmillan) 2s.6d.
Exceedingly droll mishaps befall the little maid who hides the runaway from school in her cupboard.
190. When I was a Little Girl. (Macmillan) 2s.6d.
191. Nine Years Old. (Macmillan) 2s.6d.
Great favourites with children; without much plot, but flowing on naturally.
192. Little Alice and her Sister. (Masters) 2s.
A charmingly told cure of a spoilt and passionate little girl caused by an elder sister returned from India.
193. P’s and Q’s. By C. M. YONGE. (Macmillan) 4s.6d.
Turns on the difficulty of submitting to a fresh government.
194. Henrietta’s Wish. By C. M. YONGE. (Masters) 4s.6d.
On vehemently carrying out a personal wish.
195. The Two Guardians. By C. M. YONGE. (Masters) 6s.
A religiously brought-up girl transplanted into a worldly family.
196. The Wynnes. (Masters) 5s.
A sensible, thoughtful picture of the trials of a large family.
197. One of a Covey. (Wells Gardner, Darton & Co.) 3s.6d.
A little girl taken away from a home full of brothers and sisters to find solitary luxury very wearisome.
198. Regent Rosalind. (S. Tinsley) 7s.6d.
The difficulties of a young girl brought home from school to become head of a motherless household.
199. Phil’s Mother. (S. Tinsley) 5s.
Several short and good stories, of which ‘Georgie’s Christmas Holidays’ is the best.
200. Elly’s Choice. (S.P.C.K.) 1s.6d.
201. Boys and Girls. (S.P.C.K.) 1s.
The best thing in these is a remarkable fable or allegory, quite fit to be read separately, where each person is represented as chained for life to some animal symbolising character, and the question in each case is, Will the animal subdue the human being to the ruin of both, or will the human creature make the animal his obedient servant to the salvation of both?
202. Ella’s Mistake. By LAURA LANE. (S.P.C.K.) 1s.
The damsel takes to sensational religion and despises her mother, but learns her error.
203. Courage and Cowards. By SELINA GAYE. (Nisbet) 2s.6d.
The contrast between physical daring and moral courage well brought out.
204. The Autocrat of the Nursery. By L. T. MEADE. (Hodder) 5s.
This is delightfully illustrated and is a charming story, but it has the fault—a serious one if reverence is desired—of giving holy Names misspelt for baby utterance. A touch of the pen will alter this.
205. Countess Kate and the Stokesley Secret. By C. M. YONGE. (Walter Smith) 5s.
One is a plunge into high life and the other a merry scrambling family.
206. The Six Cushions. By C. M. YONGE. (Walter Smith) 2s.
The varying fates of six cushions for the chancel step, dealt out to be worked by as many young ladies.
207. Trixy; or, Those who Live in Glass Houses should not Throw Stones. By MARGERY SYMINGTON. (Cassell) 1s.6d.
Pleasant scenes of life in a small Swiss young ladies’ school.
208. Studies for Stories. By JEAN INGELOW. (Wells Gardner, Darton, & Co.) 3s.6d.
A collection of really powerful short tales, not half sufficiently known, chiefly of girls’ school life.
209. The Old House in the Square. By ALICE WEBER. (Routledge) 3s.6d.
A well-drawn family, who are too exclusive to be hospitable to their father’s pupil, and need to be brought to a better mind.
210. North Wind and Sunshine. By ANNETTE LYSTER. (S.P.C.K.) 2s. 6d.
The contrast between piety and charity at home, and anywhere except at home.
211. Five Pounds Reward. (S.P.C.K.) 1s.
Very droll.
212. Heart Service. (S.P.C.K.) 1s.
Useful warning against selfish neglect.
213. Snowball Society. By M. BRAMSTON. (S.P.C.K.) 2s.6d.
214. Home and School. By M. BRAMSTON. (S.P.C.K.) 2s.6d.
These tell of the same family—the first of a scheme for providing poor children with a playground; the second is of high school adventures.
215. Lob Lie by the Fire. By J. H. EWING. (S.P.C.K.) 1s.
216. Story of a Short Life. By J. H. EWING. (S.P.C.K.) 1s.
217. Jan of the Mill. By J. H. EWING. (Bell) 1s.
218. Daddy Darwin’s Dovecote. By J. H. EWING. (S.P.C.K.) 1s.
These exquisite pieces of Mrs. Ewing’s are too delicately worked for the ordinary style of children or the poor, though they may be appreciated by those who have time to dream over them and, as it were, imbibe them.
219. Story of a Happy Home. By MARY HOWITT. (Nelson) 2s.
Real childish incidents of a year; hardly story, but told with the charm of Mrs. Howitt.
220. Sue and I. By Mrs. O’REILLY. (Wells Gardner, Darton, & Co.) 3s. 6d.
Delightful reminiscences of childhood.
