Comparing the efficacy of nebulizer recombinant human DNase and hypertonic saline as monotherapy and combined treatment in the treatment of persistent atelectasis in mechanically ventilated newborns

Background: The purpose of the present study was to compare the cost‐effectiveness and efficacy of nebulizer recombinant human DNase (rhDNase) and hypertonic saline (HS) as monotherapy and combined treatment in neonatal atelectasis. Methods: Eighty‐seven newborns with persistent atelectasis who did not respond to traditional treatment were studied retrospectively. Group 1 did not receive nebulizer drugs; Group 2 received 7%HS; Group 3 received rhDNase; and Group 4 received both 7%HS and rhDNase. Subjects' chest X‐ray scores, partial pressure of CO₂, respiratory rate, fraction of inspired oxygen (FiO₂) peak inspiratory pressure, atelectasis healing rate, median duration of nebulizer treatment and costs were compared. Results: Percentages of improvement in atelectasis on Day 3 of treatment in Group 1, Group 2, Group 3 and Group 4 were 27, 70, 81 and 95%, respectively, while median duration of treatment was 8.1, 3.3, 2.9 and 2.4 days, respectively. Comparison of chest X‐ray scores, partial pressure of CO₂, respiratory rate, FiO₂ and peak inspiratory pressure values before and 48 h after treatment did not yield a significant difference for the control group (P > 0.05), while a marked improvement was observed in other groups for all parameters (P < 0.05). The most distinct improvement was in Group 4, followed by Group 3. Conclusions: Although both the combined treatment with HS and rhDNase and their monotherapies are effective in the treatment of persistent atelectasis in newborns receiving mechanical ventilation, their combined use produces higher efficacy. The efficacy of rhDNase is superior to monotherapy with HS. Use of these two treatments concomitantly reduces the cost. To the best of our knowledge, the present study is the first to use HS alone or in combination with rhDNase in newborn patients.     

Nebulized hypertonic saline/salbutamol solution treatment in hospitalized children with mild to moderate bronchiolitis

Background: The objective of this study was to determine the efficacy and safety of nebulized 3% hypertonic saline solution and salbutamol in the treatment of mild to moderate bronchiolitis. Methods: In a randomized controlled trial, 93 infants with mild to moderate bronchiolitis were divided into two groups. The infants received inhalation of 2.5 mg (0.5 mL) salbutamol dissolved in either 4.0 mL normal (0.9%) saline (control group, n= 43) or 4.0 mL hypertonic (3%) saline (treatment group, n= 50). The therapy was repeated three times daily until discharge. Cough, wheezing, pulmonary physical signs, and the length of hospital stay were recorded. Results: Wheezing remission time was 3.8 ± 1.1 days in the control group and 2.7 ± 0.9 days in the treatment group (P < 0.01). Cough remission time was 6.3 ± 0.9 days in the control group and 5.3 ± 0.8 days in the treatment group (P < 0.01). The moist crackles disappeared at 5.4 ± 0.8 days in the treatment group versus 6.2 ± 0.9 days in the control group (P < 0.01). Furthermore, the average length of hospital stay decreased from 7.4 ± 1.5 days in the control group to 6.0 ± 1.2 days in the treatment group (P < 0.01). No obvious adverse effects were observed. Conclusions: Inhalation of nebulized 3% hypertonic saline solution and salbutamol is a safe and effective therapy for patients with mild to moderate bronchiolitis.     

Phototherapy for neonatal hyperbilirubinemia affects cytokine production by peripheral blood mononuclear cells

