Epidemiology of neonatal pneumothorax developed spontaneously and during respiratory supports in neonatal intensive care units.

BACKGROUND: Information on incidence and risk factors associated with different types of neonatal pneumothorax were lacking globally. OBJECTIVES: To determine incidences of pneumothorax developed spontaneously and during different modes of respiratory support, and risk factors associated with each type of pneumothorax. STUDY DESIGN: Retrospective observational study of neonates in the Malaysian National Neonatal Registry. SETTING: 44 Malaysian neonatal intensive care units (NICUs). PARTICIPANTS: All neonates born in 2015-2020 and admitted to NICUs. RESULTS: Pneumothorax developed in 3265 neonates: 37.5% occurred spontaneously, 62.5% during respiratory support. The incidence of all types of pneumothorax was 1.75 per 1000 livebirths, and of spontaneous pneumothorax was 0.58 per 1000 livebirths. Pneumothorax developed in 0.6% (450/70512) of neonates during continuous positive air way pressure therapy (nCPAPt), 1.8% (990/54994) of neonates during conventional mechanical ventilation (CMV), and 7.0% (599/8557) of neonates during high frequency ventilation (HFV). Term neonates had significantly higher pneumothorax rate than preterms (p<0.001). Multiple logistic regression analyses show that exposure to intermittent positive pressure ventilation and chest compression at birth were significant independent factors associated with increased risk of spontaneous pneumothorax and CMV, and persistent pulmonary hypertension was associated with increased risk of spontaneous pneumothorax and pneumothorax during CMV and HFV. CONCLUSIONS: The most common type of pneumothorax was spontaneous in-onset. Neonates on HFV had the highest and those on nCPAPt the lowest rate of pneumothorax. Improving training of resuscitation techniques at birth and strategies of use of invasive modes of respiratory support may reduce incidences of all types of pneumothorax.

Early-onset sepsis in Malaysian neonatal intensive care units.

OBJECTIVES: To determine the incidence, causative pathogens, morbidities, mortality, and risk factors associated with blood culture-positive early-onset sepsis (EOS, ≤72 hours of age) in symptomatic neonates admitted to the neonatal intensive care units (NICUs) of a middle-income country. STUDY DESIGN: Retrospective cohort study using data submitted prospectively to the Malaysian National Neonatal Registry (MNNR). SETTING: 44 Malaysian NICUs. PARTICIPANTS: All neonates born in 2015- 2020. RESULTS: EOS was reported in 991 neonates. The annual incidence of EOS increased from 0.46 to 0.49/1000 livebirths over the six years. The most common pathogen was Streptococcus agalactiae or Group B haemolytic streptococcus (GBS) (n=388, 39.2%), followed by Escherichia coli (E. coli) (n=80, 8.1%), Klebsiella spp (n=73, 7.4%), coagulase negative staphylococcus (CONS) (n=73, 7.4%), Pseudomonas spp (n=44, 4.4%) and methicillin-sensitive Staphylococcus aureus (n=34, 3.4%). The incidence of EOS due to GBS increased from 0.17 to 0.22/1000 livebirths. Morbidities and mortality were higher in those with EOS than without EOS. Multiple logistic regression analysis showed that Indian ethnic group, chorioamnionitis, gestation≥37weeks, female, spontaneous vaginal delivery, instrumental delivery, and surfactant therapy were significantly associated with increased risk of EOS due to GBS. Four factors were significantly associated with increased risk of non-GBS EOS (outborns, birthweight lt;1000 g, vaginal delivery, and surfactant therapy). Early continuous positive airway pressure was associated with significantly lower risk of EOS. CONCLUSION: The incidence of EOS showed an increasing trend in Malaysian NICUs. GBS was the most common causative pathogen. Several modifiable risk factors associated with EOS have been identified.

Haemoglobin Constant Spring (HbA2: c.427T>C) and Haemoglobin Adana (HbA2: c.179G>A) in jaundiced Malaysian term neonates with clinically significant hyperbilirubinemia.

