Long-term renal follow-up of extremely low birth weight infants

There is evidence that low birth weight caused by intrauterine growth retardation adversely affects normal renal development. Very little information on this issue is available on children born very prematurely. This investigation examined clinical and functional renal parameters in 40 children (23 boys, 17 girls) ranging in age between 6.1 and 12.4 years and weighing less than 1000 g at birth. Results were compared to those obtained in 43 healthy children of similar age and gender. Study subjects were significantly smaller and thinner than control subjects (mean height SDS: –0.36 vs. +0.70; and mean BMI SDS: –0.56 vs. +1.18). Systolic, diastolic, and mean blood pressures did not differ from those of controls. Renal sonography revealed no abnormality, and mean percentiles for renal length and volume appeared normal. In comparison with controls, plasma creatinine concentration (0.62±0.1 vs. 0.53±0.1 mg/dl) and estimated creatinine clearance (117±17 vs. 131±17 ml min^–1 1.73 m^–2) differed significantly. No significant differences were observed in microalbuminuria values, but five study subjects (12.5%) presented values above the upper limit of normality. A defect in tubular phosphate transport was also evident: TmP/GFR (3.6±0.4 vs. 4.2±0.8 mg/dl) and TRP (83±5% vs. 90±4%) were significantly lower, and urinary P excretion, estimated by the ratio UP/UCr, was significantly higher (1.2±0.4 vs. 0.9±0.4 mg/mg) than controls. Urinary calcium excretion, estimated by the UCa/UCr ratio, was also significantly higher (0.15±0.07 vs. 0.12±0.09 mg/mg). These data clearly demonstrate that both GFR and tubular phosphate transport are significantly diminished in school-age children born with extreme prematurity, probably as a consequence of impaired postnatal nephrogenesis.     

Iatrogenic vascular lesions in extremely low birth weight and low birth weight neonates

Purpose: Aggressive treatment has improved the long-term outcome of extremely low birth weight (ELBW) and low birth weight (LBW) neonates, but it has also increased the risk of iatrogenic lesions. The aim of this paper is to evaluate the incidence of vascular injuries observed in the neonatal intensive care unit of our hospital.Methods: From 1987 to 1994, 2898 neonates were admitted to the neonatal intensive care unit; 335 of them were either LBW or ELBW (11.5%). A review of the charts of these neonates disclosed nine neonates (four male, five female) with vascular lesions (2.6%); the mean gestational age of these patients was 28.7 weeks (range, 24 to 33 weeks), the mean weight at birth was 880 g (range, 590 to 1450 g), and the mean weight at diagnosis was 1825 g (range, 1230 to 2700 g). In the same period, 10 neonates with vascular injuries were reported in the 2563 neonates who weighed more than 1500 g (0.3%). The injuries observed in LBW and ELBW group were arteriovenous fistulas (two bilateral) at the femoral level (six neonates), carotid lesion (one neonate), and limb ischemia (two neonates). Injury was associated with venipuncture in seven neonates, and with umbilical catheter in one; the case of carotid lesion was related to surgical error. No general symptoms were observed.Results: The carotid lesion and five arteriovenous fistulas were repaired by microsurgical techniques; one case of limb ischemia was resolved with thrombolytic drugs, whereas an amputation at the knee level was required in the other after 10 days of medical treatment. One neonate with an arteriovenous fistula was just observed according to the parents' wishes. At clinical and echo-color Doppler follow-up, seven of nine neonates had normal vascular function without sequelae.Conclusions: In our experience, LBW and ELBW neonates are at greater risk than older neonates of the development of iatrogenic vascular lesions. We advocate aggressive microsurgery, medical treatment, or both to obtain good results and prevent late sequelae. (J Vasc Surg 1997;26:643-6.)     

Long-term follow-up of extremely low birth weight infants with neonatal renal failure

The long-term outcome of 20 preterm infants with extremely low birth weight and acute renal failure in the neonatal period was studied retrospectively over an 18-year period. Those with progressive renal disease are compared with those with normal renal function. Current mean age is 7.5±4.6 years (range 3.2–18.5 years). Nine patients showed deterioration in renal function (low GFR group). Increasing proteinuria, as determined by random urine protein/creatinine ratio (Up/c), correlated with deterioration in renal function (r=0.8, P<0.0001). Prominent risk factors for progression were Up/c >0.6 at 1 year of age [100% sensitivity, 75% positive predictive value (PPV), P<0.01], serum creatinine >0.6 mg/dl at 1 year of age (75% sensitivity, 80% PPV, P<0.01), and a tendency to obesity with body mass index >85th percentile (89% sensitivity, PPV 67%, P=0.03). Loss of renal mass and nephrocalcinosis were not prognostic indicators. This report begins to identify important clinical parameters that should lead to closer surveillance and potential treatment interventions for preservation of renal function in a growing population of surviving low birth weight individuals.     

