Short-term outcome of PDA ligation in the preterm infants at King Chulalongkorn Memorial Hospital, Thailand.

BACKGROUND: Failure of the ductus arteriosus to close after medical treatment is usually associated with many severe cardio-respiratory morbidities. Therefore, surgical ligation of symptomatic PDA is indicated in preterm newborn infants who do not respond or have contraindication of medical treatment. OBJECTIVE: To report the short-term outcomes of PDA ligation in preterm infants at a tertiary care hospital in Thailand. MATERIAL AND METHOD: Medical records of 42 preterm infants who underwent surgical ligation of PDA at King Chulalongkorn Memorial Hospital were reviewed All of the infants had symptomatic PDA that failed to respond to medical treatment or had a contraindication to indomethacin or ibuprofen. Surgical ligation of PDA was performed under general anesthesia. Morbidity and mortality occurring during hospitalization were reported. RESULTS: There were 42 preterm infants in the present study. All of them had large PDA with intractable congestive heart failure. Mean + SD of birth weight and gestational age were 1206 +/- 567 grams and 28.7 +/- 3.6 weeks respectively. Mean +/- SD of the infants' weight and age at the time of surgery were 1089 +/- 549 grams and 17.5 +/- 12 days respectively. Data on the size of PDA was available on 21 preterm infants. Their ductus diameter (Mean +/- SD) was 3.1 +/- 1.1 mm. All infants were successfully extubated after PDA ligation. Twelve events of complications occurred in 11 infants (26.7%). All of the complications were of mild degree and resolved within a few days except one infant with left phrenic nerve injury that needed surgical plication of the diaphragm. Two infants died at 37 and 160 days after surgery and the latter infant developed IVH grade IV on the 15th day postoperatively. These complications were probably not related to PDA ligation. CONCLUSION: PDA ligation was performed successfully on 42 preterm infants who had medical failure or had contraindication to medical treatment. Cardio-respiratory illnesses improved significantly after ligation. Two infant mortalities were not related to the procedure. Overall complication of surgery was 26.7% and resolved without sequelae.

Perinatal effects of amphetamine and heroin use during pregnancy on the mother and infant.

OBJECTIVES: To determine the perinatal impacts of heroin and amphetamine on both mothers and infants. MATERIAL AND METHOD: This is a retrospective study on the influence of amphetamine and heroin on pregnant women and their newborn infants at King Chulalongkorn Memorial Hospital in Bangkok, Thailand, between January 1997 and December 2002. The medical and demographic data of both mothers and infants were evaluated. Comparison of the consistent drug effects of these 2 drugs on the mothers and infants were also performed RESULTS: Two hundred and eleven women were identified There were 178 (84.4%) and 33 (15.6%) women addicted to amphetamine and heroin respectively. Sixty one (28.9%) of them were polydrug users. There were more polydrug users among heroin addicts than amphetamine addicts, (43.7% vs 27.2%, p < 0.05). Poor obstetric history were noted in both groups of women including lack of prenatal care (74.9%), a high incidence of previous abortion (22.3%), positive HIV serology test (11.1%), pre-eclampsia (5.2%), infection (3.3%) and antepartum hemorrhage (1.9%). Drug intoxication was found in 11 amphetamine addicted mothers, whereas 2 heroin addicts developed withdrawal symptoms during intrapartum and postpartum periods. All infants were singleton. There was one stillbirth and 2 neonatal deaths. There was no statistical difference in terms of sex ratio, mean birth weight, gestational age, length, head circumference and Apgar score between the groups of amphetamine and heroin exposed infants. The incidence of prematurity, low birth weight, IUGR and microcephaly were not statistically different between both groups of infants. The overall incidence was 31.7%, 31.7%, 9.5% and 8.6% respectively. Congenital anomalies were found in 5 (2.8%) amphetamine exposed infants. Thirty one out of 33 heroin exposed infants (93.9%) and 4 out of 178 amphetamine exposed infants (2.2%) developed drug withdrawal symptoms with the mean onset of 21.5 +/- 16.5 hours and 10.3 +/- 7.5 hours respectively, p > 0.05. All heroin withdrawal infants were successfully treated with Phenobarbital with the mean duration of treatment of 23.7 +/- 11.5 days. None of the amphetamine withdrawal infants needed specific treatment. They recovered spontaneously within 6.0 +/- 5.3 days. Eighteen infants were left in an orphanage or under the custody of their relatives. CONCLUSION: Amphetamine or heroin use during pregnancy can cause many serious adverse effects on both mothers and infants. The findings in the present study are consistent with previous reports, although they seemed to be more common and severe. Increasing awareness and improving understanding of drug abuse in the medical, legal and social aspects are needed in order to reduce these impacts.

