Mediastinal and retropharyngeal abscesses in a neonate.

Mediastinal abscess following retropharyngeal abscess is a rare entity. We report the first neonate presenting with a large mediastinal abscess as a complication of a retropharyngeal abscess. The initial manifestations of this newborn were fever and stridor. The chest sonography revealed a mediastinal mass, and the neck and chest computed tomography showed multiple abscesses in the retropharyngeal space, parapharyngeal space, and superior mediastinum. The mediastinal cystic mass was excised, and antibiotic treatment was completed for 7 weeks. She did well without any sequelae at follow-up clinic. Pediatricians should consider retropharyngeal and mediastinal abscesses among the differential diagnoses when confronting a newborn with fever and stridor.

Using non-nutritive sucking and oral glucose solution with neonates to relieve pain: a randomised controlled trial.

AIM: To compare the efficacies of non-nutritive sucking and glucose solution as pain-relief interventions for neonates undergoing a venipuncture procedure. BACKGROUND: Neonates may be subjected to painful procedures. The individual efficacies of non-nutritive sucking or oral glucose solution used alone on pain-relief for neonates still remain controversial. DESIGN: A randomised, parallel-group controlled trial was designed. METHODS: A total of 105 neonates were randomly assigned to one of the three groups: non-nutritive sucking, glucose solution, or control group. When a neonate underwent a venipuncture during a newborn screening test, his/her pain manifestations were videotaped and subsequently measured using the Neonatal Infant Pain Scale. Both the stability analysis and the analysis of repeated relationships were performed by generalised estimating equations. RESULTS: The level of pain was regressed over the study variables (time and group) and covariate (gestational age). Both the non-nutritive sucking and glucose solution groups had significantly lower pain scores than the control group during the venipuncture and recovery phases. Furthermore, non-nutritive sucking seemed to be more effective than glucose solution. CONCLUSION: Nurses can use a pain assessment tool and the pain-relief intervention to improve the quality of neonatal care in clinical practice. This study indicates that either non-nutritive sucking or glucose solution can effectively decrease the level of pain. RELEVANCE TO CLINICAL PRACTICE: If a painful procedure on neonates is inevitable, simple, convenient and effective pain-relief methods such as non-nutritive sucking or glucose solution can be provided alone. Based on a neonate's condition, nurses can provide 2 ml of 25% glucose solution through a syringe for a breastfeeding infant before an invasive procedure if nipple confusion is the concern.

Community-based epidemiological study on breastfeeding and associated factors with respect to postpartum periods in Taiwan.

AIMS: To explore the prevalence of breastfeeding in different geographical areas and identify the factors influencing breastfeeding practices during in-hospital stay and at one, four and six months postpartum in Taiwan. BACKGROUND: The national data on prevalence for breastfeeding patterns are still unknown. DESIGN: Community-based epidemiological survey design. METHODS: A total of 12,201 women were sampled from the birth registration and surveyed between June-October 2004. Data were collected through a computer-assisted telephone interview at four different postpartum periods. Logistic regression modelling was applied to determine factors influencing breastfeeding patterns and postpartum time-specific odds ratios. RESULTS: Rates of breastfeeding practices were 29.4, 33.2, 16.9 and 13.1% for in-hospital stay, the first-, fourth- and sixth-month postpartum respectively. Mother's intention to breastfeed was the most important factor to lengthen breastfeeding practices over time. The effect of an advocate programme in the hospital was significantly associated with breastfeeding only at the time of in-hospital stay. Age, family support and singleton were found to be significantly related to the continuation of breastfeeding at the fourth month postpartum. Employment status was significantly associated with the termination of breastfeeding, particularly at the later postpartum period. Geographical variation in breastfeeding practices within the first month postpartum was identified. In contrast, ethnic variation was more apparent at the later postpartum period. CONCLUSIONS: This large-scale study revealed a significantly decreasing trend after one month postpartum of breastfeeding rate in each geographical area of Taiwan. Factors associated with women's decision and continuation on breastfeeding patterns tended to be dependent on the time-specific postpartum period and varied between geographical areas. RELEVANCE TO CLINICAL PRACTICE: If breastfeeding rates are to increase, more attention should be paid to establish early breastfeeding and counter the negative influences of factors within the social environment.

Lower erythrocyte glutathione peroxidase activity in bronchopulmonary dysplasia in the first week of neonatal life.

