Quick identification of febrile neonates with low risk for serious bacterial infection: an observational study.

OBJECTIVE: To examine the possible usefulness of simple and quick criteria for identifying febrile neonates with low risk for serious bacterial infection (SBI). DESIGN: All febrile neonates who were admitted between August 1998 and August 2003 to the Pediatric Emergency Department, HaEmek Medical Center, Afula, Israel, and to the Poriya Hospital, Tiberias, Israel, were included in the study. The recommended evaluation of each neonate included details of medical history and a complete physical examination, including blood culture, erythrocyte sedimentation rate (ESR), white cell count (WBC), and analysis and culture of urine and cerebrospinal fluid. Other tests were carried out as necessary. Patients who met all the following criteria were considered to have low risk for SBI: (1) unremarkable medical history; (2) good appearance; (3) no focal physical signs of infection; (4) ESR <30 mm at the end of the first hour; (5) WBC 5000-15 000/mm(3); (6) a normal urine analysis by the dipstick method. RESULTS: Complete data were available for 386 neonates. SBI was documented in 108 (28%) neonates, of whom 14% had a urinary tract infection, 9.3% had acute otitis media, 2.3% had pneumonia, 1.3% had cellulitis, 0.5% had bacterial meningitis and 0.5% had bacterial gastroenteritis. The overall incidence of SBI was 1 in 166 (0.6%) neonates who fulfilled the criteria compared with 107 in 220 (48.6%) in the neonates who did not fulfil the criteria (p<0.001). The negative predictive value for SBI of the combination of the low-risk criteria was 99.4% (95% confidence interval 99.35% to 99.45%). CONCLUSIONS: Fulfillment of the criteria for low risk might be a reliable and useful tool for excluding SBI in febrile neonates.

Complete bony fusion of the mandible to the zygomatic complex and maxillary tuberosity: case report and review.

Congenital craniofacial disorders represent approximately 20% of all birth defects. One of these disorders is syngnathia, of which only 24 cases have been reported since 1936. Twenty cases involved fusion of the alveolar processes of the maxilla and mandible. Only four are similar to the presented case, which includes bony fusion of the ascending ramus of the mandible to the zygomatic complex and the posterior part of the maxilla. This case report will present details from the 23rd week of gestation to 8 months of age when the infant underwent the first attempt to free the syngnathia. The literature is discussed and a causative mechanism and new classification are proposed.

In utero thyroxine therapy for the induction of fetal lung maturity: long term effects.

Intra-amniotic thyroxine has been used for the induction of fetal lung maturity. The long term effects of this therapy was evaluated in a group of eighteen preschool children, 5 to 6 years of age, whose mothers received intra-amniotic thyroxine during the last trimester of their gestation. Eleven children born during the same time period were selected as controls. The children were all clinically well with no evidence of growth or endocrine abnormalities. Neurological assessment was normal and psychomotor development was in the normal range for our population and did not differ from the control subjects. Intra-amniotic thyroxine administered during the last trimester of gestation did not appear to have any significant long term detrimental effects in the treated patients.

Pharmacokinetics of intravenous clindamycin in newborn infants.

We studied 12 newborn infants (gestational ages 26-39 wk [mean +/- SD, 30.6 +/- 4.7]; birth weight 640-2700 g, [mean, 1,322 +/- 688]; postnatal age 1-24 days [mean, 9.6 +/- 8.5]) who received clindamycin phosphate for suspected or proven necrotizing enterocolitis (ten patients) or suspected anaerobic septicemia (two patients) in doses of 3.2-11 mg/kg every six hours. Range of mean serum concentration of clindamycin at steady state was between 12.7 and 40 micrograms/ml (therapeutic range = 2-10 micrograms/ml). High concentrations could be attributed to elimination T1/2 (6.3 +/- 2.1 hr) 100% longer than in older children or adults. Clindamycin clearance (61.6 +/- 31.6 hr ml/kg/hr) was lower than in older children or adults. Because of the observed prolongation in T1/2 and correspondingly lower clearance, the IV dose of clindamycin in newborn infants should be reduced to 15-20 mg/kg/day given in four daily doses.

