Prooxidant-Antioxidant Balance in Perinatal Asphyxia

Objective

To determine the prooxidant-antioxidant balance (PAB) in neonatal asphyxia and compare it with values for PAB in healthy neonates.

Methods

In a prospective observational study, serum PAB of umbilical cord blood of 30 neonates with asphyxia [pH <?7.2, low Apgar score, signs of respiratory distress syndrome (RDS)] as the case group and 35 healthy neonates (without an abnormal clinical event at birth and after the first week) as the control group were compared.

Results

Among the 35 neonates in the control group, the average level of serum PAB was 20.00 HK units, which was significantly lower than for the 30 neonates within the case group (40.46 HK units; p?=?0.019). The blood pH in the case group was significantly lower than for control group (P?<?0.001). In controls, HCO₃ ^- and pCO₂ were 18.6 mmol/L and 38.5 mmHg respectively, whilst in the case group these values were 15.5 mmol/L and 45.7 mmHg respectively (p?<?0.05).

Conclusions

Determination of PAB may be useful in the early diagnosis of perinatal asphyxia and is consistent with HCO₃ ^-, pCO₂ and Apgar score.     

Correlation of Paraoxonase1 Activities with Birth Weight

Objectives

To evaluate arylesterase and lactonase activity of paraoxonase (PON)1 in cord blood of neonates in relation to their birth weight. The authors hypothesized that cord blood PON1 arylesterase and lactonase activities will be compromised in neonates having low birth weight.

Methods

Eighty neonates born in authors’ hospital, irrespective of mode of delivery were included. Forty children with low birth weight were included in case group and 40 with normal birth weight were included as controls. PON1 arylesterase and lactonase activities were measured.

Results

Serum arylesterase activity decreased significantly in low birth weight babies (p?<?0.05). Linear regression analysis (R?=?0.728) indicated significant correlation between arylesterase and birth weight. Serum lactonase activity was also reduced in low birth weight babies. Its linear regression analysis (R?=?0.727) indicated significant correlation between lactonase and birth weight.

Conclusions

PON 1 activity is significantly reduced among low birth weight babies in comparison to normal weight babies.     

Glycerin suppository for promoting feeding tolerance in preterm very low birthweight neonates: A Randomized Controlled Trial

Objective

To compare the efficacy of glycerin suppository versus no suppository in preterm very-low-birthweight neonates for improving feeding tolerance.

Design

Randomized controlled trial.

Setting

Level III neonatal unit from Mumbai, India.

Participants

50 very-low-birthweight (birth weight between 1000 to 1500 grams) preterm (gestational age between 28 to 32 weeks) neonates randomized to glycerine suppository (n=25) or no intervention (n=26).

Intervention

Glycerin suppository (1g) once a day from day-2 to day-14 of life or no suppository, along with intermittent oral feeds and standardized care.

Primary outcome

Time required to achieve full enteral feeds (180 mL/kg/d).

Results

Baseline characteristics of neonates like gestational age, birth-weight, gender and age at the time of introduction of feeds were comparable in both groups. The mean (SD) duration to reach full enteral feed was 11.90 (3.1) days in glycerin suppository group and was not significantly different (P=0.58) from control group, [11.33 (3.57) days]. Glycerin suppository group regained birth weight 2 days earlier than control group but this difference was not significant (P=0.16). There was no significant difference in duration of hospital stay or occurrence of necrotizing enterocolitis amongst the two study groups.

Conclusion

Once daily application of glycerin suppository does not accelerate the achievement of full feeds in preterm very-low-birthweight neonates.     

The impact of early sonographic evaluation on hospital admissions of children with suspected acute appendicitis

Purpose

Early ultrasound (US) evaluation of children with abdominal pain and suspected acute appendicitis (AA) is an important diagnostic tool. Since 2007, US has become part of routine emergency room (ER) work-up performed for suspected pediatric AA in our hospital.

Methods

We retrospectively compared hospital admissions from 2007 to 2008 with those from 2005 to 2006, when most ultrasounds were done after admission to Pediatric Surgery for observation.

