Neonatal outcome of infants with umbilical cord arterial pH less than 7.

INTRODUCTION: Umbilical arterial pH of less than 7 is often used as the threshold below which the risks of neonatal death and adverse long-term neurological outcomes are considered to be higher. Yet within the group with pH <7, the risks have not been further stratified. Here, we aimed to investigate the predictors of adverse long-term outcomes of this group of infants. MATERIAL AND METHODS: This was a retrospective study of 248 infants born after 34 weeks of gestation in a tertiary obstetric unit, between 2003 and 2017, with cord arterial pH <7 or base excess ≤-12 mmol/L at birth. The infants were categorized into two groups: (1) intact survivors, or (2) neonatal/infant deaths or cerebral palsy or developmental delay. The umbilical arterial pH and base excess levels, Apgar scores, mode of delivery, gestational age, small for gestational age, birth in the era before the implementation of neonatal hypothermic therapy, and the presence of a known sentinel event, were compared between the groups using univariate analysis followed by multivariate analysis. RESULTS: Among the 248 infants, there were 222 intact survivors (89.5%) and 26 infants with poor outcomes (10.5%), including eight deaths (3.2%) and 18 (7.3%) with cerebral palsy and/or developmental delay. Univariate analysis showed that infants with adverse outcomes had significantly lower cord arterial pH (6.85 vs 6.95, with p < 0.001), lower cord arterial base excess (-19.95 vs -15.90 mmol/L, p < 0.001), a higher proportion of having AS at 5 min <7 (65.4% vs 13.1%, p < 0.001), and a higher proportion of having a sentinel event (34.6% vs 16.7%, p = 0.034). Multivariate analysis confirmed cord arterial pH of <6.9 and an Apgar score at 5 min <7 as independent prognostic factors (the adjusted odds ratios were 4.64 and 6.62, respectively). The risk of adverse outcome increased from 4.3% when the arterial pH was between 6.9 and <7, to 30% when the pH was <6.9. CONCLUSIONS: Infants born with umbilical artery pH <7 still have a high chance of 89.5% to become intact survivors. A cord arterial pH of <6.9 and an Apgar score at 5 min <7 are independent prognostic factors for neonatal/infant death or adverse long-term neurological outcomes.

Gestational age-specific neonatal mortality in Hong Kong: a population-based retrospective study.

BACKGROUND: The neonatal period is the most vulnerable period during childhood, with the risk of death being the highest even in developed countries/regions. Hong Kong's neonatal mortality (1‰) is among the world's lowest and has remained similar for 15 years. This study aimed to explore neonatal deaths in Hong Kong in detail and determine whether neonatal mortality is reducible at such a low level. METHODS: Live births in public hospitals in Hong Kong during 01 Jan 2006-31 Dec 2017 were included. Relevant data were extracted from the electronic medical records. Gestational age-specific mortality was calculated, and the trends were analyzed using the Cochran-Armitage trend test. Causes of death were summarized, and risk factors were identified in multivariate logistic regression analysis. RESULTS: In 490,034 live births, 755 cases (1.54‰) died during the neonatal period, and 293 (0.6‰) died during the post-neonatal period. The neonatal mortality remained similar overall (P = 0.17) and among infants born at 24-29 weeks' gestation (P = 0.4), while it decreased in those born at 23 (P = 0.04), 30-36 (P < 0.001) and ≥ 37 (P < 0.001) weeks' gestation. Neonates born at < 27 weeks' gestation accounted for a significantly increased proportion among cases who died (27.6% to 51.9%), with hemorrhagic conditions (24%) being the leading cause of death. Congenital anomalies were the leading cause of death in neonates born ≥ 27 weeks' gestation (52%), but its cause-specific mortality decreased (P = 0.002, 0.6‰ to 0.41‰), with most of the decrease attributed to trisomy 13/18 and multiple anomalies. CONCLUSION: Reduction of neonatal mortality in developed regions may heavily rely on improved quality of perinatal and neonatal care among extremely preterm infants.

Clinical practice guideline on the prevention and management of neonatal extravasation injury: a before-and-after study design.

