Arsenic, cadmium, lead, and aluminium concentrations in human milk at early stages of lactation.

BACKGROUND: Human milk is considered to be the best nutrition for all infants because it provides the optimal source of nutritional, immunological, developmental, psychological, economic, practical, and environmental benefits in both the short and long terms. To the best of our knowledge, few studies in Taiwan have examined the toxicant levels in breast milk and associated factors. METHODS: The research was carried out over a 6-month period. Forty-five healthy lactating women, who delivered full-term newborns at our maternity ward, were recruited, and all participants had been living in coastal urban areas of mid-Taiwan for at least 3 years. One hundred and eighty human milk samples were collected on four occasions, which were classified into four lactation stages as follows: colostrums, transitional milk, early mature milk, and mature milk. RESULTS: We found that lead, cadmium, aluminium, and arsenic concentrations were the highest in colostrums: 13.22 ± 3.58 ng/mL, 1.37 ± 0.94 ng/mL, 56.45 ± 22.77 ng/mL, and 1.50 ± 1.50 ng/mL, respectively. The results of lead, cadmium, aluminium, and arsenic determination in human milk samples demonstrated a trend of decline of microelement concentrations with advancing stages of lactation. We found that the infants of smoking mothers were exposed to more cadmium than infants of nonsmoking mothers (p < 0.05). CONCLUSION: According to our findings, frequent routine sampling of breast milk is worthwhile. Prevention strategies including behavior modification and education on proper nutrition should be provided to women who are at high risk of toxicant exposure. In summary, breastfeeding is still generally encouraged and recommended.

Risk factors of catheter-related bloodstream infection with percutaneously inserted central venous catheters in very low birth weight infants: a center's experience in Taiwan.

BACKGROUND: Infected percutaneously inserted central venous catheters (PICCs) are a problem in hospitalized patients, especially in the neonatal intensive care unit. The objective of this study was to assess the risk of infection and other PICC-associated complications in very low birth weight infants. METHODS: Between January 2005 and December 2006, we studied 412 PICCs inserted in 267 neonates with a birth body weight ≤ 1500g. PICC-related bloodstream infections and other complications were recorded and analyzed. RESULTS: These 412 PICCs were inserted for a mean duration of 16.6 ± 9.9 (SD) days. The most common catheter-related complications were catheter-related blood-stream infection (CRBSI; incidence: 8.3 per 1000 catheter days), followed by catheter occlusion (4.0 per 1000 catheter days), catheter site inflammation (3.5 per 1000 catheter days), and phlebitis (3.1 per 1000 catheter days). The most common pathogen of CRBSI was coagulase-negative staphylococcus (40.1%). Significant risk factors of CRBSI included catheters inserted at femoral sites (increased risk of CRBSI compared with nonfemoral catheters: 1.76; 95% confidence interval, 1.01-3.07, p = 0.045) and a longer duration of PICC placement (p < 0.001). A low birth body weight and gestational age were not found to significantly affect the risk of CRBSI. CONCLUSION: It is important to avoid inserting a PICC at the femoral site. Strict catheter care protocol should also be applied to reduce local site bacterial colonization and removal of PICCs as soon as they are no longer essential for patient care to reduce the incidence of infection.

Congenital colonic atresia: report of one case.

Colonic atresia is a very rare cause of intestinal obstruction, and surgical management is the mainstay of therapy. A case of congenital colonic atresia is reported in a full-term neonate who presented with delayed passage of meconium, abdominal distention and bilious vomiting. The present case and the pertinent literature are discussed, with an emphasis on surgical management.

Clinical manifestations of symptomatic intracranial hemorrhage in term neonates: 18 years of experience in a medical center.

