Correlation of functional echocardiography and clinical parameters in term neonates with shock.

BACKGROUND: To evaluate the correlation between functional echocardiography and clinical parameters in term neonates with shock. METHOD: Cross sectional study of 30 full term newborns who were clinically detected to have shock compared to 30 full term hemodynamically stable neonates. For statistical analysis, cases were further sub classified into cardiogenic and septic shock. RESULT: Functional echocardiography revealed inferior vena cava collapsibility index (cIVC), fractional shortening (FS), ejection fraction (EF), cardiac output and superior vena cava (SVC) flow were significantly lower whereas myocardial performance index (MPI) was significantly higher in babies with cardiogenic and septic shock as compared to the controls. Left ventricular end diastolic area (LVEDA) was significantly higher in cardiogenic shock whereas it was significantly lower in septic shock as compared to the controls. Also, cIVC was significantly lower and LVEDA was significantly higher in cardiogenic as compared to the septic shock. In cardiogenic shock SVC flow correlated significantly with capillary filling time and systolic blood pressure. The correlation between functional echocardiographic parameters of cardiogenic and septic shock showed that EF, FS and MPI were positively and significantly correlated (r 0.742, p 0.022 for EF, r 0.766, p 0.016 for FS and r 0.478, p 0.05 for MPI) whereas SVC flow and cIVC were negatively and significantly correlated between cardiogenic and septic shock (r - 0.655, p 0.045 for SVC flow and - 0.578, p 0.05 for cIVC). CONCLUSION: In the complex environment of neonatal intensive care unit detection of shock continues to be a major challenge. Functional echocardiography provides an adjunct information to the clinical assessment of shock and helps in monitoring the response to treatment.

Distribution, antimicrobial resistance and predictors of mortality in neonatal sepsis.

OBJECTIVE: The aim of this study is to investigate etiological agents, patterns of antimicrobial resistance and predictors of mortality in culture proven neonatal sepsis. METHOD: This is a twenty-four month retrospective cohort study of infants with culture proven sepsis. Demographic data, type of isolates and its sensitivity pattern were recorded. Multidrug resistant gram-negative isolates were defined as resistance to any three of five antibiotic classes: extended-spectrum cephalosporins, carbapenems, aminoglycosides, fluoroquinolones and piperacillin-tazobactam. RESULT: A total of 183 case with culture positive sepsis were identified. Early onset sepsis occurred in 59% of cases. The majority of isolates (56.2%) were gram-positive but the most common individual isolates were klebsiella spp. (31.1%), Staphylococcus aureus (24.5%) and coagulase-negative staphylococci (CONS) (22.9%). The pathogen mix in early-onset did not differ from late-onset sepsis. High rates of multidrug resistance were observed in klebsiella spp. (49.1%), Escherichia coli (50%), citrobacter spp (50%), acinetobacter spp. (28.5%), pseudomonas spp. (100%) isolates. Methicillin resistance prevailed in 16.6% of coagulase-negative staphylococci, 24.4% of Staphylococcus aureus and 62.5% of enterococcus spp. Multivariate analysis revealed invasive ventilation and early onset sepsis to be independently associated with increased risk of mortality in contrast to breast milk feeding which is associated with decreased risk of mortality. CONCLUSION: A high degree of antimicrobial resistance underscores the need to understand the pathogenesis of resistance, curtail the irrational prescription of antibiotics in neonates and the requirement for measures to prevent it in low-income and middle-income countries.

Bed bug outbreak in a neonatal unit.

There has been a worldwide increase in bed bug infestations over the last 10-15 years. A major stigma is placed upon the institutions found to be infested. We report our experience with an outbreak of the tropical bed bug, Cimex hemipterus, in a neonatal unit. The outbreak not only affected the admitted newborns and mothers by causing a wide variety of rashes and inducing sleeplessness, but also impinged upon the health professionals and their families by producing similar symptomology. It is important for healthcare providers to be aware of, and for each healthcare facility to have, bed bug prevention and control policies.

Homocystinuria masquerading as vitamin B12 deficiency.

BACKGROUND: Homocystinuria is a rare metabolic disorder characterized by excess homocysteine in the urine. Vitamin B12 deficiency has diverse cutaneous, nervous and ophthalmic manifestations. OBJECTIVE: To report a case of homocystinuria masquerading as vitamin B 12 deficiency. CASE: We hereby are presenting an interesting case of a 4 year old boy who was being treated for Vitamin B 12 deficiency on the basis of history of delayed milestone, abdominal pain and hyperpigmentation of skin which was diagnosed as homocystinuria. CONCLUSION: It is important to carry out ophthalmological examination in every case of megaloblastic anemia if associated with blurring of vision and mental retardation.