INTRODUCTION: Haemoglobin Constant Spring (Hb CoSp) and Haemoglobin Adana (Hb Adana), are two non-deletion type of α-thalassemia reported in Malaysia. Owing to their structural instability, they cause hemolysis and hyperbilirubinemia. This observational study was part of a large study investigating multiple factors associated with severe neonatal jaundice. In this part we aimed to determine the prevalence of Hb CoSp and Hb Adana and their association with clinically significant neonatal hyperbilirubinemia (SigNH, total serum bilirubin (TSB>290µmol/L)) among jaundiced Malaysian term neonates. MATERIALS AND METHODS: The inclusion criteria were normal term-gestation neonates admitted consecutively for phototherapy. PCR-restriction fragment length polymorphism method was applied on DNA extracted from dry blood spot specimens of each neonate to detect for Hb CoSp and Hb Adana gene. Positive samples were verified by gene sequencing. RESULTS: Of the 1121 neonates recruited (719 SigNH and 402 no-SigNH), heterozygous Hb CoSp gene was detected in only two (0.27%) neonates. Both were SigNH neonates (0.3% or 2/719). No neonate had Hb Adana variant. CONCLUSION: Hb CoSp was not common but could be a risk factor associated with SigNH. No Hb Adana was detected.

Contaminated milk is a common cause of necrotising enterocolitis: A hypothesis.

Necrotising enterocolitis (NEC) is the most commonly acquired gastrointestinal disease of neonates, particularly the very preterm (gestation <32 weeks) and/or very low birth weight (<1500g). It is associated with high morbidity and mortality. Despite improvement in neonatal care and increased use of expressed breast milk (EBM), the incidence remains high in many neonatal intensive care units (NICU), and even shows increasing trend in some countries. Numerous studies have pointed to the infective nature of NEC. Some investigators have reported an increase in the incidence of NEC in their NICU when the percentage of infants with pathogens isolated from their gut increased, and decreased when gut colonisation rate was low. Both bacteria and viruses have been reported to be associated with outbreaks of NEC. The majority (>90%) of the NEC cases occurred in neonates on enteral feeding. Studies have shown that milk (whether EBM or formula) fed to neonates was not sterile and were further contaminated during collection, transport, storage and/or feeding. Other investigators have reported a reduction in the incidence of NEC when they improved infection control measures and hygienic procedures in handling milk. It is, therefore, hypothesised that the most common cause of NEC is due to the feeding of neonates, particularly the vulnerable very preterm small neonates, with milk heavily contaminated during collection at source, transport, storage and/or feeding. Because of the immaturity of the immune system of the neonates, excessive inflammatory response to the pathogen load in the gut leads to the pathogenesis of NEC.

Frequent nasopharyngeal suctioning as a risk factor associated with neonatal coagulase-negative staphylococcal colonisation and sepsis.

INTRODUCTION: This case-control study aimed to determine whether catheter use was significantly associated with coagulase-negative staphylococci (CoNS) colonisation and/or sepsis in neonates. METHODS: Weekly swabs of the nose, umbilicus, rectum, wounds, eye discharge and intravenous catheter tips (after removal) of infants admitted to the neonatal intensive care unit of Universiti Kebangsaan Malaysia Medical Centre, Malaysia, were cultured. CoNS sepsis was diagnosed if pure growth of CoNS was cultured from the peripheral blood specimen of symptomatic infants. For each infant with CoNS colonisation or sepsis, a control infant was retrospectively and randomly selected from unaffected infants in the ward. Multivariate analyses were performed to determine whether catheter use was a significant risk factor. RESULTS: CoNS colonisation was detected in 113 (8.7%) infants. CoNS sepsis was found in 12 (10.6%) infants with CoNS colonisation and 7 (0.6%) infants without CoNS colonisation. Multivariate analysis showed that the following were significantly associated with CoNS colonisation: conjunctivitis (adjusted odds ratio [OR] 8.2, 95% confidence interval [CI] 1.9­34.8, p = 0.005); central venous catheters (adjusted OR 5.8, 95% CI 1.9­17.8, p = 0.002); and nasopharyngeal and/or oral suctioning more than twice in the 48 hours before positive culture (adjusted OR 7.3, 95% CI 3.3­16.2, p < 0.001). Exposure to frequent nasopharyngeal and/or oral suctioning (adjusted OR 20.8, 95% CI 3.5­125.3, p = 0.001) was the only significant factor associated with CoNS sepsis. CONCLUSION: Infants requiring more than two nasopharyngeal and/or oral suctions in the previous 48 hours were found to have a higher risk of developing CoNS colonisation and sepsis.

Physical activity and associated factors among young adults in Malaysia: an online exploratory survey.

