Therapeutic hypothermia for neonatal hypoxic-ischaemic encephalopathy.
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Animals↗
Biomedical subjects
V S Rajadurai
Publications and source records attributed to V S Rajadurai.
Neonatal hepatic abscess in preterm infants:a rare entity?
INTRODUCTION AND OBJECTIVE: Neonatal pyogenic hepatic abscess in preterm infants is a rare entity. We present 6 cases of neonatal liver abscesses diagnosed in our hospital as well as an approach that will facilitate the early diagnosis and management of neonatal pyogenic liver abscess based on our case series and review of the literature. MATERIALS AND METHODS: Retrospective review of case records of all 6 patients diagnosed with neonatal liver abscess from January 2000 to December 2002 in KK Women's and Children's Hospital, Singapore. RESULTS: All neonates were premature with gestational ages between 24 and 34 weeks. Persistence of positive blood culture despite appropriate antibiotic treatment in 67% of the cases prompted use of hepatobiliary ultrasounds to detect liver abscess. Surgical drainage of liver abscess was performed in 33% of the cases, with the remainder treated conservatively with appropriate intravenous antibiotics. Half of the infants recovered with resolution of their liver abscess on serial hepatobiliary ultrasound. The other half died of fulminant sepsis. CONCLUSIONS: Neonatal pyogenic liver abscess, though rare, is associated with good outcome if diagnosed promptly and appropriate treatment instituted. In a preterm infant with sepsis, a high index of suspicion is required if there is persistence of positive blood culture despite appropriate antibiotic treatment, and hepatobiliary ultrasound should be done to detect and monitor neonatal liver abscess.
Decision Trees↗
Closed versus partially ventilated endotracheal suction in extremely preterm neonates: physiologic consequences.
This randomized cross over study aimed to compare the severity and incidences of desaturation and bradycardia between the partially ventilated endotracheal suction method (PVETS) and closed tracheal suction system (CTSS) in extremely preterm neonates. Fifteen intubated and ventilated extremely low birth weight preterm infants (mean birth weight 689g) randomly underwent both suction techniques within a 12-h period to obtain a paired reading group. The process was repeated 24-48h apart until three pairs of reading groups were collected. Changes in oxygen saturation measured with pulse oximetry and heart rate changes measured with electrocardiogram were recorded using Hewlett-Packard m240A monitor trending software. The mean of each parameter's variation from baseline was obtained using SPSS descriptive statistics and analyzed using SPSS repeated measures ANOVA. Fisher Exact Test was used to analyze the incidence of desaturation and bradycardia. The closed tracheal suction system reported a significantly smaller degree of oxygen saturation fall (P<0.005) and significantly fewer incidences of desaturation. There was also a significantly smaller degree of heart rate reduction although episodes of bradycardia were not significantly different between the two methods. Oxygen saturation and heart rate were significantly more stable during the use of CTSS compared to PVETS in the extremely low birth weight preterm population.
Analysis of Variance↗
Immunogenicity and reactogenicity of two regimens of diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated polio and Haemophilus influenzae type b vaccines administered to infants primed at birth with hepatitis B vaccine.
An open, randomized study evaluated the immune response and safety of two different regimens of diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus-Haemophilus influenzae type b (DTPa-HBV-IPV-Hib) immunization in infants primed at birth with hepatitis B vaccine. One-half of the 150 healthy, full-term infants received a DTPa HBV-IPV-Hib vaccine at 1 1/2, 3 and 5 months of age; the other received a DTPa-IPV-Hib vaccine at 1 1/2, 3 and 5 months of age with separate HBV vaccine at 1 and 5 months of age. Immune response was similar following the two regimens with 100% of the vaccinees seroprotected for HBV, diphtheria, tetanus, Hib and poliovirus types 2 and 3 diseases after the full vaccination course. One vaccinee in the DTPa HBV-HPV- Hib group failed to respond to the poliovirus type 1 antigen. Response to the three pertussis antigens ranged from 92-97% in the DTPa-IPV-Hib plus separate HBV group and 100% in the DTPa HBV-IPV-Hib group. The most frequently reported post-vaccination symptoms were irritability in the DTPa-IPV-Hib plus separate HBV group (49% of vaccinees) and fever, defined as axillary temperature > or =37.5 degrees C, in the DTPa HBV- IPV-Hib group (50% of vaccinees).
