The frequency of RBC transfusions was similar in NEC patients (47/93, 51%) and control patients (52/91, 58%). Late-onset NEC (>4 weeks of age) was more frequently associated with a history of transfusion(s) than early-onset NEC (adjusted OR, 6.7; 95% CI, 1.5 to 31.2; P = .02). Compared with nontransfused patients, RBC-transfused patients were born at earlier gestational ages, had greater intensive care needs (including at the time of onset of NEC), and longer hospital stay. A history of RBC transfusions within 48-hours before NEC onset was noted in 38% of patients, most of whom were extremely low birth weight infants.
Conclusions
In most patients, RBC transfusions were temporally unrelated to NEC and may be merely a marker of overall severity of illness. However, the relationship between RBC transfusions and NEC requires further evaluation in extremely low birth weight infants using a prospective cohort design.
My Word: Few recent studies did not show any correlation between transfusions and NEC. But,
my hypothesis is that: older the blood and lower the hct,
higher the chances for NEC or hematoschezia. Older blood may accumulate oxygen radicals secondary to hemolysis and cause vasoconstriction and ischemia.
http://www.ajcn.org/content/early/2010/10/27/ajcn.2010.29799.abstract a double-blind, randomized, controlled trial Design: A double-blind, randomized, controlled clinical trial was conducted in 231 preterm infants weighing from 750 to 1499 g at birth. The intervention group was composed of 119 infants who received human milk with probiotic supplementation (B. breve and L. casei) and a control group of 112 infants who received human milk containing no probiotics. The primary outcome was the occurrence of NEC stage ≥2 as defined by Bell's modified criteria.
Results: Four confirmed cases of NEC stage ≥2 by Bell's criterion occurred only in the control group.
Though the follow up is not mentioned in this article, they compared probiotic group with those receiving breast milk alone rather than with formula. That makes it interesting!
A prospective, unmasked, randomized, controlled clinical trial was conducted in 46 eligible newborn infants who were hospitalized for TTN in the University Hospital of Bordeaux (France) between 2007 and 2009.
Results
In the NHFPV group the duration of TTN was half the time of NCPAP group (105 min ± 20 and 377 min ± 150, respectively; P < 0.0001). There was a significant decrease in duration of oxygen supplementation in the NHFPV group (6.3 min ± 3.3) compared to the NCPAP group (19.1 min ± 8.1; P < 0.001), and a significant decrease in level of oxygen supplementation [(FiO2—0.21)/time of O2 therapy] in the NHFPV group (0.29 min−1 ± 0.16) compared to the NCPAP group (0.46 min−1 ± 0.50; P < 0.001). There was no complication and NHFPV was as well tolerated as NCPAP.
My Word: The results are statistically significant but not clinically relevant 6.3 minutes vs 19 minutes! Not for prime time yet.
http://www.ajog.org/article/PIIS0002937810011117/abstract?rss=yes Children in the highest tertile of maternal CRP levels had a higher risk of experiencing recurrent wheezing (adjusted odds ratio, 2.87; 95% confidence interval, 1.23–6.71) and being diagnosed with recurrent LRTIs (odds ratio, 2.37; 95% confidence interval, 1.01–5.55), as compared with children in the lowest tertile. The rs1205 polymorphism influenced maternal serum CRP levels but not the risk of the offspring outcomes.
Conclusion:
Higher CRP levels in pregnancy are associated with wheezing and LRTIs in offspring. However, genetic variation in CRP influencing maternal levels is not related to these phenotypes.
http://www.springerlink.com/content/t6p22706q04m4100/ The study included 90 full-term neonates with Rh incompatibility unmodified by antenatal treatment and not eligible for early ET and which were randomly assigned into one of three groups: group (I), treated by conventional method; groups IIa and IIb received IVIG once at 12 h postnatal age if PT was indicated, in a dose of 0.5 and 1 g/kg, respectively.
Analysis revealed 11 neonates (22%) in the conventional group and 2 (5%) in the intervention group who administered low-dose IVIG at 12 h, while none in group IIb required exchange transfusion (p = 0.03). Mean bilirubin levels were significantly lower during the first 96 h in the intervention group compared to the conventional group (p < 0.0001). Shorter duration of phototherapy (52.8 ± 12.39 h) and hospital stay (3.25 ± 0.71 days) in the IVIG group compared to conventional group (84 ± 12.12 h and 4.72 ±0.78 days, p < 0.0001, respectively) were observed.
http://fn.bmj.com/content/95/6/F439.abstract Conclusions Persistent non-visualisation of the fetal stomach in the antenatal period was associated with a wide range of underlying diagnoses. In many cases, prognosis was poor. Only 37% of pregnancies resulted in liveborn infants surviving more than 6 months. The incidence of an abnormal karyotype was 29%. Diagnosis and outcome was normal in only 9.2% of cases. We propose an algorithm for the management of persistent non-visualisation of the fetal stomach on antenatal ultrasound.
Results A total of 67 596 VLBW infants were included in the study. Overall incidence of IVH in the sample was 14.7%; the transport group had more IVH compared to inborn group (27.4% vs 13.42%): adjusted OR 1.75 (95% CI 1.64 to 1.86; p<0.001). p="0.001).">
Conclusion Inter-hospital transport of VLBW Infants is correlated with increased incidence and severity of IVH. This correlation has remained constant over the recent years.
Objective To investigate the impact of surgical closure of PDA on rScO2 and cerebral fractional tissue oxygen extraction (cFTOE), measured by near-infrared spectroscopy, and on amplitude-integrated electro-encephalography (aEEG) measured brain activity.
