Thromboembolic complications in Thai pediatric patients.

Sixty patients with thromboembolic complications from 1987 to 1997 at the Department of Pediatrics, Ramathibodi Hospital were retrospectively studied. Twenty patients were infants and 40 patients were children and adolescents with a mean age of 18 days and 8 years, respectively. The sites of thromboembolic complications were in the central nervous system, 27.5 per cent; skin as purpura fulminans or necrotic lesions, 24.5 per cent; gangrene of the toe, finger or colon, 19 per cent; deep vein thrombosis, 16 per cent; and other sites such as heart and lungs, 13 per cent. Most of them had triggering conditions (80%) and underlying diseases (76.7%) causing thromboembolism. The low levels of either antithrombin III, protein C or protein S were found in 42 per cent (15/36). The management included administration of standard or low molecular weight heparin if not contraindicated, replacement of fresh frozen plasma 10 ml/kg twice a day and treatment of underlying and triggering conditions. The fatality rate was 15 per cent (9/60). Subsequent episodes of thromboembolism occurred in 6 patients including: pulmonary emboli in one patient with protein C deficiency who refused warfarin administration, deep vein thrombosis in 2 patients with unidentified etiology, and necrotic skin lesions in 3 patients with vasculitis who did not respond to treatment. In conclusion, a comprehensive investigation and specific treatment for patients with thromboembolic complications are emphasized in order to prevent recurring episodes.

Disseminated intravascular coagulation findings in 100 patients.

A retrospective study of 100 patients with disseminated intravascular coagulation from 1993 to 1997 is reported. Forty-five patients were neonates with a mean age of 12.6 days and 55 patients were infants, children and adolescents with a mean age of 6 years and 3 months. Most of them (91.5%) had complicated underlying conditions which included congenital anomalies, prematurity, malignancy, hematological and various diseases. Additionally, every patient had triggering conditions commonly identified as gram-negative septicemia. Bleeding and thromboembolic manifestations were found in 59.4 per cent and 19.8 per cent, respectively. The laboratory findings revealed red blood cell fragmentation, 89.6 per cent and thrombocytopenia, 85.8 per cent. Natural anticoagulants were studied in a few cases and revealed low levels of antithrombin III and protein C. The prompt effective management included treatment of underlying diseases, identification and relief of triggering conditions, correction of thrombocytopenia and coagulopathy, and fully supportive care. The overall case-fatality rate was 41.6 per cent which was not correlated with age, underlying diseases, triggering conditions, manifestation of bleeding, thromboembolism or shock, and exchange transfusion. However, a significant lower case-fatality rate was found in patients with positive culture (25%) as compared to those with sepsis and negative culture (51.7%) (p = 0.044). In addition, the febrile neutropenic patients, who showed good response to the administrated granulocyte-colony stimulating factor (G-CSF), survived from the DIC.

Risk factors associated with morbidity and mortality of pneumonia in Thai children under 5 years.

ARI is the most common cause of illness and death in children under 5 years of age. Pneumonia is the leading cause of death. This prospective study was part of an ARIC project conducted to identify risk factors associated with mortality and morbidity of community acquired pneumonia in Thai children younger than 5 years of age. Study subjects were 267 moderately severe pneumonia who were admitted to hospital. Fifteen percent required a ventilator and were categorized as severe cases. Nine patients (3.4%) died and were categorized in the fatal group. From univariate analysis only, risk factors of fatal pneumonia were lower body weight (p = 0.04), paternal age less than 35 year (OR = 6.1, p = 0.01), underlying heart disease (OR = 12.1, p = 0.0000) and protein energy malnutrition (OR = 7.9, p = 0.0087). Predictors on admission to predict fatal outcome were rapid respiratory rate > 50/minute (OR = 4.1, p = 0.03), gallop rhythm (OR = 11, p = 0.04), enlarged liver (OR = 13.2, p = 0.001), and cyanosis (OR = 12, p = 0.0006). Significant factors associated with severe pneumonia after multiple logistic regression were underlying heart disease (OR = 4.04, 95% CI 1-15.4), enlarged liver (OR = 4.31, 95% CI 1.2-15.2) and cyanosis (OR = 5, 95% CI 0.8-28.7). This information should create awareness in physicians who are responsible for young children with pneumonia. Early recognition and intervention may prevent deaths and complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Early neonatal mortality and causes of death in Ramathibodi Hospital: 1981-1990.

PIP: This study examined the trends in early neonatal mortality by birthweight during 1981-90 at Ramathibodi Hospital in Thailand. Deaths were analyzed by causes of death within the first 7 days of life. Causes included congenital malformation, immaturity, asphyxia, respiratory distress syndrome (RDS), infection, and other causes. The results showed that 71,153 births occurred during the 10 year period, an increase of 22% over the period. Low birthweight increased from 6.3% in the first five years to 7.1% in the last five years. Very low birthweight (less than 1500 g) increased from 0.47% in the first five years to 0.57% in the last five years. Early neonatal mortality decreased from 0.53% in 1981 to 0.23% in 1990, which was over a reduction of over 50%. The reduction was 60% when congenital malformations were excluded. Early neonatal mortality declined for all birthweight groups by 40-75%, with the exception of birthweights under 1000 g. 90% of early neonatal deaths were due to congenital malformation, immaturity, RDS, asphyxia, and infection. Mortality due to congenital malformation remained at a rate of about 1.3:1000 live births. Causes of death varied with birthweight group. Neonates less than 1000 g died of RDS and immaturity in both 5-year periods. Neonates between 1000-1499 g and 1500-1999 g died of congenital malformation in the most recent period; for the first period, neonatal mortality was caused by RDS and infection respectively. Congenital malformation was the primary cause over the 10-year period for births weighing 2000 and higher grams. Hospital management for delivering and postpartum women changed over the ten year period. Although there was no specific intensive care unit, equipment for intensive neonatal care management was available. The improvement in neonatal mortality occurred during a period of increased numbers of births and low birthweight babies. Neonates under 1000 g were not managed as aggressively by medical staff because of the poor chances of survival and the high cost of care. In 1990, there was a change for more aggressive management of neonates with a birthweight between 750-999 g. The incidence of infection, asphyxia, and RDS decreased or remained stable due to better management of RDS and early detection and treatment with antibiotics of infection.^ieng