Antibodies, Bacterial↗
Challenges in perinatal medicine.
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Female↗
The use and abuse of steroids in perinatal medicine.
Corticosteroids are one of the most powerful drugs increasingly used in the perinatal and neonatal period. This review discusses the merits and demerits of antenatal as well as postnatal use of steroids. A single course of antenatal corticosteroids in women at risk of premature delivery is highly effective in reducing respiratory distress syndrome (RDS), intraventricular haemorrhage and neonatal mortality and also neurodevelopmental sequelae including cerebral palsy. However, there is less evidence to support the practice of multiple courses of corticosteroids, with some animal and retrospective human studies suggesting an association with neurological impairment and reduction in birth weight as well as lung weight. Postnatal systemic corticosteroids have shown benefits in reducing chronic lung disease and improving survival for infants. However, besides short-term adverse effects, the follow-up studies have raised concern that they may increase the risk of neurodevelopmental disability, particularly cerebral palsy in survivors. Systemic corticosteroids may have a role in infants who had repeated and prolonged intubations and those with pressor-resistant hypotension. Alternative strategies for prevention of chronic lung disease, such as inhaled steroids, methylprednisolone and hydrocortisone, may need further studies with larger sample sizes. Data from animal research have revealed that fetal glucocorticoid exposure may have a role in programming the individual to adult degenerative diseases. Based on the current evidence, it is recommended that women at risk of preterm delivery receive a single course of glucocorticoids. Randomised controlled trials are needed to establish the true effects of multiple courses of antenatal corticosteroids. More research is also needed to study the long-term neurodevelopmental outcome of both multiple courses of antenatal corticosteroids, as well as postnatal corticosteroid therapy.
Animals↗
Severe newborn encephalopathy unrelated to intrapartum hypoxic events: 3 case reports.
INTRODUCTION: Newborn encephalopathy is an important clinical problem associated with considerable morbidity and mortality and is pertinent in the assignment of blame in obstetrics litigation. CLINICAL PICTURE: We report 3 babies with severe neonatal encephalopathy. OUTCOME: In all 3 cases, intrapartum hypoxic insult was unlikely to be a significant contributing factor towards the development of neonatal encephalopathy. The aetiology was unclear in the first 2 cases and there was antecedent antenatal cause of feto-maternal haemorrhage in the last case. CONCLUSION: Prevention of neonatal encephalopathy was not possible in these 3 cases. We recommend that umbilical cord blood gases be clearly documented in such cases to reduce unnecessary obstetrics litigation of intrapartum asphyxia as the significant contributing factor to the poor neonatal outcome. Clinicians must have a high index of suspicion of antecedent causes and perform the necessary investigations to elucidate the aetiology of the neonatal encephalopathy.
Adult↗
Ureaplasma urealyticum and its association with chronic lung disease in Asian neonates.