Design/methods In 20 preterm infants (gestational age 24.7–30.4 weeks; birth weight 630–1540 g), blood pressure, arterial saturation, rScO2, cFTOE and aEEG were monitored before, during and up to 24 h after surgery.
Conclusion Ductal ligation poses a risk for a further decrease in already compromised cerebral oxygenation in preterm infants.
My Word: this does not mean that PDA ligation has long term implications.
http://pen.sagepub.com/content/34/5/503.abstract Conclusions: Parenteral but not enteral Omegaven augments and accelerates structural bowel adaptation in a rat model of SBS. Increased cell proliferation and decreased apoptosis reflect increased cell turnover in Omegaven-treated animals. This study has some good clinical value and more and more studies are suggesting that omega-3 fatty acids fish oil has lot of clinical benefit especially with prolonged TPN and following bowel resection.
http://pen.sagepub.com/content/34/5/477.abstract The authors examined the lipid profiles of a unique cohort of 10 children who were exclusively administered a fish oil–based lipid emulsion while on PN for a median duration of 14 weeks. Results: After 14 weeks of fish oil monotherapy, children had a 24% increase in high-density lipoprotein. Compared to baseline, serum low-density lipoprotein, very low-density lipoprotein, total cholesterol, and triglyceride levels all significantly decreased. Eight children had their bilirubin improved with a decreased direct bilirubin from 6.9 mg/dL (range, 4.4-10.7) at baseline to 2.3 mg/dL (range, 1.3-4.0) after 14 weeks, and a decrease in total bilirubin from 8.7 mg/dL (range, 5.5-13.7) to 3.8 mg/dL (range, 2.2-6.5). Conclusion: A fish oil–based lipid emulsion used as monotherapy in children who exclusively depended on PN for survival was associated with significant improvement in all major lipid panels as well as improvement of hyperbilirubinemia. Parenteral fish oil may be the preferred lipid source in children with dyslipidemia.
www.jpen.sagepub.com september 2010 issue. The study group included 22 term and preterm newborns (group T1) who had received at least 75% of the required energy via parenteral nutrition for 3–15 days. Analyses of conjugated BAs were performed using the high-performance liquid chromatography–mass spectrometry (HPLC-MS) method. The authors’ results suggest that there is an early increase in glycine- and taurine-conjugated BAs in the plasma of newborns receiving PN for 3–15 days compared with healthy controls (CN, n = 15) and patients before PN (T0, n = 9). More specifically, patients receiving PN had significantly increased levels of glycocholic acid, taurocholic acid, and combined taurochenodeoxycholic + taurodeoxycholic + tauroursodeoxycholic acids.
Bile acids correlate quite well with histological liver damage than bilirubin and hence early recognition and modification of TPN or cycling of TPN or use of omega-3 fatty acid fish oil emulsion may prevent severe form of cholestasis-Nadia Ovchinsky commented on the study.
http://www.jpeds.com/article/S0022-3476%2810%2900398-7/abstract he study included singletons and twins alive at onset of labor between 24 and 31 weeks of gestation without congenital anomalies from the Models of Organising Access to Intensive Care for very preterm births very preterm cohort in 10 European regions in 2003 (n = 4525). The mortality rate was higher for infants with birthweights <25th percentile when compared with the 50th to 74th percentile (adjusted odds ratio, 3.98 [95% CI, 2.79-5.67] for <10th; adjusted odds ratio, 2.15 [95% CI, 1.54-3.00] for 10th-24th). BPD declined continuously with increasing birthweight. There was no association for periventricular leukomalacia or intraventricular hemorrhage.
Conclusions
A 25th percentile cutoff point was a means of identifying infants at higher risk of death and a continuous measure better described risks of BPD. Lower birthweights were associated with poor outcomes regardless of pregnancy complications.
http://www.jpeds.com/article/S0022-3476%2810%2900394-X/abstract This was a prospective observational study of neonates in the neonatal intensive care unit.
Results
Seventeen neonates had confirmed NEC, and 34 neonates had nonspecific abdominal disorders that improved rapidly. Gestational age, postnatal age, weight, sex, maternal obstetric variables, rupture of membranes, and mode of delivery did not differ between the two groups. Mean IaIp level was significantly lower in the NEC group compared with the control group (137 ± 38 mg/L; 95% confidence interval [CI], 118-157 mg/L vs 258 ± 53 mg/L; 95% CI, 238-277 mg/L; P <.0001).
Conclusions
The finding of significantly lower IaIp levels in neonates with NEC suggests that IaIp might be a useful, sensitive biomarker, allowing initiation of appropriate therapy Looks promising.
Patients were classified into two groups; group I with suspected NEC (stage I) (n = 54) and group II with definite NEC (stage ≥II) (n = 39). Pneumatosis intestinalis (PI) (n = 29), free air (n = 9), and portal venous gas (PVG) (n = 1) were observed in group II on plain radiography. In the same group, echoic free fluid (EFF) (n = 9), PVG (n = 6), PI (n = 5), and focal fluid collection (n = 3) were the most prominent sonographic findings. In patients with intestinal perforation, whereas EFF and bowel wall thinning were observed on AUS, free air was not detected on plain radiography as a sign of intestinal perforation.