Spinal anesthesia in an extremely low birth weight infant

A case of spinal anesthesia in an extremely low birth weight male infant (body weight of 930 g at time of surgery) is presented. He was born prematurely at a gestational age of 27 weeks because of a placenta tumor and had to undergo inguinal herniotomy at 34 weeks postconceptional age. He had bronchopulmonary dysplasia and oxygen supply was still required because of frequent deterioration of oxygen saturation. Spinal anesthesia was performed successfully without any complications. Relevant aspects concerning the technique and management of spinal anesthesia in preterm infants are discussed.     

Diaphragmatic plication in the extremely low birth weight infant

A case of acquired diaphragmatic paralysis in an extremely low birth weight infant complicated by respiratory failure, recurrent atelectasis, and pneumonia is described. Diaphragmatic plication led to a rapid improvement in pulmonary function and allowed for discontinuation of mechanical ventilation in less than 1 week. Therapeutic options for acquired diaphragmatic paralysis, including the rationale for early operative intervention, in this patient population are discussed.     

Vascular ring in an extremely low birth weight infant

Vascular rings due to aortic arch anomalies can be a major cause of tracheoesophageal obstruction in infants. But there is no report of vascular ring, in an extremely low birth weight (ELBW) infant. This is a report of an infant with birth weight of 560 g, who has not diagnosed vascular ring until 6 months of age because of asymptomatic process by prolonged tracheal intubation. The patient, was treated for double aortic arch with tracheomalacia surgically by simple division of the atretic left arch and the ligamentum arteriosus, aortopexy and tracheostomy before reaching full recovery at 3 years of age. We reported our management of vascular rings in the ELBW infant. This case suggested that the difficulty of extubation in ELBW infants in spite of the improvement of respiratory condition should raise a suspicion of the tracheal compression by other lesions such as vascular rings.     

Management of salt poisoning in an extremely low birth weight infant

We present the first reported case of severe salt poisoning in an extremely low birth weight neonate. The salt poisoning was managed with the careful use of intravenous fluids, insulin to manage the severe hyperglycemia, and furosemide to induce a saline diuresis. The hypertonicity was normalized slowly over 3 days by following the corrected serum sodium (Na) (serum Na+2.7 mEq for every 100 mg/dl of glucose over 100). No neurological damage was seen in our patient during the development of the hypertonicity or its correction. This suggests that the premature brain can develop osmoprotective molecules if hypertonicity develops slowly over 2–3 days. Slow correction is therefore recommended to avoid the development of water intoxication during correction. Despite the development of mild reversible renal failure, a large saline diuresis was induced with furosemide, thereby avoiding the need for dialysis in our patient. The only complication was the development of necrotizing enterocolitis, which has not been previously reported in association with salt poisoning.The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.     

Hepatoblastoma in children of extremely low birth weight: a report from a single perinatal center

Background/Purpose: The incidence of hepatoblastoma (HB) in children of low birth weight is increasing. In the authors' institute, 5 infants of extremely low birth weight (ELBW) were found to have HB. The purpose of this study was to identify the characteristics of these infants to elucidate the pathogenesis of HB arising in ELBW infants. Methods: Birth weight (BW) ranged from 554 to 750 g (mean, 654 g) and gestational age from 23 to 29 weeks (mean, 25.8 weeks). Medical records of the 5 patients were reviewed, and perinatal treatments were compared with those of ELBW infants without HB. Results: One patient with intraabdominal hemorrhage had emergency operation, which was followed by early postoperative death. The parents of one child refused treatment because of associated severe anomalies. He died of the growing tumor 4 months after diagnosis. The remaining 3 patients had radical operation performed after intraarterial chemoembolization and systemic chemotherapy. One died of hepatic failure 7 months after operation. Two are alive 5 and 9 months after operation. The incidence of HB among ELBW infants was estimated to be about 0.5% in our institute. The mean durations of mechanical ventilation, oxygen inhalation, and hospitalization during the neonatal periods in cases of HB were significantly longer than those in BW matched control infants (P [lt ] .01). Conclusions: ELBW children have a high risk for HB. In follow-up of ELBW infants, serum alpha-fetoprotein or abdominal ultrasonography may be useful to detect early HB. The children with HB received perinatal treatments for a significantly longer time, which suggests that perinatal intensive and long-term medical treatments may be involved in the tumorigenesis in the highly sensitive immature liver. J Pediatr Surg 38:134-137.     