OBJECTIVE: The aim of the present prospective cohort study was to evaluate the relationship between lower respiratory tract colonization with Ureaplasma urealyticum and development of chronic lung disease (CLD) in a high-risk neonatal population. METHODS: Prospective cohort study of preterm infants with a birthweight < 1,500 g needing mechanical ventilation within 24 h of birth in a tertiary care neonatal unit. Endotracheal aspirates from these infants were cultured within 24 h for U. urealyticum and the rate of colonization was determined. The primary outcome measure was the incidence of CLD at 28 days of life. RESULTS: Of the 41 infants studied, 10 (24%) infants were colonized with U. urealyticum. The colonization rate was higher in babies < 1,000 g compared with babies weighing 1,000-1,500 g (P = 0.04). There was no significant difference between the colonized and non-colonized groups with regard to the antenatal use of steroids, maternal prolonged rupture of membranes, gestational age, birthweight, sex, respiratory distress syndrome, use of surfactant, patent ductus arteriosus and gastrooesophageal reflux. Of the 37 survivors, 20 (54%) developed CLD; eight infants (88.5%) in the colonized group developed CLD compared with 12 infants (42.8%) in the non-colonized group (P = 0.01). CONCLUSIONS: Neonates colonized with U. urealyticum were twice as likely to have CLD than non-colonized babies (relative risk 2.01; 95% confidence interval 1.27-3.37). These data suggest a significant association between colonization with U. urealyticum and CLD in infants weighing < 1,500 g.
Chronic Disease↗
Twin-twin transfusion syndrome: a five year review.
OBJECTIVE: To determine the incidence, complications, management, and outcome in infants with twin-twin transfusion syndrome (TTTS) over a period of five years. METHODS: TTTS was diagnosed in monochorionic twins if one was pale and the other plethoric with a haemoglobin difference > or =5 g/100 ml and/or birthweight differences > or =15%. RESULTS: Eighteen (6.2%) of the 292 twin pairs had TTTS. Eight pairs (44%) had the acute type and the rest (56%) had the chronic type of TTTS. The mean (SEM) intrapair haemoglobin difference in the acute type was 4.8 (2.1) g/100 ml which gave a discordance of 7.1 (4.6)%, whereas that in the chronic type was 6.9 (2.9) g/100 ml and 24.4 (6.1)% respectively. Infants with the acute type had a significantly higher incidence of vaginal delivery (p<0.03), hypotension (p<0.025), and respiratory distress (p<0.01) compared with those with the chronic type. There was no significant difference in the incidence of anaemia, polycythaemia, asphyxia, hypoglycaemia, and hyperbilirubinaemia. Two recipients died in utero as the result of chronic TTTS, while their survivors developed spastic cerebral palsy. There were no neonatal deaths. CONCLUSIONS: TTTS, although uncommon, may have an adverse neurodevelopmental outcome especially if one twin dies in utero. Prompt recognition and management of the haemodynamic and haematological problems of infants with the acute types of TTTS will result in optimal neurodevelopmental outcome.
Acute Disease↗
Term infants with hypoxic ischaemic encephalopathy: poor neurodevelopmental outcome despite standard neonatal intensive care.
Perinatal asphyxia may be severe and affect the neurological system, causing hypoxic ischaemic encephalopathy (HIE). Twenty-three term infants with HIE were studied over 3.5 years. Nine died and of the 14 survivors, eight were normal and the rest had abnormal neurological sequelae. Favourable prognostic markers were a 5 minute Apgar score > 5, first pH > 7.1, and stage I HIE. Despite standard neonatal intensive care management, the mortality and morbidity rates for these infants remained high.
Asphyxia Neonatorum↗
Blood pressure standards for very low birthweight infants during the first day of life.
Blood pressures during the first day of life were measured prospectively in 61 very low birthweight infants using umbilical or peripheral arterial lines. Video recordings of real time waveforms were reviewed. Blood pressure correlated linearly with birthweight and gestation. Comparison with available standards showed that infants weighing under 800 g had lower acceptable mean arterial pressure (MAP). The lower limits of MAP for infants between 26 to 32 weeks of gestation were numerically similar to the gestational ages.
Blood Pressure↗
Parainfluenza type 3 viral outbreak in a neonatal nursery.
