The use of isotonic fluid as maintenance therapy prevents iatrogenic hyponatremia in pediatrics: a randomized, controlled open study

OBJECTIVES: Hypotonic fluids are widely used in pediatrics. Several articles have reported the risk of iatrogenic hyponatremia secondary to this practice. We primarily intend to determine whether the use of isotonic fluids prevents hyponatremia and, secondly, whether these fluids increase the incidence of adverse events. STUDY DESIGN: One hundred twenty-two pediatric patients hospitalized in intensive care unit requiring maintenance fluid therapy were randomized to receive isotonic fluids (isotonic group, NaCl = 140 mEq/L) or hypotonic fluids (hypotonic group, NaCl <100 mEq/L). Electrolyte blood concentration, glycaemia, and blood pressure were measured at 0, 6, and 24 hrs after the beginning of fluid therapy. Plasma creatinine, urine specific gravity, and urine electrolyte concentration were measured at 6 hrs. Standard intention-to-treat analysis and Bayesian analysis were conducted to assess the probability of hyponatremia and hypernatremia in each group. RESULTS: At the time of admission to hospital, no differences in natremia or the percentage of hyponatremia were found between groups. At 24 hrs, the percentage of hyponatremia in the hypotonic group was 20.6% as opposed to 5.1% in the isotonic group (p = 0.02). No differences in the number of adverse events other than hyponatremia were observed between groups. CONCLUSIONS: The use of hypotonic fluids increases the risk of hyponatremia when compared with isotonic fluids at 24 hrs following infusion (number needed to harm [confidence interval 95%] = 7[4;25]). In our sample, the use of isotonic fluids did not increase the incidence of adverse events compared with hypotonic fluids.     

Dehydration and hypernatremia in breast-fed term healthy neonates

Objective: The aim of the study was to determine the incidence of significant weight loss, dehydration, hypernatremia and hyperbilirubinemia in exclusively breast-fed term healthy neonates and compare the incidence of these problems in the warm and cool months.Methods: During the study period 496 neonates were recruited.Results: 157 neonates (31.6%) had significant weight loss (>10% cumulative weight loss or per day weight loss >5%). Clinical dehydration was present in 2.2% of neonates. Of these 157 neonates, 31.8% had hypernatremia and 28% had hyperbilirubinemia.Conclusion: The incidence of the above mentioned problems were higher in the warm months but the difference was not statistically significant.     

Hyponatremia in hospitalized critically Ill children : Current concepts

Hyponatremia (serum sodium to <136 mEqJl) is the most common electrolyte abnormality in critically ill children. It could result from a deficit of sodium, or surplus of water. Impaired water excretion, ‘inappropriate’ release of vasopressin, use of hypotonic fluids, redistribution of sodium and water, sick cell syndrome, several drugs and primary illness all may contribute to hyponatremia. Acute hyponatremia, defined as a fall in serum sodium to -120 mEqJl within 48 hours may result in acute cerebral edema and brain stem herniation particularly in children. However, there is paucity of data on hyponatremia in hospitalized critically ill patients. Studies addressing incidence, cause and outcome of hyponatremia in critically ill patients are needed to plan rational fluid therapy protocols, and resolve the current debate, which calls for abandonment of NJ5 saline in 5% dextrose solution as maintenance intravenous fluid in favour of normal saline to prevent hyponatremia. At present it is not fully correct to assume that isotonic maintenance fluids would be superior to current maintenance fluids. Reducing the volume of maintenance fluid to about 75% of normal maintenance volume may be more appropriate way to prevent hyponatremia in view of water retaining effect of high ADH and reduced renal free water clearance in critically ill children.     

Phase II trial of isotonic fluid resuscitation in Kenyan children with severe malnutrition and hypovolaemia

Background  

Children with severe malnutrition who develop shock have a high mortality. Contrary to contemporaneous paediatric practice, current guidelines recommend use of low dose hypotonic fluid resuscitation (half-strength Darrows/5% dextrose (HSD/5D). We evaluated the safety and efficacy of this guideline compared to resuscitation with a standard isotonic solution.     

