Hypernatremic Dehydration in Breast Fed Infants: Lessons from a Baby-Friendly Hospital.

AIM: To determine the incidence, presentation and outcome of all neonates admitted to the University Hospital of the West Indies with a diagnosis of breastfeeding associated hypernatremic dehydration during a 15-year period and make comparisons with an earlier study done at the institution. METHODS: A retrospective review of the files of neonates admitted to the neonatal unit with breastfeeding associated hypernatremic dehydration between January 2002 and December 2016 was conducted. Data on maternal and neonatal demographics, presentation, laboratory results and outcome were extracted and descriptive analyses performed. Statistical significance was taken at the level p < 0.05. RESULTS: Eighty neonates were entered into the study, 79 were inborn giving an incidence of 2.5 per 1000 live births. Fifty-five (71%) mothers were primiparous, with a mean ± SD age of 29.5 ± 5.6 years and mean ± SD length of hospital stay 2.6 ± 1.5 days. Fifty-six (71%) neonates were exclusively breastfed with a mean ± SD age at presentation of 5.6 ± 3.8 days, mean ± SD percentage weight loss of 16.3% ± 6.1% and a mean serum ± SD sodium of 156.1 ± 8.3 mmol/l. Fifty-four (68%) neonates were admitted from home and 22 (28%) from the postnatal ward. Complications seen included acute kidney injury 6 (8%), seizures 2 (3%), hypotonia 1 (1%) and bradycardia 1 (1%). The neonates were detected earlier, presented with a significantly lower mean serum sodium, urea and creatinine (p < 0.05), had less severe complications and no deaths compared with neonates in the previous study. CONCLUSION: Early intervention can make a positive impact on the severity and complications of breastfeeding associated hypernatremia.

The Spectrum of Neonatal Disorders Managed at the University Hospital of the West Indies over the Past Two Decades / El Espectro de los Trastornos Neonatales Tratados en el Hospital Universitario de West Indies Durante las dos últimas Décadas

ABSTRACT Objective: To define the spectrum of medical disorders managed on the neonatal unit at the University Hospital of the West Indies (UHWI) over the past two decades. Method: A review of published data pertaining to neonatal medical disorders managed at the UHWI over the past 20 years was conducted. Pertinent findings, implications of these findings and recommendations based on these findings were collated and presented under themes. Results: Common medical disorders managed includes complications of prematurity and very low birthweight infants, neonatal sepsis, hypoxic ischaemic encephalopathy, meconium aspiration syndrome, neonatal jaundice, hypernatraemic dehydration, complications of macrosomia and complications resulting from neonatal transport. Conclusion: It is clear that a diverse spectrum of neonatal disorders is managed on the neonatal unit of the UHWI and that the fledgling neonatal unit providing basic care for neonates of the 1960s has matured into the level II Newborn Special Care Nursery and Level III NICU that it is today. The time is now opportune for Neonatology to gain independent status as a Division of Neonatology within the Department of Child and Adolescent Health at the UHWI.

RESUMEN Objetivo: Definir el espectro de trastornos médicos tratados en la Unidad Neonatal del Hospital Universitario de West Indies (UHWI) en las últimas dos décadas. Método: Se realizó una revisión de los datos publicados sobre los trastornos médicos neonatales tratados en UHWI durante los últimos 20 años. Los hallazgos pertinentes, las implicaciones de estos hallazgos y las recomendaciones basadas en estos hallazgos fueron recopiladas y presentadas en temas. Resultados: Los trastornos médicos comunes tratados incluyen complicaciones de la prematuridad y los neonatos de muy bajo peso al nacer, sepsis neonatal, encefalopatía isquémica, síndrome de aspiración de meconio, ictericia neonatal, deshidratación hipernatrémica, complicaciones de macrosomía y las complicaciones resultantes del transporte neonatal. Conclusión: Está claro que un espectro diverso de trastornos neonatales es tratado en la Unidad Neonatal de UHWI, y que la unidad neonatal incipiente que proporcionó atención básica a los neonatos de los años 60 ha madurado, llegando a ser hoy la Sala de Atención Especial a Neonatos de Nivel II y la Unidad de Cuidados Intensivos Neonatales (UCIN) de Nivel III. Es hora ya de que la Neonatología tenga estatus independiente como División de Neonatología dentro del Departamento de Salud de Niños y Adolescentes de UHWI.