The capacity of peripheral blood mononuclear cells (PBMC) to produce interleukin (IL) IL-1β, IL-2, IL-3, IL-6, IL-10 and tumor necrosis factor-α (TNFα) was examined in term newborns with hyperbilirubinemia after 24 hours' exposure to phototherapy (wave length 425–475 nm). The results were compared with those from untreated neonates. Fifty newborns spontaneously delivered at term were included in the study. Blood samples were collected from 20 newborns before and 24 h after phototherapy. The control group consisted of 30 neonates examined on two consecutive days. PBMC isolated from blood samples were incubated in vitro for cytokine production. The concentration of cytokines in the supernatants was tested using ELISA kits (for IL-1β, IL-6, IL-10 and TNFα), or by bioassays (for IL-2 and IL-3). Phototherapy caused a 70% increase in IL-2 secretion (123 ± 27 vs 208 ± 30 units/ml, P < 0.01) and 56% in IL-10 production (1.07 ± 0.19 vs 1.67 ± 0.33 ng/ml, P < 0.03), whereas the spontaneous secretion of IL-1β was reduced by 43% (13.7 ± 2.3 vs 7.3 ± 1.7 ng/ml, P < 0.02). In the control group the secretion of these cytokines was similar on the two consecutive days and did not differ significantly from secretion in the other group before phototherapy. On the other hand, lipopolysaccharide induced TNFα production was higher on the second day in the two groups of newborns irrespective of phototherapy (388 ± 58 vs 683 ± 88 pg/ml, P < 0.001, in the control group and 384 ± 75 vs 588 ± 91, P < 0.05, before and after phototherapy). The synthesis of IL-3 and IL-6 did not change significantly between the two days of the study. The results demonstrate that in addition to the well-known positive effect of phototherapy on the neonate serum bilirubin level, this treatment affects the function of the immune system in newborns via alterations in cytokine production. Received: 4 September 1997 / Accepted: 14 February 1998     

Urinary enzyme changes in newborns with unconjugated hyperbilirubinemia

Various changes in renal function caused by unconjugated hyperbilirubinemia in newborns have been suggested in previous reports. Disclosing an injury in renal tubulus epithelium is feasible by measurement of urinary enzymes. Thus, renal function tests and urinary enzymes in 25 term newborns with unconjugated hyperbilirubinemia were evaluated before and after phototherapy. Ten healthy term newborns without hyperbilirubinemia formed the control group. Mean values of the variables obtained before and after phototherapy in the study group and in the controls were, respectively: urine osmolality (osm/kg H₂O); 0.147 ± 0.009, 0.174 ± 0.011, and 0.153 ± 0.018; endogenous creatinine clearance (mL/min per 1.73 m²): 45.7 ± 2.15, 46.0 ± 1.6 and 46.7 ± 3.9; fractional excretion of sodium (%): 1.27 ± 0.30, 0.79 ± 0.19 and 1.24 ± 0.07; tubular phosphorus reabsorption (%): 85.8 ± 3.3, 87.8 ± 2.8 and 86.6 ± 1.7; urinary N-acetyl-β-D glucosaminidase/creatinine (IU/mg): 0.617 ± 0.226, 0.574 ± 0.214 and 0.619 ± 0.210; fractional excretion of alkaline phosphatase (%): 0.422 ± 0.103, 1.001 ± 0.374 and 0.596 ± 0.201; fractional excretion of lactic dehydrogenase (LDH; %): 0.102 ± 0.019, 0.121 ± 0.023 and 0.119 ± 0.041; fractional excretion of AST (%): 0.433 ± 0.127, 0.530 ± 0.113 and 0.502 ± 0.074; fractional excretion of alanine aminotransferase (ALT; %) 0.856 ± 0.413, 1.619 ± 1.076 and 1.066 ± 0.366. No significant difference was found between these values before and after phototherapy in the study group, or between the values before phototherapy in hyperbilirubinemic neonates and in the control group. In conclusion, unconjugated hyperbilirubinemia up to a serum level of 18.4 mg/dL in term neonates does not seem to result in injury of normal tubulus epithelium as shown by urinary enzyme levels.     

Expression of T subsets and mIL-2R in peripheral blood of newborns with hypoxic ischemic encephalopathy