Results

During the study (2005?C2008), 6,511 children came to the ER with acute abdominal pain. Although pediatric ER sonography increased from 28.1% (865/3,079) in 2005?C2006 to 51.7% (1,775/3,432) in 2007?C2008 (p?<?0.0001), hospitalizations decreased from 33 to 30.1% (p?=?0.011). Concurrently, ER US for AA increased from 20.8% (639/2,440) to 38.9% (1,336/2,096) (p?<?0.0001), admissions for suspected AA decreased from 51.8% (331/639) to 42% (561/1,336) (p?<?0.0001).

Conclusions

Sonography led to a significant decline in admissions and better selection of patients who required surgery for AA. Recurrent ER referrals for the same complaint within 2?weeks was very low (2.9%) with no difference between the two study periods (p?=?1); none had AA. These findings encourage us to continue early US in children with suspected AA. This effective tool decreases unnecessary hospital stays, investigative procedures, and surgery, while reducing costs.     

Does Mesenchymal Stem Cell Population in Umbilical Cord Blood Vary at Different Gestational Periods?

Objective

To identify and quantitatively determine Mesenchymal stem cells (MSCs) in the umbilical cord blood (UCB) of neonates born at different gestational periods.

Methods

UCB was collected at birth in neonates of three different gestational groups. The mononuclear cells (MNCs) were phenotypically analyzed by flow cytometer.

Results

The yield of total MNCs did not differ much with gestation; the average values were 22.6?±?6.48?×?106 cells/ml. The MSCs were significantly higher in the lower gestation group. These were 0.0219?±?0.012 %, 0.0044?±?0.003 % and 0.0022?±?0.003 % in 28 to 31 wk, 32 to 35 wk and >36 wk, respectively (P?=?0.00). There was a significant inverse correlation between the gestational age and the presence of MSCs with a correlation co-efficient of ?0.54 (P?=?0.0001).

Conclusions

The MSCs population was significantly higher in infants born at lesser gestation than those born at term gestation.     

A Comparative Study on Reliability of Point of Care Sodium and Potassium Estimation in a Pediatric Intensive Care Unit

Objective

To compare sodium and potassium levels in children as done with Blood Gas Analyzer (BGA) at point of care testing in pediatric ICU vs. that done in laboratory electrolyte analyzer.

Methods

This prospective method comparison study was done from February to April 2012 in Pediatric ICU of tertiary care hospital at Delhi. Sixty consecutive patients were tested during the period. Paired blood samples for venous blood gas to be tested on BGA and serum electrolytes to be tested on auto-analyzers (AA) were taken as per standard technique. Data was collected and 59 paired samples were analyzed for sodium and potassium levels. They were analyzed according to CLSI document EP15-A2 using ACB method comparison software.

Results

Mean sodium measured on the BGA was 132.8?±?12.2 mmol/L where as measured by AA was 141.5?±?11.1 mmol/L. The mean difference between the two was ?8.76 mmol/L (p?<?0.001). The difference was statistically significant in all three subgroups of hypernatremia, isonatremia and hyponatremia (p?<?0.001). Potassium level in BGA was 3.53?±?0.81 mmol/L and AA was 4.28?±?1.05 mmol/L. The mean difference between the BGA and AA was ?0.75 mmol/L (p?<?0.0001). The difference was statistically significant in patients with normokalemia and hyperkalemia (p?<?0.0001). The difference was non significant in patients with hypokalemia (p?=?0.051).

Conclusions

Blood gas analyzers underestimates Na?+?and K?+?values if sampling is done using liquid sodium heparin and if all other potential pre-analytical errors of testing are taken care of. The Bland Altman’s analysis in the present study showed a significant systematic bias and very wide limits of agreement for both sodium and potassium, which is not clinically acceptable.     

Effect of Oil Massage on Growth in Preterm Neonates Less than 1800 g: A Randomized Control Trial

Objective

To study the effect of oil massage on growth in preterm babies less than 1800 g.

Methods

This randomised controlled trial was conducted in Neonatal intensive care unit of a level II hospital. Neonates with birth weight?<?1800 g, gestation?<?35 wk and?<?48 h of age at enrolment were included in the studies. Eligible neonates were randomized to one of the two groups (a) Oil massage along with standard care of low birth weight (b) Standard care of low birth weight without massage. Weight, length and head circumference was measured in the two groups at 7 d intervals. Serum triglyceride levels were measured at enrolment and at completion of study. Primary outcome variable was weight gain at 28 d after enrolment.

