RAM Cannula Versus Bi-Nasal Prongs as Respiratory Device Interfaces in Neonates of Thirty-Two or More Weeks of Gestation With Respiratory Distress: The First "ProRAM" Randomized Trial Report.

Background: Using bilateral short nasal prongs as an interface for noninvasive respiratory support is challenging, and it is associated with nasal injury. We aimed to compare RAM cannula with nasal prongs in delivering noninvasive ventilation to newborn infants. Methods: This is a single-center randomized trial (trial registry: ISRCTN10561691). The setting involves a tertiary neonatal unit with a capacity of 30 beds and more than 13 years of experience in neonatal noninvasive ventilation. We included 50 infants born at ≥ 32 weeks of gestation, who had respiratory distress at birth. We excluded those with major congenital anomalies and those who required intubation in the delivery room. Primary outcomes were intubation rate and use of noninvasive positive-pressure ventilation (NIPPV); other outcomes included air leak and nasal injury rate. The infants were assigned using randomly generated numbers into bi-nasal prong and RAM canula groups in a 1:1 ratio. Results: Two and four babies in the RAM and prong groups, respectively, were upgraded to NIPPV (P = 0.600). One versus no baby in the RAM vs. prong groups was intubated (P = 1.000). Newborns in the prong group required oxygen support for a longer period (mean duration: 154.6 ± 255.2 h) than those in the RAM group (40.7 ± 72.6 h, P = 0.030). None of the patients in the RAM group had traumatic nasal injury compared to five babies in the prong group (P = 0.050). Four babies in our study developed air leaks, with two in each group. Conclusions: The use of RAM cannula in delivering noninvasive ventilation to newborns ≥ 32 weeks of age did not affect the noninvasive ventilation failure rate or incidence of air leak. The use was associated with a shorter duration of respiratory support and a reduced risk of nasal septal injury.

Congenital Diaphragmatic Hernia at a Non-ECMO Center in Jordan.

OBJECTIVES: We studied the clinical characteristics and outcomes of neonates with congenital diaphragmatic hernia (CDH) admitted to a non-extracorporeal membrane oxygenation (ECMO) center. METHODS: A retrospective chart review of neonates with CDH admitted to a University Hospital, in Amman, Jordan, between 2005 and 2019. Demographic characteristics and their management details were extracted and factors associated with survival were analyzed. RESULTS: A total of 28 neonates born with CDH were included; their survival rate was 39.3%. Onset of respiratory distress, pre-operative ventilation, and length of hospitalization were significantly associated with mortality. Survival after surgery was significantly associated with a higher gestational age and a longer hospital stay. CONCLUSION: Our study showed a high mortality rate for CDH patients. Decreasing the health inequity and improved clinical interventions could improve outcomes.

Decreasing the options' number in multiple choice questions in the assessment of senior medical students and its effect on exam psychometrics and distractors' function.

BACKGROUND: Studies that have investigated the effect options' number in MCQ tests used in the assessments of senior medical students are scarce. This study aims to compare exam psychometrics between three- and five-option MCQ tests in final-year assessments. METHODS: A cluster randomized study was applied. Participants were classified into three groups, according to their academic levels. Students in each of those levels were randomized into either the three- or five-option test groups. RESULTS: Mean time to finish the five-option test was 45 min, versus 32 min for the three-option group. Cronbach's alpha was 0.89 for the three-option group, versus 0.81 for the five-options, p-value = 0.19. The mean difficulty index for the three-option group was 0.75, compared to 0.73 for the five-option group, p-value = 0.57. The mean discriminating index was 0.53 for the three-option group, and 0.45 for the five-options, p-value = 0.07. The frequency of non-functioning distractors was higher in the five-option test, 111 (56%), versus 39 (39%) in the three-options, with p-value < 0.01. CONCLUSIONS: This study has shown that three-option MCQs are comparable to five-option MCQs, in terms of exam psychometrics. Three-option MCQs are superior to five-option tests regarding distractors' effectiveness and saving administrative time.

Impact of Parental Consanguinity on the Frequency of Orofacial Clefts in Jordan.