Conclusion Our results suggest AUS to be superior to plain radiography on early detection of intestinal perforation by demonstrating PVG and EFF collection. Therefore, it may be life-saving by directing the surgeon to perform surgical intervention in the case of clinical deterioration in the course of NEC.
http://pen.sagepub.com/content/34/5/542.abstract. Journal of Parenteral and Enteral Nutrition
Background: The provision of high amounts of calcium and phosphate in parenteral nutrition (PN) solution for neonates is important for bone mass accretion. Because of the risk of calcium phosphate precipitation, a well-documented incompatibility for inorganic salts, the concentrations of these electrolytes in PN are generally limited to 5 mmol/L. The aim of this study was to assess the risk of precipitation of calcium phosphate when organic calcium and phosphate salts are used instead of inorganic salts. Methods: Precipitation curves were determined for inorganic and organic calcium and phosphate salts in a PN solution favorable to precipitation (low concentration of amino acids and glucose) using visual inspection and particle counts. Results: The use of organic phosphate salt was associated with a decreased risk of precipitation of calcium phosphate. No precipitation occurred up to a concentration of 50 mmol/L of calcium and phosphate. In contrast, organic calcium salt only slightly decreased the risk of precipitation. Conclusion: Up to 50 mmol/L of organic calcium and phosphate salts can be safely mixed in PN, even in unstable conditions, making it possible to follow the current European recommendations for requirements in neonates.
doi: 10.1203/PDR.0b013e3181e6a068.
This study is a retrospective, case control study involving 535 preterm infants examining the roles of sequence polymorphisms in genes that mediate host immune responses to bacterial infection in newborn infants. A total of 49 single nucleotide polymorphisms (SNPs) in 19 candidate genes including inflammatory cytokines (IL6, IL10, IL1B, and TNF), cytokine receptors (IL1RN), toll-like receptors (TLR2, TLR4, and TLR5), and cell surface receptors (CD14) were genotyped.
Allelic variants in PLA2G2A and TLR2 were associated with Gram-positive infections, whereas IL10 was associated with Gram-negative infections (p <>PLA2G2A, TLR2, TLR5, and IL10 may moderate the predisposition to sepsis in preterm infants.
http://onlinelibrary.wiley.com/doi/10.1002/jcu.20741/abstract;jsessionid=06AFD85D417B9CD25216DF49E386CEA3.d01t01 Of 762 fetuses evaluated by US, 48 (6.3%) were found to have an ICEF.
After 24 h of treatment, PC activity levels increased from an average of 19% to 57%, and they were within normal limits before the last PCConc bolus. During the treatment period, a shortening of PT (P = 0.04) and activated partial thromboplastin time (P = 0.02), and an increase in antithrombin levels (P <>P = 0.005) and NTISS values (P = 0.003). No adverse events were observed. This pilot study shows that in neonatal severe sepsis, normalization of PC levels is safe and probably effective in modulating the inflammatory response and in controlling coagulopathy. However, for the potential beneficial effects of PCConc administration on morbidity and mortality, a placebo-controlled, double-blind study is required.
Chylothorax is a well-recognized complication after neonatal cardiothoracic surgery. Management strategies include cessation of enteral feedings, repeated aspiration, chest drainage, and total parenteral nutrition. Somatostatin and its analogue, octreotide, have been used with promising results. The authors present three cases of neonatal postoperative chylothorax in which octreotide was used. After literature review, we can say that octreotide is relatively safe, and may reduce clinical course and complications associated with neonatal postoperative chylothorax. One should be aware of possible association between octreotide and necrotizing enterocolitis. Prospective controlled trials supporting octreotide use are lacking. http://www.springerlink.com/content/dk0155j31v6l13p2/
Objective: To compare and evaluate the efficacy of nebulized 3% hypertonic saline (HS) and recombinant human Dnase (rhDNase) treatment for resolution of persistent atelectasis in newborns.
Study Design: Forty newborns (38 preterms) who did not respond to conventional treatment enrolled to receive either nebulized 3% HS solution (n = 20) or rhDNase (n = 20) between September 2007 and March 2008. Clinical parameters, oxygen saturation and radiological response (chest X-ray scoring) were analyzed before and after administration of 3% HS or rhDNase.
Resolution time of atelectasis did not differ between two groups after whole treatment but the percentage of atelectasis resolution after 3 days treatment were 90% (18/20) in the 3%HS group and 70% (14/20) in the rhDNase group. The patients in the 3% HS group improved better also in clinical parameters in comparison to the rhDNase treatment. The difference of oxygen saturation before and after the treatment was 4.6 ± 0.8 in 3% HS group as in comparison to 2.6 ± 0.1 in the rhDNase group (p <>
Early Human Development Volume 86, Issue 8, August 2010, Pages 499-502 Intratracheal catheter suction removes the same volume of meconium with less impact on desaturation compared with meconium aspirator in meconium aspiration syndrome.
Methods
MAS was induced in ventilated rabbits using 3.5 ml/kg of 20% human meconium. Tracheal suction with either catheter suction (CS) or meconium aspirator (MA) was performed after meconium instillation. Percentage of meconium collection rate, PaO2 trends for 2 h after tracheal suction, and acute-phase SpO2 trends were compared between CS and the other three groups, the tube was withdrawn while meconium was aspirated with an MA, then the trachea was reintubated 5, 10 or 15 s after suctioning of meconium.
Results
Percentage of meconium collection rate and PaO2 showed no significant differences between groups. The MA group taking 15 s for reintubation after meconium suctioning, showed a significantly lower acute-phase SpO2 than the CS group (P <>2 to return to ≥ 90% was also longer in the MA group taking 15 s for reintubation than in the CS group (P <>
Among 1804 pregnancies exposed to acyclovir, valacyclovir,or famciclovir in the first trimester, 40 infants (2.2%) werediagnosed with a major birth defect compared with 19 920(2.4%) among the unexposed (adjusted POR, 0.89; 95% confidenceinterval [CI], 0.65-1.22). It seems quite safe.