Results

A total of forty-eight neonates were randomisd to either oil massage group (n?=?25) or standard care of low birth weight without massage group (n?=?23). Mean (SD) weight of babies in the two groups was 1466.4?±?226.8 g in oil massage group and 1416.6?±?229.9 g in the control group. At 28 d, weight gain in the oil massage group (476.76?±?47.9 g) was higher compared to the control group (334.96?±?46.4 g) (p?<?0.05). At 7 d, less weight loss (7.80?±?9.8 g) was observed in babies in oil massage group compared to control group (21.52?±?19.4 g) (p?=?0.003). However, there was no significant difference in serum triglycerides and other anthropometric parameters.

Conclusions

Oil application has a potential to improve weight gain and cause less weight loss in first 7 d in low birth weight neonates     

Outcome of Intubate Surfactant Rapidly Extubate (InSuRE): An Indian Experience

Objective

To assess outcome of InSuRE (Intubation, Surfactant and Rapid Extubation) in managing preterm neonates with respiratory distress syndrome (RDS).

Methods

Preterm neonates fulfilling inclusion criteria were enrolled after obtaining informed parental consent. Criteria for success of InSuRE was predefined. Proportion of neonates with success or failure of InSuRE was the primary outcome.

Results

From August 2008 through July 2009, 28 babies underwent InSuRE. Sixteen babies (57 %) succeeded InSuRE. Median birth weight in successful group was 1362.5 (850–2,150) g and in failure group was 1,805 (990–2,560) g (p?=?0.015). Nasal continuous positive airway pressure (nCPAP) was started at 0.5 (0–5.0)?h of life in successful group and at 3.0 (0.5–6.0) h in failure group (p?=?0.005). Babies in successful group received surfactant at median age of 2.0 (1.0–6.0) h, and in failure group at 4.0 (2.0–8.0) h (p?=?0.002). Two patients in successful group died of neonatal sepsis, while none died in failure group (p?=?0.492).

Conclusions

InSuRE is feasible in developing countries. However, we need large multicentric randomised controlled trials to prove the safety and efficacy in our settings.     

Splanchnic-cerebral oxygenation ratio (SCOR) values in healthy term infants as measured by near-infrared spectroscopy (NIRS)

Purpose

The splanchnic-cerebral oxygenation ratio (SCOR) is a measurement comparing regional tissue oxygen saturation of splanchnic organs and brain tissue. SCOR has been previously proposed as a marker of clinical conditions associated with gut ischemia. Our goal was to determine SCOR values in healthy neonates in their first and second days of life.

Methods

Prospective observational study measuring SCOR in term neonates in the nursery using near-infrared spectroscopy (NIRS).

Results

Forty-five subjects with a mean gestational age of 39.4 ± 1.3 weeks were included. Mean SCOR on the first day was 0.90 ± 0.16 and 0.97 ± 0.16 on the second day, p = 0.02 (n = 45). No correlation was found between SCOR and gestational age; however, we did find a positive correlation between hour of life and SCOR values (r = 0.28, r ²  = 0.08, p < 0.01, two tails); SCOR appears to stabilize by 36 h.

Conclusions

Our findings demonstrate SCOR values in healthy neonates consistent with those previously theorized and help to validate it as a diagnostic measure. In addition, we have demonstrated that SCOR values may normally be lower in infants during their first days of life, and this information may be helpful to clinicians using NIRS as a diagnostic tool.     

Kangaroo Mother Care in Reducing Pain in Preterm Neonates on Heel Prick

Objectives

To determine the effect of Kangaroo Mother Care (KMC) of small duration of 15 min in decreasing pain in preterm neonates between 32–36 wk 6 d on heel prick by a 26 gauge needle.

Methods

Randomized controlled double masked crossover trial involving 50 neonates, between 32 wk and 36 wk 6 d gestation and weighing less than 2500 g, within 10 d of birth, vitally stable, breathing without assistance or on Continuous positive airway pressure (CPAP), without any clinically evident neurological signs, not having received analgesics/sedatives within last 24 h and not fed within last 30 min and requiring heel pricking were eligible. Outcome measured was the Premature Infant Pain Profile (PIPP). Analysis was done using independent sample t test, with Bonferroni correction applied for comparing individual components of PIPP score.