Neonatal abstinence syndrome.

Intrauterine exposure to drugs by mothers is not an uncommon finding ine our society. Due to the mother's suppression of a medical history, the diagnosis of neonatal abstinence syndrome is often missed. We report a case of a term, female, newborn, who presented with the following features;e restlessness, inconsolable crying, along with sweating, vigorous sucking; andadiarrhoea. No conclusion was derived from routine investigations. Eventually, with a high degree of suspicion regarding maternal drug addiction, her history was reviewed and it was discovered that the mother was a heroin addict. The baby was diagnosed as a case of Neonatal Abstinence Syndrome. The neonate was successfully managed thereafter and discharged.

Inflammatory markers in meconium induced lung injury in neonates and effect of steroids on their levels: a randomized controlled trial.

PURPOSE: To determine the levels of TNFa and IL-1beta in tracheal aspirates of neonates with meconium aspiration syndrome (MAS) and to ascertain whether the use of steroids by systemic or nebulized routes suppresses the levels of these inflammatory markers. METHODS: This was a double blind, randomized, controlled, prospective, interventional study done over one year period in the neonatal unit of the Lady Hardinge Medical College. Fifty-one babies of MAS which were randomly distributed into three groups; control, systemic and nebulized steroids; were included in the study. Methyl prednisolone was given intravenously in the dosage of 0.5 mg/kg/day in two divided doses while nebulized budecort was given in a dosage of 50 mcg/dose twice daily. Tracheal aspirates were taken on day 1, 3 and 4 and were analyzed for TNFa and IL-1b by ELISA technique. RESULTS: TNFa in tracheal aspirates showed an increasing trend in babies of MAS in first four days, thereby signifying an inflammatory process underlying the condition. The levels of TNFa were suppressed by use of steroids. Higher levels of TNFa were associated with longer stay in hospital. IL-1b did not show any significant correlation. CONCLUSIONS: TNFa is associated with meconium-associated inflammation. Its level is suppressed with the use of steroids and can also be used to assess prognosis of neonates with MAS.

Free oxygen radicals and immune profile in newborns with lung diseases.

Respiratory difficulties constitute the commonest cause of morbidity in new born infants and pulmonary pathology is the most frequent autopsy finding. Various components, such as free oxygen radicals, immunoglobulins, and compliment systems, play an important role in immunopathology and immune defence. The aim of the present study was to assess free oxygen radical markers in neonatal lung diseases, studying their relationship with immune profile and ascertaining their relevance as predictors of clinical outcome. Full term newborns with respiratory distress and X-ray proven lung disease formed the study group. Blood samples were assessed for lipid peroxide (LPO), superoxide dismutase (SOD), glutathione peroxidase (GPx), immunoglobulins IgM and G, CD4 and CD8 subpopulations of T-lymphocytes. Levels of free radical markers were significantly higher in the study group. The humoral immune response was seen in terms of raised IgM levels in the study group which were still within the normal range. The cellular immune response was demonstrated by a raised percentage of CD4 T-lymphocytes which in turn accentuated the CD4:CD8 ratio. Higher levels of reactive oxygen species (ROS) were associated with a prolonged duration of respiratory distress and oxygen dependence. Since the free radicals have emerged as the major final common pathway of tissue injury, free radical ablation offers substantial potential for treatment; but whether antioxidants, scavengers and other modalities would have a significant impact on clinical outcome, remains to be investigated.

Misuse of oxygen in a neonatal unit.

PIP: Oxygen is the most liberally and often used medication in any neonatal unit. Appropriate oxygen therapy has resulted in improved neonatal survival and a reduction in oxygen-related morbidity over the past 2 decades. However, the degree of arterial oxygenation needs to be continuously and precisely monitored when managing critically ill neonates in order to prevent the adverse effects of both hypoxia and hyperoxia. The authors measured the extent of hyperoxia in spontaneously breathing neonates receiving supplemental oxygen by hood and the utility of pulse oximeters in detecting hyperoxia in newborn infants. The study was conducted during January-April 1996 among 63 preterm and 60 term babies admitted to the Neonatal Unit of Kalawati Saran Children's Hospital, who required supplemental oxygen by hood. All of the infants were independently evaluated by an observer after initial stabilization of temperature and perfusion. 91% of spontaneously breathing infants receiving supplemental oxygen by hood were hyperoxemic, with no relation to the type of morbidity for which oxygen therapy was indicated.^ieng

Neonatal mechanical ventilation--experience at a level II care centre.