Background  Infantile and undifferentiated immune cells in the pathogenesis of neonates with HIE have been studied in recent years. This study was undertaken to observe the expression level of T subsets and membrane interleukin-2 receptor (mIL-2R) in the peripheral blood of newborns with hypoxic ischemic encephalopathy (HIE) and its clinical manifestations. Methods  The peripheral blood mononuclear cells (PBMCs) of newborns with HIE and normal controls were isolated by the routine Ficoll-Hypaque method, and the rates of CD₃ ⁺, CD₄ ⁺, CD₈ ⁺, CD₄ ⁺/CD₈ ⁺ and mIL-2R induced and not induced by phytohemagglutinin (PHA) were detected by biotin-streptavidin (BSA) at the first, third and seventh day after birth. Results  At the first day after birth, the positive rates of CD₃ ⁺, CD₄ ⁺, CD₈ ⁺, CD₄ ⁺/CD₈ ⁺ and mIL-2R induced and not induced by PHA were (37.4±6.7)%, (29.4±6.9)%, (16.7±3.3)%, 1.8±0.5, (3.6±1.1)% and (20.9±4.8)%, respectively. Significant differences were observed between the HIE group and the normal controls (P<0.01-P<0.05). At the third day after birth, the positive rates of CD₃ ⁺, CD₄ ⁺, CD₈ ⁺, CD₄ ⁺/CD₈ ⁺ and mIL-2R induced and not induced by PHA were (41.0±7.4)%, (35.8±6.9)%, (22.6±4.5)%, (1.7±0.5), (3.9±1.2)%, and (22.8±5.1)%, respectively. There were significant differences between the HIE group and the normal controls (P<0.05). At the seventh day after birth, the positive rates of CD₃ ⁺, CD₄ ⁺, CD₈ ⁺ were (41.8±6.1)%, (36.4±5.1)% and (25.6±4.3)%, respectively. There was significant difference between the HIE group and the normal controls (P<0.05). The ratio of CD₄ ⁺/CD₈ ⁺ and the expression level of mIL-2R induced and not induced by PHA were 1.5±0.3, (4.1±1.2)% and (23.8±5.2)%, respectively. There was no significant difference between the HIE group and the normal controls (P>0.05). Conclusions  Peripheral blood mononuclear cells of newborns are immature and undifferentiated with a very low expression level of surface markers. The changes of cell immunity involve in the pathogenesis of HIE. The disorder of cellular immune function exists in newborns with HIE. Cell immunity and immune regulative response in newborns are gradually improved or mature during the period of growing, facilitating the recovery from brain injury caused by HIE.     

Time‐course effect of a single dose of hydrocortisone for refractory hypotension in preterm infants

Background: The aim of this study was to determine the time‐course effect of a single dose of hydrocortisone (HC) on arterial blood pressure in extremely low gestational age newborns (ELGAN) with refractory hypotension during the first 3 days of life. Methods: We carried out a matched case–control study of a cohort of 116 infants born between 23 and 27 weeks' gestation at a tertiary center. Twelve infants (10%) were treated with HC for refractory hypotension (HC group). HC was administered at a dose of 2 mg/kg when mean arterial pressure (MAP) was below 30 mmHg (25 mmHg for infants <25 weeks of gestational age) despite the use of inotropes and volume expanders. Changes in the MAP after the HC administration were compared with those in the infants who were not treated with HC and matched for gestational age (Control group). Results: The mean MAP before administration of HC was significantly lower in the HC group than that in the control group (24.0 ± 3.2 vs 33.3 ± 4.8 mmHg; P < 0.01). The mean MAP in the HC group increased significantly at 2 h after HC treatment, and then reached levels comparable to those in the Control group at 5 h (31.3 ± 4.0 vs 33.9 ± 4.7 mmHg; P= 0.18), and remained at normal levels until 12 h after HC treatment. Conclusion: A single dose of HC treatment induces a rapid and sustained improvement in blood pressure in ELGAN with refractory hypotension.     

The effect of inhaled nitric oxide therapy on thromboelastogram in newborns with persistent pulmonary hypertension

Studies about the effects of inhaled nitric oxide (iNO) on bleeding time and platelet aggregation in newborns are limited in number and have inconclusive results. Thromboelastogram (TEG) shows the combined effects of coagulation factors and platelet functions. In this preliminary study, we aimed to evaluate the effects of iNO on coagulation using TEG in newborns with persistent pulmonary hypertension (PPH). TEG assays were performed in 10 term infants receiving iNO treatment for PPH and 32 healthy term infants. Samples of the iNO group were collected before and during iNO. Clot reaction time (R), clot kinetics (K), maximum amplitude (MA), and alpha angle were obtained from the TEG tracing. TEG-R values were statistically higher during iNO treatment (7.75?±?3.34) when compared to the values before iNO (4.83?±?1.38) and the healthy controls (3.75?±?0.98). The alpha angle was lower in iNO treated infants at both periods (before iNO, 55.33?±?8.58; during iNO, 42.90?±?18.34) compared to the control group (64.95?±?6.88). MA values before iNO treatment were the lowest (44.43?±?14.09) and improved with the iNO treatment (48.40?±?9.49) despite still being lower compared to the controls (53.67?±?5.56). Conclusion: Both PPH and iNO may negatively effect in vitro coagulation tests. Therefore, newborns with PPH requiring iNO treatment should be closely monitored for coagulation problems.     