BACKGROUND: Intracranial hemorrhage (ICH) is an uncommon but important cause of morbidity and mortality in term neonates. We conducted a retrospective analysis of the clinical characteristics and developmental outcomes of symptomatic ICH in term neonates. METHODS: A retrospective chart review was conducted of all term neonates (less than 1 month old) diagnosed with ICH and admitted to the neonatal intensive care unit of Kaohsiung Chang Gung Hospital from December 1991 to December 2008. Demographic characteristics, mode of delivery, laboratory data, clinical presentation, and developmental status were recorded. RESULTS: Data for 24 term neonates (17 boys and 7 girls) with a diagnosis of ICH were collected for analysis. The clinical manifestations of ICH included anemia (13/24, 54%), seizure (11/24, 46%), cyanosis (7/24, 29%), tachypnea (5/24, 21%), fever (1/24, 4%), hypothermia (1/24, 4%), and poor feeding (1/24, 4%). Age at symptom onset ranged from 2 hours to 11 days following birth. The most common type of ICH was subdural hemorrhage. All ICHs resolved, except in one infant, who died from hypoxicischemic encephalopathy at 25 days. Ten children with symptomatic ICH were reported to have normal development, while the remainder (13/23, 57%) showed developmental delays or disabilities. CONCLUSION: Unexplained anemia, seizure, and cyanosis were the major presenting signs in infants with symptomatic ICH. A diagnosis of ICH should be considered in term neonates who present with one or more of these signs. Although the mortality in term infants with symptomatic ICH was low, more than half.

Congenital diaphragmatic hernia in the neonatal period: review of 21 years' experience.

BACKGROUND: Despite advances in therapeutic modalities, congenital diaphragmatic hernia (CDH) still accounts for significant neonatal mortality. This study aimed to describe the demographic features, clinical experiences of postnatal care, and differences between non-survivors and survivors with CDH. METHODS: We retrospectively reviewed medical records of neonates with CDH admitted to Kaohsiung Chang Gung Memorial Hospital over a 21-year period. Neonates with diaphragmatic eventration and those transferred after surgery were excluded. RESULTS: A total of 24 live-born neonates fulfilled the study criteria; 13 (54%) were boys and 11 (46%) were girls. Eight (33%) patients were prenatally diagnosed. The mean gestational age was 38.8 +/- 1.8 weeks (range, 35-41 weeks). Twenty-three (96%) had Bochdalek hernia [19 (83%) left-sided, 4 (17%) right-sided], and one (4%) had right-sided Morgagni hernia. Additional major congenital anomalies were identified in five patients (21%). The overall mortality was 21% (5/24); all deaths occurred before surgery. Statistically significant differences between survivors and non-survivors were found for right-sided CDH, low 1-minute and 5-minute Apgar scores, and low pH of the first arterial blood gas. Deaths were attributed to severe persistent pulmonary hypertension, unresponsiveness to aggressive resuscitation at birth, and major associated malformations. CONCLUSION: Seventy-nine percent of our CDH patients survived to hospital discharge. Resuscitation by a skilled neonatology team to prevent low Apgar scores and low pH, careful evaluation of other anomalies, and overcoming pulmonary hypertension might improve the survival rate. Recognizing unfavorable factors in CDH may help clinicians manage the critical care of these babies.

Biliary atresia associated with meconium peritonitis.

Biliary atresia, malrotation, meconium peritonitis and transient hypothyroidism are occasionally seen in neonatal infants. Biliary atresia associated with malrotation has been reported in some patients with polysplenia syndrome, but biliary atresia associated with meconium peritonitis has only been described by a few investigators. Here we present a case of meconium peritonitis due to malrotation with volvulus, followed by biliary atresia and transient hypothyroidism during early infancy.

The effect of supplementation of docosahexaenoic acid and arachidonic acid on visual acuity and neurodevelopment in larger preterm infants.