One hundred and fifty nine neonates were ventilated over a period of one year of whom 74 (46.54%) survived. This study aims to analyse the indications, complications and outcome of babies requiring mechanical ventilation. The early outcome measures were (i) survival rate with respect to birth weight, gestation and indication of ventilation, and (ii) Complications of assisted ventilation. One hundred and forty seven babies received IPPV and 34 received CPAP. Twenty two out of these 34 required IPPV later. Survival was cent percent on exclusive CPAP mode. HMD was the commonest indication for ventilation followed by Birth asphyxia, Apnea of prematurity, Meconium Aspiration Syndrome and Persistent Pulmonary Hypertension of the New born. Survival rates increased with increasing birth weight and gestational age, changing from 25% for < 1000 gm and 20% for < 28 wks to 53% for > 2500 gms and 50.2% for > 37 wks. Prolonged ventilatory support was needed for HMD (mean 114 hrs) and PPHN (mean 156 hrs). Commonest complication was Sepsis (26%) followed by Pulmonary hemorrhage, Pneumothorax and IVH. Lower success rates in ventilation is due to the poor survival of babies weighing < 1000 gms and those with a gestation of < 28 wks with nosocomial infections as a major complication of assisted ventilation being an additional factor.

Free oxygen radicals--predictors of neonatal outcome following perinatal asphyxia.

The study was undertaken to evaluate the role of free oxygen radicals in asphyxiated neonates. Thirty term neonates appropriate for gestational age and with severe birth asphyxia (Apgar score of 3 or less at 1 minute of life) formed the study subjects. The levels of superoxide dismutase (SOD), glutathione peroxidase (GPx), creatine phosphokinase (CPK) and lipid peroxidase (LPO) in the CSF of these neonates were estimated between 12 and 48 hrs of life. Enzyme estimation was performed by standard methods and the results were analysed statistically using Multivariate Logistic Regression analysis and non parametric tests namely Kruskal Wallis test and Wilcoxon's rank sum test. Out of the thirty babies, 14 were observed to be neurologically normal, 9 had significant morbidity and 7 died. The SOD levels ranged from 12.4 to 140 units/ml, GPx from 128 to 1933 nmol/min/dl, CPK from 2 to 2098 IU/dl and LPO from 5.4 to 30.8 umol/hr/dl. The SOD and GPx levels had an inverse relationship whereas rise in LPO and CPK levels were directly proportional to the extent of neurological damage and ultimate clinical outcome. CPK levels higher than 140 IU/ml were lethal and associated with 100% mortality whereas all normal neonates had CPK below 37 IU/ml. The levels of antioxidant enzymes can reliably and significantly predict mortality and morbidity whereas level of an enzyme cannot confidently confer normalcy. Hence antioxidant enzyme levels with a cut off value can be a useful marker and serve as a prognostic indicator in times to come.

Seroconversion following killed polio vaccine in neonates.

The study was carried out to evaluate the efficacy of IPV in neonates and to study the additive effect of IPV or OPV at birth on seroconversion with three subsequent doses of OPV. Addition of IPV or OPV at birth to the conventional OPV schedule resulted in significantly higher seroconversion rates than in the controls, who received three doses of OPV. Three doses of IPV beginning from birth resulted in significantly better seroconversion rates than in the control group. Children receiving 3 doses of IPV showed significantly greater seroconversion rates against type III polio virus than those receiving IPV/OPV at birth followed by 3 doses of OPV. The difference in the seroconversion rates against the other virus types was not significant. A significantly greater number of children who received some vaccine at birth (IPV or OPV) were protected against poliomyelitis by 6 weeks age as compared to those who received no immunization at birth. The study recommends that seroconversion rates following three doses of IPV are satisfactory. Addition of IPV or OPV at birth to the conventional schedule markedly increases the seroconversion rates. Immunization can be started at birth to ensure early protection against poliomyelitis.

End tidal carbon dioxide monitoring--its reliability in neonates.