An outbreak of parainfluenza virus type 3 infection that occurred in a special neonatal care unit is described. Birth weights of affected infants ranged from 1860 to 2080 g and gestational ages were between 28 and 32 weeks. Three infants presented with recurrent episodes of apnoea associated with oxygen desaturations on postnatal ages of 16 days, 26 days and 66 days respectively; upper respiratory tract infection symptoms such as coryza were absent in them. Two older infants who had oxygen dependent bronchopulmonary dysplasia presented with worsening of the respiratory status due to bronchiolitis at 5 and 6 months of age respectively. All infants required supplemental oxygen and assisted ventilatory support and there were no deaths. Parainfluenza virus type 3 was identified by direct antigen detection in 3 cases and was isolated in the other two. The outbreak was controlled by isolating the infected infants, use of gowns and strict hand washing. Nonporous surfaces contaminated with parainfluenza virus type 3 were cleansed with water and detergent. Viral respiratory infections should be considered in the differential diagnosis when growing premature infants present with recurrent apnoeic episodes and they may be severe enough to require assisted ventilatory support. The source of the outbreak was possibly a medical officer and a medical student who had an upper respiratory tract infection prior to the outbreak in the nursery. Medical and nursing staff with viral respiratory infections should avoid working in the nurseries until they are well.
Antigens, Viral↗
Perinatal drug abuse in KK Women's and Children's Hospital.
No local figures are available in Singapore on the incidence of perinatal drug abuse and its effect on the foetus and the neonate. The objectives of this study were to determine the incidence of perinatal drug abuse and neonatal abstinence syndrome; to identify a maternal profile at high risk for substance abuse and to document the presenting features and treatment of infants with neonatal abstinence syndrome. Out of 14,690 births during the period January 1994 to December 1996, 38 (0.25%) had evidence of perinatal drug abuse. The study revealed that a high-risk maternal profile for drug abuse comprised of single mothers (52%); history of smoking (52%); no antenatal care (37%) and belonging to the Malay ethnic group (82%); and younger maternal age. Self-reporting was uncommon, occurring only in 8% and in 40% of cases, there was no known history of maternal drug addiction. The drug abused in all cases was heroin. Human immunodeficiency virus (HIV) screening was done only in a minority (21%) of the mothers and it was negative in all. Eighteen (47%) infants had evidence of neonatal abstinence syndrome with neurological manifestations being the commonest. Urine toxicology screening was positive in 26% of cases and had only 70% sensitivity and 41% positive predictive value. On follow up, default rate was high with 42% babies not attending follow up at the outpatient clinic. In conclusion, there is a need to maintain a high index of suspicion of substance abuse in those with high-risk maternal profile and their neonates should be closely watched for features of neonatal abstinence syndrome. Alternative methods of toxicology screening apart from urine need to be evaluated in order to improve the drug detection rate.
Adolescent↗
Effect of fetal haemoglobin on the accuracy of pulse oximetry in preterm infants.
Pulse oximeters are programmed with a calibration curve derived from studies done in adults. Whether fetal haemoglobin levels affect their reliability is unclear. This study reports the accuracy of pulse oximetry in 22 preterm infants (mean 31 weeks, range 25-36 weeks gestation) between 1 h and 73 days of age. Oxygen saturation obtained from a Nellcor N-200 pulse oximeter (SpO2) was compared with simultaneous arterial values (functional SaO2) measured by a Radiometer OSM3 Hemoximeter over a SpO2 range of 83-99%. Fetal haemoglobin (HbF), carboxyhaemoglobin (HbCO) and methaemoglobin (HbMet) measured by the hemoximeter ranged between 0-100%, 0-3.5% and 0-0.8% respectively. Linear regression analysis revealed a close correlation between SpO2 and functional SaO2 (SpO2 = 0.75 SaO2 + 24.43, r = 0.88, P less than 0.001) over a wide range of values for PCV, heart rate, blood pressure, PaO2, PaCO2 and pH. The mean SpO2-SaO2 difference of 1.3, (s.d. 2.5%, P less than 0.001) was unaffected by HgF, HbCO or HbMet but was increased in infants receiving inotropic support. We conclude that the Nellcor N-200 pulse oximeter gives reliable oxygen saturation measurements unaffected by the HbF level in preterm infants.