ABSTRACT: Orofacial clefts (OFCs) are the most common craniofacial congenital anomalies, and its prevalence is highest among Asian populations. The aim of this retrospective case-control study is to evaluate the effect of parental consanguinity on the frequency of OFCs at Jordan University Hospital over a 15-year-period. The study group consists of all patients with OFCs presented to the major tertiary referral center in Jordan during the last 15 years, along with age and gender-matched controls. The authors analyzed the risk of different predictors, including consanguinity, on the development of OFCs, both cleft lip with or without cleft palate (CL/P) and cleft palate only. A total of 332 participants were included in this study, with a mean age of 74.36 (±48.75) months. The authors included 129 (38.9%) OFCs, and 203 (61.1%) controls. The percentage of parental consanguinity among OFCs group was 41.1%, compared to only 24.1% for controls, a difference that was statistically significant (P = 0.001). On logistic regression analysis, the authors found that parental consanguinity is a significant predictor for the occurrence of OFCs (P = 0.007), where people with consanguineous marriage have 2 times higher risk (odds ratio of 0.504, with 95% confidence interval 0.306-0.830) to have offspring with OFCs. Moreover, lower birth weight babies are also significantly more associated with OFCs (P = 0.014), with an odds ratio of 1.819 (95% confidence interval 1.131 2.926). Among the Jordanian population, the authors found that consanguinity and lower birth weight were the only variables significantly associated with the development of OFCs.

Perinatal Transmission and Clinical Outcomes of Neonates Born to SARS-CoV-2-Positive Mothers.

BACKGROUND: The aim of the study was to investigate the clinical outcomes and rate of virus detection in neonates born to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive mothers. METHODS: This prospective study included neonates born to SARS-CoV-2-positive mothers, documenting their viral polymerase chain reaction results and clinical outcomes. RESULTS: Of the 130 neonates born to 122 SARS-CoV-2-positive mothers, 12% tested positive. Most (62%) neonates were delivered via cesarean section at an average gestational age of 36 weeks, with a birth weight of 2,900 g. Only 38% neonates required admission. SARS-CoV-2-positive infants were born at a significantly lower gestational age; had a significantly lower birth weight; and had significantly higher admission rates, surfactant therapy, and bradycardia than SARS-CoV-2-negative infants. There was no significant difference in mortality rates. CONCLUSION: This study documents perinatal transmission of SARS-CoV-2. It reports for the first time the occurrence of neonatal bradycardia as a complication of maternal SARS-CoV-2 infection. Despite that, neonates born to SARS-CoV-2-positive mothers had relatively good short-term outcomes.

Coronavirus disease 2019 (COVID-19): a brief overview of features and current treatment.

Since the report of the first cases of pneumonia caused by SARS-CoV-2 in December 2019, COVID-19 has become a pandemic and is globally overwhelming healthcare systems. The symptoms of COVID-19 vary from asymptomatic infection to severe complicated pneumonia with acute respiratory distress syndrome (ARDS) and multiple organ failure leading to death. The estimated case-fatality rate among infected patients in Wuhan, the city where the first case appeared, was 1.4%, with 5.1 times increase in the death rate among those aged above 59 years than those aged 30-59 years. In the absence of a proven effective and licensed treatment, many agents that showed activity against previous coronavirus outbreaks such as SARS and MERS have been used to treat SARS-CoV-2 infection. The SARS-CoV-2 is reported to be 80% homologous with SARS-CoV, and some enzymes are almost 90% homologous. Antiviral drugs are urgently required to reduce case fatality-rate and hospitalizations to relieve the burden on healthcare systems worldwide. Randomized controlled trials are ongoing to assess the efficacy and safety of several treatment regimens.

Esophageal atresia: Associated anomalies, mortality, and morbidity in Jordan.