喘乐宁空气压缩雾化治疗婴儿毛细支气管炎疗效判定

目的　应用 β2 受体激动剂治疗的急性毛细支气管炎效果一直有争议。该研究观察毛细支气管炎患儿喘乐宁雾化吸入治疗前后肺功能的变化 ,并探讨其临床意义。方法　 30例急性毛细支气管炎患儿随机分为治疗组 1 6例 (喘乐宁雾化吸入 )和对照组 1 4例 (生理盐水雾化吸入 ) ,在雾化吸入前、吸入后即刻、1 5min和 30min分别测定潮气呼吸流速容量环 (TBFV)、呼吸系统静态顺应性及阻力的变化。结果　治疗组到达潮气呼气峰流速时呼出气量 /潮气量 (%V PF)在吸入后 30min与吸入前比较 ,差异有显著性 (P <0 .0 5 )。两组雾化后即刻 2 5 /PF、吸气时间 (Ti)差异有显著性 (P <0 .0 5 )。结论　喘乐宁雾化吸入后 30min可明显降低小气道阻力 ,改善通气。     

Effects of dobutamine on left ventricular performance in newborns as determined by systolic time intervals

To evaluate the effects of dobutamine on myocardial function in newborns, left ventricular systolic time intervals (STI) — normalized pre-ejection period (PEPI), normalized left ventricular ejection time (LVETI) and pre-ejection period to left ventricular ejection time ratio (PEP/LVET) — were assessed by echocardiography in 18 newborns treated with dobutamine for clinically diagnosed heart failure. Examinations were performed prior to and 30 min after starting dobutamine infusion (7.5 or 10 μg/kg per min). Patients were assigned to two groups according to their PEP/LVET prior to dobutamine administration: group I (n=9) with pre-treatment PEP/LVET ≤ 0.35 and group II (n=9) with pre-treatment PEP/LVET > 0.35. While there was no change of STI in group I, dobutamine infusion resulted in a significant decrease in PEPI (from 102±4.8 to 87.8±4.2; mean ± SEM;P<0.01) and of PEP/LVET (from 0.56±0.05 to 0.45±0.05; mean ±SEM;P<0.01) and in a significant increase of LVETI (from 237.6±5.6 to 253.3±5.2; mean ±SEM;P<0.01) in group II. Heart rate increased significantly in both groups. Left ventricular end-diastolic dimension, also assessed by echocardiography, did not change in the eight studies performed. An increase in mean arterial pressure was found in three out of five newborns of group II and in one out of four patients in group I. It is concluded that dobutamine can improve cardiac performance in newborns with impaired left venfricular function. This effect is probably due to an improvement in myocardial contractility.     

Interpreting positive cultures of endotracheal aspirates: factors associated with treatment decisions in ventilated neonates

Aims: Diagnosis of ventilator‐associated pneumonia in newborns is challenging because of ease of colonisation, non‐specific chest radiograph changes and lack of a consensus definition. The aims of this study were to review treatment decisions in neonates with culture‐positive endotracheal aspirate and to assess impact on respiratory outcomes using blinded review of radiological studies. Methods: Charts from all very low birthweight neonates ventilated for >48 h and with positive culture were assessed. Chest radiographs were reviewed by a radiologist masked to the grouping of the episode (treated/not treated). Clinical, investigational and radiological features used in practice were assessed on impact on treatment decisions. Association between treatment and outcomes was assessed. Results: Seventy‐four episodes of culture‐positive endotracheal aspirate were analysed in 38 babies. Fifty‐eight episodes were treated with antibiotics. Gestational age at birth and birthweight in both groups (treated vs. non‐treated) were statistically comparable (25.5 ± 3.1 vs. 27.2 ± 2.3 weeks and 809 ± 302 vs. 870 ± 262 g). Comparative chest radiographs were available in 51 of 58 treated episodes; deterioration was noted in 42 (82.3%). Ventilatory parameters were significantly higher in the treatment group and showed a significant improvement after antibiotics. Twenty‐three babies developed chronic lung disease. Odds ratio (of having chronic lung disease when treatment is initiated) was 4.5 (95% confidence interval = 0.97–20.8, P= 0.06). Conclusions: Treated culture‐positive aspirate episodes were accompanied by higher ventilatory requirements, increased symptoms and elevated septic markers. Need for treatment was associated with greater likelihood of developing chronic lung disease.     