BACKGROUND: Preterm infants may be born with deficits of both docosahexaenoic acid (DHA) and arachidonic acid (AA), but studies on supplementation of DHA and AA for preterm infants are limited. METHODS: Preterm infants with a gestational age between 30 and 37 weeks who met all the inclusion criteria were enrolled in this double blind, randomized, comparative study. Infants over 2000 g body weight, over 32 weeks of gestation and in full feeding status would enter into the active intervention period of 6 months. Sixteen infants received Neoangelac Plus with AA and DHA supplementation. Eleven infants received Neoangelac without AA and DHA supplementation. The babies had scheduled physical examinations and their cognitive development, visual acuity, and vital signs to be checked. Adverse events were also recorded. RESULTS: The mean Mental Development Index (MDI) scores for the supplementation and non-supplementation groups were 96.1 +/- 8.6 and 91.7 +/- 10.4 respectively at 6 months and 98.7 +/- 8.0 and 90.5 +/- 6.9 respectively at 1 year. The mean Physical Development Index (PDI) scores of these two groups were 102.2 +/- 10.5 and 95.4 +/- 13.2 respectively at 6 months and 98.0 +/- 5.8 and 86.7 +/- 11.1 respectively at 1 year. By repeated measures ANOVA, significant differences existed between groups for MDI and PDI (p = 0.020 and 0.008). However, there were no differences in visual acuity, physical examination variables or vital signs between these two groups. No obvious adverse effects were observed during the study period. CONCLUSION: These results showed possible benefits in the neurodevelopment of larger preterm infants given formula supplemented with DHA and AA.

Risk factors for hemodynamically-unrelated cystic periventricular leukomalacia in very low birth weight premature infants.

BACKGROUND AND PURPOSE: Periventricular leukomalacia (PVL) is one of the most important complications of prematurity, but its cause remains unclear. This study investigated the risk factors for hemodynamically-unrelated cystic PVL in very low birth weight (VLBW) premature infants. METHODS: VLBW premature infants admitted to the neonatal intensive care unit from 1998 through 2002 were included in this retrospective study. Infants who had congenital lethal anomalies or who died before a cranial scan could be done were excluded. All VLBW infants received serial cranial ultrasound examinations to screen for cystic PVL during hospitalization. Infants with cystic PVL were divided into those with or without a hemodynamic event of sufficient severity to potentially cause cystic PVL. The charts of all included infants were reviewed and relevant clinical parameters were analyzed. RESULTS: Cystic PVL occurred in 20 VLBW infants (6.9%) during the study period. Four of these infants (20%) had hemodynamic events before the development of cystic PVL and 16 (80%) had hemodynamically-unrelated cystic PVL. Univariate analysis showed that infants with hemodynamically-unrelated cystic PVL were more likely to have symptomatic patent ductus arteriosus (PDA) [p < 0.01] and bronchopulmonary dysplasia (BPD) [p < 0.01]. However, logistic regression indicated VLBW premature infants with BPD combined with symptomatic PDA (odds ratio, 8.92; 95% confidence interval, 2.55-31.20; p < 0.01) were at greatest risk for development of hemodynamically-unrelated cystic PVL. CONCLUSION: BPD and symptomatic PDA were more common in infants with hemodynamically-unrelated cystic PVL, although the reasons for these associations were unclear. Serial cranial scans are strongly suggested for VLBW premature infants with BPD and symptomatic PDA to screen for the development of cystic PVL.

Risk factors of retinopathy of prematurity in premature infants weighing less than 1600 g.

There are many risk factors contributing to retinopathy of prematurity (ROP). Some are still controversial, including the use of glucocorticoid and intraventricular hemorrhage. Hence, a retrospective study was performed to evaluate the association between the suspected risk factors and ROP in a medical center in southern Taiwan. One hundred fifty-nine infants with birth body weight < 1600 g admitted to our neonatal intensive care unit before the 29th day of life were enrolled into this study. Clinical data were analyzed by means of logistic regression. The prevalence of ROP in all infants (birthweight < 1600 g) is 36.48% (58 of 159) and 59.46% (22 of 37) in extremely low birthweight infants (birthweight < or = 1000 g). One infant with gestational age 32 weeks and birthweight 1420 g developed stage III ROP. Logistic regression revealed six factors to be significant variables. Birthweight < or = 1000 g, intraventricular hemorrhage, sepsis, and use of glucocorticoid or dopamine were risk factors associated with higher incidence of ROP. Supplementation of vitamin E was shown to relate to lower incidence of ROP. This study confirms several risk factors recognized in previous statistical analyses. Sepsis is the most significant factor contributing to ROP. Vitamin E was proven to be effective in prophylaxis of development of ROP. The possibility of development of ROP could not be excluded in infants with gestational age > 32 weeks.