BACKGROUND: Esophageal atresia is a developmental disorder in which the upper and lower esophagus fail to connect. It has an estimated prevalence of 1 in 2,500-4,500 live births and has poorer outcomes in low- and middle-income countries than in high-income countries. This study focused on the disorder's epidemiology, morbidity, and mortality in Jordan to address the lack of data regarding esophageal atresia in this country. METHODS: This was a retrospective study covering a 16-year period at a tertiary care academic hospital. Data were extracted from archived medical records and operative notes. All patients who had complete congenital esophageal atresia data were included. In total, the records of 55 patients were analyzed. RESULTS: Of the included patients, 9% were diagnosed prenatally and 47% were diagnosed with polyhydramnios. The mean gestational age was 37 weeks, the mean birthweight was 2,550 g, and 60% of patients were male. Isolated cases of esophageal atresia were reported in 58.2% of patients. There was a high rate of associated congenital anomalies (41.8%), with cardiac lesions the most common (20%), and 5.5% were syndromic. Parental consanguinity was found in 18.2% of patients. Postoperative surgical-related morbidities included stricture (18/24; 75%) and leakage (5/24; 20.8%). Fistula recurrence occurred in one patient (4.2%). The mortality rate was 12.8%. CONCLUSION: Esophageal atresia causes a high rate of mortality and exhibits post-operative morbidities. Moreover, associated anomalies were frequently observed. A high level of the malformation was found among offspring from consanguineous marriages.

Impact of Computerized Prescription on Medication Errors and Workflow Efficiency in Neonatal Intensive Care Units: A Quasi-Experimental Three-Phase Study.

BACKGROUND: Neonates are highly vulnerable to preventable medication errors due to their extensive exposure to medications in the neonatal intensive care units (NICUs). These errors, which can be made by medical, nursing, or pharmacy personnel, are costly and can be life-threatening. This study aimed to investigate the newly developed computerized neonatal pharmaceutical health care system (NPHCS) in terms of its ability to (1) minimize neonatal medication prescription errors (NMPEs) and (2) improve workflow efficiency compared with the traditional manual prescribing approach. METHODS: A computerized neonatal medication prescription system was designed, developed, and tested successfully through a pilot clinical trial for over 6 months in 100 neonates. A three phase quasi-experimental study was then conducted using standardized monitoring checklists for the assessment of NMPEs before and after utilization of the developed prescribing system. RESULTS: The obtained result showed a high rate of NMPEs in both systems, especially for the antibiotic drug group. However, the use of newly developed NPHCS significantly improved workflow efficacy. The identified errors were significantly more common in the manual mode than in the computerized mode (158.8 vs. 55 per 100 medications). These errors were distributed among different categories, including the documentation of patient identity, birth weight, and gestational age, as well as statements of dose, unit, interval, and diagnosis. Analysis of variance across different categories showed a p-value of <0.05. CONCLUSION: The use of the computerized NPHCS improved patient safety in NICUs by decreasing NMPEs. It also significantly reduced the time required for dose calculation, prescription generation, and electronic documentation of medical records, compared with the traditional handwritten approach.

Intravenous Immunoglobulins as Adjunct Treatment to Phototherapy in Isoimmune Hemolytic Disease of the Newborn: A Retrospective Case-Control Study.

BACKGROUND: Isoimmune hemolytic disease is a major cause of neonatal severe indirect hyperbilirubinemia that requires phototherapy or exchange transfusion which is an invasive procedure to avoid brain injury. Administration of intravenous immunoglobulin (IVIG) is used as an adjunct treatment to phototherapy in order to decrease the rate of exchange transfusion. METHODS: This retrospective case-control study aimed to describe the safety and efficacy of IVIG therapy in newborns with isoimmune hemolytic disease and to compare their clinical outcomes to those of a control group who were treated only with phototherapy. Criteria for IVIG treatment were variable; when phototherapy threshold was reached or when exchange transfusion level was approached, using either indication is based on the attending discretion. RESULTS: Ninety-four infants were included in the IVIG group, compared to 108 infants in the control group. Most of the included infants were term infants and most common cause was ABO incompatibility. There were no side effects documented in all the included infants. The IVIG group had more severe hemolysis with average highest bilirubin of 14.6 ± 3.7 mg/dL in the IVIG group versus 12.6 ± 3 in the control group (P = 0.0001). Complication of hemolysis was seen more in the IVIG group with higher rate of rebound hyperbilirubinemia, blood transfusion and exchange transfusion. CONCLUSIONS: IVIG use as an adjunct treatment to phototherapy in isoimmune hemolytic disease of the newborns is safe. The favorable results of the phototherapy only group were supportive of using selective criteria for administration of IVIG in neonates with isoimmune hemolytic disease.

Prenatal detection of fetal heart disease at Jordan University Hospital: early experience in a developing country.