Choice of maintenance intravenous fluids among paediatric residents in Canada

BackgroundRecent literature and guidelines support routine use of isotonic intravenous (IV) fluids for maintenance therapy in hospitalized infants and children. Current prescribing practices are unknown.ObjectiveTo elicit paediatric residents’ choice of maintenance IV fluids, particularly with regard to tonicity, in a variety of clinical scenarios and patient ages. We hypothesized that residents would choose isotonic fluids in most cases, but there would be substantially more variability in fluid choice in the neonatal age group.MethodsAn Internet-based survey was e-mailed to trainees in the 17 paediatric residency programs across Canada, via the Canadian Paediatric Program Directors. The survey instrument included questions related to training, followed by a series of questions eliciting choice of IV fluid in a variety of clinical situations.ResultsA total of 147 survey responses were submitted (22% response rate). Isotonic solutions were selected by >75% across all clinical scenarios involving infants and children. Very hypotonic fluids were seldom chosen. There was more variability in fluid choice in neonates, with evidence of significant differences in fluid tonicity based on senior versus junior resident status and geographical location.ConclusionsResults imply a predominance of isotonic fluid use in infants and children, suggesting that clinical practice has changed in response to risk of hyponatremia with hypotonic IV fluids. As hypothesized, there was more variability with respect to choice of maintenance fluids in neonates. This likely reflects a paucity of guidance in an age group with unique physiologic factors affecting fluid and electrolyte status.     

A randomized controlled trial of fluid supplementation in term neonates with severe hyperbilirubinemia

OBJECTIVE: To evaluate the effectiveness of fluid supplementation in decreasing the rate of exchange transfusion and the duration of phototherapy in term neonates with severe nonhemolytic hyperbilirubinemia. STUDY DESIGN: This was a randomized controlled trial conducted in a tertiary care referral unit in northern India. Seventy-four term neonates with severe nonhemolytic hyperbilirubinemia (total serum bilirubin > 18 mg/dL [308 micromol/L] to < 25 mg/dL [427 micromol/L]). The subjects were randomized to an "extra fluids" group (intravenous fluid supplementation for 8 hours and oral supplementation for the duration of phototherapy; n = 37) or a control group (n = 37). RESULTS: At inclusion, 54 infants (73%) had high serum osmolality, including 28 (75%) in the extra fluids group and 26 (70%) in the control group. The proportion of infants who underwent exchange transfusion was lower in the extra fluids group than in the control group: 6 (16%) versus 20 (54%)(P = .001; relative risk = 0.30; 95% confidence interval = 0.14 to 0.66). The duration of phototherapy was also shorter in the extra fluids group: 52 +/- 18 hours versus 73 +/- 31 hours (P = .004). CONCLUSION: Fluid supplementation in term neonates presenting with severe hyperbilirubinemia decreased the rate of exchange transfusion and duration of phototherapy.     

Validation of transcutaneous bilirubin nomogram for identifying neonatal hyperbilirubinemia in healthy Chinese term and late‐preterm infants: a multicenter study

Objectiveto prospectively validate a previously constructed transcutaneous bilirubin (TcB) nomogram for identifying severe hyperbilirubinemia in healthy Chinese term and late‐preterm infants.Methodsthis was a multicenter study that included 9,174 healthy term and late‐preterm infants in eight hospitals of China. TcB measurements were performed using a JM‐103 bilirubinometer. TcB values were plotted on a previously developed TcB nomogram, to identify the predictive ability for subsequent significant hyperbilirubinemia.Resultsin the present study, 972 neonates (10.6%) developed significant hyperbilirubinemia. The 40^th percentile of the nomogram could identify all neonates who were at risk of significant hyperbilirubinemia, but with a low positive predictive value (PPV) (18.9%). Of the 453 neonates above the 95^th percentile, 275 subsequently developed significant hyperbilirubinemia, with a high PPV (60.7%), but with low sensitivity (28.3%). The 75^th percentile was highly specific (81.9%) and moderately sensitive (79.8%). The area under the curve (AUC) for the TcB nomogram was 0.875.Conclusionsthis study validated the previously developed TcB nomogram, which could be used to predict subsequent significant hyperbilirubinemia in healthy Chinese term and late‐preterm infants. However, combining TcB nomogram and clinical risk factors could improve the predictive accuracy for severe hyperbilirubinemia, which was not assessed in the study. Further studies are necessary to confirm this combination.     