Periventricular echogenicity is related to delayed neurodevelopment of preterm infants.

Periventricular leukomalacia (PVL) is one of the most commonly seen neuropathologic lesions and is related to many neurodevelopmental handicaps in premature infants. Periventricular echogenicities (PVE) are considered to be at the milder end of the spectrum of PVL, and thus might affect the neurodevelopment of the preterm infants as well. In this retrospective cohort study medical records of 257 preterm infants who were discharged from our neonatal intensive care unit (NICU) during October 1996 to August 2000 were reviewed. A total of 114 records of preterm infants fulfilling our criteria were included in the survey. On the basis of the craniosonographic findings and birth history, the candidates were divided into three subgroups: group 1 (control) included infants with normal craniosonographic image during the neonatal period; group 2 included infants with PVEs for < 2 weeks during the neonatal period; group 3 included infants with PVEs> or = 2 weeks during the neonatal period. Neurodevelopmental assessment using the Bayley Scale of Infant Development II at 6, 12, and 18 months of corrected age of each group was compared. There were no significant differences among the three groups in gestational age, birth weight, and gender prevalence. Infants in group 3 had lower Mental Developmental Index and Psychomotor Developmental Index scores as compared with those in groups 1 and 2 at 6 ( p< 0.01), 12 ( p < 0.001), and 18 ( p < 0.01) months of corrected age, respectively. In conclusion, infants with PVEs that persisted for at least a 2-week period have significantly higher risk of delayed developmental outcomes as compared with infants with normal craniosonography or infants with PVEs that persisted for less than 2 weeks. It might be prudent to arrange therapeutic intervention for rehabilitation to these high-risk infants as early as possible to reduce the intensity of possible handicap in the future.

Sudden hearing loss as the initial manifestation of chronic myeloid leukemia in a child.

Hearing loss and blindness rarely occur in patients with chronic myeloid leukemia (CML). In this article, we present a 12-year-old girl who had right-side hearing loss as the initial manifestation of CML, followed by left-side hearing loss and blindness of the left eye several days after initiating treatment. The initial white cell count was 181,700/mm3. Audiometry showed severe sensorineural hearing loss of her right ear and moderate mixed hearing loss of the left ear. An ophthalmic examination showed optic neuropathy with subhyaloid hemorrhage in the left eye. A brain magnetic resonance image showed minor hemorrhaging in the right lower frontal area and anterior thalamus. These findings might have implied leukostasis with hyperviscosity syndrome. She died on the 9th hospital day. This case illustrates that CML should be considered 1 of the rare diagnoses in a patient with sudden onset of hearing loss.

Neonatal group B streptococcal infection: a 7-year experience.

BACKGROUND: This retrospective study was designed to determine the trend of neonatal group B streptococcal (GBS) infection during the past 7 years at the Chang Gung Memorial Hospital of Kaohsiung, as well as to assess the risk factors, clinical features and patient outcomes. METHODS: Medical records of infants with neonatal GBS infection identified by positive results of cultures of sterile body fluid in our hospital from January 1996 through December 2002 were reviewed for demographic and clinical data. RESULTS: There were 33 infants with neonatal GBS infections during the past 7 years in our hospital. The number of patients increased from 1996 to 2001. Sixteen infants had early onset infections and 17 infants had late onset infections. Of the nine patients with maternal risk factors in the early onset group, prolonged rupture of membranes (7, 44%) was most frequently encountered. Distressed respiratory sign (8, 50%) was the most common clinical presentation in early onset group, while fever >38 degrees C (17, 100%) was the most common presentation in late-onset group. The mortality rates were 13% and 6% in early and late onset groups, respectively. Gestational age (p = 0.05) and pneumonia (p = 0.015) were two most important factors influencing the mortality rate. CONCLUSIONS: The number of GBS-infected infants seemed to have increased during the past 7 years in our hospital. Because the incidence of neonatal GBS infection and maternal colonization in Taiwan has not been collected, we could not determine the necessity of intrapartum chemoprophylaxis. Setting a comprehensive surveillance in Taiwan should be considered.