Sonography of periventricular leukomalacia.

Periventricular leukomalacia (PVL) is a pathological entity characterized by ischemic changes in areas adjacent to the external angles of the lateral ventricles. It is associated with serious neurodevelopmental sequelae, especially spastic diplegia. With the increased use of ultrasound in the Neonatal Intensive Care Unit, changes consistent with PVL are being noted. Hemorrhagic and nonhemorrhagic forms of this condition exist, both of which may appear sonographically as increased periventricular echogenicity. Two cases of PVL are described; one of them was associated with ventricular dilatation and intraventricular bleeding and the other with a small subependymal hemorrhage. The pathological and clinical features, methods of in vivo diagnosis, and the role of ultrasound in the evaluation of PVL are discussed.

Selective bronchial intubation for pulmonary emphysema.

Two neonates with respiratory distress syndrome developed unilateral pulmonary interstitial emphysema causing mediastinal shift and compressive atelectasis. Treatment with contralateral bronchial intubation for five days proved to be life saving.

Effects of indomethacin on digoxin pharmacokinetics in preterm infants.

Indomethacin is commonly coadministered with digoxin for the treatment of patent ductus arteriosus (PDA) in preterm infants. The combination of digoxin that is eliminated almost exclusively by the kidney and indomethacin, which tends to reduce renal function, has potential hazards. We report 11 preterm infants (gestational age 25-33 week) treated with digoxin for PDA in whom a standard indomethacin therapy (mean of total dose = 0.32 mg/kg) resulted in a significant elevation of serum digoxin to potentially toxic levels (from 2.2 +/- 0.7 ng/ml to 3.2 +/- 0.7) (P less than 0.001). This phenomenon correlated well with decreased urine output (from 86 +/- 34 ml to 43 +/- 24 per 24 hour) (P less than 0.001) following indomethacin. No significant change was found in serum creatinine concentration pre- and post-indomethacin. Digoxin half-life was significantly prolonged (mean 97 +/- 17 hour) following indomethacin therapy as compared with an age matched control group (mean half-life 43 +/- 19 hour) (P less than 0.05). Our data suggest that when indomethacin is added to digoxin therapy, the digoxin dosage should be reduced by 50% until urine output and digoxin serum levels can be better assessed.

Low flow oxygen therapy in infants.

Fifty one infants who were oxygen dependent after treatment for neonatal respiratory disease were entered into a study programme where 100% oxygen was delivered at low flow through a nasal catheter. Thirty five (69%) of the infants were discharged home and the remainder were either discharged to a convalescent hospital or back to their peripheral referring hospital. Excluding repeat admissions for monitoring or for the treatment of acute infections, 2760 hospital days (79 days/patient) were saved, representing a financial saving of $11990 (pounds 6500) per treated infant. A home low flow oxygen therapy programme has benefits to the infant/parent relationship, provides a more constant flow of oxygen than conventional methods, and the early hospital discharge represents a considerable financial saving.

[Acute recurrent suppurative thyroiditis in childhood].

Acute suppurative thyroiditis in children is very rare and has been reported in only six cases. We describe a 4 1/2 year old girl who presented with acute suppurative thyroiditis of the left lobe. All thyroid function tests were normal but the radioisotope scan showed decreased activity over the upper pole of the left lobe. The child was treated with massive doses of antibiotics and gradually recovered. Three years later she presented with exactly the same findings in the left lobe of the thyroid. Thyroid function tests were again normal but repeated radioisotopic scan showed decreased activity over the left upper pole. Again she recovered gradually under massive antibiotic treatment. A follow up scan showed great improvement with almost complete recovery of activity in the left lobe.