Recommendation: Voiding cystourethrogram is recommended for children with high-grade (Society of Fetal Urology grade 3 and 4) hydronephrosis, hydroureter or an abnormal bladder on ultrasound (late term prenatal or postnatal), or who develop a urinary tract infection on observation. Option: An observational approach without screening for VUR, with prompt treatment of any urinary tract infection, may be taken for children with prenatally detected hydronephrosis (SFU grade 1 or 2), given the unproven value of identifying and treating VUR. It is also considered an option to perform a voiding cystourethrogram in these patients to screen for VUR. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/vur2010/ScreenNeonateinfantWithPrenatalHydronephrosis.pdf (for complete article). Summary:In screened populations with prenatal hydronephrosis the prevalence of vesicoureteral reflux is 16.2%. Reflux in the contralateral nondilated kidney accounted for a mean of 25.2% of detected cases for a mean prevalence of 4.1%. In patients with a normal postnatal renal ultrasound the prevalence of reflux is 17%. The prenatal anteroposterior renal pelvic diameter was not predictive of reflux prevalence.
https://www.thieme-connect.com/ejournals/abstract/ajp/doi/10.1055/s-0030-1263298 In view of our experience and the review of the literature, we suggest that unilateral intubation is an efficient and relatively safe therapy in cases of neonatal air leak syndrome. It is also suggested that appropriate treatment duration should be at least 48 hours. Amer J Perinatol : DOI: 10.1055/s-0030-1263298
http://www3.interscience.wiley.com/journal/123531601/abstract?CRETRY=1&SRETRY=0 401 newborns were prospectively followed and clinical signs and CRP values were recorded and blood culture results were compared. Conclusion: In this selected population of infants with suspected sepsis, apnoea and hypotension are independently predictive of a confirmed diagnosis, while bradycardia is more predictive among preterm infants and tachypnea among term infants. Apnea, hypotension and CRP were independently predictive of positive blood culture.
The Lancet, Early Online Publication, 22 July 2010
doi:10.1016/S0140-6736(10)60664-2 Methods: 800 preterm infants with a gestational age at birth of between 24 weeks and 28 weeks plus 6 days (inclusive), weighing at least 500 g, requiring surfactant or continuous positive airway pressure for respiratory distress syndrome within 24 h of birth were randomly assigned in a one-to-one ratio to inhaled nitric oxide (5 parts per million) or placebo gas (nitrogen gas) for a minimum of 7 days and a maximum of 21 days in a double-blind study
Interpretation:Early use of low-dose inhaled nitric oxide in very premature babies did not improve survival without bronchopulmonary dysplasia or brain injury, suggesting that such a preventive treatment strategy is unsuccessful.
Reese J et al. – Exposure of premature infants to unintended vasodilatory stimuli may be one of the risk factors for PDA that is underrecognized. In this article, authors summarize the clinical factors that are associated with PDA and review commonly used neonatal drugs for their vasodilatory properties. Data demonstrating relaxation of the ductus arteriosus by gentamicin and other aminoglycoside antibiotics, by cimetidine and other H2 receptor antagonists, and by heparin are provided as examples of neonatal therapies that have unanticipated effects that may promote PDA.
I need to check the original articles to check the how significant this is!
Whew! We all settled down and drove calmly to our next fortuity-the mini boat tour. These are small air filled 13’ boats and only 4 people can ride at any time. I had seen the pictures on the web; it was very exciting and a new kind of sport. I saw people riding them in calm back waters of the ocean. Fun filled activity I thought and booked the tour in advance paid the charges in full. I wanted this to be a pleasant surprise for my family.
It was blistering hot and the ride in the ocean should cool us down, I thought. There were five groups of fun seeking fanatics. The main leader gave us inspiring speech praising us for selecting this one and only kind of ADVENTURE. Yes, he stressed- it is an adventure as we would go in the real ocean to two different islands for snorkeling. You got it right, real turbulent ocean and not the calm back waters, as I originally envisioned. Besides, this surly surprise, I noticed that there were only two leaders and we were 5 groups. As I was trying to comprehend the impending calamity, the leader’s announcement enhanced my bemusement. He declared that I am the captain of my boat and will be driving my family in to the ocean. I thought I would be a rider and not a driver myself! Money was non refundable besides my prestige was at stake, if I backed out. It was a blissful blithe for my kids and astounding astonishment for me. One man’s pleasure is other man’s pressure.
The other groups were elated and my fears were unabated! The leader zoomed past us in to the open seas and I followed. Oh Shoots! I don’t know swimming-the harsh truth dawned upon me in the middle of the sojourn. I am a driver but, will I be a survivor? As we proceeded, it was titillation for others and trepidation for me. As time went by, I got used to the waves, the distress regressed, and I wore a smile after a while. We snorkeled and it was phenomenal. We ventured out to the second island. Just then a storm system was approaching us very fast. The leader declared that if we stopped at the second island, we could be struck for the whole night and hence, we should rush back to the main land.
The ocean became choppy because of the storm. If I went slowly, I could be caught in the middle of the ferocious winds and may make it to the obituary column. I had no choice, my family lives were in my hands. I used the full throttle, the waves were humongous, and the boat was whammed from all directions by the rough sea. As the boat was thrashed, my back was bashed. Should I have worn a diaper, a thought just flashed! Boat was repeatedly tossed in to the air and would come down with a huge thud. The impact was so enormous it broke my daughter’s seat. We were falling from a height of at least 6-10feet constantly and consistently and my back took the brunt of the impact.