OBJECTIVE: To report on the first 5 years of establishment of fetal echocardiographic services at the Jordan University Hospital with emphasis on diagnosis and outcome. METHODS: A retrospective chart review was conducted on all fetal echocardiographic studies performed between January 2011 and December 2015. Data collected included maternal demographics, referral indications, fetal cardiac diagnosis, correlation to post-natal diagnosis, outcome of pregnancy including pre-mature delivery and perinatal mortality. Basic statistical analysis was performed including demographic analysis, and calculation of fetal echocardiographic sensitivity and specificity. RESULTS: A total of 208 fetuses underwent fetal echocardiographic evaluation at a mean gestational age of 26.5 (±5) weeks. The most common referral indication was a suspicion of CHD during the obstetric ultrasound (44.2%), followed by cardiac dysfunction (18.2%), and a family history of CHD (14.9%). Fetal echocardiography showed CHD in 71 fetuses (34%), heart failure in 26 (12.5%), arrhythmia in 9 (4.3%), and intracardiac masses in 2. In the remaining 100 fetuses (48%), fetal echocardiography showed normal evaluation. For detecting CHD, fetal echocardiography had a sensitivity and specificity of 91.7% and 95.4%, respectively. Perinatal mortality including termination of pregnancy, intrauterine fetal death, and neonatal mortality was highest in heart failure (77%), and was 41% for CHD. CONCLUSION: The fetal cardiac diagnostic services at the Jordan University Hospital have encouraging initial results with a relatively high sensitivity and specificity. The services further positively impacted the quality of counselling offered and facilitated pre- and post-natal management.

Nutritional Support of Very Low Birth Weight Infants in a Tertiary Center in a Developing Country.

BACKGROUND: Very low birth weight infants (VLBWIs) are at high risk for nutritional deficiency. Enteral feeding is usually challenged by increased risk of necrotizing enterocolitis (NEC). The nutritional needs of VLBWIs are usually dependent on parenteral nutrition during early postnatal life. This study aimed to evaluate the nutritional service of VLBWIs at Jordan University Hospital. METHODS: This was a prospective follow-up study of VLBWIs with birth weight ≤ 1,500 g. Data were extracted from medical charts and laboratory database. RESULTS: In total, 43 VLBWIs met our inclusion criteria; of them, 21% were extremely low birth weight infants (ELBWIs). The mean gestational age was 29 weeks, and the mean birth weight was 1,218 g. The mean age of starting feeds was 3 days. Mean full feed age is 2 weeks. The most common side effect of total parenteral nutrition (TPN) was hypertriglyceridemia (35%). CONCLUSIONS: Nutritional care of VLBWIs is well established in our center. Initiating fortification earlier and working to increase mother's own breast milk supply is vital to improve growth in low resource setting.

Prolonged Rupture of Membranes, Neonatal Outcomes and Management Guidelines.

BACKGROUND: Prolonged rupture of membranes (PROM) is a risk factor for early-onset neonatal sepsis (EOS). In the absence of early specific and sensitive diagnostic tools, management of asymptomatic infants is difficult. This study was conducted to investigate clinical outcomes of newborns born to mothers with PROM. METHODS: A retrospective study of neonates ≥ 34 weeks admitted due to PROM was conducted. Medical charts were reviewed. Neonates were classified into three categories based on their status at birth: ill appearing, well, and equivocal. Sepsis risk calculator was retrospectively applied. RESULTS: A total of 176 neonates were included. All mothers had unknown group B streptococcus (GBS) status. Of them, 74.4% were asymptomatic. Nine infants (5%) had positive cultures, and 23 infants (13%) had culture-negative sepsis. The newborns with sepsis fit into the "ill appearing" category with a significantly higher proportion (12.5% vs. 0.0%, P value < 0.0). CONCLUSIONS: Reliable early diagnostic tools for neonatal sepsis are lacking. Adopting a protocol that utilizes multiple methods and follow-up for the clinical condition of these infants are the key factors to avoid missing neonates with true sepsis and decreasing the use of antibiotics in those without infection.

Congenital glucose-galactose malabsorption: A case report with a novel SLC5A1 mutation.

A three-day-old newborn girl presented with decreased feeding and dehydration. She was sick and in shock. She had renal impairment and hypernatremia. With the resumption of breast feeding, she developed watery stools and hypernatremia. Glucose-Galactose Malabsorption was suspected and confirmed by the presence of a likely pathogenic homozygous variant in SLC5A1.