The burden of non-communicable diseases is increasing in Malaysia. Insufficient Physical Activity, which is an important risk factor for non-communicable diseases, is less researched in Malaysia. We aimed to assess the level of physical activity and identify its correlates. An online survey was carried out during October, 2011 in the University Tunku Abdul Rahman by the opinion poll research committee. Young adults answered the Short International Physical Activity Questionnaire and a questionnaire about factors according to a socio-ecological model which was adapted from published studies. Metabolic equivalent (MET)-hours and MET-minutes were calculated. Physical activity was classified as sufficient when MET-minutes were > 840. The mean age of the 474 participants was 22.4 years (S.D. = 4.7), and 253 (53.4%) were females. Their mean and median of MET-hours of PA done during the previous seven days were 31.36 (S.D., 52.19) and 14.7 (IQR, 5.77-32.07), respectively. Physical activity done was sufficient among 242 (51.1%) participants. Using univariate analysis, being male, good self-rated health, positive intention, self-efficacy, perceived benefits, social support, and availability of facilities were associated with sufficient physical activity. Using multivariate analysis sufficient physical activity was associated with participants' intention (OR 0.75, 95% CIs 0.64, 0.88), self-efficacy (OR 0.91, 95% CIs 0.85, 0.97) and facility availability (OR 0.81, 95% CIs 0.73, 0.91). The proportion of participants with sufficient physical activity was low. Positive intention and self-efficacy associated with sufficient physical activity should be supported by availability of facilities and a safely-built environment. A nationwide survey about physical and associated socialecological factors is needed to design rational health promotion strategies.

Malaysian mothers' knowledge & practices on care of neonatal jaundice.

This study aimed to determine the gaps of knowledge and practices of care of neonatal jaundice among Malaysian mothers. It was a cross sectional study of 400 mothers who attended the obstetric clinics or were admitted to the obstetric wards of a general hospital. They were surveyed with a structured set of questionnaire. The results showed that a majority (93.8%) of them knew about neonatal jaundice, and 71.7% knew that jaundice lasting more than 2 weeks was abnormal. However, only 34.3% of them were aware that jaundice appearing during the first 36 hours of life was abnormal. Less than 20% knew about glucose-6-phosphate dehydrogenase deficiency and that fetal-maternal blood group differences could cause jaundice. Although 71.7% and 69.7%, respectively, of the mothers knew that severe jaundice could cause death and brain damage, only 38.4% of them were aware that severe jaundice could result in hearing impairment. A very low proportion (27.1%) of them was aware that putting jaundiced infants under the direct sun could result in dehydration and worsening of jaundice. Out of a maximum score of 15, the mean maternal knowledge score was 7.4 (95% confidence intervals: 7.1, 7.7). Majority (83.1%) of the multiparous mothers with a past history of having children developing neonatal jaundice (n = 154) practiced placing their infants under the direct sun. This study revealed that there was a wide knowledge gap among Malaysian mothers on care of neonatal jaundice. Placing infants under the direct sun was still a common practice.

Refractive status of children under the age of three years born premature without retinopathy of prematurity.

OBJECTIVES: A cross-sectional study was undertaken to determine and compare the refractive status of premature children without retinopathy of prematurity (ROP) and full term children below the age of three years. MATERIALS AND METHODS: Seventy children were examined. One group comprised of 40 children born premature without ROP and another group consisted of 30 children born full term and normal. Refractive error was determined using the Mohindra technique. RESULTS: Children below the age of three years born premature without ROP were significantly less hyperopic compared to children born full term and normal (t = 3.76, p = 0.0003). Our results show that children born premature without ROP are emmetropic when compared to children born full term. CONCLUSION: It is appears that emmetropization does occur in children born premature and full term. RESULTS: Need to be written in a new paragraph and in italics

Brain herniation in a neonate.

Brain herniation is generally thought to be unlikely to occur in newborns due to the presence of the patent fontanelles and cranial sutures. A review of the literature published from 1993 to 2008 via MEDLINE search revealed no reports on neonatal brain herniation from intracranial tumour. We report a preterm Malay male infant born via elective Caesarean section for antenatally diagnosed intracerebral tumour, which subsequently developed herniation. Cerebral magnetic resonance imaging showed features that were compatible with a large complex intracranial tumour causing mass effect and gross hydrocephalus. Tumour excision was scheduled when the infant was two weeks old. Unfortunately, on the morning of the surgery, he developed signs of brain herniation and had profuse tumour haemorrhage during the attempted excision. Histopathological examination revealed an embryonal tumour, possibly an atypical rhabdoid/teratoid tumour. This case illustrates that intracranial tumours in newborns can herniate and should therefore be closely monitored.