Double phototherapy in jaundiced term infants with hemolysis.

OBJECTIVE: To compare the efficacy of double phototherapy and conventional phototherapy in term newborn infants with hemolytic jaundice. METHOD: Full-term infants with evidence of severe hemolysis on the peripheral blood smear, whose serum bilirubin levels were between 15-21 mg/dl were divided into 2 groups, depending on the availability of the phototherapy bed. Group 1 infants received double phototherapy consisting of conventional (single) phototherapy plus an extra light source from a phototherapy bed (Medela Billibed, Switzerland). Group 2 infants received only conventional phototherapy. Maternal and infants' blood groups and Rh, direct Coomb's test, G6PD screening test and hematocrit were determined on every infant. Phototherapy was given until the serum bilirubin level dropped to < or = 13 mg/dl. Exchange transfusion was indicated when the serum bilirubin level was > or = 21 mg/dl after phototherapy had been given for 4-6 hours. RESULTS: There were 110 infants included in this study, 62 and 48 in group 1 and 2 respectively. There was no statistical difference in terms of birth weight, sex ratio, proportion of breast feeding infants and the initial hematocrit level. However, the initial mean +/- SD of bilirubin level of group 1 infants was higher than that of group 2, (17.7 +/- 1.6 mg/dl vs 16.2 +/- 0.9 mg/dl, p < 0.001). Causes of hemolysis could be determined in 74 infants; 27 (24.5%), 39 (35.5%) and 8 (7.3%) infants had ABO incompatibility, G6PD deficiency and both ABO incompatibility and G6PD deficiency respectively. Rate of bilirubin reduction in group 1 infants was significantly faster, (3.3 +/- 2.4 mg/dl/24 h vs 2.1 +/- 1.1 mg/dl/24 h, p < 0.01). Duration of phototherapy was also shorter in group 1 infants, (45.8 +/- 29.7 hours vs 58.5 +/- 26.0 hours, p < 0.05). Four infants failed to respond to the phototherapy that was assigned. Two infants in group 2 had to be switched to receive double phototherapy because of rapid rising of serum bilirubin. One in each group needed exchange transfusion. CONCLUSION: The study demonstrated that double phototherapy is more efficient than conventional phototherapy in term infants with severe jaundice caused by hemolysis.

Nephrocalcinosis in very low birth weight infants: a single center experience.

OBJECTIVES: To determine the incidence and risk factors of nephrocalcinosis in very low birth weight infants. MATERIAL AND METHOD: Medical records of inborn infants with gestational age less than 32 weeks or birth weight less than 1,250 grams were collected and analyzed. All infants were born at King Chulalongkorn Memorial Hospital in the year 2003. At least one renal ultrasonographic scan was performed on every infant as a routine screening before discharge. Data on family history of renal stone, gestational age, birthweight, infant's illness,fluid intake during the first 6 weeks of life, duration of respiratory support, medications, serum calcium, phosphate and alkaline phosphatase level, duration of parenteral nutrition, length of hospitalization, ultrasonographic findings and related renal morbidity were collected and compared between the groups of infants with and without nephrocalcinosis. RESULTS: Thirty six infants were included in the present study. Fourteen had abnormal ultrasound scans compatible with nephrocalcinosis giving an overall incidence of 38.9%. Factors associated with nephrocalcinosis included severity of respiratory illness, PDA, oxygen dependency, furosemide therapy, and fluid restriction. Urinary tract infection was the renal morbidity found in 3 infants (21.4%). Nephrocalcinosis was resolved in one out of 7 infants who had repeated renal ultrasound scan at about 2 months after the first scan. CONCLUSION: Very low birth weight, preterm infants have a risk of developing nephrocalcinosis especially those with severe respiratory illness and prolonged use of furosemide. Infants at risk should be screened with renal ultrasonography prior to discharge from the hospital.

