Continuous hemodialysis therapy for an extremely low‐birthweight infant with hyperammonemia

Hyperammonemia of newborns should be treated promptly, and the outcome depends on the rapid elimination of excessive plasma ammonia. We encountered a case of transient hyperammonemia in an extremely low‐birthweight infant whose plasma ammonia decreased sufficiently after continuous hemodialysis therapy. It seems that continuous hemodialysis therapy using the peripheral artery and umbilical vein is useful for hyperammonemia of extremely low‐birthweight infants; however, there are several problems to consider due to the immaturity of these infants.     

Left atrium thrombus in an extremely low‐birthweight infant with late‐onset circulatory dysfunction

A left atrium thrombus, potentially a life‐threatening complication, is an extremely rare in early infancy. Most cases are caused by mal‐placement of central venous catheters or related to congenital heart diseases with left atrial blood congestion. Here we present an extremely low birth weight infant who developed a left atrial thrombus during the course of late onset circulatory dysfunction. The thrombus was successfully treated by recombinant tissue plasminogen activator. A hemodynamically unstable condition like late onset circulatory dysfunction should be taken into consideration as a potential risk condition of this rare disease.     

Outcomes of inborn and transported extremely premature very‐low‐birthweight infants in Hawai‘i

Background: Delivery of premature infants outside tertiary care centers is not always preventable. The aim of this study was to compare rates of survival and common morbidities in extremely premature babies transported to a level III facility versus those born at the level III center. Methods: Retrospective chart review was performed on all neonates born at ≤ 28 weeks of gestation with birthweight ≤1500 g who were admitted to the Newborn Intensive Care Unit at Kapi‘olani Medical Center for Women and Children (KMCWC) between 1 January 2000 and 31 December 2005. Infants were divided into two groups, those born at KMCWC (Inborn) and those born at level I institutions and subsequently transported (Transport) to KMCWC. Results: A total of 394 neonates met the study criteria; 349 were inborn while 45 were transported. Survival rates were identical for both groups. However, the Transport group survivors displayed a significantly longer mean length of stay and higher rate of severe retinopathy of prematurity than those in the Inborn group (P≤ 0.01). Conclusion: Identical rates of survival in both groups suggest that community medical professionals are providing satisfactory care to stabilize critical neonates without reducing their chances of survival. However, increased length of stay and higher rate of retinopathy of prematurity in the Transport group suggest that differences in medical management during the first few hours of life may adversely affect outcomes.     

Meconium‐related ileus in extremely low‐birthweight neonates: Etiological considerations from histology and radiology

Background: A nationwide survey on neonatal surgery conducted by the Japanese Society of Pediatric Surgeons has demonstrated that the mortality of neonatal intestinal perforation has risen over the past 15 years. The incidence of intestinal perforation in extremely low‐birthweight (ELBW) neonates has been increasing as more ELBW neonates survive and as the live‐birth rate of ELBW has increased. In contrast to necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP), the pathogenesis of meconium‐related ileus, defined as functional bowel obstruction characterized by delayed meconium excretion and microcolon, remains unclarified. Methods: The histology of 13 ELBW neonates with intestinal perforation secondary to meconium‐related ileus was reviewed, and the radiology of 33 cases of meconium‐related ileus diagnosed on contrast enema was reviewed. Specimens obtained from 16 ELBW neonates without gastrointestinal disease served as age‐matched controls for histological assessment. Results: The size of the ganglion cell nucleus in meconium‐related ileus and in control subjects was 47.3 ± 22.0 µm² and 37.8 ± 11.6 µm², respectively, which was not significantly different. In all cases of meconium‐related ileus, contrast enema demonstrated a microcolon or small‐sized colon, with a gradual caliber change in the ileum and filling defects due to meconium in the ileum or colon, showing not‐identical locations of caliber changes and filling defects. Conclusion: Morphological immaturity of ganglia was not suggested to be the pathogenesis of meconium‐related ileus. Impaction of inspissated meconium is not the cause of obstruction, but the result of excessive water absorption in the hypoperistaltic bowel before birth, although the underlying mechanism responsible for the fetal hypoperistalsis remains unclear.     

Fluctuations in relative humidity provided to extremely low‐birthweight infants (R1)

Background: In extremely low‐birthweight infants, the addition of relative humidity (RH) improves thermal stability, fluid and electrolyte balance. However, during routine care this microenvironment is frequently disturbed. The objective of this study was to determine the frequency, magnitude and direction of fluctuations in RH provided to extremely low‐birthweight infants. Methods: All infants in our study had ambient temperature and RH continuously recorded for 48 h using a datalogger device (RH32S‐C2). A clinically acceptable range for RH was defined as the set point ±10%. A secondary analysis was performed to compare outcomes between infants that spent > 50% of the time out‐of‐range (OOR) or inside the range (IR). A P‐value < 0.05 was significant. Results: A total of 20 infants were included. Important fluctuations were detected by the device with infants spending 40% and 14% of the time above and below the range, respectively. However, the RH set point did not differ from the mean levels measured over 48 h by the RH32S‐C2 or the incubator. Infants in the OOR group spent significantly more time at values higher than the planned range when compared to IR infants. Conclusion: Although significant fluctuations in RH above the desired range were detected in more than half of the infants, the average values were similar to the set points. Nevertheless, knowledge of these dynamic changes may help to optimize individualized care.     