生理盐水与白蛋白部分换血治疗新生儿红细胞增多症对照研究

目的　比较生理盐水与 5 %白蛋白作为置换液部分换血 (PET)治疗新生儿红细胞增多症的疗效。方法　 6 2例新生儿红细胞增多症患儿被随机分配接受生理盐水 (n =30 )或 5 %白蛋白 (n =32 )PET治疗。结果　生理盐水组和白蛋白组接受PET后红细胞压积 (HCT)均显著下降 ,分别从换血前的 (0 .72± 0 .0 4)和 (0 .71±0 .0 3)降至换血后 2 4h的 (0 .5 6± 0 .0 5 )和 (0 .5 5± 0 .0 4) ,两组前后比较差异均有非常显著意义 (P <0 .0 1) ,两组间HCT比较差异无显著意义 ;两组血Na+,血K+和血总蛋白 (TP)换血后无显著影响。结论　生理盐水和 5 %白蛋白作为置换液治疗新生儿红细胞增多症疗效显著 ;生理盐水价廉、无潜在感染危险可替代白蛋白治疗新生儿红细胞增多症。     

Management of meningitis in children with oral fluid restriction or intravenous fluid at maintenance volumes: a randomised trial

A multi-centre randomised open trial was done to determine whether moderate oral fluid restriction or intravenous fluid at full maintenance volumes would result in a better outcome for children with bacterial meningitis in Papua New Guinea, and what clinical signs could guide fluid management. Children with clinical signs and cerebrospinal fluid suggestive of bacterial meningitis received either breast milk by nasogastric tube at 60% of normal maintenance volumes (n = 172) or intravenous half-normal saline and 5% dextrose at 100% of normal maintenance volumes (n = 174) for the 1st 48 hrs of treatment. An adverse outcome was death or severe neurological sequelae, and a good outcome was defined as intact survival or survival with at worst mild-to-moderate neurological sequelae. The probability of an adverse outcome was 24.7% in the intravenous group and 33.1% in the oral-restricted group, but the difference was not statistically significant (RR 0.75, 0.53-1.04, p = 0.08). Sunken eyes or reduced skin turgor at presentation were risk factors for an adverse outcome (OR 5.70, 95% CI 2.87-11.29) and were most strongly associated with adverse outcome in the fluid-restricted group. Eyelid oedema during treatment was also a risk factor for an adverse outcome (OR 2.54, 95% CI 1.36-4.75) and eyelid oedema was much more common in the intravenous group (26%) than in the restricted group (5%). For many children with bacterial meningitis in less developed countries, moderate fluid restriction is unnecessary and will be harmful; a normal state of hydration should be achieved but over-hydration should be avoided. Giving 100% of normal maintenance fluids, especially with intravenous hypotonic fluid, will lead to oedema in up to one quarter of children with bacterial meningitis. If additional intravenous fluids are required for children with meningitis, an isotonic solution should be used.     

