Does ultrasound guidance for peripherally inserted central catheter (PICC) insertion reduce the incidence of tip malposition? - a randomized trial.

OBJECTIVE: The aim of the study was to evaluate the incidence of peripheral inserted central catheter (PICC) tip malposition when the catheter is inserted under real-time ultrasound (RTUS) guidance when compared with conventional landmark (CL) technique in neonates. Additional objectives were to evaluate the PICC longevity and central line associated blood stream infections (CLABSI). STUDY DESIGN: In this randomised controlled trial, neonates were randomised to 'RTUS' (n = 40) or 'CL' (n = 40) groups. PICC tip was placed under ultrasound guidance in lower third of superior vena cava in the RTUS group. In 'CL' group, PICC was inserted as calculated by anatomical landmarks. RESULTS: The birth weight (1286 (926, 1662) vs. 1061 (889, 1636) g) and gestation (31.12 (3.1) vs. 31.4 (3.6) wks) were comparable among the groups. RTUS guidance during PICC insertion reduced incidence of tip malposition by 52% (67.5 vs. 32.5%; RR: 0.48; 95% CI: 0.29-0.79). The longevity of PICC and episodes of CLABSI were however similar in the two groups. CONCLUSIONS: Real-time ultrasound guidance during PICC placement reduces the incidence of tip malposition.

Nasal masks or binasal prongs for delivering continuous positive airway pressure in preterm neonates-a randomised trial.

The objective of this study was to compare the efficacy and safety of continuous positive airway pressure (CPAP) delivered using nasal masks with binasal prongs. We randomly allocated 72 neonates between 26 and 32 weeks gestation to receive bubble CPAP by either nasal mask (n = 37) or short binasal prongs (n = 35). Primary outcome was mean FiO2 requirement at 6, 12 and 24 h of CPAP initiation and the area under curve (AUC) of FiO2 against time during the first 24 h (FiO2 AUC0-24). Secondary outcomes were the incidence of CPAP failure and nasal trauma. FiO2 requirement at 6, 12 and 24 h (mean (SD); 25 (5.8) vs. 27.9 (8); 23.8 (4.5) vs. 25.4 (6.8) and 22.6 (6.8) vs. 22.7 (3.3)) as well as FiO2 AUC0-24 (584.0 (117.8) vs. 610.6 (123.6)) were similar between the groups. There was no difference in the incidence of CPAP failure (14 vs. 20%; relative risk 0.67; 95% confidence interval 0.24-1.93). Incidence of severe nasal trauma was lower with the use of nasal masks (0 vs. 31%; p < .001). CONCLUSIONS: Nasal masks appear to be as efficacious as binasal prongs in providing CPAP. Masks are associated with lower risk of severe nasal trauma. TRIAL REGISTRATION: CTRI2012/08/002868 What is Known? • Binasal prongs are better than single nasal and nasopharyngeal prongs for delivering continuous positive airway pressure (CPAP) in preventing need for re-intubation. • It is unclear if they are superior to newer generation nasal masks in preterm neonates requiring CPAP. What is New? • Oxygen requirement during the first 24 h of CPAP delivery is comparable with use of nasal masks and binasal prongs. • Use of nasal masks is, however, associated with significantly lower risk of severe grades of nasal injury.

Iron Stores in Term and Late Preterm Small for Gestational Age and Appropriate for Gestational Age Neonates at Birth and in Early Infancy.

OBJECTIVE: To compare body iron stores in late preterm and term small for gestational age (SGA) infants with gestation matched appropriate-for-gestational age (AGA) infants at birth and at 2 mo of age. METHODS: In this prospective observational study, live births of 34-42 wk gestation and SGA (<10th centile for GA) were enrolled along with gestation matched AGA (10th-90th centile for GA) infants. Infants' blood samples were taken within 2 h of delivery, and repeated at 60 ± 7 d of life. Primary outcome was serum ferritin at birth and 60 d of age. Secondary outcomes were hematocrit at birth and 60 d and need for transfusion until 60 d of life. RESULTS: A total of 37 SGA (gestation 37.2 ± 1.9 wk, birth weight 1861 ± 401 g) and 30 AGA infants (gestation 37.3 ± 1.9 wk, birth weight 2607 ± 405 g) were enrolled in the study. There was no difference in the serum ferritin between AGA and SGA infants at birth {median [IQR]: 254.0 [214.3-293.8] vs. 259.7 [217.8-301.5] µg/L; p = 0.85} or 60 d of life {147.2 [101.4-193.0] vs. 155.0 [106.6-203.6] µg/L; p = 0.81}. Mean hematocrit was 55.5 ± 9.6 vs. 52.4 ± 5.0 at birth (p = 0.10) and 32.1 ± 4.9 vs. 31.6 ± 3.8 at 60 d (p = 0.77) in SGA and AGA infants respectively. No infant required blood transfusion during the study period. CONCLUSIONS: Iron stores of late preterm and term SGA infants are comparable to term AGA infants at birth and 2 mo of age. Recommendations on iron supplementation to these infants need to be formulated through appropriately designed randomized trials.

Short-term outcomes of acute fulminant myocarditis in children.

Data on the clinical profile, echocardiographic findings, and outcome of acute fulminant myocarditis (AFM) in children from resource limited countries are limited. To study the clinical profile and short-term outcomes of children aged 2 months to 17 years with AFM managed with only supportive care. We enrolled all children admitted with AFM in our hospital from January 2009 to October 2010. Although the information on patients admitted from January 2009 to March 2010 were retrieved from the case records, data of children admitted from April 2010 were recorded prospectively. AFM was diagnosed based on clinical and echocardiographic criteria. We collected information regarding clinical course, treatment details, and echocardiography findings using a structured performa. All of the children, including those for whom baseline information was collected from the records, were followed-up prospectively to determine short-term outcomes. A total of 10 children, of whom 6 were male, presented with AFM. Their median age was 7.5 (interquartile range [IQR] 2 to 13) years, and the mean left-ventricular ejection fraction (LVEF) was 26% (SD 11.5). Of the 10 children, 9 were discharged, and 1 child died. At discharge, all children showed improvement in the symptoms, but only 4 had improvement in LV function on echocardiography. Factors associated with poor recovery of LV function at discharge were anasarca, low LVEF, and increased serum glutamate pyruvate transaminase levels at admission. One child had died at 2-month follow-up, and another child developed dilated cardiomyopathy at 15 months after discharge. Children with AFM had good immediate- and short-term outcomes even without the use of mechanical assist devices. Decreased LVEF at admission was found to be one of the most important determinants of poor immediate outcomes in these children.

Hypoglycemia in the newborn.

Hypoglycemia in a neonate is defined as blood sugar value below 40 mg/dL. It is commonly associated with a variety of neonatal conditions like prematurity, intrauterine growth restriction and maternal diabetes. Screening for hypoglycemia in high-risk situations is recommended. Supervised breast-feeding may be an initial treatment option in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with a continuous infusion of parenteral dextrose. Neonates needing dextrose infusion rates above 12 mg/kg/min should be investigated for a definite cause of hypoglycemia. Hypoglycemia has been linked to poor neuro-developmental outcome, and hence aggressive screening and treatment is recommended.