Anaesthetic considerations for the management of very low and extremely low birth weight infants

The opportunities for very low birth weight infants (birth weight < 1500 g) and extremely low birth weight infants (birth weight < 1000 g) to undergo surgery are increasing. These infants are prone to prematurity-related morbidities including respiratory distress syndrome, intraventricular haemorrhage, periventricular leukomalacia, retinopathy of prematurity, patent ductus arteriosus and necrotising enterocolitis. Evidence is accumulating that preterm infants are also sensitive to pain and stress. The pharmacokinetics of drugs in preterm infants is not fully understood but smaller doses of anaesthetic drugs are usually required in preterm infants compared to term infants and older children and their effects last longer due to low clearance rates and longer elimination half-lives. Key anaesthetic considerations are (i) inspired oxygen concentration that should be adjusted to avoid hyperoxia, (ii) haemodynamic parameters that should be kept stable and (iii) prevention of hypothermia by using adequate measures to keep the infants warm. These precautions must be continuously taken during the operation and the transport to and from the operating theatre.     

The impact of surgery on infants born at extremely low birth weight

Purpose

The aim of this study was to determine the outcome of extremely low-birth-weight infants (ELBW) requiring surgical interventions for the complications of prematurity

Methods

One hundred eighty-seven consecutive infants with a birth weight less than 1,000 g treated over a 5-year period were reviewed. Outcome variables included number and types of surgical procedures; length of stay; survival rate and; pulmonary, neurologic, and gastrointestinal morbidity.

Results

Surgical interventions were required in 66 (35%) infants (group S) weighing less than 1,000 g at birth (33% necrotizing enterocolitis/bowel perforation, 36% patent ductus arteriosus, 56% other). Overall mortality rate for group S infants was 23% compared with 22% for those not requiring surgery (group NS; P > .05). Mortality rate rose to 38% for those infants undergoing procedures for necrotizing enterocolitis/bowel perforation (P < .05). Although neurologic and pulmonary morbidity for the entire population were high, there was no difference in their incidence between surgical and nonsurgical groups (29% v 26% and 44% v 65%, group S v group NS, respectively; P > .05).

Conclusions

These data suggest an improving outcome for ELBW infants. Common associated morbidities of prematurity do not appear adversely affected by surgical interventions supporting an aggressive approach to the care of these infants at the extreme of life.     

Anesthesia for emergency surgery in 2 extremely low birth weight infants with ileus

Two extremely-low-birth-weight infants, weighing each 684 and 975 g at birth, underwent emergency surgery because of ileus. Our previous experience with an extremely low birth weight infant, whose hemodynamic control during the surgery had been difficult without administering extra preoperative fluid and transfusion, made us administer enough fluid and transfusion during operation although their urine output was more than 2 ml.kg-1.hr-1. We gave intravenous volume to the present 2 cases before the operations despite the level of preoperative urine output and made their hemodynamic situation more stable during surgeries. We conclude it is very important to administer some amounts of intravenous volume (approximately 8-12 ml.kg-1.hr-1) in extremely low birth weight infants for emergency surgery with ileus regardless of their preoperative urine output.     

2例超低体质量极早早产儿的早期生命支持

对2例出生体质量<500 g、孕周不满24周的极早早产儿进行早期生命支持,包括STABLE院前转运技术、NIDCAP护理、NRP急救、PICC置管、外周动脉置管以及皮肤护理、液体管理等。结果 2例患儿中1例救治12 h因呼吸衰竭死亡;1例成功存活了120 h,病情平稳,终因家庭原因放弃治疗。     

Comparison of different definitions of acute kidney injury in extremely low birth weight infants

Background

The definition of acute kidney injury (AKI) has evolved over the years, and three definitions have been adapted including pediatric risk injury failure, loss of kidney function (pRIFLE), Acute Kidney Injury Network (AKIN), and Neonatal Modified Kidney Disease Improving Global Outcomes (KDIGO). We sought to report the prevalence and outcome of (AKI) according to the three existing definitions in extremely low birth weight (ELBW) infants.