BACKGROUND: Bronchopulmonary dysplasia (BPD) is a major pulmonary complication in premature infants and is considered a free radical disorder. Erythrocyte catalase (CAT) and cellular glutathione peroxidase (c-GPx) are antioxidant enzymes that detoxify peroxides generated from dismutation of superoxide anion. The study goal was to measure enzyme activity for preterm infants during the first week of life. METHODS: Blood samples were collected from umbilical arterial lines or the radial artery of 44 preterm infants (gestational age range: 25-30 weeks) on days 0, 2, and 5 after delivery. Erythrocyte CAT and c-GPx activities were evaluated, while clinical data were obtained and the correlations of enzyme activity and BPD status were examined. RESULTS: There was no correlation between enzyme activity and gestational age or birth weight. Packed red cell transfusion did not affect enzyme activity and there was no difference in CAT activity between the patient groups. C-GPx activity from preterm infants with BPD was significantly lower than those of preterm infants without BPD on day 5. CONCLUSIONS: Erythrocyte c-GPx may play an important role in the development of BPD. Lower c-GPx activity in early post-natal life might be a risk factor of BPD.

Prognostic factors and clinical features in liveborn neonates with hydrops fetalis.

The purpose of this study was to delineate the etiology and the clinical features of liveborn neonates with hydrops fetalis, and to explore the prognostic factors for survival. Medical records of 28 liveborn neonates with hydrops fetalis between April 1995 and March 2005 were reviewed retrospectively. Demographic data, clinical manifestations, laboratory findings, and outcomes were analyzed. Most patients presented with pleural effusions (21 of 28) and ascites (22 of 28). The majority of patients had hydrops due to cardiovascular diseases (seven of 28), hematologic disorders (six of 28), lymphatic malformations (six of 28), and idiopathic origins (six of 28). The overall survival rate was 50% and was highest (83%) in infants with lymphatic malformations. By univariate analysis, risk factors for mortality are earlier ages at diagnosis and at birth, low Apgar scores, need for resuscitation in the delivery room, low serum albumin level, and severe acidemia. After using stepwise multiple logistic regression analysis, the most significant factors associated with fatality were younger gestational age at birth and lower serum albumin level. Hydrops fetalis remains a complex condition with a high mortality rate. Hydrops resulting from lymphatic malformations has a favorable outcome. Preterm birth at less than 34 weeks and serum albumin concentration lower than 2 g/dL are two poor prognostic factors for survival.

Health-related quality of life among 3--4-year-old children born with very low birthweight.

AIM: This paper reports a study comparing health-related quality of life at 3-4 years of age among children born with very low birthweight (

Evolution of breast cancer screening in countries with intermediate and increasing incidence of breast cancer.

BACKGROUND: Few studies have been published regarding the practice of breast cancer screening in Asian countries. AIMS: The present study illustrates how the health policy for breast cancer screening has evolved in Taiwan from selective mammographic screening within a high-risk group, firstly to a programme of physical examination by public health nurses, and finally to a two-stage breast cancer screening programme, with a risk assessment followed by mammography for those at moderate to high risk. DATA SOURCES: Breast cancer screening has evolved from 1995 to 2004 in Taiwan in three stages: (1) selective screening for breast cancer with mammography, ultrasound and physical examination only in first-degree relatives of breast cancer cases (1995-1998); (2) a programme of mass screening (1999-2001) with physical examination by public health nurses; and (3) two-stage breast cancer screening with a risk factor questionnaire and mammography for those deemed at moderate-to-high risk (2002-2004). The questionnaire was based on significant risk factors in a previous epidemiological study, in conjunction with the physical examination programme, a risk score was constructed from the logistic regression coefficients from the previous study, and women with a score above the median in the previous epidemiological study were assigned to mammography. RESULTS: Two-stage mammography screening had the most favourable results compared with the two previous screening regimes. It had a positive predictive value of recall after mammography of 14%, compared with 8% for selective screening and 2% for physical examination. Of screen-detected cancers in the two-stage programme, 71% were either ductal carcinoma in situ or stage T1, compared with 61% for selective screening and 60% for physical examination. The area under the receiver operating characteristic curve was 71% for the two-stage programme. CONCLUSIONS: For a low- to medium-risk country such as Taiwan, two-stage screening has acceptable parameters of recall and cancer detection, and compares well with other screening strategies.

Successful removal of a ruptured silastic percutaneous central venous catheter in a tiny premature infant.

