Long-term follow-up of otherwise healthy term infants with marked hyperbilirubinaemia: should the limits of exchange transfusion be changed in Turkey?

AIM: To evaluate prospectively non-haemolytic term infants with marked hyperbilirubinaemia treated by phototherapy only for evidence of bilirubin toxicity at 2-6 y of age, and to determine the suitability for Turkish children of the exchange transfusion limits recently reported by the American Academy of Pediatrics. METHODS: The study group included a total of 30 children, aged 2-6 y, who had developed marked hyperbilirubinaemia (20-24 mg dl(-1), 342-410 micromol l(-1)) during the newborn period (gestational age >37 wk, birthweight >2500 g) and were treated without exchange transfusion because intensive phototherapy, instituted during the preparations for exchange transfusion, was successful in decreasing their serum bilirubin levels. The control group consisted of 30 children of the same age group without clinical jaundice in the newborn period. Physical and neurological examinations, brainstem auditory-evoked potentials (BAEPs) and developmental tests for Turkish children were performed in both the study and control children. RESULTS: There was no difference between the groups with regard to mean BAEP latencies and developmental scores. None of the infants had hearing loss, developmental delay or abnormal neurological findings. CONCLUSION: The results suggest that successful intensive phototherapy without exchange transfusion in otherwise healthy term newborn infants with marked hyperbilirubinaemia (20-24 mg dl(-1), 342-410 micromol l(-1)) might not increase the risk of bilirubin brain injury and that the conventional limit of 20 mg dl(-1) (342 micromol l(-1)) could be changed to 22-24 mg dl(-1) (376-410 micromol l(-1)) for healthy term infants in Turkey. These limits, however, address only infants who do not have haemolytic disease, and the data are not sufficient to draw conclusions on the safety of even higher bilirubin levels (i.e. >24 mg dl(-1), 410 micromol l(-1)) in this population.

Exotic arteriovenous fistulas for hemodialysis.

The rate of patients with exhausted upper extremity arteriovenous fistula (AVF) sites who have lost all chances for a conventional upper extremity AVF has been increasing in line with the general increase in the hemodialysis patient population. In this prospective study, we report the early and late follow-up results of "exotic" AVFs in which central veins are used for the outflow. Patients having no chance for an upper extremity AVF based on previous catheterization, surgical AVF history, detailed physical examination, and radiological assessment, were included in the study. Between June 1999 and January 2003, 27 central AVFs were created with a 6 mm synthetic vascular graft in 26 patients. The inflow artery was the proximal axillary artery in all except one. All but one operation was done by the same surgeon. The outflow vein was the internal jugular vein in 16 and infraclavicular axillary vein in 11 cases. One-year primary and secondary graft patency rates were 33.33 +/- 10.49 and 57.06 +/- 11.29, respectively. The early complications were facial edema and hemiparesis, both of which resolved spontaneously. The only late complication, pseudoaneursym, was treated by a graft interposition. In selected patients who have no suitable upper extremity vessels for an AVF, the central veins may be used with an acceptable success rate. Another advantage of this procedure is the avoidance of undesired femoral interventions; sometimes it may be the only opportunity and lifesaving for the patient.

Dermal bilirubin kinetics during phototherapy in term neonates.

AIM: To investigate dermal bilirubin kinetics during phototherapy in the presence of neonatal indirect hyperbilirubinaemia. METHODS: 33 neonates with non-haemolytic indirect hyperbilirubinaemia, who required phototherapy, were included in the study. Phototherapy modules containing four normal and four blue fluorescent lamps were used during the study. The transcutaneous bilirubin index (TcBI) was measured in an area of the forehead covered by a 2.5 cm diameter opaque patch and a nearby exposed site. The TcBI obtained from patched and unpatched areas and simultaneous serum bilirubin (SB) concentrations were measured before the start of phototherapy and after 6, 12, 18, 30, 42 and 66 h of phototherapy. RESULTS: SB concentration and the TcBI from the unpatched area decreased significantly during the first 6 h of exposure, while the TcBI obtained from the patched area decreased significantly after 12 h. The TcBI from the unpatched area was consistently lower than that from the patched area during phototherapy. After the onset of phototherapy, there was a weak, non-significant correlation between SB concentrations and the TcBI from patched and unpatched areas. CONCLUSION: Phototherapy was effective for both patched and unpatched areas, but the rate of decline was slower in patched areas, only becoming significant in the second 6 h of treatment. There was no significant correlation between the levels of SB and TcBI after the onset of phototherapy, and therefore the use of TcBI cannot be recommended as a surrogate measure of SB.

Are the stool characteristics of preterm infants affected by infant formulas?

The aim of this study was to investigate the relationship between the type of formula consumed and the stool characteristics and gastrointestinal symptoms of preterm infants prospectively. Seventy-five preterm infants weighing < 2000 g in our neonatal intensive care unit (NICU) were investigated. Four groups of 15 each were fed one of four commercial formula preparations (Prematil, Neonatal, Humana-0 and S-26) and the fifth group was breast-fed in a prospective, randomized, double-blind study. The stool characteristics and gastrointestinal problems were recorded daily from the first day till the time they were discharged by the nurses of NICU. No significant differences of daily weight gain was observed between the groups. No significant difference was observed in daily frequency of stool, distention, vomiting and gas passage between the groups during the enteral + parenteral and full-enteral nutrition periods. The infants fed by Prematil during the enteral + parenteral nutrition period had a higher percentage of hard stool occurrence than infants receiving Humana-0 and breast milk. In the full-enteral nutrition period, infants receiving Prematil had a higher percentage of hard stool occurrence than all the other groups, whereas breast-fed infants had a lower percentage of hard stool than all the other groups. While the group fed with Humana-0 had a higher percentage of green stool occurrence in the enteral + parenteral nutrition period, no significant difference was observed in the full-enteral nutrition period. In the enteral + parenteral nutrition period no additional therapy affected stool characteristics or the gastrointestinal system except in the case of the infant receiving phototherapy for whom the daily number of detections was significantly high. In this study, it was shown that the color and consistency of stool in preterm infant differs according to the preterm infant formulas, but no differences were observed in the frequency of defecation or in gastrointestinal system problems. When the infant formulas were compared with breast milk, it was shown that they cause a higher percentage of hard stool occurrence. An increased number of formula feedings are necessary to obtain a similar daily weight gain, but the color and the frequency of the stool and the gastrointestinal system problems were similar for breast-fed and formula-fed infants.