Heterogeneity of Ventricular Repolarization in Newborns With Severe Aortic Coarctation

Sudden death is a possible occurrence for newborns younger than 1 year with severe aortic coarctation (CoA) before surgical correction. Basic research and animal experiments have shown electrophysiologic changes during mechanical ventricular pressure overload. The current study aimed to evaluate the effect of severe CoA on the heterogeneity of ventricular repolarization by examining corrected QT and JT interval dispersion (respectively, QTc-D and JTc-D) and electrocardiographic parameters of spatial heterogeneity of ventricular repolarization in newborns with no associated congenital cardiac malformations. The study enrolled 30 isolated severe CoA neonates (age, 45 ± 15 days; 17 males) with normal size and wall thickness of the left ventricle before surgical correction and 30 age- and sex-matched healthy newborns used as control subjects. Heart rate, QRS duration, maximum and minimum QT and JT intervals, and QTc-D and JTc-D measurements were performed. The healthy control group did not significantly differ from the CoA group in terms of heart rate, weight, height, and echocardiographic parameters. Compared with the healthy control group, the CoA group presented significantly increased values of QTc-D (109.7 ± 43.4 vs. 23 ± 15 ms; P = 0.03) and JTc-D (99.1 ± 43.3 vs. 65.8 ± 24.1 ms; P = 0.04). A statistically significant correlation was found between the Doppler peak pressure gradient across the coarctation site and the values of QTc-D (r = 0.48; P = 0.03) and JTc-D (r = 0.42; P = 0.04). Our study showed significantly increased QTc-D and JTc-D in isolated CoA newborns with normal left ventricular geometry.     

Treatment of encapsulated pleural effusions in children: A prospective trial

Background: The aim of this study was to improve the efficacy of treatment of complicated pleural effusions. Methods: In this prospective study, 76 consecutive children (average age 5.0 ± 4.14 years) fulfilling the required classification criteria were duly treated with chest tube placement and divided into two groups depending on the presence of encapsulated or non‐encapsulated effusions. Treatment of the former group was supplemented by intrapleural fibrinolysis. The effectiveness of treatment was assessed in terms of chest tube dwell‐time and total length of hospitalization. Regression analysis was performed using independent factors that were associated with these dependent factors. Value differences for P < 0.05 were considered significant. Results: The ultrasound pleural distance and lactic‐dehydrogenase content in the pleural fluid was significantly associated with the length of treatment (P < 0.01). Improved response to treatment, reduced duration of hospitalization (9.2 ± 1.9 vs 11.5 ± 0.9; P < 0.01) and tube dwell‐time (7.6 ± 1.3 vs 9.5 ± 0.9; P < 0.01) was achieved in the intrapleural‐fibrinolysis‐treated group (n= 38) compared with controls (n= 38), with virtually the same total tube output (606.1 ± 257.5 vs 673.1 ± 347.4; P= 0.175). All patients were completely cured. Following 104 applications of the fibrinolytic agent there was one change in coagulation parameters: hypofibrinogenemia (in 1%). Conclusions: The authors recommend intrapleural fibrinolysis as an effective and safe alternative treatment strategy in treating encapsulated pleural effusions in children.     

Brain Maturity and Brain Injury in Newborns With Cyanotic Congenital Heart Disease

Patients with congenital heart disease (CHD) are at high risk for adverse neurodevelopmental outcomes. The aim of this work was to assess brain maturity and brain injury in newborns with cyanotic CHD using proton magnetic resonance spectroscopy (MRS). The study included 38 newborns with cyanotic CHD (study group) and 20 healthy full-term newborns (control group) matched together regarding gestational age and sex. Three-dimensional MRS showed that the mean ratio of N-acetylaspartate to choline (Ch) was significantly lower in newborns with cyanotic CHD (0.55 ± 0.08) compared with controls (0.67 ± 0.11) (p < 0.001). However, the mean ratio of lactate to Ch metabolite was significantly higher in the studied cases (0.14 ± 0.04) compared with controls (0.09 ± 0.04) (p < 0.001). The mean value for average diffusivity was 1.41 ± 0.06 in newborns with cyanotic CHD compared with 1.27 ± 0.07 in control newborns (p < 0.001), and the mean value for white-matter fractional anisotropy was 0.19 ± 0.03 in cyanotic newborns and 0.25 ± 0.08 in controls (p < 0.001). Newborns with cyanotic CHD are at increased risk of cerebral white matter injury as well as poor brain maturity. MRS provides a surrogate marker for early detection of such brain abnormalities.     