221. Aunt Judy’s Tales. By Mrs. GATTY. (Bell) 3s.6d.
222. Aunt Judy’s Letters. By Mrs. GATTY. (Bell) 3s.6d.
223. Aunt Sally’s History. By Mrs. GATTY. (Bell) 2s.6d.
Needing no words of recommendation.
224. Castle Blair. By FLORA SHAW. (Kegan Paul) 3s.6d.
A wild Irish story, very attractive and exciting.
225. EDGEWORTH’S Early Lessons. ” Frank.
” Rosamond. ” Parent’s Assistant. ” Harry and Lucy.
These are real classics, and ought to be well read by every child. There are many points of good sense, refinement, and honour better given in them than in most modern books. They have been so often republished that they may be had at almost any price.
226. Tip Cat. (Smith) 3s.6d.
Has much grace and tenderness.
227. May Cunningham’s Trial. (Cassell) 2s.
Interesting and spirited.
228. Pat. By STELLA AUSTIN. (Masters) 3s.6d.
By far the best of Stella Austin’s stories, which are popular, but have for the most part the fault of admiring the children’s simplicity too palpably, and might foster affectation or self-consciousness.
229. Sidney Grey. By ANNIE KEARY. (Warne) 3s.6d.
A story of much excellence and reality.
230. The School-boy Baronet. By the Hon. Mrs. GREENE. (Warne) 3s.6d.
A young tyrant cured of his overbearing ways by seeing their exaggeration in lower life.
231. Cushions and Corners. By the Hon. Mrs. GREENE. (Warne) 2s. 6d.
A clever story on angular and gentle tempers.
232. Blind Man’s Holiday. By ANNIE KEARY. (Warne) 2s.
233. Father Phim. By ANNIE KEARY. (Warne) 1s.
In the first we have touches from the author’s own childhood. The second is very beautiful, and perhaps the most perfect of the author’s works.
234. New Honours. By Mrs. SELBY LOWNDES. (Warne) 2s.
Children whose first experiences of their father’s peerage are not pleasant.
235. Mistress Mary. By Mrs. SITWELL. (S.P.C.K.) 1s.6d.
A charming story of a quaint little girl and her noble-minded parents.
236. Dora and Nora. By ANNETTE LYSTER. (S.P.C.K.) 2s.
Two girls who endure in a very different manner the trial of living with a cross old aunt.
237. Carry’s Rose. By Mrs. CUPPLES. (Nelson) 9d.
Against teasing.
238. The Launch of the ‘Victory.’ (Nelson) 6d.
Of a wholesome friendship made over a toy ship.
239. The Phantom Picture. By the Hon. Mrs. GREENE. (Nelson) 2s.
Disobedience detected by the culprit unconsciously photographing himself.
240. Silverthorns. By Mrs. MOLESWORTH. (Hatchard) 6s.
A harsh judgment and incipient jealousy confuted. Very sweet characters.
241. The Linen Room Window. By C. BIRLEY. (Wells Gardner, Darton, & Co.) 1s.6d.
The effect of sunshine through a convex bit of glass.
242. A Story for the Schoolroom. (S.P.C.K.) 2s.
Excitement at going to stay with a girl of higher rank ending in wholesome discipline and mortification of self-importance.
ON THE CATECHISM.
These are not studies on the Catechism, but illustrations.
243. Stories and Lessons on the Catechism. (Walter Smith) 3 vols. 13s.
A companion to the lessons on the Collects, with a class of girls instead of boys. The using of it for many years has tested its excellence.
244. Stories on the Catechism. By C. A. JONES. (Masters) 4 vols. 2s.6d.each.
Detached stories, with questions at the end of each on the portion to which it applies.
245. Laneton Parsonage. (See No. 180.)
Written mainly to illustrate the Catechism.
246. Tales illustrative of the Apostles’ Creed. By J. M. NEALE. (Masters) 2s.6d.
247. Stories on the Commandments. (S.P.C.K.) 1s.6d.
248. Stories on my Duty to God. (S.P.C.K.) 1s.6d.
249. Stories on my Duty to my Neighbour. (S.P.C.K.) 1s.6d.
250. Stories on the Lord’s Prayer. By E. SEWELL. (Masters) 6d.
All the above may be usefully read, or lent, to children, one by one, as comments on the lesson freshly taught.
251. The Little Camp on Eagle Hill. By E. WETHERELL. (Warne) 1s. 6d.
Somewhat striking conversations upon the Lord’s Prayer.
252. Children of the Church. Part 1. By Mrs. O’REILLY. (Wells Gardner, Darton & Co.) 1s.6d.
253. Teachings for the Little Ones on the Catechism. By C. M. YONGE. (Walter Smith) 2s.6d.
These last are more of Sunday-school books than intended to be lent, but as most of the instruction to very little ones must be conveyed either by reading or speaking to them, it has been thought that the recommendation of these might be an assistance to teachers preparing lessons.