Antibody response to hepatitis B immunization in infants born to HIV-infected mothers.

OBJECTIVES: To determine the antibody response of hepatitis B immunization begun at birth in HIV-1 exposed infants. DESIGN: Prospective, clinical trial. SITE: King Chulalongkorn Memorial Hospital, Bangkok, Thailand. MATERIAL AND METHOD: Seventy six infants born to HIV-1 seropositive mothers, who were not hepatitis B carriers, received three 10 microgram doses of recombinant DNA hepatitis B vaccine (Engerix B, Smith Kline, Belgium) in a 0, 1 and 6 month schedule. The first dose was given at birth. Serum hepatitis B surface antibody (Anti -HBs) was measured at age 3, 9 and 12 months. Anti-HBs levels were determined by enzyme-linked immunoassay using the commercial kits (AUSAB EIA diagnostic kits, Abbott Laboratories, Chicago, USA) Antibody titer > or = 10 mIU/ml was defined as seroconversion. HIV infection was diagnosed by a positive test of HIV antibody at age > or = 18 months and/or by positive test of HIV polymerase chain reaction at age > or = 3 months. RESULTS: There were 14 HIV-1 infected (group 1) and 62 HIV-1 non infected (group 2) infants enrolled in this study. Anti-HBs titers of group 1 infants were significantly lower than those of groups 2 infants at both 3 and 6 months after the 3rd dose of vaccine, (Mann Whitney U test, p=0.019 and 0.001 respectively). Ten infants in group 1 and 57 infants in group 2 had anti-HBs titer > or = 10 mIU/ml. Their peak antibody titers were also noted at both 3 and 6 months after the 3rd dose of vaccine. Seroconversion rates were 71.4 per cent and 91.9 per cent in group 1 and 2 infants respectively, (p<0.05). Among the infants who had blood tests performed at age 12 months or 6 months after the 3rd dose of vaccine, anti-HBs titers declined in approximately 50 per cent of both groups of infants. There was a significantly higher percentage of seroconverters in group 1 who lost their protective titers than those in group 2, (p<0.001). CONCLUSION: The results in this study suggested that HIV-1 infected infants have poor antibody response to hepatitis B immunization and the protection was less durable. A fourth dose of vaccine at 6 months after the 3rd dose may be necessary.

Dose-escalating study of the safety and pharmacokinetics of nelfinavir in HIV-exposed neonates.

The pharmacokinetics of nelfinavir (NFV) in neonates younger than 4 weeks of age was assessed. Three cohorts of HIV-exposed neonates were enrolled in cohorts to receive 15, 30, and 45 mg of NFV/kg twice daily in combination with stavudine and didanosine for 4 weeks after birth. Trough NFV concentrations (C(min)) were measured at 1 and 7 days of age. Intensive pharmacokinetic evaluations were performed at 14 and 28 days of age. The median NFV C(min) values in the 15 mg/kg (6 patients), 30 mg/kg (5), and 45 mg/kg (11) cohorts at 1, 7, 14, and 28 days of age were 0.19, 1.21, 0.51, and 0.33; 1.02, 3.18, 0.73, and 0.55; and 0.67, 3.21, 0.70, and 0.73 mg/L, respectively. The median area under the plasma concentration-versus-time curve values over 12 hours in the three cohorts at 14 and 28 days of age were 14.4 and 8.7, 19.4 and 15.8, and 23.4 and 18.5 (h. mg)/L, respectively. No serious adverse events were observed. In conclusion, the systemic exposure of NFV decreased after 7 days of age, possibly because of hepatic enzyme maturation, autoinduction of NFV metabolism, and/or changes in NFV absorption. The highly variable systemic exposure observed in the study indicates that therapeutic drug monitoring seems warranted to ensure adequate NFV dosing in this population.