Randomised controlled trial: comparison of colloid or crystalloid for partial exchange transfusion for treatment of neonatal polycythaemia

AIM—To compare the efficacy of using isotonic saline (crystalloid) or 5% albumin (colloid) as replacement fluid in partial exchange transfusion (PET) for the treatment of neonatal polycythaemia.
METHODS—One hundred and two polycythaemic full term infants were randomly allocated to receive PET with either isotonic saline or 5% albumin. The criteria for PET were: (a) venous haematocrit ⩾ 0.7; or (b) venous haematocrit 0.65-0.69 with symptoms or signs attributable to polycythaemia.
RESULTS—PET with either saline (n=53) or 5% albumin (n=50) resulted in a significant and sustained decline in haematocrit up to 24 hours after PET. Although the immediate haemodilution effect of isotonic saline was statistically smaller than that of 5% albumin (decline in haematocrit 19.3% vs 22.8% of pre-PET value), the difference was too small to be of any clinical significance, and the haematocrit at 4 or 24 hours after PET did not differ significantly between the two groups. PET with either replacement fluid was not associated with any complication. The serum sodium and potassium concentrations were not significantly affected by the PET in either group.
CONCLUSIONS—Both isotonic saline and 5% albumin are effective when used as replacement fluid in PET for the treatment of neonatal polycythaemia. Isotonic saline, which is cheaper and free of infection, should be the replacement fluid of choice.

     

Cord Blood Alkaline Phosphatase as an Indicator of Neonatal Jaundice

Background:

Management of hyperbilirubinemia remains a challenge for neonatal medicine because of the risk of neurological complications related to the toxicity of severe hyperbilirubinemia.

Objectives:

The purpose of this study was to examine the validity of cord blood alkaline phosphatase level for predicting neonatal hyperbilirubinemia.

Patients and Methods:

Between October and December 2013 a total of 102 healthy term infants born to healthy mothers were studied. Cord blood samples were collected for measurement of alkaline Phosphatase levels immediately after birth. Neonates were followed-up for the emergence of jaundice. Newborns with clinical jaundice were recalled and serum bilirubin levels measured. Appropriate treatment based on serum bilirubin level was performed. Alkaline phosphatase levels between the non-jaundiced and jaundiced treated neonates were compared.

Results:

The incidence of severe jaundice that required treatment among followed-up neonates was 9.8%. The mean alkaline phosphatase level was 309.09 ± 82.51 IU/L in the non-jaundiced group and 367.80 ± 73.82 IU/L in the severely jaundiced group (P = 0.040). The cutoff value of 314 IU/L was associated with sensitivity 80% and specificity 63% for predicting neonatal hyperbilirubinemia requiring treatment.

Conclusions:

The cord blood alkaline phosphatase level can be used as a predictor of severe neonatal jaundice.     

江苏省13家医院新生儿严重高胆红素血症现状调查

目的 了解江苏省新生儿严重高胆红素血症的发生情况及诊治、随访等管理情况,为新生儿严重高胆红素血症的预防及规范化管理提供依据。方法 以2018年1~12月江苏省13家医院收治的严重高胆红素血症新生儿为研究对象,回顾性分析患儿的临床资料及随访资料。结果 江苏省13家医院2018年严重高胆红素血症新生儿病例共上报740例,占新生儿科收治病例总数的2.70%（740/27 386）,其中重度高胆红素血症620例（83.8%）,极重度高胆红素血症106例（14.3%）,危险性高胆红血症14例（1.9%）;诊断为急性胆红素脑病共4例（0.5%）。484例（65.4%）新生儿于分娩机构出院后因严重高胆红素血症返回医院住院治疗,中位入院日龄为7 d,其中214例（44.2%）再入院前进行过门诊黄疸随访,第1次门诊中位随访日龄为6 d。住院期间行头颅MRI检查211例（28.5%）,其中85例（40.3%）提示双侧基底节、苍白球T1WI信号偏高;行脑干听觉诱发电位检查238例（32.2%）,其中14例（5.9%）仅一侧通过,7例（2.9%）双侧均未通过。急性胆红素脑病或危险性高胆红素血症患儿（共17例）进行了随访,除1例失访外,均无异常神经系统症状。结论 新生儿严重高胆红素血症在新生儿科住院病人中的占比较高;新生儿从分娩机构出院后黄疸监测及管理需要加强;对并发了严重高胆红素血症的患儿,住院期间相关检查需更完善,出院后均需全面系统地随访。     