The prevalence of obesity among clinical students in a Malaysian medical school.

INTRODUCTION: This study aimed to determine the prevalence of obesity among medical students and its relationship with their dietary intake and physical activities. METHODS: This observational study was carried out on 240 medical students during the clinical phase of their medical course in a private medical school. Their body weight and height were measured, and a standardised questionnaire was used to collect information on their physical activities and dietary intake. RESULTS: The median body weight of the participants was 59.0 kg (interquartile range: 51.3-66.8), the mean body height was 166.1 cm (standard deviation [SD] 8.5 cm), and the mean body mass index (BMI) was 21.8 kg/m2 (SD 3.4 kg/m2). Based on the World Health Organization BMI cut-offs for the Asian population, 30.1 percent (n is equal to 72) of the students were overweight or obese, with a BMI that was equal to or greater than 23.0 kg/m2. Logistic regression analysis showed that, after controlling for various potential confounders, the only significant risk factors associated with overweight/obesity among these students were: male gender (adjusted odds ratio [OR] 2.1; 95 percent confidence intervals [CI] of 1.1 and 4.1; p is equal to 0.03), Malay ethnic group (adjusted OR 2.4; 95 percent CI 1.0 and 5.7; p is equal to 0.04), Indian ethnic group (adjusted OR 3.6; 95 percent CI 1.5 and 8.9; p is equal to 0.005), and the number of soft drinks consumed per week (adjusted OR 1.3; 95 percent CI 1.0 and 1.5; p is equal to 0.02). Skipping breakfast, the frequency of physical exercise per week, the number of hours of sleep per day, and eating noodles or roti canai (a type of Malaysian pancake) for breakfast were not significant risk factors. CONCLUSION: Obesity remains a common problem among medical students in their clinical years.

Inhaled nitric oxide and intravenous magnesium sulphate for the treatment of persistent pulmonary hypertension of the newborn.

INTRODUCTION: The aim of this study was to compare the response and survival rates of term infants with persistent pulmonary hypertension of the newborn (PPHN) on high frequency oscillatory ventilation (HFOV) treated with either inhaled nitric oxide (iNO) or intravenous magnesium sulphate (MgSO4). METHODS: This was a randomised controlled study. The inclusion criteria were infants with respiratory distress, oxygen index equal to or greater than 25 despite HFOV support, and echocardiographic evidence of PPHN. Infants in the MgSO4 group (n is 13) were loaded with MgSO4 200 mg/kg infused over half an hour, followed by continuous infusion at 50-150 mg/kg/hour to attain a serum magnesium level of 5.0-7.0 mmol/L. Infants in the iNO group (n is 12) were administered nitric oxide at an initial concentration of 20 ppm. Analysis was done on an intention-to-treat basis. RESULTS: There was no significant difference in the median age when the vasodilators were commenced (MgSO4 group: 14.0 hours, interquartile range [IQR]: 7.5, 27.0; iNO group: 14.8 hours, IQR: 12.5, 35.3, p is 0.8). There was no significant difference in the proportion of infants who responded primarily to either vasodilator (MgSO4: 23.3%, iNO: 33.3%, p is 1.0) . After switching over to iNO following a failed MgSO4 therapy, a significantly higher proportion (9 out of 10) of the non-respondents in the MgSO4 group recovered from PPHN and survived compared to the non-respondents in the iNO group (1 out of 8) who switched over to intravenous MgSO4 (p is less than 0.03). CONCLUSION: Infants who were administered iNO following a failed MgSO4 therapy were associated with a better outcome than those who were administered MgSO4 following a failed iNO therapy.

The usefulness of early ultrasonography, electroencephalography and clinical parameters in predicting adverse outcomes in asphyxiated term infants.