The spontaneous rupture of a Silastic catheter is a rare occurrence. We describe our experience of managing a tiny premature infant with embolization of a Silastic percutaneous central venous catheter (PCVC) and discuss the possible mechanisms of the embolization. A 28-week, 980 g, preterm male infant received a Silastic PCVC (Epicutaneo Cava Catheter, Vygon, Germany) for parenteral nutritional support at 4 days of age. The catheter was introduced percutaneously and advanced without difficulty through the right antecubital vein, and was subsequently withdrawn 2 cm following confirmation of tip position using radiography. A following chest radiograph, taken 15 hours later, showed rupture of the catheter, and an echocardiogram revealed a piece of the catheter had lodged between the right atrium and the right ventricle. The dislodged fragment of the catheter was retrieved successfully using a snare catheter (Microvena, White Bear Lake, Minn) by a pediatric cardiologist without complications. We want to stress that clinicians should be aware that rupture of the catheter is rare and can also occur asymptomatically and that an embolized fragment can be safely removed without extensive surgical manipulation, even in a tiny premature infant.

Development and psychometric properties of the Chinese language version of the TAPQOL: a health-related quality of life instrument for preschool children.

The objectives of this study were to assess psychometric properties of the Mandarin version of the TZO-AZL Preschool Children Quality of Life (TAPQOL) questionnaire in Taiwanese preschool children. Two groups of children, a very low birthweight group (n=118) and a not-very low birthweight group (n=170), were recruited. The internal consistency was acceptable and the correlation coefficients between the 12 subscales were low. Confirmatory factor analysis supported the 12-factor structure. Children with very low birthweight had significantly lower quality of life scores. This instrument may be used in clinical and research applications to investigate quality of life among preschool children.

Erythrocyte Cu/Zn superoxide dismutase activity in preterm infants with and without bronchopulmonary dysplasia.

BACKGROUND: Erythrocyte Cu/Zn superoxide dismutase is believed to play a major role as a first-line antioxidant defense. Studies have reported varying results from measures of superoxide dismutase activity in cord blood samples from neonates. OBJECTIVE: The study goal was to assess enzyme activity for preterm infants representing a range of gestational ages during the 1st week of life. Clinical data were obtained and correlations with superoxide dismutase activity were examined. METHODS: We collected blood samples from umbilical arterial lines or the radial artery of 44 preterm infants (gestational age range 25-30 weeks) on days 1, 3, and 6 after delivery and evaluated erythrocyte Cu/Zn superoxide dismutase activity. RESULTS: There was no correlation between enzyme activity and gestational age or birth weight. Superoxide dismutase activity gradually increased in preterm infants with bronchopulmonary dysplasia on days 3 and 6, with levels significantly higher than those of preterm infants without bronchopulmonary dysplasia on day 6. We found that packed red cell transfusion did not affect erythrocyte superoxide dismutase activity in either group. However, higher cumulative oxygen administration was noted in preterm infants with bronchopulmonary dysplasia. CONCLUSION: Higher cumulative oxygen administration may be one factor that upregulates the activity of erythrocyte superoxide dismutase.

Early-onset Escherichia coli sepsis presenting as acute scrotum in preterm infant.

Epididymitis, or epididymo-orchitis, and infected hydrocele are unusual in the neonatal period. It is critical to differentiate them rapidly from testicular torsion to salvage the affected testis and avoid unnecessary surgical exploration. Escherichia coli is an important gram-negative bacteria causing diverse neonatal infections and is also the common bacteria causing epididymo-orchitis from an ascending route. We report the case of a preterm infant affected with epididymo-orchitis and infected hydrocele caused by early-onset E. coli sepsis. We highlight the importance of sampling proper cultures and using suitable antibiotics after excluding testicular torsion in a neonate with an acute scrotum.

Connatal tuberculosis in a very premature infant.

UNLABELLED: Connatal tuberculosis is increasing in incidence and the mortality and morbidity of this disease remains high. We report a 27-week-old, 896 g female premature infant who had mild respiratory distress syndrome after birth. She developed signs of infection, progressive pneumonia and atelectasis which did not respond to mechanical ventilation and antibiotics. At 41 days of age, Mycobacterium tuberculosis was isolated from the non-bronchoscopic bronchoalveolar lavage. The isolate was sensitive to isoniazid, rifampin, streptomycin, and pyrazinamide. Miliary tuberculosis was subsequently diagnosed in her mother on a chest X-ray film and sputum cultures. The infant was treated successfully with anti-tuberculosis drugs. She had normal growth and development at the chronological age of 20 months old. CONCLUSION: Connatal tuberculosis should be considered in premature infants with symptoms of sepsis refractory to antibiotics. Most premature infants with connatal tuberculosis have lung involvement, and non-bronchoscopic bronchoalveolar lavage can be a useful procedure to establish the diagnosis.