Plasma cortisol levels in acute asthma

Objective : The study was undertaken with the aim to determine correlation between the initial plasma cortisol level and severity of asthma attack and the response to standard treatment for acute exacerbation of bronchial asthma in pediatric age group.Methods : The study was performed in 33 asthmatic patients between 5 2–12 years of age, presenting to pediatric emergency with acute exacerbation of bronchial asthma. None of the patients included in the present study was on steroids. Venous blood sample for determination of plasma cortisol level was taken and patients were nebulized with salbutamol every 20minutes, upto 1 hour. The patients who failed to respond even after three nebulizations were labeled as nonresponders and repeat venous blood sample for plasma cortisol estimation was taken before giving injection hydrocortisone. In responders sample was taken 1hour after last nebulization.Results : The mean plasma cortisol value at the time of admission in responders (12.42 ± 1.9 ng/dl) was not found to be significantly different from that in nonresponders (13.1 ± 2.74 ng/dl). Children with severe attack of asthma had significantly higher plasma cortisol levels both at the time of admission (p=0.03) and at the end of study (p=0.001), as compared to patients with moderate attack. The mean percentage change in plasma cortisol levels in nonresponders was an increase of 80.65 ± 60.64%, whereas, in responders it decreased by 16.49 ± 21.7% and this difference was statistically significant (p s<0.05).Conclusion : The hypothalamo pituitary adrenal axis functions normally in asthmatic patients, producing a rise in cortisol levels corresponding to degree of stress; and from initial cortisol level alone, it cannot be predicted, whether a patient will respond to β-2 agonist (salbutamol) nebulization alone or will require exogenous corticosteroids. An erratum to this article is available at .     

以胸闷为主诉的不典型支气管哮喘患儿激发试验前后的肺功能特点

目的 了解以胸闷为主诉的不典型支气管哮喘患儿在支气管激发试验前后的肺功能特点。方法 选取2010 年1 月至2013 年12 月在我院肺功能室进行支气管激发试验的不典型哮喘患儿34 例为研究对象(不典型哮喘组),同期选取典型哮喘患儿34 例为对照,检测不典型哮喘组患儿支气管激发试验前后的肺功能,以及典型哮喘组患儿发作期和缓解期肺功能。结果 不典型哮喘组激发前肺功能指标用力肺活量(FVC)、第1 秒最大呼气量(FEV1)、FEV1/FVC、呼气峰流速(PEF)、用力呼气25 %、50 %、75%肺活量时的呼气峰流速(FEF25、FEF50、FEF75)、最大呼气中期流量(MMEF75/25)分别为105%±12%、104%±12%、100%±7%、88% ±13%、90% ±14%、81% ±17%、73% ±25%、80%±17%,明显高于典型哮喘组患儿发作期肺功能各指标(PP>0.05)。不典型哮喘组激发后肺功能各指标与典型哮喘组发作期相比差异无统计学意义(P>0.05),但均低于典型哮喘组缓解期和不典型哮喘组激发前水平。结论 支气管激发试验有助于不典型哮喘患儿的诊断。     