Mechanical Ventilation of Neonates at the University Hospital of the West Indies 1987-2015 / Ventilación Mecánica de Neonatos en el Hospital Universitario de West Indies 1987-2015

ABSTRACT Aim: To compare present trends in utilization of the neonatal intensive care unit (NICU) with trends seen during the period when neonates were ventilated in the main intensive care unit of the University Hospital of the West Indies. Methods: Data from previously published studies on outcome of neonates ventilated at the main intensive care unit 1987-2001, the neonatal intensive care unit 2002-2004 and the annual perinatal statistics (2006-2010, 2015) were reviewed to detect trends in mechanical ventilation, utilization and outcome. Descriptive analyses were performed. Results: The number of neonates mechanically ventilated per thousand admissions increased from 10/1000 in the 1990s to 73/1000 in 2015. Percentage mortality for ventilated neonates increased from 51% between 1987-1991 to 62 % in 2015. The proportion of extremely low birthweight infants (< 1000 g) mechanically ventilated increased from 29% in 1987-1991 to 50% in 2015. The percentage mortality for extremely low birthweight infants increased from 17.5% in 1987-1991 to 40.6% in 2015. The percentage mortality for all other birthweight categories decreased over time. Respiratory distress syndrome remains the major reason for neonates requiring mechanical ventilation. Fifty per cent of neonates < 1500 g ventilated for respiratory distress syndrome received surfactant replacement therapy. Conclusion: Access to mechanical ventilation by neonates has increased tremendously at the University Hospital of the West Indies. The present challenge, however, is decreasing mortality in these neonates who access this technology.

RESUMEN Objetivo: Comparar las tendencias actuales en la utilización de la Unidad de Cuidados Intensivos Neonatales (UCIN) con las tendencias observadas durante el período en que los neonatos eran ventilados en la Unidad Principal de Cuidados Intensivos del Hospital Universitario de West Indies. Métodos: Se revisaron los datos de estudios publicados anteriormente sobre el resultado clínico de los neonatos ventilados en la Unidad Principal de Cuidados Intensivos en 1987-2001, La Unidad de Cuidados Intensivos Neonatales en 2002-2004 y las y las Esta-dísticas Perinatales Anuales (2006-2010, 2015) con el propósito de detectar las tendencias en la utilización y los resultados de la ventilación mecánica. Se realizaron análisis descriptivos. Resultados: El número de neonatos ventilados mecánicamente por cada mil ingresos aumentó de 10/1000 en la década de 1990 a 73/1000 en 2015. El porcentaje de mortalidad de neonatos ventilados aumentó de 51% entre 1987-1991 a 62% en 2015. La proporción de neonatos de peso extremadamente bajo al nacer (< 1000 g) ventilados mecánicamente aumentó de 29% en 1987-1991 a 50% en 2015. El porcentaje de mortalidad de recién nacidos de peso extremadamente bajo al nacer aumentó de 17.5% en 1987-1991 a 40.6% en 2015. La mortalidad porcentual para todas las otras categorías de peso al nacer disminuyó con el tiempo. El síndrome de dificultad respiratoria sigue siendo la razón principal por la que los neonatos requieren ventilación mecánica. El cincuenta por ciento de los neonatos < 1500 g ventilados por el síndrome de dificultad respiratoria recibió terapia de reemplazo de surfactantes. Conclusión: El acceso a la ventilación mecánica por los neonatos ha aumentado enormemente en el Hospital Universitario de West Indies. No obstante, el reto actual es disminuir la mortalidad de los neonatos que acceden a esta tecnología.