Antioxidant profiles in full term and preterm neonates.

BACKGROUND: Free radical damage has been recognized to be a common pathogenic mechanism of many neonatal diseases associated with oxygen toxicity. METHODS: A set of antioxidant measurements were used to investigate differences in levels between full term and premature infants after birth. Four groups of full term and preterm infants were enrolled, including full term appropriate-for-age (FT-AGA), full term small-for-age (FT-SGA), larger preterm (LPT) and smaller preterm infants (SPT). After birth, seven antioxidants, including superoxide dismutase (SOD), catalase (CAT), glutathione (GSH), nicotinamide-adenine dinucleotide phosphate (NADP) represented by the NADPH ratio (NADPH, the reduced form of NADP)/(NADPNADPH), glucose-6-phosphate dehydrogenase (G6PD), and vitamins A and E were measured. RESULTS: FT-SGA infants had significantly lower levels of GSH, NADPH ratio and vitamin A than the FT-AGA infants but higher CAT, G6PD and vitamin E levels. LPT infants had lower levels of CAT, GSH, NADPH ratio and vitamin A but higher G6PD activity than the FT-AGA infants. SPT infants showed the same pattern of differences in various antioxidants as those of the LPT infants when compared to FT-AGA infants. Vitamin E levels did not statistically differ between SPT and LPT infants. SPT infants had significantly lower levels of GSH and NADPH ratio than the LPT infants. CONCLUSIONS: Intrauterine growth retardation and prematurity may influence antioxidant imbalance and free radical damage. In addition, such data for healthy full term and preterm infants may be used as reference data when evaluating antioxidant deficiency in high-risk neonates.

Reexpansion pulmonary edema following patent ductus arteriosus ligation in a preterm infant.

Reexpansion pulmonary edema (RPE) is rare and usually follows rapid reexpansion of a collapsed lung. We report on a preterm infant who developed pulmonary edema within an hour of surgical ligation of patent ductus arteriosus (PDA). There were no other cardiac anomalies, fluid overload or airway obstruction to explain the change in clinical status. With supportive treatment the patient's condition became stable and was extubated within 48 hours. Lung retraction for better field exposure is often needed when performing PDA ligation in preterm infants. Reinflation of a retracted lung is thought to be the cause of our patient's pulmonary edema. We conclude that RPE, although uncommon, may occur following surgical ductal ligation and that clinicians should be aware of such a possible complication.

Extravasation of calcium gluconate concomitant with osteomyelitis in a neonate.

Extravasation of calcium gluconate is not an uncommon complication in neonatal units, which may result in skin and soft tissue inflammation, injury and even infection. We report an 11-day-old preterm infant who developed osteomyelitis at an infiltrated intravenous site through which calcium gluconate was infused. The patient was initially treated conservatively as a simple calcium-infiltrate. Clinical condition deteriorated until proper antibiotic treatment was given. We exclude other possible causes and assume that calcium-infiltrate had an important role in the pathogenesis. We conclude that osteomyelitis should be considered in a patient with calcium extravasation whose soft tissue inflammation does not improve as expected. Furthermore, using a diluted calcium solution and checking the insertion site frequently in order to identify extravasation earlier would prevent the complication.

[Concepts and measures of health-related quality of life for children].

Health-related quality of life is considered an important outcome indicator in medical care, yet few studies have been conducted on Taiwanese children's health-related quality of life due to the lack of a measurement tool and no clear agreement on a concept definition. The authors present a review of previous work done in this area with the intended goal of helping Taiwanese health professionals gain insights into the concept of children's quality of life and to incorporate their new knowledge into their care plans. It is also hoped that the information will help researchers in their efforts to study quality of life among children as an indicator for assessing pediatric patient outcomes.

Clinical experience with ganciclovir and anti-cytomegalovirus immunoglobulin treatment for a severe case of congenital cytomegalovirus infection.

