Umbilical cord blood gas and lactate levels as a marker of birth asphyxia in neonates with particular reference to resource limited countries

Birth asphyxia remains an important cause of neonatal mortality and morbidity in the developing world. Babies who suffer birth asphyxia may develop cerebral palsy, learning difficulties and epilepsy. Early diagnosis and prompt placement of rehabilitative measures would help to reduce the burden of complications arising as a result of birth asphyxia. Time and again effort has been made to develop markers that would help in predicting outcome of neonates who have had an asphyxial insult. One such parameter that is now routinely being used in the developed world is the measurement of umbilical cord blood lactate level measured from blood gases. This review highlights the importance of early diagnosis of birth asphyxia and the role of umbilical cord blood lactate level in identifying babies who have had birth asphyxia in resource limited countries with a particular reference to Pakistan

Neonatal sepsis in the very low birth weight preterm infants: part 1: review of patho-physiology

Over the last fifty years neonatal care has made tremendous progress; increasing survival, reducing morbidity, developing newer modalities of care and therapy for the very low birth weight [VLBW] and premature infant. However, mortality from neonatal sepsis in this group of infants has remained between 18-20% in the developed world and around 80% in the developing world for last three decades with little sign of decline. There is also clear evidence that VLBW infants who survive infection in the neonatal period are at significantly greater risk of neuro-developmental delay; making sepsis the most important cause of mortality and morbidity in this group of infants today. The objective of this review is to highlight the reasons for this lack of success in combating neonatal sepsis successfully. These can be attributed to four main reasons; 1] poor host defences, 2] clinician's inability to diagnose sepsis early and accurately [due to lack of or general availability of highly sensitive and specific markers], 3] clinician's poor understanding of the 'process' i.e. patho-physiology of neonatal sepsis, thus not being able to institute early 'goal' directed therapy, and 4] total reliance on killing the pathogen[s] with inadequate attention to correcting the consequences of the inflammatory process itself. This review presents a brief epidemiological background to neonatal infections in the VLBW infants, discusses host defence systems and how immune compromised VLBW infant combats infection by describing the pathophysiological 'process' of sepsis in detail. It is our belief that understanding the heterogeneity and complexity of host response and the defence systems is fundamental in formulating management strategies. By discussing patho-physiology, current available diagnostic tests and presenting an evidence based management 'care bundle' it is hoped to change clinician's paradigm to use more immune and molecular markers for diagnosis and monitoring of the infection process and in management considering adjunctive therapies that boost host defences. It is recognised that while this review is static i.e. it presents evidence as we understand it today, sepsis is a dynamic process. Our understanding, ability to diagnose and manage neo-natal sepsis is constantly changing and will continue to change and evolve. By presenting this review it is hoped that over a period of time more of our practices would become evidence based and dogma abandoned

Neonatal sepsis in the very low birth weight preterm infants: part 2: review of definition, diagnosis and management

Having presented brief epidemiology of neonatal infection and patho-physiology of neonatal sepsis in the first part of this review we now address the difficulties in defining, diagnosing and treating neonatal sepsis. The objective of this part of the review is firstly, to highlight the reasons for lack of consensus on the definition of neonatal sepsis despite a number of international conferences of experts on the subject. Secondly, to discuss the increasing sophistication of available laboratory tests and why they all lack the certainty desired by the clinician and thirdly to discuss the various evidence based treatment modalities available to treat neonatal sepsis. It is suggested that pragmatic definition of sepsis as suggested by us should be adopted. Greater use of biomarkers and molecular tests should be made to diagnose sepsis early and accurately. Lastly, it is hoped to change the clinician's paradigm by using evidence based management care bundle/package that includes adjunctive immune-modulatory and host defence boosting drugs

Use of intravenous immunoglobulin in the treatment of neonatal sepsis: a pragmatic review and analysis

To review literature and assess whether adjunctive therapy with polyclonal and or enriched intravenous immunoglobulin [IVIG] reduces mortality in neonates with sepsis. Data Source: MEDLINE, EMBASE and Cochrane systematic review. All studies published in English language evaluating IVIG treatment in neonatal sepsis. Data Synthesis: Effect of all cause mortality was quantified using fixed-effect meta-analysis. Fifteen studies published between 1986 and 2006 were identified of which fourteen reported mortality and were included in the analysis. Most studies involved small number of neonates, used different preparations and dosing regimens of IVIG, however, there was significant reduction in all cause mortality associated with use of IVIG in neonatal sepsis with pooled odds ratio of 0.41 [95% confidence interval 0.29-0.58] and a risk ratio of 0.52 [95% confidence interval 0.40-0.67; p < 0.00001]. There was no statistically significant difference between-study heterogeneity for the outcome of mortality in the two analyses. I2=0%. Number required to treat 7. This analysis shows that addition of polyclonal or enriched IVIG as adjunct to standard therapy significantly reduces all cause mortality in neonatal sepsis

Theophylline therapy for apnea of prematurity in Saudi preterm infants: therapeutic serum level and dosage