Bubble CPAP therapy for neonatal respiratory distress in level III neonatal unit in Amman, Jordan: a prospective observational study.

PURPOSE: Bubble continuous positive airway pressure (bCPAP), a noninvasive respiratory support modality used to manage newborns with respiratory distress, provides continuous pressure that helps prevent derecruitment of alveoli, increasing the lungs' functional residual capacity, and thus decreasing the work of breathing. bCPAP can be used to manage various respiratory conditions in the newborn. In this prospective study, we describe our experience using bCPAP therapy as the primary respiratory support in a level III neonatal unit in Amman, Jordan. In addition to reporting therapeutic indications, durations, and side effects, we aimed to identify areas requiring improvement in bCPAP therapy in our population. PATIENTS AND METHODS: This prospective observational study investigated the usage of bCPAP in the management of respiratory distress in newborns admitted to a Jordan University Hospital in Amman. The newborns were followed until discharge. The patients' demographic and clinical data were recorded. RESULTS: A total of 143 babies (mean gestational age, 36±2.7 weeks; mean birth weight, 2,770±1,800 g) were included. All received bCPAP as the primary respiratory support. The most common underlying cause of respiratory distress was transient tachypnea of the newborn (42%), followed by prolonged respiratory transition (34%). The therapy success rate was 93.7%; only nine infants failed bCPAP. The most common side effect was physical facial injury. CONCLUSION: The use of neonatal bCPAP therapy is well established in Jordan University Hospital. The area of potential improvement was the low rate of bCPAP use as a primary respiratory support in extremely premature infants.

Adoption of the American Academy of Pediatrics' neonatal hyperbilirubinemia guidelines and its effect on blood exchange transfusion rate in a tertiary care center in Amman, Jordan.

INTRODUCTION: Severe neonatal hyperbilirubinemia can cause mortality and serious morbidities. When phototherapy fails, neonates with severe hyperbilirubinemia should undergo double volume blood exchange transfusion (BET). As this procedure carries a significant risk of mortality and morbidity, adopting guidelines for the treatment of neonatal hyperbilirubinemia is critical to avoid hyperbilirubinemia toxicity and also the complication of an unindicated procedure. METHODS: This study investigated the causes, complications, and trend of BET rate in our unit over a 13-year period. The medical charts and laboratory databases of all infants who underwent BET in Jordan University Hospital between 2003 and 2015 were retrospectively reviewed. RESULTS: The rate of exchange cases decreased significantly after adopting the guidelines of American Academy of Pediatrics (P<0.0001). Most neonates were term newborns (69%). Average birth weight was 2,800 g. The most common causes of exchange transfusion were non-hemolytic conditions. Late prematurity alone accounted for 20% of the cases. Thrombocytopenia was the most commonly encountered complication (33%). Chronic neurological complications were seen in 12% of those who were followed for >12 months of age. CONCLUSIONS: This study showed a clear decline in the rate of BET after implementing the guidelines of American Academy of Pediatrics. In addition to improving the strategies for the identification and follow-up of at-risk newborns, we should intensify our efforts to prevent the progression of neonatal hyperbilirubinemia to the exchange level by enhancing parents' awareness of this potentially harmful neonatal condition.

Oral paracetamol versus oral ibuprofen for treatment of patent ductus arteriosus.

Objective This study was performed to investigate the safety and efficacy of oral paracetamol versus oral ibuprofen in the treatment of patent ductus arteriosus (PDA) in premature infants. Methods Premature infants with PDA with a gestational age of ≤32 weeks or birth weight of ≤1500 g were included in this randomized study. Results A total of 120 premature infants fulfilled the inclusion criteria. Of these 120 infants, 34 fulfilled the treatment criteria and 22 were finally randomized. We found no significant difference in the mortality or primary closure rates between the two groups. We also found no significant difference in the short-term neonatal outcomes. Conclusions Either oral paracetamol or oral ibuprofen can be used safely and effectively to treat PDA in premature infants.

Benign pneumoperitoneum in newborns: which abdomen to open and which one to observe?

Benign pneumoperitoneum in newborns is not a rare condition that should be managed conservatively. Neonatologists and surgical teams should work together to avoid unnecessary and potentially risky procedures.