Methods

In a retrospective cohort study, medical records of all ELBW infants (<1000 g) admitted to our neonatal intensive care unit (NICU) between Jan 2002 and Dec 2011 were reviewed. Infants’ demographics, anthropometric measurements, and clinical characteristics were collected at the time of birth and at discharge from the NICU. Infants were staged according to the three different definitions.

Results

During the study period, 483 ELBW infants met our inclusion criteria. The incidence of AKI was 56, 59, and 60% according to pRIFLE, AKIN, and KDIGO, respectively. Mortality, NICU length of stay, and serum creatinine (SCr) at NICU discharge were higher in infants with advanced AKI stages regardless of the definition. In addition, discharge NICU weight and length z scores were lower in infants with advanced AKI stages. SCr at 72 h of life and SCr peak were predictable of NICU mortality [AUC 0.667 (95% CI 0.604–0.731), p < 0.001 and AUC 0.747 (95% CI 0.693–0.801), p < 0.001, respectively].

Conclusion

Regardless of the definition, advanced AKI is associated with increased mortality, prolonged NICU length of stay, and poor growth in ELBW infants. SCr at 72 h of life and SCr peak may be predictable of NICU mortality.

     

Less invasive surgical closure of patent ductus arteriosus in extremely low birth weight infants

Minimally invasive surgery is widely used in pediatric surgery. Extremely low birth weight infants (ELBWI) are literally so fragile to surgical stress that the minimum invasive procedures should be required. We report 15 ELBWI cases with patent ductus arteriosus (PDA), who underwent surgical closure. All of them had failed treatment with indomethacin to close PDA or had contraindicated to its use. The mean gestational age at birth was 26.0±2.7 weeks (24–34 weeks) and birth weight 702±140 g (479–966 g). The mean age at operation was 23±11 days (2–48 days) and body weight at operation 679±151 g (428–969 g). The surgery-related mortality was none. No complications were also encountered. Our surgical procedures consist of 2 modalities, one is clipping PDA, not ligation. Clipping technique attributes to minimize the dissection of surrounding tissue of PDA. The other is posterolateral muscle sparing thoracotomy, which would reduce long-term physical impairment and deformity. We believe our surgical technique can be accomplished safely and would be an alternative approach for ELBWI with a lower probability of PDA closure with indomethacin or an increased risk of complications for medical treatment.     

1周内母乳喂养量对极低/超低出生体重儿的影响

目的探讨出生后1周内母乳喂养量对极低/超低出生体重儿坏死性小肠结肠炎(NEC)和喂养不耐受的影响。方法回顾性分析270例产科出生的极低/超低出生体重儿病例资料,按母乳喂养量占总喂养量的比例分为60%组、≤60%组,配方奶喂养组,比较三组第1周母乳喂养量对NEC和喂养不耐受的影响。结果≤60%组、配方奶喂养组NEC发生率显著高于60%组,OR(95%CI)分别为13.455(95%CI 1.718,105.343)、19.425(95%CI 2.317,162.845)(P0.05,P0.01);≤60%组、配方奶喂养组喂养不耐受率显著高于60%组,OR(95%CI)分别为10.976(95%CI 4.605,26.163)、9.876(95%CI 3.688,26.595)(均P0.01)。结论 1周内多量母乳喂养可降低极低/超低出生体重儿喂养不耐受和NEC发生率。     

Acquired Bartter-like syndrome association with netilmicin therapy in an extremely low birth weight infant

Aminoglycosides are commonly used antibiotics with excellent renal parenchymal penetration. Their clinical effectiveness is counter balanced with the risk of renal toxicity, which develops in a dose-dependent fashion. Aminoglycoside-induced renal tubular dysfunction could result in diffuse damage or manifest as a Fanconi-like syndrome, Bartter-like syndrome (BLS), or distal renal tubular acidosis.^1–4 Although tubulopathy associated with amikacin and gentamicin was reported in adults and rarely children, to the best of our knowledge, netilmicin-associated BLS neither in adults nor in children has been reported in the literature. We here report a 30-week, 770?g male preterm infant who developed BLS just after netilmicin treatment for neonatal sepsis and recovered 6 weeks after the drug cessation.