Neonatal Mortality at the University Hospital of the West Indies Over Six Decades: Trends and Causes / Mortalidad Neonatal en el Hospital Universitario de West Indies Durante Seis Décadas: Tendencias y Causas

ABSTRACT Aim: To describe the pattern of neonatal mortality at the University Hospital of the West Indies (UHWI) over the past six decades. Methods: Data from previously published studies on neonatal mortality at the UHWI, monthly perinatal statistics (1987, 1996) and the annual perinatal statistics for the UHWI (2005-2010, 2014, 2015) were reviewed to detect trends in neonatal mortality at the UHWI. Descriptive analyses were performed. Results: There has been a decrease in the neonatal mortality from 21.9/1000 live births during the period 1953-1962 to 14.7/1000 live births in 2015. The percentage of total live births represented by neonates weighing between 1001 and 1500 g has doubled between 1976-2015 and tripled for neonates ≤ 1000 g. Neonates ≤ 1500 g accounted for 64% of overall mortality although they represented less than 5% of live births and neonates ≤ 1000 g accounted for 46% of overall mortality although they represented less than 2% of live births. While the contribution of intrapartum anoxia/perinatal asphyxia to mortality has decreased, the contribution of prematurity and the complication of hyaline membrane disease/respiratory distress syndrome HMD/(RDS) has steadily increased across the decades. Conclusion: There has been a decrease in the neonatal mortality rate (NMR) over the past six decades but further intervention is needed to achieve the "Every Newborn Action Plan" goal of less than ten neonatal deaths per thousand live births at the UHWI.

RESUMEN Objetivo: Describir el patrón de mortalidad neonatal en el Hospital Universitario de West Indies (UHWI) en las últimas seis décadas. Métodos: Los datos de estudios publicados previamente sobre mortalidad en el UHWI, las estadísticas perinatales mensuales (1987, 1996) y las estadísticas perinatales anuales de UHWI (2005-2010, 2014, 2015) fueron revisados para detectar las tendencias en la mortalidad neonatal en el UHWI. Se realizaron análisis descriptivos. Resultados: Se ha producido una disminución en la mortalidad neonatal de 21.9/1000 nacidos vivos durante el período 1953-1962 a 14.7/1000 nacidos vivos en 2015. El porciento del total de nacidos vivos representado por neonatos que pesan entre 1001 y 1500 g se ha duplicado entre 1976-2015 y triplicado en los neonatos ≤ 1000 g. Los neonatos ≤ 1500 g representaron el 64% de la mortalidad general, aunque representaron menos del 5% de los nacidos vivos; y los neonatos ≤ 1000 g representaron el 46% de la mortalidad general, aunque representaron menos del 2% de los nacidos vivos. Si bien la contribución de la anoxia intraparto/asfixia perinatal a la mortalidad ha disminuido, la contribución de la prematuridad y la complicación de la enfermedad de la membrana hialina/síndrome de dificultad respiratoria (HMD/(SDR) ha aumentado constantemente a través de las décadas. Conclusión: Se ha producido una disminución de la tasa de mortalidad neonatal (TMN) en las últimas seis décadas, pero se necesita más intervención para lograr el objetivo de desarrollo sostenible de menos de diez muertes neonatales por cada mil nacidos vivos en UHWI.

Outcome of Late Preterm Infants at the University Hospital of the West Indies.

Objective The objective of this study was to determine the outcome of late preterm infants at the University Hospital of the West Indies (UHWI) over a 2-year period. Design and Methods A retrospective, descriptive, case-controlled study was performed. Data were extracted from the maternal and neonatal medical records of 163 late preterm infants and matched term controls. Descriptive analyses were performed comparing morbidity and mortality between the groups. Results There was an overall incidence of 3.8% late preterm births. Late preterm infants were more likely to require admission to the neonatal unit than term controls (odds ratio:13.6; confidence interval: 7.95-23.34; p < 0.001) and they had a longer mean duration of stay (p < 0.05). During admission, late preterm infants had a significantly higher incidence of hypothermia, neonatal jaundice, and need for respiratory support than term controls (p < 0.05). There, however, was no increased risk of mortality. Mothers of late preterm infants had a higher incidence of hypertension in pregnancy, prolonged rupture of membranes (p < 0.001), and operative delivery than mothers of term controls (p < 0.05). Conclusion Late preterm infants at the UHWI were shown to be at increased risk of morbidity. This finding has implications for antenatal care, timing of delivery, and monitoring of these infants postdelivery.