Results

The heart rate, behaviour and facial scores were statistically significant and lower in KMC group. But there was no statistically significant difference in oxygen saturation (SpO₂₎. The difference(4.85) in PIPP score was clinically and statistically significant (p?<?0.0001).

Conclusions

The findings suggest that short duration KMC (15 min) has stress reducing benefits. Preterm neonates above 32 wk gestational age can benefit from KMC to decrease pain from heel prick procedure.     

Role of Hematological Parameters in Predicting Retinopathy of Prematurity (ROP) in Preterm Neonates

Objectives

To study the role of hematological parameters in predicting retinopathy of prematurity (ROP) in preterm neonates.

Method

Two hundred forty eight babies less than 34 wk and/or with a birth weight of less than 2,000 g were evaluated. Peripheral blood smear and complete blood count were done on day one of life. Ophthalmological examination was done as per guidelines and grades of ROP classified and followed up till 40 wk of gestation for complete vascularisation. Cases were matched with similar number of controls (n?=?67) and the sensitivity, specificity and positive predictive value of different parameters were assessed.

Results

The incidence of ROP on screening was found to be 27 %. Sixty seven cases were matched with 67 controls as per birth weight and gestational age. Significant risk factors for ROP included longer duration of ventilation, higher FiO₂, culture proven sepsis and apnea requiring pharmacotherapy. The incidence of Stage I was 10.5 % (n?=?7), Stage II 58.2 % (n?=?39) and Stage III was 31.3 % (n?=?21). The absolute nucleated RBC (ANRBC) count was found to be the only parameter which was significantly higher in babies with ROP (p?<?0.001). The ANRBC was higher with increasing severity of ROP (p?=?0.003). The sensitivity, specificity and positive predictive value of ANRBC with ROP was higher than other parameters.

Conclusions

Increase in ANRBC count correlated with intrauterine hypoxia. Hence, an increase in ANRBC count could be used as a screening tool for the early prediction of ROP in babies.     

Reference ranges for sonographic dimensions of the liver and spleen in preterm infants

Background

Preterm infants usually have multiple comorbidities that affect spleen and liver. Ultrasonographic measurement of organ sizes is an important and reliable parameter in evaluation of spleen and liver pathology in preterm newborns.

Objective

The purpose of this study was to determine reference values of ultrasonographic measurements of the liver and spleen in preterm newborns.

Materials and methods

We prospectively performed sonography on 498 preterm newborns in the first week of life. We measured spleen and liver dimensions and statistically analyzed relationships between the dimensions and gender, gestational age (based on mother’s last menstrual period), height and weight. Reference ranges of dimensions were defined.

Results

Longitudinal and anteroposterior dimensions of the liver and spleen were statistically significantly different between the boys and girls (P?<?0.05) and showed high correlation with the gestational age, weight and height. Weight was the parameter best correlated with the dimensions.

Conclusion

Nomograms from these data are useful for sonographic evaluation of the liver and spleen in preterm newborns.     

Comparison of transcutaneous bilirubin measurement with total serum bilirubin levels in preterm neonates receiving phototherapy

Objective

To compare transcutaneous bilirubin with total serum bilirubin in preterm neonates after initiation of phototherapy.

Methods

Jaundice was assessed in 30 preterm neonates with transcutaneous bilirubin and total serum bilirubin before initiation of phototherapy and at 12 hr after initiation of phototherapy. A photo-occlusive patch was applied over the sternum.

Results

Transcutaneous bilirubin has a good correlation with total serum bilirubin after initiation of phototherapy. (r=0.918, P<0.001). Transcutaneous bilirubin at 28-32 weeks of gestation (r = 0.97) was better correlated with total serum bilirubin than those at 32-37 weeks (r =0.88). The correlation was better for neonates <72 hours old (r = 0.96) than those >72 hours of age (r = 0.82).

Conclusion

Transcutaneous bilirubin correlates significantly with total serum bilirubin at the patched sternal site after initiation of phototherapy in preterm neonates.