Fetal Hemoglobin↗
Fetal arrhythmias: a 3-year experience.
Eight cases of fetal arrhythmia were seen over a 3-year period. Two had atrial and/or ventricular extrasystoles, 1 had complete atrioventricular block and 5 had tachyarrhythmias--3 supraventricular tachycardia, 1 atrial flutter and 1 ectopic atrial tachycardia. All had structurally normal hearts. Nonimmune hydrops fetalis was the initial presentation in 3 of the 5 cases with tachyarrhythmias. There were 2 deaths--a stillbirth and a neonatal death, while 2 others required neonatal intensive care. The 6 survivors have remained well and are now off treatment. The diagnosis, careful assessment and management of a fetal arrhythmia may lead to a successful outcome. The complexity of the problems experienced may warrant early referral to a tertiary centre where the overall management of the mother, fetus and neonate, may be undertaken.
Arrhythmias, Cardiac↗
Valvar vegetations in the neonate due to fetal endocarditis.
Mass lesions were observed on the tricuspid valve by cross-sectional echocardiography in 5 neonates, 4 of whom presented with fetal distress. Four went on to develop severe respiratory distress, 3 from meconium aspiration and 1 from hyaline membrane disease, with 2 deaths despite intensive treatment. Autopsy confirmed meconium aspiration pneumonia. Sterile, unorganised vegetations were seen on the tricuspid valve (and in 1 infant the mitral valve too). Perinatal factors such as hypoxia, haemodynamic and coagulation disturbances may have contributed to the formation of the vegetations and may reflect the severity and refractoriness of persistent pulmonary hypertension.
Endocarditis↗
Intravenous indomethacin therapy in preterm neonates with patent ductus arteriosus.
This study examined the response of the patent ductus arteriosus (PDA) to intravenous Indomethacin using serial two dimensional and Doppler echocardiography and documented the complications associated with therapy. Thirty-six preterm neonates who were oxygen and ventilator dependent were studied when they were aged 3-7 days. The PDA initially closed in 22 (61%) and constricted in seven (19%) of the infants. It was non-responsive in five (14%) and the treatment was stopped because of complications in two (6%). Only three (43%) of seven neonates given a second course had PDA closure. In the 25 instances where there was PDA closure following Indomethacin, re-opening was documented echocardiographically on three (12%) occasions. Overall, Indomethacin therapy was successful in 29 (81%) neonates, PDA ligation was required in four (11%) and three died from unrelated causes. Three (8%) neonates developed major complications: multiple gastric perforations in the first, focal ileal perforation in the second, and necrotizing enterocolitis in the third. Treatment failure, PDA ligation and major complications occurred exclusively in neonates less than 28 weeks gestation. In view of the relatively low efficacy and high major complication rate in these extremely preterm infants, a randomized clinical trial needs to be conducted using two dimensional and Doppler echocardiography to allow accurate assessment of the PDA response to intravenous Indomethacin.
Ductus Arteriosus, Patent↗
Late onset bowel stenoses after neonatal necrotizing enterocolitis.
In 14 cases of bowel stenoses occurring after neonatal necrotizing enterocolitis (NEC), eight cases presented early, within 8 weeks from the onset of NEC and three beyond 4 months. In the other three cases the stenoses occurred in defunctionalized loops. The late onset stenoses remained undiagnosed until they presented with acute, life-threatening complications, and one of these patients died. We draw attention to these late onset stenoses which could be missed in early contrast studies, and recommend a study at 4 months rather than at 4 weeks, as previously recommended. Those presenting early should not be missed, as all of our cases presented with acute and obvious intestinal obstructions, and they were all still in hospital or undergoing frequent review.
Barium Sulfate↗