Risk factors for the delivery of macrosomic infants at the University Hospital of the West Indies.

OBJECTIVE: The aim of this study is to determine the risk factors for the delivery of macrosomic infants at the University Hospital of the West Indies over a 3-year period. DESIGN AND METHODS: A retrospective, descriptive, case-controlled study was performed. Data were extracted from the maternal medical records of 316 macrosomic infants (weighing ≥ 4,000 g) and 316 controls (weighing from 2,500-3,999 g) delivered at the University Hospital of the West Indies. Descriptive analyses were performed comparing maternal characteristics between the two groups. Risk factors were determined using multiple logistic regression models. RESULTS: The incidence of macrosomia for the study period was 4.3%. Women who delivered a macrosomic infant were older, taller, and heavier with a greater body mass index at the start of the pregnancy and gained more weight during pregnancy than their counterparts in the control group (p < 0.05). Maternal obesity, height > 164 cm, abnormalities of glucose control, weight gain > 15 kg, gestational age > 40 weeks, and male gender of the infant were found to increase the risk of delivering a macrosomic infant by over 2-fold (p < 0.05). The greatest risk factor was that of having had a previous macrosomic infant which increased the risk of delivering a macrosomic infant by as much as 6-fold (adjusted odds ratio, 6.0; 95% confidence interval, 1.9-18.7). CONCLUSION: The maternal risk factors for fetal macrosomia identified in this study mirror those of previous studies.

What is the best predictor of mortality in a very low birth weight infant population with a high mortality rate in a medical setting with limited resources?

OBJECTIVE: To determine the best predictor of mortality risk in very low birth weight (VLBW) infants in resource limited settings. METHODS: The Clinical Risk Index for Babies (CRIB) II score and the simplified age-weight-sex (SAWS) score for all VLBW infants born during the period January 2005 to June 2006 at the University Hospital of the West Indies were retrospectively calculated. The respective ability of each score, birth weight, and calculated or assessed gestational age to predict mortality was quantified using the area under receiver operating curves. RESULTS: Fifty two (48%) males and 57 (52%) females were entered into the study, out of which 58 (53%) infants died. The CRIB II score was found to be a better predictor of mortality (p = 0.02) when compared with calculated gestational age but had similar predictive power when compared with assessed gestational age. The SAWS score was found to have equal predictive value of mortality (p = 0.1) as the CRIB II score, however it was a better predictor of mortality than calculated gestational age (p = 0.002) but had no predictive advantage over assessed gestational age. Birth weight however, proved to be the best predictor of mortality (p < 0.01) with an area under the curve of 0.91 (standard error 0.03; 95% confidence interval 0.85-0.96). CONCLUSION: In resource poor settings where mortality of VLBW infants is high there may be no benefit in the addition of other variables to birth weight in predicting outcome.

Stress and neurodevelopmental processes in the emergence of psychosis.

The notion that stress plays a role in the etiology of psychotic disorders, especially schizophrenia, is longstanding. However, it is only in recent years that the potential neural mechanisms mediating this effect have come into sharper focus. The introduction of more sophisticated models of the interplay between psychosocial factors and brain function has expanded our opportunities for conceptualizing more detailed psychobiological models of stress in psychosis. Further, scientific advances in our understanding of adolescent brain development have shed light on a pivotal question that has challenged researchers; namely, why the first episode of psychosis typically occurs in late adolescence/young adulthood. In this paper, we begin by reviewing the evidence supporting associations between psychosocial stress and psychosis in diagnosed patients as well as individuals at clinical high risk for psychosis. We then discuss biological stress systems and examine changes that precede and follow psychosis onset. Next, research findings on structural and functional brain characteristics associated with psychosis are presented; these findings suggest that normal adolescent neuromaturational processes may go awry, thereby setting the stage for the emergence of psychotic syndromes. Finally, a model of neural mechanisms underlying the pathogenesis of psychosis is presented and directions for future research strategies are explored.