BACKGROUND: Extravasation injury resulting from intravenous therapies delivered via peripheral intravenous catheters or umbilical and peripherally inserted central venous catheters is a common iatrogenic complication occurring in neonatal intensive care units. This study aimed to evaluate the effectiveness of an evidence-based clinical practice guideline in the prevention and management of neonatal extravasation injury by nurses. METHODS: A controlled before-and-after study was conducted in a neonatal unit. The clinical practice guideline was developed, and a multifaceted educational program was delivered to nurses. Neonatal outcomes, including the rates of peripheral intravenous extravasation and extravasation from a central line, were collected at the pre- and post-intervention periods. Post-intervention data for nurses, including the nurses' level of knowledge and adherence, were collected at six months after the program. RESULTS: 104 and 109 neonates were recruited in the pre-intervention period (control) and the post-intervention period (intervention), respectively. The extravasation rate before and after the intervention was 14.04 and 2.90 per 1,000 peripheral intravenous catheters days, respectively. The adjusted odds ratio of peripheral intravenous extravasation post-intervention compared with that of pre-intervention was 0.20 (95% confidence interval: 0.05-0.74; p = 0.02) after adjusting for peripheral intravenous catheter days. The extravasation from a central line rate of the control and intervention groups post-intervention was 4.94 and zero per 1,000 central venous catheter days, respectively. Fifty-nine registered nurses were recruited. At six months post-program, there were significant improvements in the nurses' level of knowledge and adherence. CONCLUSIONS: These findings suggest that the implementation of an evidence-based clinical practice guideline significantly reduced the rate of peripheral intravenous extravasation and extravasation from a central line in neonates. However, to maintain nurses' knowledge and adherence to the evidence-based practice, the educational program will have to be conducted periodically and incorporated into the nurses' induction program. TRIAL REGISTRATION: ClinicalTrials.gov, Identifiers: NCT04321447 . Registered 20 March 2020 - Retrospectively registered.

Rotavirus vaccine effectiveness in Hong Kong children.

BACKGROUND: Rotavirus is a common infectious cause of childhood hospitalisation in Hong Kong. Rotavirus vaccines have been used in the private sector since licensure in 2006 but have not been incorporated in the government's universal Childhood Immunisation Programme. This study aimed to evaluate rotavirus vaccine effectiveness against hospitalisation. METHODS: This case-control study was conducted in the 2014/2015 rotavirus season in six public hospitals. Hospitalised acute gastroenteritis patients meeting inclusion criteria were recruited and copies of their immunisation records were collected. Case-patients were defined as enrolled subjects with stool specimens obtained in the first 48h of hospitalisation that tested positive for rotavirus, whereas control-patients were those with stool specimens obtained in the first 48h of hospitalisation testing negative for rotavirus. Vaccine effectiveness for administration of at least one dose of either Rotarix(®) (GlaxoSmithKline Biologicals) or RotaTeq(®) (Merck Research Laboratories) was calculated as 1 minus the odds ratio for rotavirus vaccination history for case-patients versus control-patients. RESULTS: Among the 525 eligible subjects recruited, immunisation records were seen in 404 (77%) subjects. 31% (162/525 and 126/404) tested positive for rotavirus. In the 404 subjects assessed for vaccine effectiveness, 2.4% and 24% received at least 1 dose of either rotavirus vaccine in case- and control-patients respectively. The unmatched vaccine effectiveness against hospitalisation for administration of at least one dose of either rotavirus vaccines was 92% (95% confidence interval [CI]: 75%, 98%). The matched analyses by age only and both age and admission date showed 96% (95% CI: 72%, 100%) and 89% (95% CI: 51%, 97%) protection against rotavirus hospitalisation respectively. CONCLUSIONS: Rotavirus vaccine is highly effective in preventing hospitalisation from rotavirus disease in young Hong Kong children.

Cervical myelopathy in an adolescent with Hallervorden-Spatz disease.

Hallervorden-Spatz disease is a rare neurodegenerative disorder characterized by progressive dystonia, rigidity, and dementia. In these patients, chronic repeated dystonic movements, especially of the head and neck, can lead to excessive stress on the cervical spine, resulting in early degenerative changes and myelopathy. This report focuses on a young patient with Hallervorden-Spatz disease who presented with C4 to C5 cervical disk extrusion and cord compression because of premature spondylotic changes of the cervical spine. Other authors have documented cervical spondylosis caused by movement disorders, but there had been no reported cases of cervical myelopathy as a complication of Hallervorden-Spatz disease. Because these patients already manifest a longstanding and progressive neurologic disorder, clinicians may encounter difficulties recognizing the symptoms and signs of new cervical pathology, especially if the spondylosis and myelopathy has an insidious onset. For follow-up of patients with Hallervorden-Spatz disease who have multiple disabilities, a multidisciplinary approach with active involvement of physiotherapists, occupational and speech therapists, experienced nurses, caregivers, and clinicians is recommended. The clinician should also monitor the neurologic and functional status of the patient and screen for cervical pathology if suspicion arises. Good control of dystonia may be helpful in prevention of cervical spondylosis but may be difficult to achieve. Treatment modalities for dystonia are also discussed.