We report on a female neonate with severe onset of congenital cytomegalovirus (CMV) infection. She was noted to have cerebral ventriculomegaly on antenatal ultrasound, and presented with petechia after birth. Laboratory tests revealed severe thrombocytopenia (platelet count, 11,000/mm3) and hypoglycemia (serum glucose level, 5 mg/dl). Hepatosplenomegaly with elevated hepatic enzymes, retinitis, conjugated hyperbilirubinemia, and diffuse brainstem anomaly were also found in subsequent examinations. The diagnosis was confirmed by positive CMV-IgM from serum and the isolation of CMV from a urine sample. The patient received intravenous ganciclovir and human anti-CMV immunoglobulin during admission. She was discharged at the age of 61 days and followed-up monthly at our clinics. Symptoms and signs subsided except for mild cerebral ventriculomegaly at her last visit. We demonstrate a successful treatment with the combined use of ganciclovir and anti-CMV immunoglobulin.

Hyperbilirubinemia in healthy neonates with glucose-6-phosphate dehydrogenase deficiency.

A cohort study was carried out to assess the association between glucose-6-phosphate dehydrogenase (G6PD) deficiency, diagnosed by quantitative enzyme assay, and neonatal hyperbilirubinemia, defined as serum total bilirubin >/=15 mg/dl, in the well-baby nursery of Chang Gung Children's Hospital. Among 42,110 inborn infants, 757 male (3.54%) and 326 female (1.57%) newborns were G6PD-deficient. Compared to the occurrence of hyperbilirubinemia in G6PD-normal newborns (1.41% in male, 1.44% in female) in the well-baby nursery, a significantly higher incidence was observed in both G6PD-deficient male (11.36%) and female (7.06%) newborns. Further analyses demonstrated that the enzyme activity of G6PD in G6PD-deficient male newborns with hyperbilirubinemia (1.56+/-1.37 U/g Hb) were significantly lower than the subjects without hyperbilirubinemia (2.01+/-1.7 U/g Hb). No significant difference was observed in G6PD-deficient female newborns with hyperbilirubinemia (6.91+/-2.76 U/g Hb) compared to those without hyperbilirubinemia (7.81+/-2.84 U/g Hb). These data suggest that the G6PD-deficient neonates are at increased risk for hyperbilirubinemia even in the nursery free from agents that can potentially cause hemolysis to G6PD-deficient red cells. The lower G6PD enzyme activity was associated with the neonatal hyperbilirubinemia in G6PD-deficient male neonates.

Clinical consequences of twin-to-twin transfusion.

Twin-to-twin transfusion (TTT) is a complication of monochorionic twins that may result in high mortality and morbidity. To better understand pathophysiology in TTT and the consequences for affected fetuses and neonates, we describe the clinical features of 19 consecutive pregnancies complicated by TTT over 5 years. The diagnosis was made based on the findings of polyhydramnios-oligohydramnios sequence with weight discordance judged by obstetrical sonogram in monochorionic twins. Serial amnioreductions were performed as the sole modality of therapeutic intervention when indicated. The obstetrical diagnosis of TTT was first made at a median gestational age of 26 weeks (range 20-35 weeks). Median age of delivery was 30 weeks (range 26-36 weeks). Thirty-three babies of the 19 pairs of twins were born alive, but only 21 of them lived beyond 28 days of life. Fifteen pairs of twins with TTT had weight discordance greater than 20%, but only one pair showed initial hemoglobin difference greater than 5 g/dl. Newborn infants with TTT were at risk for development of renal insufficiency, periventricular leukomalacia, and necrotizing enterocolitis. Intrauterine fetal demise of one twin and severe anemia (hemoglobin <10 g/dl) at birth were poor prognostic factors. Recent advances in perinatal care improves pregnancy outcome of TTT; however, surviving neonates are still at risk for morbidities arising from hemodynamic aberrations.

Catheter-related superior vena cava syndrome complicated by chylothorax in a premature infant.

A premature infant experienced respiratory distress due to chylothorax. Contrast-enhanced chest computed tomography showed superior vena cava (SVC) obstruction with collaterals, and surgery confirmed an obstruction of the SVC by intravascular fibrotic tissue and thrombi caused by placement of a central venous catheter. The respiratory distress improved after surgical intervention. In the differential diagnosis of acute respiratory distress, it is necessary to consider catheter-related chylothorax and SVC syndrome when a previously stable patient has an acute change in cardiopulmonary status, regardless of the duration of catheter use. Although often considered safe and easy, central venous catheter placement may result in complications. Using appropriate catheters and choosing proper insertion sites can minimize these events. Early diagnosis and treatment can be life-saving should complications occur.