Prostaglandin E2 After Septostomy for Simple Transposition

In simple transposition of the great arteries (sTGA), balloon atrial septostomy is performed prior to arterial switch to improve mixing of systemic and pulmonary circulations. Following septostomy, some patients are also given prostaglandin E2 (PGE2) until surgical repair. The aims of our study were to identify how often PGE2 is given after septostomy, the indications for starting PGE2, and the effect this has on postoperative outcome. The study was a retrospective review of infants born with sTGA between 2000 and 2005, who underwent arterial switch at Yorkhill Children’s Hospital, Glasgow. Over a 5-year period, 26 infants (16 male) with sTGA underwent septostomy. There was a significant rise in mean oxygen saturation following septostomy (mean, 61.4 ± 11.5% before, 81.5 ± 9.4% after; p < 0.05). Four of 26 (15%) did not receive PGE2 at all (group 1) and 8 of 26 (30%) received PGE2 before but not after septostomy (group 2). A total of 14 of 26 infants (54%) were given PGE2 following septostomy. This comprised 11 who received PGE2 before and after septostomy (group 3) and 3 who did not receive PGE2 prior to septostomy but did after (group 4). Groups 2 and 3 were compared directly, as they both received PGE2 before septostomy. In group 3, oxygen saturations were lower when PGE2 was started compared with saturations immediately after septostomy (45 ± 23.6% vs. 80 ± 10.3%; p < 0.05). Groups 2 and 3 showed no difference in atrial gap after septostomy (9.4 ± 3 vs. 8 ± 1 mm; p > 0.05). Fifty percent of infants in group 3 underwent echocardiography prior to restarting PGE2, which revealed a patent arterial duct in all but one patient. Despite PGE2, Group 3 had lower saturations at arterial switch compared with Group 2 (71 ± 14% vs. 82 ± 8%; p < 0.05). No difference was observed between group 2 and group 3 with regard to length of cardiopulmonary bypass (group 2, 173 ± 101.4 min, vs. group 3, 157.9 ± 42.1 min; p > 0.05). However, the Intensive Care Unit stay was longer for patients who received PGE2 following septostomy (8.5 ± 10.3 vs. 5 ± 0.93 days; p < 0.05). Total postoperative stay was also longer for infants who received PGE2 after septostomy (26.8 ± 14.3 vs. 16.8 ± 6.3 days; p < 0.05). In conclusion, the use of pulse oximetry has led to an increase in the administration of PGE2 after septostomy. PGE2 administration was associated with a longer ICU stay. The association between administration of PGE2 and longer postoperative stay supports the approach of early surgical repair with minimal preoperative medical intervention. This article is submitted with the full approval of both authors. Beattie LM, McLeod K. Neonatal transposition: atrial gap and post-septostomy prostaglandin E2. Presented at the British Paediatric Cardiac Association, Royal College of Paediatrics and Child Health Annual Spring Meeting, York, UK, April 5, 2006.     

Predictive risk factors for coronary artery abnormalities in Kawasaki disease

Clinical characteristics to predict the development of coronary artery abnormalities (CAA) in Kawasaki disease (KD) were assessed by reviewing medical records of patients diagnosed with KD at Korea University Medical Center from March 2001 to February 2005. Of the 285 patients diagnosed with KD, 19 developed CAA (6.7%). Compared with the CAA(−) group, the CAA(+) group had a longer duration of fever after intravenous gamma-globulin (IVGG) injection (2.4±2.9 vs. 1.5±1.2 days, p=0.008) and higher C-reactive protein (CRP)(12.3±7.8 vs. 8.7±7.1 mg/dL, p=0.038). In particular, the CAA(+) group tended to have more than 7 days of fever before IVGG and more than 3 days of fever after IVGG (26.3 vs. 5.3%, p<0.001; 26.3 vs. 6.4%, p=0.002). When the IVGG responsiveness was defined by the presence of defervescence within 3 days after IVGG, IVGG-non-responders showed a higher incidence of CAA (22.7 vs. 5.3%, p=0.002). Non-responders had a longer duration of fever after IVGG (5.5±1.9 vs. 1.2±0.6 days, p<0.001) and a significantly increased CRP, AST, ALT and total bilirubin. Multivariate regression analysis for CAA showed that the only factor significantly associated with the development of CAA was total fever that lasted for longer than 8 days (OR=4.052, 95% CI=1.151–14.263, p=0.0293). Conclusively, the most important predictor of CAA in KD is total duration of fever longer than 8 days. Early identification of IVGG non-responders and active therapeutic intervention for fever in KD cases might decrease the incidence of CAA.     

Postoperative Use of Oral Sildenafil in Pediatric Patients with Congenital Heart Disease

We sought to determine the efficacy of postoperative oral sildenafil therapy (OST) in pediatric patients with congenital heart disease (CHD). A retrospective review of 45 postoperative patients with CHD who received OST was performed. Patients were categorized into three groups according to clinical indications: (1) to stabilize pulmonary vascular reactivity after biventricular repair (group 1 [n = 15]), (2) to lower pulmonary vascular resistance after bidirectional cavopulmonary shunt (group 2 [n = 12]), and (3) to improve post-Fontan hemodynamics (group 3 [n = 18]). Thirty-four patients (34 of 45 [75.6%]) had received inhaled nitric oxide (iNO) while on OST. Mean pulmonary arterial pressure (mPAP), mean systemic blood pressure (mSBP), and peripheral oxygen saturation (SpO₂) were recorded during the first 24 hours after the initiation of OST. In group 1, the baseline mPAP/mSBP ratio (0.60 ± 0.17) decreased significantly after the second (0.46 ± 0.14, p = 0.004) and fourth (0.50 ± 0.18, p = 0.025) doses of OST. In group 2, baseline SpO₂ (71.0 ± 12.3%) increased after the fourth dose (75.1 ± 12.3%, p = 0.04) of OST, without significant changes in mPAP. In group 3, baseline mPAP (14.8 ± 3.3 mmHg) decreased significantly after the first (13.9 ± 2.8 mmHg, p = 0.025) and second (13.3 ± 1.9 mmHg, p = 0.016) doses of OST, without changes in SpO₂. In thirty-one (31 of 34 [92%]) subjects, iNO was discontinued within a median of 2 days after the initiation of OST, without rebound phenomena. There were no OST-related complications. Sildenafil citrate can be used safely in postoperative pediatric patients with CHD. Benefits from OST may be manifested differently in various clinical settings.     