INTRODUCTION: The early identification of asphyxiated infants at high risk of adverse outcomes and the early selection of those who might benefit from neuroprotective therapies are required. A prospective observational study was conducted to determine if there were any early clinical, neuroimaging or neurophysiological parameters that might predict the outcome in term newborns with asphyxia. METHODS: 44 term newborns with acute asphyxia had a cranial ultrasonography (US), electroencephalography (EEG) and clinical examination performed between three and eight hours of life to determine the parameters that might predict outcome. US findings were classified as normal or abnormal (ventricular dilatation or compression and/or focal/diffuse echogenicities). EEG background activity was classified into two categories: normal/mildly abnormal/intermediate, or severely abnormal (low voltage activity or "suppression-burst"). An intrapartum score (based on graded abnormalities of foetal heart monitoring, umbilical arterial base deficit and five-minute Apgar score) and a hypoxic ischaemic encephalopathy (HIE) score (based on graded abnormalities of the neurological and respiratory status at 3-8 hours of life) was also obtained. RESULTS: At one year of life, eight infants had died, six had defaulted follow-up, five had major impairment, two minor impairment and 23 were normal. On univariate analysis, poor outcome (death or major impairment) was associated with abnormal cranial US, severely abnormal EEG and a high HIE score (greater than or equal to 15). The positive predictive value was 54.5, 100 and 100 percent, respectively, while the negative predictive value was 93.8, 80.6 and 80.6 percent, respectively. Combining these factors did not improve the predictive values. CONCLUSION: There was no added advantage in combining EEG or US parameters over a clinical neurological scoring system alone in predicting the outcome of asphyxiated term newborns.

Neonatal resuscitation programme in Malaysia: an eight-year experience.

INTRODUCTION: The neonatal resuscitation programme (NRP) published by the American Academy of Paediatrics and American Heart Association was launched in Malaysia in 1996. This study aimed to review the outcome of NRP in Malaysia during the first eight years. METHODS: Information on basic demographical data and training activities of NRP providers were collected prospectively from NRP instructors from all over Malaysia during the eight years following the inception of the NRP. The national perinatal and neonatal mortality data during the five-year period before and eight years following implementation of the NRP were compared. RESULTS: During the eight years following the launch, 14,575 personnel were trained. 40 percent of NRP-certified personnel worked in areas where delivery services were provided, viz. labour room, operation theatre, obstetric ward, emergency department and maternal and child health clinic. There were very few NRP-certified providers working in emergency departments and most of them were medical assistants. Most of the providers working in neonatal intensive care units (NICUs) and labour rooms were nurses while those in paediatric wards were doctors. All NRP-certified doctors working in NICUs and labour rooms obtained full certificates. Only 80 percent of NRP-certified nurses in these two areas obtained full certificates. There was further serial decrease in perinatal mortality and neonatal mortality rates in Malaysia during the years following the launch of the NRP programme. CONCLUSION: The launch of the Malaysian NRP was associated with further improvement in perinatal and neonatal mortality rates.

Comparison of detection of glucose-6-phosphate dehydrogenase deficiency using fluorescent spot test, enzyme assay and molecular method for prediction of severe neonatal hyperbilirubinaemia.

INTRODUCTION: This study aimed to compare the detection rates of glucose-6-phosphate dehydrogenase (G6PD) deficiency in neonates by fluorescent spot test (FST), enzyme assay and molecular methods, and to identify which method was a significant predictor of severe hyperbilirubinaemia. METHODS: 74 term infants of Chinese descent admitted with severe hyperbilirubinaemia (total serum bilirubin equal or greater than 300 micromol/L) and 125 healthy term infants born in the hospital without severe hyperbilirubinaemia were recruited into the study. Specimens of blood were collected from each infant for FST, G6PD enzyme assay and TaqMan minor groove binder single nucleotide polymorphism genotyping assay. RESULTS: 26 (13.1 percent) infants were diagnosed to have G6PD deficiency by FST. They had significantly lower median enzyme levels (0.8 IU/g Hb, interquartile range [IQR] 0.4-4.3) than those diagnosed to be normal (12.0 IU/g Hb, IQR 10.3-15.8) (p-value is less than 0.0001). Based on the enzyme assay, 39 (19.6 percent) infants had G6PD deficiency at an enzyme cut-off level of less than 8.5 IU/g Hb. G6PD mutation was detected in 27 (13.6 percent) infants. Logistic regression analysis showed that the only significant predictors of severe hyperbilirubinaemia were G6PD deficiency based on a cut-off level of less than 8.5 IU/g Hb (adjusted odds ratio [OR] 5.3, 95 percent confidence interval [CI] 2.4-11.4; p-value is less than 0.0001) and exclusive breast-feeding (adjusted OR 11.4, 95 percent CI 3.1-42.4; p-value is less than 0.0001). The gender and birth weight of infants, FST results, G6PD mutation and the actual G6PD enzyme levels were not significant predictors. CONCLUSION: A G6PD enzyme level of less than 8.5 IU/g Hb is a significant predictor of severe hyperbilirubinaemia.