红细胞储存时间对高胆红素血症新生儿换血治疗的疗效及内环境的影响

目的 探讨不同储存时间的红细胞对高胆红素血症新生儿换血治疗的疗效及内环境的影响。方法 回顾性分析2015年1月至2018年8月经换血治疗的135例高胆红素血症新生儿的临床资料,按输入红细胞的储存时间分为短期储存组（储存时间≤ 7 d,n=56）和长期储存组（储存时间 > 7 d,n=79）。比较两组患儿换血后0 h、12 h的血清总胆红素（TBIL）水平与TBIL下降率,以及换血后继续光疗时间及再次换血率。比较分析两组患儿换血前及换血后0 h的血常规、电解质、血糖及血气分析指标的变化。结果 换血后0 h,两组患儿TBIL水平及TBIL下降率比较差异无统计学意义（P > 0.05）;换血后12 h,长期储存组TBIL水平高于短期储存组,TBIL下降率低于短期储存组（P < 0.01）;长期储存组换血后的继续光疗时间更长（P < 0.05）;长期储存组低血钠、高血钾及代谢性酸中毒等换血并发症的发生率较短期储存组增加（P < 0.05）。结论 使用储存时间 > 7 d的红细胞输入不影响新生儿换血治疗的即时效果,但换血后继续光疗效果较差,亦增加了低血钠、高血钾及代谢性酸中毒的发生风险。     

Treatment of severe meconium aspiration syndrome with porcine surfactant: a multicentre, randomized, controlled trial

Aim: A randomized, controlled clinical trial was performed in 19 Chinese neonatal intensive care units to evaluate the safety and efficacy of exogenous surfactant replacement therapy for severe meconium aspiration syndrome (MAS) in term and near‐term neonates. Methods: Sixty‐one term infants with severe MAS were randomly assigned to either a surfactant or a control group within 36 h after birth. The infants in the surfactant group (n=31) received an initial dose of porcine lung‐derived surfactant (Curosurf®) at 200 mg/kg, and repeated doses of 200, 100 and 100 mg/kg were given at 6–12 h intervals to a maximum of four doses if oxygenation index (OI) deteriorated by >2 from baseline. The primary outcomes were a reduction of OI to less than 10 and an increase of the pre‐treatment a/A PO₂ ratio of 100% over baseline 24 h after surfactant treatment. The secondary outcomes were duration of mechanical ventilation, incidence of complications and survival to discharge from hospital. Results: The general demographic characteristics of the study subjects were similar. There was a trend for surfactant‐treated infants to have an improvement in arterial oxygenation compared to the control group. In comparison with the control group at 24 h, the surfactant group had a lower mean OI (8.1 vs 10.9), more infants with a 100% increase of a/A PO₂ (83% vs 48%, p<0.01) over baseline, and a larger area under the curve for PaO₂/FiO₂ over baseline (3762±1877 vs 2715±1644 mmHg^.h, p<0.05). Repeated measures of these parameters were also in favour of the surfactant group during 24 h to 3 and 7 d compared to the baseline (p<0.05). No differences were found in mean duration of mechanical ventilation, incidence of major complications and number of survivors between the two groups. Conclusion: Surfactant replacement therapy improved oxygenation in the study subjects, suggesting that surfactant may have a role in the treatment of severe MAS in term and near‐term infants.     

Preliminary observation of impaired water excretion in treated status asthmaticus