End tidal Carbon dioxide monitoring was undertaken prospectively in all Ventilated neonates in our NICU admitted from March 1995 to August 1995 irrespective of the birth weight, gestational age and indication of ventilation. The aim was to determine the correlation between ETCO2 and PaCO2 in various clinical situations. The arterial blood gases were obtained in all ventilated babies with simultaneous and continuous ETCO2 monitoring and were analysed by AVL 995 Hb blood gas analyser. ETCO2 was analysed by side stream technique by Datex Cardiocap II monitor. A total of 152 samples from in-dwelling radial artery catheters were analysed from babies with birth weight from 900 g to 3400 g, gestation age from 28 to 42 wks and were ventilated for various indications like Severe Birth Asphyxia (SBA), Meconium Aspiration Syndrome (MAS), Recurrent Apnoea and Hyaline Membrane Disease (HMD). Statistical analysis was done in 10 groups to see if the ETCO2 correlated with its corresponding PaCO2 value. The study groups comprised three groups based on birth weight being < 1.5-2.5 kg and > 2.5 kg three groups as per the gestational age being 28-31+6 wks, 32-36+6 wks and 37-41+6 wks and four groups as per the need for ventilation being Severe Birth Asphyxia, Meconium Aspiration Syndrome, Apnoea of Prematurity and Hyaline Membrane Disease. Results of the correlation analysis revealed that the correlation coefficient in the study group ranged from 0.55 to 0.96 and was statistically significant in babies > 2.5 kg and 1.5-2.5 kg, in term and preterms 32-36 wks, and in babies with MAS, SBA and Recurrent Apnoea. The correlation coefficient was lowest in babies with HMD, being 0.55. The study showed that ETCO2 correlates closely with PaCO2 in most clinical situations in neonates and we recommend its use in all level III NICUs in ventilated babies.

Immunogenicity and tolerance of H. influenzae type b, tetanus toxoid conjugate vaccine given concurrently or in combination.

The present prospective, open, controlled, randomised comparative trial was undertaken to evaluate the sero response and side effects of PRP-T Conjugate Vaccine (ACT-HIB) in infants and children aged 2 months and 16-24 months. Fifty four babies aged 2 months formed group A, 56 children aged 16-24 months formed group B. Groups A and B were further subdivided into two sub groups each destined to receive either PRP-T vaccine in association with DPT vaccine at different sites (I) or PRP-T and DPT both vaccines at the same site mixed in the same syringe (II). Group A received 3 doses at 2, 3 and 4 months of age and group B received one dose between 16-24 months. The Geometric mean titres of Anti PRP antibodies observed in primary immunisation schedule (A) and single dose vaccination schedule (B) were comparable and significantly higher to prevaccination titres. A serum anti PRP level of > 1.0 mcg/ml after immunisation is believed to correlate with long term protection. Ninety-six percent of infants in Group A and 98% in Group B achieved titres > 1.0 mcg/ml. The side effects were minimal, local and were comparable between the study and control groups, suggesting that PRP-T vaccine is highly immunogenic and well tolerated in Indian infants and children.

Immune status of full-term small-for-gestational age neonates in India.

The immune status of 25 full-term small-for-gestational age neonates was studied and compared with another 25 term appropriate-for-gestational age neonates, who served as controls. It was observed that the term SGA's had an altered immunological profile. The lymphocyte percentage was low. Cellular immunity as assessed by CD4 and CD8 subset of T-cells, and their ratio was deranged. IgG levels were lower in SGA neonates and showed a linear relation with birth weight. IgM and IgA levels were not affected in SGAs. Complement C3 levels were significantly lower in the SGA neonates. The SGAs are allegedly more prone to infections and this deranged immune status could be the underlying explanation for the predisposition.

Phototherapy induced hypocalcemia.

Sixty neonates with hyperbilirubinemia were included in the study. There were 20 preterm (Group A) and 20 full term (Group B) neonates. Ten neonates from each group formed the control group. The study group neonates were managed with phototherapy while the control group neonates were not subjected to phototherapy. Serum calcium levels of the two groups were studied. Ninety per cent preterm neonates and seventy-five per cent full term neonates developed hypocalcemia after being subjected to phototherapy. There was a highly significant fall in the total as well as ionized calcium levels in the study group in contrast to the control group. It is recommended that neonates under phototherapy should be given supplemental calcium to prevent hypocalcemia.

Hemostatic profile in septicemic neonates with and without bleeding.

Hemostatic profile was studied in 25 full term, non-asphyxiated neonates with blood culture-proven septicemia. Nine (36%) of these neonates manifested bleeding. Detailed coagulation tests and platelet studies were deranged in 24 (96%) of neonates with septicemia. Abnormalities in coagulation tests did not differ in those with and without bleeding. Only platelet aggregation with ADP was deranged to a significantly greater extent in those with bleeding as compared with those without bleeding.

Reliability of capillary blood gas estimation in neonates.

In order to compare the reliability of capillary blood gases to the arterial blood gases, we studied fifty one neonates with moderate birth asphyxia. A significant difference (p less than 0.05) was found between the capillary and the arterial blood gas values with respect to blood pH, PCO2 PO2 and oxygen saturation. However, the levels of blood bicarbonate as assessed by the 2 samples were comparable. Capillary blood gas values are unsatisfactory indicators of the arterial blood gas values and may result in inappropriate management.