Disseminated intravascular coagulation in children: diagnosis, management and outcome.

A retrospective study of 46 patients with disseminated intravascular coagulation (DIC) is reported. Twenty three patients were neonates with a mean age of 6.7 days (SD = 10) and twenty three patients had a mean age of 2.4 years (SD = 3.3). The ratio of males to females was 1:1. Thirty-two out of 46 patients (69.6%) had underlying diseases such as congenital abnormalities in cardiovascular and gastrointestinal systems. The diagnosis of DIC was suspected in the critically ill patients who had certain conditions that could trigger DIC. The laboratory findings revealed red blood cell fragmentation 93.4%, thrombocytopenia 95.5%, prolonged coagulogram 71.9% and increased FDP 74%. The management included treatment of underlying diseases, identification and relief of triggering conditions, correction of coagulopathy and supportive care. In terms of infection, appropriate antimicrobial agents were administered. Exchange transfusion was performed in 21 patients and heparin was given to patients with major vessel thrombosis such as renal vein thrombosis. Inspite of the above mentioned managements, the overall case-fatality rate was 52%. Factors related to high case-fatality rate were accompanying fatal diseases, shock, hemorrhage or thrombosis. There were no correlations between fatality rate and age, sex, triggered conditions or exchange transfusion. There is a need to establish an effective treatment that can stop the rapid ongoing process of DIC in order to achieve a better outcome in patients with DIC.

An outbreak of Salmonella urbana infection in neonatal nurseries.

An outbreak of neonatal infection with Salmonella urbana in three neonatal wards of a teaching hospital in Bangkok, Thailand is described. The outbreak lasted for 5 days. Fifty-seven neonates had gastrointestinal infection, 37 had diarrhoea, and three had bacteraemia. The attack rates were 43% for infection, 29% for diarrhoea, and 2.3% for bacteraemia. Epidemiological evaluation suggested that a contaminated wash basin in the labour nursery was the source of infection. Delay in controlling this outbreak occurred because the staff assumed that person-to-person transmission was the mode of spread, thus ignoring epidemiological data that would have led to the identification of the source of infection.

A study of nonbacterial agents of acute lower respiratory tract infection in Thai children.

From January 1986 to December 1987, 596 children less than 5 years of age with lower respiratory tract infection (LRI)--manifested as laryngitis, croup, bronchitis, bronchiolitis, and pneumonia--were studied for evidence of infection with respiratory tract viruses Mycoplasma pneumoniae, and Chlamydia trachomatis. Of the 596 children in the study, 315 were ambulatory and 281 were hospitalized. Virologic studies included isolation and rapid diagnosis of virus from specimens of nasopharyngeal aspirate (NPA) and serologic studies of blood samples. Cultures of NPA for C. trachomatis were performed for children less than 6 months of age who had pneumonia. Of the LRI cases, 45% were associated with viral infections of the respiratory tract and 12.1% were associated with C. trachomatis. Respiratory syncytial virus (RSV) accounted for 45.2% of infections with viral agents and was associated with acute bronchitis, acute bronchiolitis, and pneumonia. Parainfluenza type 3 virus was the most common virus found in conjunction with laryngitis and croup. The incidence of infections due to RSV peaked in July and August, while that of infections due to parainfluenza viruses peaked in February and March; influenza viruses and adenoviruses were isolated throughout the year.

Clinical trial of special premature formula for low-birth-weight infants.

Feeding 25 low birth weight infants during a one month period either with special premature formula or with standard formula resulted in better weight gain, nutritional efficacy, fat absorption, and lower frequency of metabolic acidosis in the special premature formula group. Various biochemical indices demonstrated excellent protein and mineral metabolization of this formula, which seem appropriate for the infants studied (1,000-1,750 g birth weight). Both formulae were well tolerated without any untoward effects.

Factors affecting nursery survival of very low birth weight infants.

398 infants with birthweight (BW) 500-1500 g born from January 2 1982 to December 1983 were studied to determine incidence and survival rate by BW and gestational age (GA) categories and to determine causes of death and factors influencing mortality. 58% of the group survived. Factors other than those in the perinatal and postnatal period did not significantly influence survival. Infants with BW below 1000 g delivered by elective C-section had better survival than those delivered vaginally. Survival increased progressively with increasing BW and GA categories with GA more than BW being the limiting factor. Eleven (6.6%) of the deaths in the very low birth weight infants occurred during the nursery period after 28 days of age. These deaths would not have been addressed in the neonatal mortality.