Clinical research informing neonatal care at the University Hospital of the West Indies: 50 years experience.

Neonatology has rapidly grown over the past few years to its present status of a highly technologically driven specialty. Centres in resource restricted countries tend to adopt management guidelines from the developed world and integrate them into local practice. Although international neonatal practices have influenced neonatal care at the University Hospital of the West Indies (UHWI), over the past fifty years there has been local clinical research done at the hospital that has informed local practice. Causes of neonatal mortality have been documented and this has informed neonatal resuscitation practices, infection control policies and ventilatory support of premature infants. Changes in the incidence of various aetiologies of jaundice over the years have altered how jaundiced neonates are investigated and managed. Research on neonatal sepsis has informed antibiotic choices and treatment regimes. Studies on preterm infants have informed management polices on ensuring optimal thermal environment, on the timing of discharge and on neurodevelopmental follow-up. It is clear that clinical research at the UHWI has informed neonatal care at the institution over the past 50 years and it is hoped that it will continue to do so for the next 50 years and beyond.

Review of mortality of very low birthweight infants at the University Hospital of the West Indies over the past four decades.

A review of two previously published studies done at the University Hospital of the West Indies, an unpublished study and annual perinatal statistics was conducted to detect trends in the mortality of very low birthweight infants at the institution over four decades. Mortality decreased from 54% to 38% over the time period, the decrease was greater for infants weighing 1001-1500 g (40%) than those weighing < or = 1000 g (28%). Despite increased access to mechanical ventilation over time, there was no appreciable decrease in mortality for infants weighing < or = 750 g. There was a statistically significant decrease in mortality with increasing birthweight for the time period 1987-2002, p < 0.001. The mean +/- SD weight of survivors 1.18 +/- 0.24 kg was significantly greater than that for non-survivors 0.89 +/- 0.21 kg for the same period. Further decrease in mortality of very low birthweight infants will involve measures aimed at decreasing mortality in infants weighing < or = 750 g and increasing the availability of parenteral nutrition and the accessibility of surfactant.

Epidemiology of neonatal jaundice at the University Hospital of the West Indies.

OBJECTIVE: To describe the epidemiology of neonatal jaundice at the University Hospital of the West Indies (UHWI). METHODS: A retrospective review of all neonates at the UHWI with clinically significant jaundice between January 1, 2006 and June 30, 2007 was performed. Demographic, clinical and laboratory data were collected. Descriptive analyses were performed. RESULTS: The incidence of clinically significant neonatal jaundice at the UHWI was 4.6% for the study period. There were 103 male (61%) and 67 (39%) female infants. The aetiology ofjaundice in the infant was attributed to ABO incompatibility in 59 (35%), infection in 30 (18%), prematurity in 19 (11%), G6PD deficiency in 8 (5%), Rhesus incompatibility in 6 (3.5%) and no cause was identified in 16 (9%) infants. There was a low incidence (26%) ofscreening for G6PD deficiency although it was the most common aetiology for infants presenting from home. Nine (5%) neonates required exchange blood transfusion. Infants admitted from home had a significantly higher mean total bilirubin value at presentation, a significantly higher mean peak bilirubin level andpresented significantly later than those who were admitted from the postnatal ward (p < 0.001). One patient was discharged with a diagnosis of bilirubin encephalopathy but defaulted from follow-up. Two neonates died but from causes unrelated to neonatal jaundice. Sixty-two patients (37%) were followed-up post discharge; 50% had hearing tests done, all tests were normal. Sixty-one (98%) infants had normal development at the time of the study; one patient had impaired motor development but this infant also had a myelomeningocoele. CONCLUSION: To further reduce morbidity associated with neonatal jaundice at the UHWI, there should be increased screening for G6PD deficiency; current systems in place for follow-up and monitoring of infants discharged from hospital prior to 72 hours must also be expanded and strengthened.