We reached the land finally. I could barely walk and the pain was intolerable. The medications I had gave little relief and a unanimous decision was made to send me to get a massage at the Chakra spa of the resort. The spa receptionist added perplexity to my predicament. Do you need a male or a female therapist? I never faced such a tough question in my life. It was a double edged sword. A dialogue specially scripted for me, I pondered. If I say, man, would they think that I am a homosexual and if I answered female, do they think I have a passion for perversion? Why should my life be a perplexing byzantine enigma? I wanted to pull my hair. That was a more difficult task to perform than answering her contentious and controversy generating question! I cleared my throat but, what should I say?
I wish Radha was by my side and she would have saved me from this quandary. I asked who is more experienced. I thought, I had found a great solution to the problem. However, the receptionist was very diplomatic and did not divulge the truth to make things more intricate and prolong my torture. But, I had a reprieve, when she said, which time you want. I picked 10am for the massage. It was open and I took it. I was curious, who was the therapist. It was a woman. Well, like a loyal husband, I conveyed the same to Radha. She was not amused that another woman was going to touch my body.
She started her prayers on the beach.
I went the next day to the Chakra spa. I was seated in a small but beautifully decorated room. “Good morning sir, please meet your massage therapist”, a pleasant voice greeted me and shut the door locked. I shyly turned my head and looked at her. What! Is this chakra or Vishnu Chakra! (a deadly weapon in Indian mythology). Am I punished? Did Radha talk to the receptionist and arrange this? I was like a rat beside a great cat. Her hair style was like a Sumo wrestler. I may be puny but not loony! I was expecting suma maina (delicate, soft) maalish not SUMO mardhana (violent bashing). I stood like a lamb (bakra) before the sacrifice (Chakra pe Bakra!) and there was not even a window to escape! It was a non-refundable commitment or was it atonement! It seemed that she was specially hired for me and was flown from Japan. Can I have a No-Touch Technique massage? I begged. Radha’s prayers were answered!
At last the trip was finalized, yet I was skeptical about the itinerary. Is this island, worthy of 5 days of our vacation? Do I need to book for excursions to other islands? Will I be able to provide memorable vacation for my family? My mind was rattled with emotional commotion. All my apprehensions seemed to have dissipated by the heat of this beautiful tropical island.
The resort was beautiful and apotheosis (ideal example) of perfect requiescence (A state of quiescence; rest; repose). The lobby was large and the commanding view of the vast Atlantic Ocean was magnetically enticing. Soft and soothing breeze was seducing us to the beach on the resort. “Do you want us to use the credit card on record?”the affable voice of the receptionist brought me back to the mollifying lounge. We checked in to the room, which was oceanfront. It set the pace for rest of our vacation.“It is beautiful daddy!”, said my eldest one, leaning on my shoulder. As I was priding myself, I felt someone was pinching me repeatedly! I thought it was Radha. She was engrossed in enjoying the enthralling views of Atlantic. Whereas, mindless mosquitoes were mercilessly marauding my blood. I was prepared. I immediately wore the medicated mosquito repellant band. They were amused and began to focus around the band instead of rest of the body.I was very soon thrashing myself and ended up with bumps and bruises.
Radha realized that the enchanting beauty should be shared with me. She turned around and was flabbergasted. How could I get so many hickies? She thought. She looked around ferociously for the perpetrator and I pointed her to the beguiling band. It is an arthropod allurer specially sold at CVS. The bewitching beauty of the resort and island made the mosquito menace a miniscule issue.
We explored the island with Lety. She showed us some historic places and beautiful beaches in her huge minivan. Roads were perhaps built for one person to walk, but Lety managed to navigate her truck size minivan with impeccable dexterity. Other faster alternative would have been-training under Tarzan, jumping from tree to tree. We immensely enjoyed the serene atmosphere on the island and decided to explore the main island in 36 hours. We flew in a small 6 seater plane. We were seated by weight and no one dared to sneeze or cough after the flight took off, lest it might disturb the delicate balance in midair. No one took chances! Ride was comfortable. It flew low over the ocean giving us a panoramic view of the turquoise waters, but I found everyone was focused upon finding the life jackets beneath their seats. Before they could retrieve, they had a reprieve as the plane glided on to the runway.
Renting a car was no brainer but for driving, we needed a trainer. All the signs were non-English. You do not know if the sign says east or west as they are spelled so similarly. If you are a fresher, use the right lane but, if you are a thinker-then left lane (lost in thoughts and oblivious to the minimum speed limits). But, if you want to pass, you may use the shoulder. Yes, it is complex in a simple way! We were told not to use the express lane at the toll as it is meant for ez-pass holders. So, we comfortably avoided that lane, but ended up in cash only lane. To make it simply complicated it was the lane for exact change. I threw a quarter and it wanted more, how much more? I had no clue. I found one more quarter and threw it in to the receptacle. It was not satisfied. I had no more change, I threw a dollar note, it gulped it down but did not register any transaction. Drivers behind me became restless and started honking. I was flustered and everyone in the car exhorted me to throw one more dollar note. I did, but to no avail. The honking increased to a ferocious level. I was nervous and I could not go back as cars were blocking me and no savior in sight. I was frantic and decided to something and started to remove my socks and shoes to throw them in to the money mongering monster. Fortunately, my kids found some dimes and nickels and that seemed to have satisfied the fastidious appetite for change. The gate opened, the honking dampened, seat belt fastened, anxiety lessened and speed heightened. I was saved of losing my garments. Wow! Study before your sojourn and verify (signs) before you venture in a foreign place. Phew! to be continued.....