A quality assurance study on the administration of medication by nurses in a neonatal intensive care unit.

INTRODUCTION: This study aimed to determine the rates of non-adherence to standard steps of medication administration and medication administration errors committed by registered nurses in a neonatal intensive care unit before and after intervention. METHODS: A baseline assessment of compliance with ten standard medication administration steps by neonatal intensive care unit nurses was carried out over a two-week period. Following this, a re-education programme was launched. Three months later, they were re-assessed similarly. RESULTS: The baseline assessment showed that the nurses did not carry out at least one of the ten standard administrative steps during the administration of 188 medication doses. The most common steps omitted were having another nurse to witness drug administration (95 percent); labelling of individual medication prepared prior to administration (88 percent), checking prescription charts against patients' identification prior to administration (85 percent) and visually inspecting a patient's identification tag (71 percent) . Medication administration errors occurred in 31 percent (59/188) of doses administered, all due to imprecise timing of medication administration. There were no resultant adverse outcomes. Following implementation of remedial measures, there was a significant reduction in non-adherence of seven of the ten medication administration steps and the rate of medication administration errors (p-value is less than 0.001). However, in 94 percent of doses administered, the nurses still did not get a witness to countercheck calculations of drug dosages before administration. CONCLUSION: Non-compliance with the standard practice of medication administration by nurses is common but can be improved by continuing re-education and monitoring, plus the implementation of a standard operating procedure.

Detection of sensorineural hearing loss using automated auditory brainstem-evoked response and transient-evoked otoacoustic emission in term neonates with severe hyperbilirubinaemia.

INTRODUCTION: This study was designed to compare the sensitivity and specificity of detecting sensorineural hearing loss (SNHL) using the transient-evoked otoacoustic emissions (OAE) machine (the Madsen TE Echoscreen) and automated auditory brainstem response (AABR) machine (the Sabre Compac portable AABR) in term neonates exposed to severe hyperbilirubinaemia. METHODS: This was a prospective study carried out over a 30-month period in a neonatal intensive care unit. Term infants (gestation equal to or greater than 37 weeks) with severe hyperbilirubinaemia (peak total serum bilirubin level equal to or greater than 300 umol/L) were recruited. Hearing tests were carried out before discharge. RESULTS: The median age of the 250 study infants when OAE and AABR were tested, was eight days (IQR four days) and their median age when auditory brainstem-evoked response (ABR) was done was 58 days (IQR 56 days). Based on the findings of ABR, 32 (12.8 percent) infants had unilateral or bilateral SNHL. There was no significant difference in the peak total serum bilirubin levels between infants with SNHL (median 333 umol/L, IQR 57) and those without (median 340 umol/L, IQR: 58) (p-value is 0.3). The sensitivity of OAE for detecting SNHL was 15.9 percent, and its specificity 95.2 percent. The sensitivity of the Sabre Compac portable AABR machine for detecting SNHL was 40.9 percent and its specificity was 63.2 percent. CONCLUSION: Both the OAE machine and the Sabre AABR machine were not sensitive enough for mass screening of SNHL in infants exposed to severe hyperbilirubinaemia.

Usefulness of a semi-quantitative procalcitonin test kit for early diagnosis of neonatal sepsis.