Impaired SynGAP expression and long-term spatial learning and memory in hippocampal CA1 area from rats previously exposed to perinatal hypoxia-induced insults: beneficial effects of A68930.

Hypoxic encephalopathy is a common cause of neonatal seizures and long-term neurological cognitive deficits. In rats at postnatal days 10-12 (P10-P12), global hypoxia induced spontaneous seizures and chronic brain injury, mimicking clinical aspects of neonatal hypoxia. Synaptic Ras-GTPase activating protein (SynGAP) has important roles in RAS/MAPK-dependent synaptic plasticity and mammalian learning. We investigated possible alterations of SynGAP expression occurring in memory-impaired animals previously exposed to perinatal hypoxia insults. We also evaluated the therapeutic efficacy of A68930, a selective agonist of dopamine D1/D5 receptors, on perinatal hypoxia insults. In the hippocampal CA1 region, perinatal hypoxia insults (P10) led to a reduction in SynGAP expression associated with impairment in long-term spatial learning and memory performance at P45. The use of A68930 (at a dose of 1, 2, 3mg/kg, P17-P23) effectively attenuated the deleterious effects as described above. Our results may indicate the involvement of SynGAP in certain forms of brain injury, leading to long-term learning and memory deficits. A68930 may have clinical potential as a therapeutic agent for alleviation of long-term cognitive deficits in rats and other animal models.

Cord blood myeloperoxidase in preterm infants with periventricular hyperechogenicity.

BACKGROUND: Cytokines, adhesion molecules, and inflammatory mediators are believed to play central roles in the pathophysiologic mechanisms of brain white matter lesions. To examine the relationships of cytokines, adhesion molecules, and inflammatory mediators in the cord blood of preterm infants and neonatal cerebral ultrasound periventricular hyperechogenicity (PVH), cord blood cytokines, adhesion molecules, and inflammatory mediators were analyzed, and routine cerebral ultrasound scans were performed in all 96 premature infants. METHODS: The non-PVH group consisted of 20 infants with normal cerebral ultrasound findings during the first week of life. The PVH group consisted of 20 infants with PVH during the first week of life. Cytokines, adhesion molecules, and inflammatory mediators in cord blood including interleukin-8 (IL-8), prostaglandin E2 (PGE2), P-selectin, soluble vascular cell adhesion molecules (sVCAMs), and myeloperoxidase (MPO) were examined by enzyme-linked immunosorbent assay. RESULTS: There were no significant differences in IL-8, PGE2, P-selectin, and sVCAM levels between patients with and without PVH. Interestingly, MPO levels were marginally significantly higher in patients with PVH than those without PVH (7.46 +/- 3.6 vs. 4.81 +/- 3.5; p = 0.024). CONCLUSIONS: It is concluded that MPO from leukocytes may contribute to the occurrence of PVH in premature infants.

Feasibility of blood spot PCR in large-scale screening of fragile X syndrome in southern Taiwan.

BACKGROUND AND PURPOSE: Fragile X syndrome (FXS) is the most common form of hereditary mental retardation. Early diagnosis of the disease may lead to better prognosis for children who participate in early intervention programs. This study attempted to evaluate whether screening newborn boys with simple polymerase chain reaction (PCR) assay could be an effective approach for detection of mutation carriers and FXS, a process that may also facilitate detection of young carrier mothers. METHODS: Filter paper blood spot samples of 4843 newborn boys were collected from five hospitals in southern Taiwan. They were tested with a simple non-radioactive PCR for the presence of FMR1 gene mutation by determining the number of FMR1 CGG repeats. By this method, the examined sample can be reliably classified as normal (<40), intermediate (40-54), and mutant group (> 54), according to the number of CGG repeats. RESULTS: The FMR1 CGC repeat number of all but four samples was below 54, with 90 samples (1.8%) between 40 and 54 (the intermediate range). Two of the four abnormal samples were carriers of the premutation. The other two failed repeatedly in PCR amplification for the FMR1 gene, but not for the control K-ras gene. Hence, these samples seemed to be candidate carriers of large premutation or even full mutation, indicating the need for confirmation with standard Southern blot analysis. CONCLUSIONS: This study demonstrated that a simple PCR combined with blood spot sampling is effective and feasible for large-scale screening of newborn boys for fragile X carrier status. The relatively low carrier rate in this population suggests that the cost-effectiveness of implementation of such screening on a population-wide basis would be lower than in the Jewish and Caucasian populations.