Predictive Value of Bile Duct Dimensions Measured by Ultrasound in Neonates Presenting With Cholestasis
Fitzpatrick, E; Jardine, R; Farrant, P; Karani, J; Davenport, M; Mieli-Vergani, G; Baker, A
http://journals.lww.com/jpgn/Abstract/2010/07000/Predictive_Value_of_Bile_Duct_Dimensions_Measured.11.aspx Conclusions: Bile duct dilatation <3>4 mm is likely to be associated with choledochal malformation or need for intervention. The intermediate group is likely to be associated with inspissated bile syndrome following resolution of which innocent biliary dilatation may persist.
In a small study, researchers have found improved outcomes at 18 months. 17 in prophylactic group (40mg/kg) 21 in the control group were followed up for neurological outcomes with whole body cooling. Three infants in the prophylaxis group (15%) and 18 in the control group (82%) had seizures while they were in the NICU (p < 0.0001). There was a trend towards other benefits. But it is a small study with no EEG in all patients. Hence, take it with a pinch of salt. The study is in Jour. Pediatrics.
Although the number of newborns in this study was limited, the short-term outcome and the safety data appear to support the evaluation of topiramate in clinical trials to explore its possible additive neuroprotective action.
Interesting. What is the mechanism of action? I will try and find out.
Mean baseline BNP levels were higher in neonates who were non-responders (2234 ± 991 pg/mL) than neonates who were responders (983 ± 814 pg/mL; P = .001). A baseline BNP level >1805 pg/mL had a sensitivity rate of 88% and a specificity rate of 87% for predicting indomethacin non-responsiveness (P = .003).
This was an interesting study shedding some light on the response of PDA to indomethacin.
Smoking in pregnancy: a risk factor for adverse neurodevelopmental outcome in preterm infants? U Kiechl-Kohlendorfer (ursula.kohlendorfer@i-med.ac.at), E Ralser, U Pupp Peglow, G Reiter, E Griesmaier, R Trawöger Acta Paediatrica/Acta Paediatrica 2010 99, pp. 1016–1019 prospectively enrolled 181 infants born alive between 23 and 32 weeks of gestation; 142 infants (78.5%) completed the follow-up visit. Smoking in pregnancy, small for gestational age and chronic lung disease maintained significance in a multivariable analysis.
Acta Paediatrica latest issue has one interesting article.
http://www3.interscience.wiley.com/journal/123415876/abstract Gestational age was 26–32 weeks. Transcutaneous carbon dioxide was between 4.7 and 8.5 kPa and mean arterial blood pressure between 22 and 55 mmHg. a plateau over a certain blood pressure threshold and a positive slope below this threshold, the relation to white matter flow percentage was statistically significant (p = 0.02). The threshold was 29 mmHg (95% confidence limits 26–33).
Acta paediatrica http://www3.interscience.wiley.com/journal/123476689/abstract?CRETRY=1&SRETRY=0 published an interesting study about the effect of delivery on blood sugar levels. The C/s infants though had lower sugar comparatively at birth, had their blood sugars increased in two hours. Cord blood glucose concentration was higher in VD (81.3 ± 16.9 mg/dL) than CS infants (70.3 ± 9.7 mg/dL, p = 0.039). The change in blood glucose concentration over the first 2-h of life differed significantly between the two groups, being an increase in CS versus a decrease in VD infants (−3.5 ± 15.2 vs. −15.4 ± 24.6 mg/dL, p = 0.013).
The correlation between positioning by US and plain radiography was very good (r=0.97, r2=0.94, p<0.0001). The time needed to verify LL placement by US was shorter by a mean 15min compared to plain radiography.
Conclusions: US can accurately guide LL tip positioning. We believe that because of the potential gain of time it offers and its lack of ionising radiation, it to be considered as an interesting tool for the positioning of LL in neonates. Yet more accurate results could be obtained with a better-trained staff.
I am copying the statement from the web site "Mobilife introduces innovative application technologies into the market of mobile medicine by pairing the widely-available Windows Mobile platform with computer-assisted intravital microscopy to provide in-field analysis of the human microcirculation to detect microangiopathy in children. The project offers a scientifically-validated approach that cost-effectively provides accurate microcirculatory information to diagnose vascular diseases to ultimately reduce child mortality rates throughout the world." here is the link http://mobilife.us/learn.html I am not sure where they validated this application. I will try and find out.
http://www.withings.com/en/bodyscale/videos It is an interesting concept that can be used for managing obese/overweight pediatric patients. The weight can be configured to be transmitted to google personal health data site and even can be tracked on Iphone. Pediatrician can suggest the goals and pediatric patients can actively participate in their weight management. But, the hitch is how many obese patients have wireless network at home!
An article in Informationweek briefly described how Cincinnati Children's Hospital Medical Center is linking patients in ambulances with remote medical specialists. Their ambulances are equipped with video cameras and digital stethoscopes. "This is telemedicine on the go," said Dr. Hamilton Schwartz, who came up with an idea for using high-resolution video and other telemedicine gear, such as digital stethoscopes, for pediatric patients--including sick premature infants--while these children are in transit to Cincinnati Children's Hospital Medical Center from other area hospitals. Mass gen.hospital PICU is equipped with BOTS or PICU BOTS which link attendings at home to PICU patients and can virtually examine them and advise the in-house physicians. My dream is coming through! I talked about this kind of technology in 2001.
http://bjo.bmj.com/content/early/2010/04/12/bjo.2009.169284.short?q=w_bjo_ahead_tab A descriptive case series of 20 patients and all are exposed to methadone in utero.
reduced acuity (95%), nystagmus (70%), strabismus (30%), refractive errors (30%), and cerebral visual impairment (25%). Visual electrophysiology was abnormal in 60%. A quarter of the children had associated neurodevelopmental abnormalities. The majority of children with nystagmus (79%) had been treated for neonatal abstinence syndrome (NAS). Exact cause is unknown. This is concerning and we need to follow up our babies experiencing neonatal abstinence syndrome more closely. Br J Ophthalmol doi:10.1136/bjo.2009.169284
An increased Lp(a) level was found in 26 mothers [38%; 95% confidence interval (CI) 28–50%] and in 15 children (22%; 95% CI 13–33%). Both rates were higher than the reference range reported in the general Caucasian population (10% in adults and 5% in children).