Patients in status asthmaticus often have elevated plasma antidiuretic hormone levels. To determine if children in status asthmaticus have impaired water excretion and an increased risk of developing significant hyponatremia when given a fluid challenge, five consecutive patients who showed moderate asthmatic symptoms after taking two doses of epinephrine hydrochloride were given a fluid challenge (20 mL/kg of 5% dextrose in 0.2% normal saline solution given intravenously over 30 minutes followed by maintenance fluids [1,500 mL/sq m/24 hr] for 50 minutes). Urine was collected at 20-minute intervals for measurement of free-water clearance and percent water-load excretion in 80 minutes. This protocol was repeated 24 to 48 hours later, after clinical improvement. None of the patients was hyponatremic during status asthmaticus before water loading. However, four of five patients were mildly hyponatremic (serum sodium level between 130 and 132 mEq/L) between status asthmaticus and after clinical improvement. These same four patients also became mildly hyponatremic after fluid challenge during status asthmaticus. Maximal free-water clearance and percent water load excretion in 80 minutes were significantly lower during status asthmaticus after fluid challenge compared with results obtained after water loading when the patients' conditions were clinically improved. We conclude that patients in status asthmaticus have impaired water excretion after water loading but with a small risk of significant hyponatremia; a patient remaining in status asthmaticus and given large volumes of hypotonic fluid over a prolonged period of time may be at higher risk for significant hyponatremia.     

新生儿窒息与多脏器功能障碍综合征的临床关系分析

目的 探讨新生儿窒息后多脏器功能障碍综合征（ＭＯＤＳ）的发生率、病死率及其与窒息程度、胎龄、出生体重的关系。方法 对１００例新生儿窒息进行前瞻性研究，观察轻、重度窒息组ＭＯＤＳ及单器官损害的发生率和病死率，以及围产因素与ＭＯＤＳ的关系。结果 重度窒息组ＭＯＤＳ的发生率为７１．４％，高于轻度窒息组（３０．８％）（χ２＝１５．２０，Ｐ＜ ０．０１）；重度窒息组脑、肺、心血管、肾、胃肠损害发生率分别为９１．４％，７７．１％，５４．３％，３４．３％，２２．９％，轻度窒息组分别为３８．５％，３３．８％，２０．０％，１２．３％，７．７％，差异均有显著性（Ｐ＜００１或 ０．０５），重度窒息组病死率（２２．９％）高于轻度窒息组（６．２％）（χ２＝６．０１，Ｐ＜０．０５）。窒息患儿中早产儿、低出生体重儿ＭＯＤＳ的发生率及病死率较足月儿、正常体重儿高，差异有显著性（Ｐ＜０．０５）。结论 重视围产期保健，降低早产儿、低出生体重儿的发生率，防止新生儿窒息，是减少ＭＯＤＳ的关键。     

Effect of clofibrate in non-hemolytic indirect hyperbilirubinemia in full term neonates

Objective Jaundice is a common clinical problem in neonatal period which may result in brain damage even in healthy full term newborns, when it is severe. The aim of this study was to characterize the therapeutic effect of clofibrate in full term neonates who present with nonhemolytic jaundice. Methods A clinical controlled study was performed on 60 full term neonates who presented with non-hemolytic jaundice. 30 neonates were treated with a single oral dose of clofibrate (100 mg/Kg) plus phototherapy (case group), while 30 neonates received only phototherapy (control group). Both groups were compared in regard to post therapeutic mean total and indirect plasma bilirubin levels, admission duration and the rate of exchange transfusion. Results The reduction rate of total and indirect plasma bilirubin levels were significantly higher in the clofibrate-treated group as compared with the control group (P<0.05). The mean duration of admission was found to be reduced from 2.9 +/− 0.9 days in the control groupl to 2.2 +/− 0.6 days in clofibrate-treated group (P=0.002). The mean plasma total bilirubin level was lower in the clofibrate-treated group. No cases required phototherapy after 48 hour in clofibrate-treated group, while 9 neonates (30%) and 2 neonates (6.7%) required phototherapy after 72 hour and 96 hour respectively in the control group. There was no difference between both the groups for sex, the time of developing jaundice and the rate of exchange transfusion. Conclusion A single dose of clofibrate (100 mg/Kg) alongwith phototherapy is more effective than phototherapy alone in treating non-hemolytic hyperbilirubinemia in term healthy newborn infants.     