Effect of nucleotides on diarrhea and immune responses in healthy term infants in Taiwan.

OBJECTIVES: The aim of this study was to compare the effects of an infant formula fortified with nucleotides (NF) with those of a control formula (CF) on the incidence of diarrhea, respiratory tract infections (RTIs), and immune responses in healthy term infants. METHODS: This 12-month, double-blind study was conducted on 1- to 7-day-old infants randomized to receive NF or CF exclusively until 12 weeks of age, and fed the assigned formula with solid food until 12 months. NF was supplemented with 72 mg/L of nucleotides, based on the total potentially available nucleotide content of human milk. Subjects were evaluated within 1 week of birth, at 4 weeks, and every 4 weeks thereafter until 48 weeks of age. The primary outcome variable was the incidence of diarrhea. Secondary variables included RTIs, serum immunoglobulin concentrations, and response to hepatitis B vaccine. RESULTS: Compared with subjects fed CF (n = 170), those fed NF (n = 166) had a trend toward reduced risk of diarrhea from 8 to 48 weeks of age and a significantly lower risk of 25.4% (P = 0.05) between 8 and 28 weeks. NF subjects had significantly higher serum immunoglobulin A concentrations ( P < 0.05) throughout the 48-week study. The NF group had an increased risk of upper RTIs, the same incidence of lower RTIs, and the same antibody response to hepatitis B vaccination as the CF group, based on one-sided tests. Growth was normal in both groups, and no adverse events were considered to be formula-related. CONCLUSIONS: Healthy term infants from 8 to 28 weeks of life are less likely to experience diarrhea and have higher serum immunoglobulin A concentrations with NF compared with formula without added nucleotides.

Liver abscess in children: a single institutional experience in southern Taiwan.

Liver abscess is uncommon in children. The purpose of this study is to evaluate the predisposing factors, pathogens, duration of hospitalization, and the managements of liver abscess in children. From 1986 to 2001, fifteen children were admitted to our hospital under the diagnosis of liver abscess. Thirteen cases were older than 8 years old and two were younger than one year old. Fever (15/15, 100%) and abdominal pain (13/15, 87%) were the most common symptoms. Twelve patients (80%) had prolonged fever (fever for 7 days or longer before diagnosis). Eleven (73%) cases were cryptogenic in origin. Most of the microorganisms were obtained solely from cultures of pus. Klebsiella pneumoniae was the most common organism isolated (6/15, 40%). Beside administration of antibiotics, percutaneous catheter drainage (PCD) was performed in 11 patients (73%); only one underwent surgical intervention due to poor response to PCD management. All of our patients were surviving after at least one year follow-up. In conclusion, liver abscess should be suspected in the patients with prolonged fever of unknown origin and abdominal pain. PCD combined with adequate antibiotics were sufficient for therapy of liver abscess in most cases. K. pneumoniae was the most common isolated pathogen in southern Taiwan.

Infected cephalohematoma complicated with meningitis: report of one case.

Infected cephalohematoma associated with meningitis is rarely reported. We report the case of 19-day-old female newborn with a cephalohematoma infected by Escherichia coli, and whose cerebrospinal fluid showed pleocytosis. Antibiotics alone could not eradicate the infection of the cephalohematoma, and surgical incision and drainage resulted in obvious clinical improvement. Three weeks of antibiotic usage completed the course of treatment.