Conclusions: Elevated maternal Lp(a) is apparently a risk factor for neonatal arterial ischemic stroke. We speculate that the pathological mechanism of this relation may be mediated through a dysfunction of the placental vascularization. Neonatology 2010;98:225-228
Conclusion Compared with placebo, BLF supplementation alone or in combination with Lactobacillus rhamnosus GG (LGG),reduced the incidence of a first episode of late-onset sepsis in VLBW neonates. JAMA 2009;302:1421-8.
April issue of J Peds showed a significant difference in the incidence of surgical NEC between those who received bovine HMF and those who received PROLACTA a human milk based fortifier. The bovine group actually received higher amounts of mother's own milk but also had HMF based on bovine protein. Prolacta is very expensive at this time, but may consider it if NEC incidence is high in their units or if babies are intolerant to cows milk protein.
J Peds Vol 156 No.4- interesting association between PET and BPD is brought up. Placenta is in a anti-angiogenic condition in PET and similar condition may exist in fetal lung as well disrupting angiogenesis in the lung --> BPD. This may be more common in growth restricted than in AGA preterms. However, this study lacks many important postnatal variables to conclude strongly. This study lays indirect role for nitric oxide post natally and vascular endothelial growth factor for antenatal use. A working hypothesis is that disruption of angiogenesis during lung development impairs alveolarization contributing to BPD and that preservation of vascular growth and endothelial survival promotes growth and sustains the architecture of the distal airspace.[10] Withdrawal of angiogenic growth factors (such as vascular endothelial growth factor [VEGF} and nitric oxide) disrupts lung vascular growth and impairs alveolarization in infant rats
J Peds April issue Vol 156, No.4 pg 525 has an interesting study which evaluated 219 surviving <26 week preterms who are now 11 years and noted that there was 8% incidence of autism in these preterms compared to none in term born classmates. Not having breast milk was also associated with autism spectrum disorders. There is lot more to be done in our NICU population to improve their outcomes. One good news is breast milk may help in this aspect as well.
http://archopht.ama-assn.org/cgi/content/abstract/128/4/443 To validate longitudinal postnatal weight gain as a method for predicting severe retinopathy of prematurity (ROP) in a US cohort. Harvard and Sweden researchers showed that postnatal weight gain can predict severe ROP and validates WINROP study. The results showed A high-risk alarm occurred in 81 infants (25.5%) and detected all infants who developed severe ROP a median of 9 weeks before diagnosis. The remaining infants received no alarm or a low-risk alarm. None of these infants developed more than mild ROP.
http://stroke.ahajournals.org/cgi/content/abstract/STROKEAHA.109.570325v1 Stroke journal published a study supporting the role of erythropoietin as a neuroprotective agent in reperfusion phase of hypoxic ishemic damage. Study demonstrates that delayed administration of EPO promotes oligodendrogenesis and attenuates white matter injury concurrently with increased neurogenesis. These effects likely contribute to the observed improvement in neurological functional outcomes.
Arch Dis Child Feta Neonatal Ed March 2010. Gianluca et.al showed that in a RCT of 40 babies of 30 weeks mean GA, that Bi-level CPAP (8cm/4.5cms) needed shorter respiratory support 3.8 +/-1 days vs 6.2+/- 2 days in CPAP (6 cms) and shorter O2 dependency 6.5 +/- 4 days vs 13.8 +/- 8 days and discharged early at 35.6 weeks +/- 1.2 weeks vs 36.7 +/- 2.5 weeks. All were statistically significant. I would like to see similar advantages in more premature babies such as <1 kg.
A study published in Neonatology Vol. 98, No. 2, 2010, compared impact of 5 french catheters placed either via the nostrils or oral route on apneas of prematurity. They did not notice any difference. Most important take from this study is that, smallest NG tube may be safer for nasal placement. Since, highest airway resistance is in the nostrils, it is better to use smallest possible NG tubes. http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ArtikelNr=279617&Ausgabe=253868&ProduktNr=224215
J.Ped.Surg Feb 2010. NET trial compared the peritoneal drainage (PD) in NEC with perforation with laporotomy. PD did not stabilize before intervention. Moreover, PD group had worsening cardiovascular status. Hence, PD does not stabilize the infants with NEC with perforation.
Journ.Ped. Surgery Feb 2010 page 310- if 3 metabolic derangement were noted within 24 hours of observation then operation is better than observation. The 7 metabolic derangement were 1) positive blood culture <96 hours, 2) pH <7.25 or receiving Hco3, 3) I/T of >0.2 4) Na <130, 5) Platelets <50k and neutrophils <2000. babies with bad outcome-death or TPn at discharge was higher if 3 or more metabolic derangement were noted.
European Journal of Pediatrics March 2 2010. http://www.springerlink.com/content/5x66262886393842/ If an oxygen saturation (SpO2) of ≤95% was measured on lower extremities and confirmed after 1 h, complete clinical examination and echocardiography were performed. POS was true positive in 14, false positive in 40, true negative in 41,384 and false negative in four children (three had been excluded for violation of study protocol). Sensitivity, specificity, positive and negative predictive value were 77.78%, 99.90%, 25.93% and 99.99%, respectively. POS can substantially reduce the postnatal diagnostic gap in cCHD, and false-positive results leading to unnecessary examinations of healthy newborns are rare. POS should be implemented in routine postnatal care.