INTRODUCTION: This study was designed to determine the sensitivity and specificity of a semi-quantitative procalcitonin (PCT) test kit for the diagnosis of neonatal sepsis. METHODS: Infants admitted to the neonatal intensive care unit with signs suggestive of sepsis were recruited into the study. Prior to commencement on antibiotics, the following investigations were carried out on each of these infants: blood culture and sensitivity, PCT semi-quantitation and C-reactive protein (CRP) estimation. Infants already on antibiotics, or who developed signs of sepsis within 72 hours of discontinuation of antibiotics, were excluded from the study. RESULTS: Of the 87 infants recruited, 18 (20.7 percent) were confirmed to have sepsis based on positive blood culture results. At a PCT cut-off level of greater than or equal to 2 ng/ml, the sensitivity of the PCT-Q kit in detecting neonatal sepsis at the onset of symptoms was 88.9 percent and its specificity was 65.2 percent. The sensitivity of CRP for diagnosis of sepsis was 55.6 percent and its specificity was 89.9 percent. CONCLUSION: The semi-quantitative PCT test kit is of moderate sensitivity but poor specificity for early diagnosis of neonatal sepsis. A negative PCT test result may help to "rule out", while a raised CRP result helps to "rule in", the possibility of sepsis.

Early outcome of congenital diaphragmatic hernia in a Malaysian tertiary centre.

INTRODUCTION: This prospective observational study was conducted to determine the outcome of newborns with congenital diaphragmatic hernia (CDH). They were managed with a protocol of gentle ventilation to avoid barotraumas, and inhaled nitric oxide (iNO) or intravenous magnesium sulphate for treatment of persistent pulmonary hypertension of newborns (PPHN). METHODS: All newborns with CDH admitted to neonatal intensive care unit of this hospital during the six-year study period were recruited. High frequency oscillatory ventilation was used when infants required peak inspiratory pressure of more than 25 mmHg. iNO at 20 ppm or intravenous magnesium sulphate was used when PPHN developed. Arterial blood pH was maintained between 7.35 and 7.45, and partial pressure of arterial carbon dioxide was kept above 35 mmHg. Surgery was performed when the infants' general condition and blood gases were stabilised for at least 24 hours. RESULTS: Of 21 infants recruited (15 males and six females, median gestational age 39.0 weeks, median birth weight 2,800 grams), 52.4 percent had PPHN. 12 (57.1 percent) underwent surgery at a median age of 4.9 days. One died postoperatively due to PPHN. Out of the 21 subjects, 11 (52.4 percent) survived to discharge. There was no significant difference in the demographic characteristics, side and size of CDH defects, presence of PPHN, or type of treatment received, between infants who survived and died. However, infants who died had significantly lower mean Apgar scores at five minutes of life (p-value is 0.02), and higher mean oxygenation indexes (OI) (p-value is 0.01) than those of survivors. Two (18.2 percent) of the 11 survivors developed chronic lung disease. CONCLUSION: Low Apgar scores and high OI were associated with poor outcome in infants with CDH.

Risk factors associated with low birth weight infants in the Malaysian population.

This study aimed to identify the risk factors which were significantly associated with low birth weight (LBW, <2500 g) infants among the Malaysian population. This was a case-control study carried out at the Tuanku Jaafar Hospital, Seremban, Malaysia over a five-month period. Cases were all infants born with birth weight less than 2500 g. Control infant were selected with the help a random sampling table from among infants with birth weight of > or =2500 g born on the same day in the hospital. Of 3341 livebirths delivered in the hospital, 422 (12.6%) were LBW infants. Logistic regression analysis showed that, after controlling for various potential confounders, the only significant risk factors associated with infants of LBW were gestational age (adjusted odds ratio (OR)=0.6, 95% C.I.: 0.5, 0.6; < 0.0001), maternal pre-pregnancy weight (adjusted OR = 0.97, 95% C.I.: 0.95, 0.99; p < 0.0001), nulliparity (adjusted OR = 3.4, 95% C.I.: 2.2, 5.1; p < 0.0001), previous history of LBW infants (adjusted OR = 2.3, 95% C.I.: 1.4, 3.8; p=0.001) and PIH during current pregnancy (adjusted OR=3.3, 95% C.I.: 1.6, 6.6; p = 0.001). A number of potentially preventable or treatable risk factors were identified to be associated with LBW infants in Malaysia.

A rare case of ambiguous genitalia.

Genes on the Y chromosome are essential for normal sex determination and sex differentiation of male genitalia. However, genes on the X chromosome and other autosomes have been shown to be anti-testes and have a detrimental effect on this process. Addition of X chromosomes to the 46,XY karyotype results in seminiferous tubules dysgenesis, hypogonadism and malformed genitalia. We report a term male newborn with 49,XXXXY syndrome presenting with ambiguous genitalia, multiple extra-gonadal anomalies, facial dysmorphism, and radioulnar synostosis.