Ampicillin versus penicillin in the empiric therapy of extremely low‐birthweight neonates at risk of early onset sepsis

Background: There are no comparative data on the impact of different empiric antibiotic regimens on early bowel colonization as well as on clinical efficacy in extremely low‐birthweight (ELBW) neonates at risk of early onset sepsis (EOS). Methods: A subgroup analysis was carried out of ELBW neonates recruited into a two‐center, prospective, cluster randomized study comparing ampicillin and penicillin both combined with gentamicin, within the first 72 h of life. A composite primary end‐point (need for change of antibiotics within 72 h and/or 7 day all‐cause mortality) and the rate and duration of colonization by opportunistic aerobic microorganisms were assessed using hierarchical models corrected for study center and period. Results: In the ampicillin (n= 36) and penicillin (n= 39) groups change of antibiotics, 7 day mortality and the composite end‐point occurred at similar rates. Neonatal intensive care unit mortality for infants with gestational age <26 weeks was lower in the ampicillin group. Ampicillin treatment was associated with a higher colonization rate by Klebsiella pneumoniae, including ampicillin‐resistant strains. Conclusion: Preliminary data indicate an urgent need for adequately powered studies of early antibiotic therapy in the subpopulation of ELBW neonates at risk of EOS.     

Effect of PMX‐DHP for sepsis due to ESBL‐producing E. coli in an extremely low‐birthweight infant

We report a case of early onset sepsis caused by (CTX for cefotaximase and M for Munich)‐type extended‐spectrum β ‐lactamase‐producing Escherichia coli (ESBL E. coli) in a preterm infant weighing 601 g. He was given meropenem and treated for endotoxin absorption with polymyxin B‐immobilized fibers with only 8 mL of priming volume. The patient survived without any short‐term neurological or respiratory sequelae. The choice of antibiotics is particularly important in seriously ill neonates with sepsis due to ESBL‐producing organisms. Polymyxin B hemoperfusion might be an innovative therapy for severe neonatal sepsis and could improve outcome even in an extremely low‐birthweight infant.     

Effect of Bifidobacterium administration on very‐low‐birthweight infants

Background: The aim of this study was to evaluate the efficacy and safety of early administration of Bifidobacterium bifidum OLB6378 (B. bifidum) on accelerating enteral feeding and bacterial colonization in very‐low‐birthweight (VLBW) infants. Methods: We conducted a single‐center prospective pilot study. Thirty‐six VLBW infants were randomly divided into two groups: group E, wherein B. bifidum was supplemented within 48 h of birth, and group L, wherein it was supplemented more than 48 h after birth. Results: Group E and group L reached a total feeding volume of 100 mL/(kg/day) after 10 [7–13] days and 11 [10–15] days, respectively (median [quartile]). The daily bodyweight gain in group E was significantly higher (21.4 ± 3.2 g/day vs 18.3 ± 4.0 g/day, P < 0.02; 11.1 ± 1.5 g/kg/day vs 10.4 ± 1.2 g/kg/day, P < 0.04). No significant differences were found in the fecal Bifidobacterium level between the groups quantitated with a real‐time polymerase chain reaction assay at 1 and 4 weeks of age. However, the highest colonization rate of Bifidobacterium was observed when the supplementation started between 24 and 48 h after birth. The incidence of morbidities between the groups was similar. Conclusion: The early administration of B. bifidum to VLBW infants seems effective in promoting growth during the stay in the neonatal intensive care unit without increasing the incidence of morbidity. Furthermore, the preferable timing of starting the probiotic supplementation for VLBW infants is at latest less than 48 h after birth.     

Hydrocortisone and long‐term outcomes in very‐low‐birthweight infants

Background: The long‐term effects of hydrocortisone (HDC) used for very‐low‐birthweight (VLBW) infants with chronic lung disease (CLD) are not fully understood. The aim of this study was to examine the short‐term clinical effects and long‐term impact of a physiological replacement dose of HDC on acute deterioration of CLD in VLBW infants. Methods: This prospective case–control study included 110 of the 174 VLBW infants admitted to our facility between 2003 and 2006 who were followed up to a corrected age of 18 months. Infant deaths and infants with congenital deformities were excluded from the study. The infants were classified into the following three groups: infants with CLD and treated with HDC (1–2 mg/kg/dose) due to progressive deterioration in oxygenation (CLD treatment group; n= 24); infants with CLD but not treated with HDC (CLD untreated group; n= 40); and infants without CLD (non‐CLD group; n= 46). Results: The fraction of inspired oxygen (F_IO₂) in the CLD treatment group improved significantly after treatment (P < 0.01). There were no significant differences among the three groups in terms of growth and neurodevelopmental quotient at the corrected age of 18 months following adjustment for birthweight, sex, and presence of light‐for‐date infants. There were also no significant intergroup differences in all three areas of developmental quotient. Conclusions: Physiological doses of HDC replacement are effective in treating acute deterioration in oxygenation in VLBW infants with CLD. Furthermore, this treatment modality did not adversely affect the growth and development of infants at the corrected age of 18 months.