In a controlled study, 150 Saudi preterm infants were treated with 1.5 mg/kg/day of thephyline for apnea of prematurity. In 96.8% of infants the apnea was either reduced by more than 50% or abolished completely. The effective therapeutic plasma level for these infants was 4.5 +/- 2.1 micro g/mL. a loading dose was found to be unnecessary. Theophylline at these doses appears to be effective and safe treatment for apnea of prematuity in Saudi infants

Periventrucular-intra ventricular hemorrhage in the newborn

In a retrospective study spanning 4 years[1404-1407H] and including a total of 11, 050 births, the incidence of periventricular/intraventricular hemorrhage [PVH/IVH] in infants born at King Khalid University Hospital at or before 35 weeks of gestation was 20.9% and in those weighing 1500 g or less at birth was 40.8%. Incidence, grade, associations, and outcome of infants suffering PVH/IVH were tabulated. Most common was grade 1 hemorrhage; PVH/IVH was most frequently seen in infants born between 26 and 30 week's gestation [42.5%] and in those weighing between 500 and 750[g] [42.9%] at birth. Respiratory distress syndrome was associated in 81.3% of the infants with PVH/IVH

scheme for better perinatal care in the Kingdom of Saudi Arabia

Despite great developments in the health sector within the Kingdom, maternal and perinatal mortality rates remain unacceptably high. The main reason for this is the lack of an organized and coordinated system of perinatal care. This paper reviews the current state of perinatal care in the Kingdom and the reasons for the high rates of maternal and perinatal mortality. A scheme for a regionalized perinatal care system based on three different levels of care [Level I-III] is suggested

Infant feeding practices in Riyadh, Saudi Arabia

Infant-feeding patterns were studied in 6, 653 randomly selected Saudi families living in Riyadh. The 4, 796 infants studied were under 1 year of age and were fed with breast milk plus bottle complements. Bottle-feeding was started in 27.3% of infants during the first months after birth. The mean age at which solid food was introduced was 3.45 months. The overall results suggest a decreasing incidence of breast-feeding along with diminishing length of nursing period

Perinatal mortality at King Khalid University Hospital Riyadh

One of the major goals in perinatal practice is to achieve the lowest possible perinatal mortality. We evaluated the pattern of perinatal mortality at the King Khalid University Hospital [KKUH] over four years, from 1403H through 1406H [October 1982 through August 1986]. Over this period the number of births at KKUH increased by 175%. In 1406H perinatal mortality was 14.5/1000 birth; survival of infants weighing 754 g was over 80%, and those weighing between 500 and 750 g was 30%. The likelihood of survival for an infant born at or after 27 weeks of gestation was greater than 80%

Smith-Lemli-Optiz syndrome in one Arab child: a case report

The first case of Smith-Lemli-Opitz syndrome from Saudi Arabia is described. The relevant literature is reviewed

Trial of a new high density milk formula [prematalac] in Saudi preterm and low birth weight infants

After birth there is a steady increase in the food intake of the newborn accompanied by a rise in the metabolic rate. The nutritional needs of preterm and low birth weight infants differ considerably from those of full term infants. Recent trends in the feeding of preterm infants include the use of special infant formulae the so called premature formulae that mimic human milk composition with special attention to the unique composition of the preterm human milk. Low birth weight [LBW] infants fed standard modified cows milk formula are at risk because a high fluid intake is needed for adequate nutrition and there is also a danger of hyponatraemia if the sodium intake fails to match the large renal losses which these infants have soon after birth. A new cows' milk formula [cow and gate prematalac], providing 79 kcal 2.4g of fat and 2.60 m mol of sodium per 100 ml was compared with a standard modified cows' milk formula [cow and gate premium]. Twenty preterm and LBW Saudi infants were fed prematalc and compared with 20 similar infants who were fed on premium. All the infants grew at a rate similar to that which would have been expected had they remained inside the uterus. However infants on prematalac grew significantly faster [p<0.005]. Biochemical and haematological changes were also studied and are reported. Prematalac was well tolerated by these infants with no evidence of malabsorption

Evaluation of a new oral rehydration solution [osterlyte] in Saudi children

A prepacked ready-to-feed rehydration solution Osterlyte, containing 50mmo1/1 of sodium was evaluated in 150 Saudi children aged between 3 weeks and 34 months with moderate to severe dehydration, secondary to enteritis. The solution was found to be safe and effective in rehydrating and maintaining hydration in these children

Outcome of low and very low birth weight infants: a case for regionalization of perinatal care in Saudi Arabia

The morbidity and mortality of all 259 low birth weight deliveries [between 500 and 2,500 grams] born at the King Khalid University Hospital [KKUH], in Riyadh Saudi Arabia, between the Hejira years 1403-1404 [Gregorian years: mid-October 1982] are weighing less than 1, 000 gm at birth was 70%. There was a short-term handicap rate of 7%, of which 5% were deemed to have a major handicap. A case is made for regionalization to improve reproductive medical care in the Kingdom