     

Effect of Pseudoephedrine on Cardiac Rhythm of Children with Rhinitis

Objective

To investigate the effect of pseudoephedrine on heart rhythm of children with rhinitis.

Methods

The study included 25 children diagnosed with rhinitis from March 2009 through February 2010 in the Department of Pediatrics. Holter records were obtained for 24 h before and at the fourth day of pseudoephedrine treatments.

Results

Study group consisted of 18 girls (72%) and 7 boys (28%) with a mean age of 8.7?±?3.4 (4–17.9 years). Common complaints of the patients were rhinorrhea (100%), cough (68%) fatigue (48%), sore throat (36%), and headache (28%). Of the 25 patients whose Holter recordings were evaluated, rare supraventricular extrasystoles were observed in one prior to the administration of pseudoephedrine, which were not repeated on this patient’s follow-up recording on day four. There were two ventricular extrasystoles in the day four Holter recording of another patient. None of the patients complained of chest pain or palpitation. There were no observations of supraventricular tachycardia, ventricular tachycardia or ventricular fibrillation. No statistical differences could be found (p?>?0.05) in the values before treatment and those on day four of treatment of either the time-dependent Heart rate variability (HRV) parameters SDNN, SDNN index, SDANN and RMSSD, or the frequency-dependent parameters (TP, HF, LF). No statistical difference could be determined between heart rate values of the patients before treatment and those on day four of treatment (p?>?0.05).

Conclusions

This study has established that therapeutic doses of pseudoephedrine do not cause an additional dysrhythmia risk for children with no health problem except rhinitis.     

Magnetic resonance imaging in children with sickle cell disease—detecting alterations in the apparent diffusion coefficient in hips with avascular necrosis

Background

Avascular necrosis (AVN) is a common morbidity in children with sickle cell disease (SCD) that leads to pain and joint immobility. However, the diagnosis is often uncertain or delayed.

Objective

To examine the ability of apparent diffusion coefficient (ADC) measurements on diffusion-weighted imaging to detect AVN in children with SCD.

Materials and methods

ADC values were calculated at the hips of normal children (n?=?19) and children with SCD who were either asymptomatic with no known previous hip disease (n?=?13) or presented for the first time with clinical symptoms of hip pathology (n?=?12). ADC values were compared for differences among groups with and without AVN using non-parametric statistical methods.

Results

The ADC values were elevated in the hips of children with AVN (median ADC?=?1.57?×?10^?3?mm²/s [95% confidence interval?=?0.86–2.10]) and differed significantly in pairwise comparisons (all P?Conclusion Children with sickle cell disease have elevated apparent diffusion coefficient values in their affected hips on initial diagnosis of avascular necrosis.     

Serum neutrophil gelatinase-associated lipocalin as a marker of acute kidney injury in asphyxiated neonates

Objective

To determine the clinical utility of serum neutrophil gelatinase-associated lipocalin (NGAL) as an early marker of acute kidney injury in asphyxiated neonates with hypoxic ischemic encephalopathy (HIE).

Design

Cohort study.

Settings

National Intensive Care Unit of Maternity Hospital, Ain Shams University, Cairo, Egypt.

Patients

The study included 30 term asphyxiated neonates (8 with mild, 13 with moderate and 9 with severe HIE) and 20 control neonates.

Intervention

Serum NGAL level was measured within 6 hours after birth using an enzyme linked immunosorbent assay.

Main outcome measures

Patients were subsequently discriminated into AKI (n=12) and no-AKI (n=18) groups.

Results

The median (Interquartile range) serum NGAL concentration was 95.0 (70.75–180.00) ng/mL in asphyxiated neonates, and 39.75 (6.0–48.0) ng/mL in control neonates; (P<0.001). Serum NGAL correlated with HIE severity: mean (SD) was 65.50 (3.77) ng/mL in infants with mild HIE, 115.07 (45.83) ng/mL in infants with moderate HIE and 229.66 (79.50) ng/mL in infants with severe HIE; (P<0.01). The median (Interquartiles) serum NGAL level was 182.50 (166.25–301.75) ng/mL in patients with AKI, 74.00 (66.00–78.75) ng/mL in those without AKI; (P<0.001). A cutoff value 157 ng/mL for serum NGAL could detect AKI in asphyxiated neonates with a sensitivity of 83.3% and a specificity of 94.4%.