重度高胆红素血症新生儿总胆红素/白蛋白比值及酸中毒与脑干听觉诱发电位异常的关系

目的：探讨重度高胆红素血症新生儿总胆红素/白蛋白比值（B/A比值）、酸中毒与脑干听觉诱发电位（BAEP）异常的关系及其临床意义。方法：纳入2008年11月至2009年10月间重度高胆红素血症患儿967例。按照BAEP的结果,分为BAEP正常组（799例）和BAEP异常组（168例）。对B/A比值、酸中毒与BAEP的关系分别进行单因素分析,再根据日龄因素分别进行分层χ2检验。结果：单因素分析结果显示,BAEP异常组较BAEP正常组具有更低的pH值和BE值以及更高的B/A比值,差异有统计学意义。分层χ2检验分析结果显示,对于重度高胆红素血症任何日龄组的患儿,当存在酸中毒或当B/A比值>1时,其BAEP异常的发生率均较对照组增高,差异均有统计学意义。结论：高B/A比值、酸中毒是重度高胆红素血症患儿发生BAEP异常的危险因素,且对于任何日龄段的患儿均是如此。故对于任何日龄组的重度高胆红素血症患儿,当存在上述危险因素时,应尽快纠正其酸中毒,降低B/A比值,以降低胆红素听力损伤的发生。     

Mandibular distraction in neonates: indications, technique, results

Background

Early discharge of healthy late preterm and full term newborn infants has become common practice because of the current social and economic necessities. Severe jaundice, and even kernicterus, has developed in some term infants discharged early. This study was designed to elaborate a percentile-based hour specific total serum bilirubin (TSB) nomogram and to assess its ability to predict the absence of risk for subsequent non physiologic severe hyperbilirubinaemia before discharge.

Methods

A percentile-based hour-specific nomogram for TSB values was performed using TSB data of 1708 healthy full term neonates. The nomogram's predictive ability was then prospectively assessed in five different first level neonatal units, using a single TSB value determined before discharge.

Results

The 75 ^th percentile of hour specific TSB nomogram allows to predict newborn babies without significant hyperbilirubinemia only after the first 72 hours of life. In the first 48 hours of life the observation of false negative results did not permit a safe discharge from the hospital.

Conclusion

The hour-specific TSB nomogram is able to predict all neonates without risk of non physiologic hyperbilirubinemia only after 48 to 72 hours of life. The combination of TSB determination and risk factors for hyperbilirubinemia could facilitate a safe discharge from the hospital and a targeted intervention and follow-up.     

Septicaemia and meningitis in neonates and during early infancy in the Göteborg area of Sweden

In a retrospective study of neonatal septicaemia and meningitis carried out in 1987–1996 in the Göteborg area of Sweden, 305 cases during the first 28 d of life were found. The incidence was 3.7/1000 live births, which was higher than that found in a study from 1975 to 1986 in the same area, 2.8/1000 live births. The most common pathogens were group B streptococci, aerobic Gram‐negative rods, Staphylococcus aureus and enterococci. The cases were approximately equally divided between very early, early and late onset infections. The case‐fatality rate was lower in the present study (9%) than that in the previous study (15%). The case‐fatality rate varied between 23% in neonates with a gestational age of ≤29 wk and 3% in full‐term neonates. Eighty‐three very late onset infections occurred between days 28 and 120 after birth, corresponding to an incidence of 1.0/1000 live births. Of those, 47 occurred in preterm neonates. The most common organisms were aerobic Gram‐negative rods. Coagulase‐negative staphylococci (CoNS) were studied separately. This organism was isolated in 60 and 32 cases during the first 28 d of life and between days 28 and 120, respectively, in neonates fulfilling the criteria of the Yale‐New Haven Hospital for infections caused by commensal species. The incidence rates of CoNS infections were 0.7 and 0.4/1000 live births, respectively. Conclusion: The incidence of neonatal infections increased and the case‐fatality rate decreased in the Göteborg area compared to the findings of a previous study. Very late onset infections should be added to the total burden of neonatal infections. CoNS are important pathogens but their role is difficult to determine since they are both pathogens and contaminants of cultures from blood and cerebrospinal fluid.