Journal of perinatology-http://www.nature.com/jp/journal/vaop/ncurrent/abs/jp201014a.html
Serial echocardiograms obtained in 115 ELBW at less than or equal to10 day postnatal were examined to estimate PDA size using the PDA:left pulmonary artery (LPA) diameter ratio: greater than or equal to1 indicated a large PDA. Neonates with moderate to large PDA at less than or equal to4 day had 15-times greater likelihood of requiring treatment for sPDA than those with a small PDA (95% confidence interval (CI): 5.6–41). Sensitivity, specificity and PPV of the PDA:LPA at <27 weeks was 80, 86 and 92%, respectively.
Journal of Pediatric Surgery- 25 laparoscopic and 32 open. The time to goal feeds was significantly shorter for the laparoscopic group (4.3 ± 0.4 vs 6.1 ± 0.6 days, P = .04). The 24-hour postoperative narcotic requirement was significantly lower in the laparoscopic group (0.24 ± 0.05 vs 0.55 ± 0.08 mg/kg, P = .007). Operation times (111 ± 5 [open] vs 113 ± 5 minutes, P = .76) and estimated blood loss (13 ± 2 [open] vs 11 ± 1 mL, P = .33) were comparable for both groups. http://www.jpedsurg.org/article/PIIS0022346809008720/abstract?rss=yes
A small series of 6 newborns with seizures were followed in Seizure-European Journal of Epilepsy on Levetiracetam. All six patients treated with oral LEV became seizure free within 6 days. Five patients remained seizure free after 3 months with ongoing LEV monotherapy. One infant developed pharmacoresistent epilepsy. Seizures relapsed later in the clinical course of two more patients, one of whom was no longer under LEV therapy. This drug is beginning to be used more often in neonatal population. We are now seeing some studies.
Cars-Technology I think by now everyone knows that I am a lover of technology. If I bought a luxury model car, it is because it had all the technology I love. Previously, Radha and I used to fight, whenever we took a long journey before, as I used to insist on her to give me the directions, and I used to get mad. She had a knack; a unique extra sensory perception to turn around and talk to kids or bend down to collect something from the floor just before she needed to inform me about an exit, and I used to be upset. After having lost the exit I used to rely on her again for rerouting instructions. This used to put her under a lot of stress. Hence, we decided to buy a GPS. However, I wanted to use my older discarded pocket pc and install GPS software on that. Since it was an earlier generation PDA, it had very low memory and after warning us CAUTION, exceeding the speed limit; it used to get frustrated and freeze. I never knew that older PDAs were prone to DEPRRESION leading to no EXPRESSION culminating in DIGRESSION with multiple exits being missed . I needed to stop and provide anti-depressants (reset the old pocket pc) and it used to function well for some time. We, therefore, decided to go for higher end GPS and bought a car with all bells and whistles.
Cool! On one day, I was driving to the hospital. Shoots! I slapped my forehead! Where are my car keys? Did I forget them at home? Car keys had my office room key attached and wondered how would I get in? It then struck me, how could I be driving without the keys? This car had a button start and keys were in my pocket. I proudly smiled despite my stupidity.
It was our marriage anniversary. I booked at an exotic restaurant by the river side far from the madding crowd. I entered the address and set to go. We took the exit and drove through woods. I was happily humming Tom Jones song. Then I saw the road dividing into three ways. Just then my GPS announced "No more mapping directions available beyond this follow your local map Hee, HEE, HEE". I thought it was mocking at me! I remembered Robert Frost's poem " TWO roads diverged in a yellow wood, And sorry I could not travel both..... I took the one less traveled by, And that has made all the difference. This fellow talked about two roads, Man! I have three roads to choose. Reading poetry is of no use when you have to navigate on country roads. I looked at Radha with meek expression and asked her to call the restaurant. Lo!
We were in a dead-zone. No cell phone signal...
The other day, I was training the voice commands in my car and successfully entered some phone numbers. Even Srinidhi was impressed and excited. She played with it for some time, and it was COOL! I was a proud father now catering to children's futuristic needs as well. It was time to demonstrate this to Radha. As we were driving, I pressed the voice command button and said "Call wife". It immediately responded "Calling SUSAN!"
I was shocked! What! Susan! Who is she? Am I dead now? Radha must have thought this new car knew more things than she did! Srinidhi was laughing aloud in the back seat. The voice command declared, “No number found". I was very much relieved. I immediately turned into a parking lot, stopped and pressed the button with all burning anger and commanded "call wife", It promptly responded, "calling Radha". Radha was smiling all through; I did not dare to look at her all that time. It was the ambient noise when driving fast interfering with the clear interpretation by the software.
As per DIAMOND study published in Am J Clin Nutr (February 3, 2010). doi:10.3945/ajcn.2009.28557, showed that 0.32% Docasahexanoic acid supplementation to term infants improved visual acuity at 12 months. We need longer follow up to see if this effect persists.
J.Peds has lot of NICU related articles this month. They noted "Prenatal smoking exposure was associated with significantly smaller frontal lobe and cerebellar volumes in the brains of preterm infants".
J.Peds Feb 2010 issue has an artcile showing some promising utility of lactulose as a prebiotic when used in 23- to 34-weeks premature infants. They noted in their results "The lactulose group tended to have less intolerance to enteral feedings, to reach full oral feeds earlier, and to be discharged home earlier. They also tended to have fewer episodes of late-onset sepsis, lower Bell stage necrotizing enterocolitis, and their nutritional laboratory indices were better, especially calcium and total protein".
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