Conclusion

Elevated serum NGAL measured within 6 hours after birth reliably indicates acute kidney injury in asphyxiated neonates.     

A case–control study of risk factors for severe hand–foot–mouth disease among children in Ningbo, China, 2010–2011

Background

A small fraction of hand–foot–mouth disease (HFMD) progression from the onset of severity to fatality may be remarkably rapid. Early recognition of children at risk of severity is critical to increase treatment effectiveness and reduce acute mortality.

Methods

A frequency-matched case–control study was conducted between January 2010 and June 2011 in Ningbo to identify risk factors associated with the occurrence of severity in children with HFMD. Data including demographic characteristics, clinical features, and laboratory test results were collected by trained interviewers through retrospective medical record review and/or face-to-face interviews with children’s parents using a standardized questionnaire.

Results

Eighty-nine cases with severe HFMD and 267 controls with mild HFMD were recruited in this study. Palm rashes (OR?=?0.004, 95%CI?=?0.000–0.039, p?p?p?=?0.030), leg trembling (OR?=?29.008, 95%CI?=?1.535–548.178, p?=?0.025), papule rash (OR?=?4.622, 95%CI?=?1.110–19.252, p?=?0.035), a raised WBC count?>?10.8?×?10⁹/L (OR?=?4.495, 95%CI?=?1.311–15.415, p?=?0.017), and human enterovirus 71 infection (OR?=?39.172, 95%CI?=?9.803–156.522, p?Conclusion Clinicians should pay increased attention to children diagnosed as HFMD with the independent risk factors above.     

Prognostic value of gradient echo T2* sequences for brain MR imaging in preterm infants

Background

Gradient echo T2*-W sequences are more sensitive than T2-W spin-echo sequences for detecting hemorrhages in the brain.

Objective

The aim of this study is to correlate presence of hemosiderin deposits in the brain of very preterm infants (gestational age <32 weeks) detected by T2*-W gradient echo MRI to white matter injury and neurodevelopmental outcome at 2 years.

Materials and methods

In 101 preterm infants, presence and location of hemosiderin were assessed on T2*-W gradient echo MRI performed around term-equivalent age (range: 40–60 weeks). White matter injury was defined as the presence of >6 non-hemorrhagic punctate white matter lesions (PWML), cysts and/or ventricular dilatation. Six infants with post-hemorrhagic ventricular dilatation detected by US in the neonatal period were excluded. Infants were seen for follow-up at 2 years. Univariate and regression analysis assessed the relation between presence and location of hemosiderin, white matter injury and neurodevelopmental outcome.

Results

In 38/95 (40%) of the infants, hemosiderin was detected. Twenty percent (19/95) of the infants were lost to follow-up. There was a correlation between hemosiderin in the ventricular wall with >6 PWML (P?<?0.001) and cysts (P?<?0.001) at term-equivalent age, and with a lower psychomotor development index (PDI) (P=0.02) at 2 years. After correcting for known confounders (gestational age, gender, intrauterine growth retardation and white matter injury), the correlation with PDI was no longer significant.

Conclusion

The clinical importance of detecting small hemosiderin deposits is limited as there is no independent association with neurodevelopmental outcome.     

Reference ranges for sonographic renal dimensions in preterm infants

Background

Ultrasonographic measurement of kidney dimensions is important in evaluation of renal disease in preterm infants who have multiple comorbidities that affect renal function.

Objective

The purpose of this study was to determine the reference ranges of kidney dimensions in preterm newborns and to provide a chart to use easily in daily practice.

Materials and methods

We evaluated renal dimensions in 498 preterm infants with a gestational age of <37 weeks using sonography within the first week of life. We statistically analyzed the relationships between all dimensions and gender, gestational age (based on the last menstrual period), height and weight. Minimum and maximum values of dimensions were defined.

Results

All dimensions of the kidneys were statistically different in boys and girls (P?<?0.05). Both longitudinal and anteroposterior dimensions of the right and left kidneys showed high correlation with gestational age, weight and height in girls and boys. Weight correlated best with dimensions.

Conclusion

Nomograms from these data can be used to determine an abnormality in kidneys of preterm newborns.