Creation and Enlargement of Atrial Defects in Congenital Heart Disease

Transcatheter creation and enlargement of interatrial defects (IAD) may improve hemodynamics; however, procedural outcomes have not been well defined. Hospital records were reviewed for children who underwent percutaneous procedures to create and enlarge an IAD and were grouped as follows: (1) right and (2) left heart obstructive lesions, (3) left atrial (LA) decompression during left heart assist, (4) failing Fontan circulation, and (5) miscellaneous. Forty-five children (mean age, 3.4 ± 4.7 years; 30 (67%) male) were identified. In group 1 (n = 6), all achieved endpoints of right atrial (RA) decompression (n = 2), improved left ventricular filling (n = 3), or improved arterial saturations (n = 1). In group 2 (n =18), mean LA pressure decreased (21 ± 6 to 13 ± 5 mmHg, p < 0.001) and arterial saturations increased (61 ± 13% to 78 ± 11%, p < 0.001). All except 2 patients achieved definitive repair, further palliation (n = 9), or heart transplantation (HTX) (n = 7). In group 3 (n = 5), the LA was decompressed (21 to 13 mmHg, p = 0.03) in all, and all except 1 patient survived to HTX (n = 2) or full recovery (n = 2). In group 4 (n = 11), of 7 patients with a low cardiac output syndrome after surgery, despite improved atrial shunting, 3 died and 1 required a HTX. In group 5 (n=5), RA decompression (n = 1) or improved arterial saturation (n = 4) was achieved in all. Overall, 5-year HTX free survival was 75%. Mechanical ventilation before the procedure (p < 0.001), the need for a blade septostomy (p = 0.002), and higher LA pressures after the procedure (p = 0.04) independently predicted mortality or the requirement for HTX. Transcatheter optimization of an atrial communication can help optimize treatment strategies and has a low procedural risk.     

Frequency and risk factors of fetal malnutrition among liveborn singleton term neonates using a computerised perinatal database, 2000–2006

Aim: The aim of this study was to determine the frequency, risk factors and anthropometric measurements of fetally malnourished, liveborn singleton term neonates. Methods: The computed delivery room data of 11.741 liveborn singleton term neonates was used to compare malnourished and nourished newborns. Results: Of the total subjects, 577 (4.9%) were malnourished. There were no differences between the groups with regard to gender distribution, Apgar scores, maternal parity, smoking during pregnancy and type of delivery. Maternal age and neonatal gestational age (GA) were significantly lower in malnourished newborns (P < 0.001). Birthweight (BW), birth length (BL) and head circumference (HC) were significantly lower in the malnourished group compared with well‐nourished group (P < 0.001). Mean BW (g) was 2724.7 ± 17.0 in the malnourished group versus 3234.3 ± 3.8 in the well‐nourished group; BL (cm) was 47.8 ± 0.1 in malnourished versus 49.5 ± 0.0 in well‐nourished neonates; HC (cm) was 33.25 ± 0.1 in the malnourished versus 34.3 ± 0.0 in the well‐nourished group. Between the groups, there were significant differences in the ratio of small, appropriate and large for GA (P < 0.001). Of the malnourished newborns, 35.5% were small for GA, 63.3% were appropriate for GA and 1.2% were large for GA. Conclusion: Fetal malnutrition (FM) still exists despite the advances in current obstetric care. Neonates of adolescent mothers and of low GA are particularly at risk for FM. The BW, BL and HC of fetally malnourished neonates are lower than that of well‐nourished neonates. Like term singleton appropriate and small for GA neonates, term singleton large for GA neonates could also have been fetally malnourished.