Clinical research informing neonatal care at the University Hospital of the West Indies: 50 years experience / La investigación clínica al servicio de la información para el cuidado neonatal en la Universidad de West Indies: 50 años de experiencias

Neonatology has rapidly grown over the past few years to its present status of a highly technologically driven specialty. Centres in resource restricted countries tend to adopt management guidelines from the developed world and integrate them into local practice. Although international neonatal practices have influenced neonatal care at the University Hospital of the West Indies (UHWI), over the past fifty years there has been local clinical research done at the hospital that has informed local practice. Causes of neonatal mortality have been documented and this has informed neonatal resuscitation practices, infection control policies and ventilatory support of premature infants. Changes in the incidence of various aetiologies of jaundice over the years have altered how jaundiced neonates are investigated and managed. Research on neonatal sepsis has informed antibiotic choices and treatment regimes. Studies on preterm infants have informed management polices on ensuring optimal thermal environment, on the timing of discharge and on neurodevelopmental follow-up. It is clear that clinical research at the UHWI has informed neonatal care at the institution over the past 50 years and it is hoped that it will continue to do so for the next 50 years and beyond.

La neonatología se ha desarrollado rapidamente en los últimos años hasta alcanzar su presente estado como especialidad altamente informada por la tecnologia. Los centros en países con recursos limitados tienden a adoptar lineamientos para el tratamiento tomados del mundo desarrollado e integrarlos a la práctica local. Aunque las prácticas neonatales a nivel internacional han influido en el cuidado neonatal en el Hospital Universitario de West Indies (HUWI), durante los últimos cincuenta años se han realizado investigaciones clínicas locales en el hospital, que han informado la práctica local. Las causas de la mortalidad neonatal han sido documentadas, y la información obtenida ha venido a formar parte de las prácticas de resucitación neonatal, las políticas de control de las infecciones, y el soporte ventilatorio de los infantes prematuros. Los cambios en la incidencia de varias etiologías de ictericia a lo largo de los años, han alterado la forma en que se investigan y tratan los neonatos con ictericia. La investigación sobre la sepsis neonatal ha informado las opciones sobre los antibióticos así como los regimenes de tratamiento. Los estudios sobre los infantespretérmino (bebésprematuros) han pasado a informar las conductas de tratamiento con respecto a asegurar un ambiente térmico, en relación con el tiempo del alta, así como con respecto al seguimiento del neurodesarrollo. Está claro que la información proveniente de la investigación clínica en HUWI ha pasado a ser parte del cuidado neonatal en la institución en los últimos 50 años, y se espera que continúe siéndolo más allá de los próximos 50 años.

Review of mortality of very low birthweight infants at the University Hospital of the West Indies over the past four decades / Examen de la mortalidad en neonatos de peso muy bajo al nacer en el Hospital de West Indies en las últimas cuatro décadas

A review of two previously published studies done at the University Hospital of the West Indies, an unpublished study and annual perinatal statistics was conducted to detect trends in the mortality of very low birthweight infants at the institution over four decades. Mortality decreased from 54% to 38% over the time period, the decrease was greater for infants weighing 1001-1500 g (40%) than those weighing ≤ 1000 g (28%). Despite increased access to mechanical ventilation over time, there was no appreciable decrease in mortality for infants weighing ≤ 750 g. There was a statistically significant decrease in mortality with increasing birthweight for the time period 1987-2002, p < 0.001. The mean ± SD weight of survivors 1.18 ± 0.24 kg was significantly greater than that for non-survivors 0.89 ± 0.21 kg for the same period. Further decrease in mortality of very low birthweight infants will involve measures aimed at decreasing mortality in infants weighing ≤ 750 g and increasing the availability of parenteral nutrition and the accessibility of surfactant.

Se llevó a cabo un examen de dos estudios previamente publicados realizados en el Hospital Universitario de West Indies, un estudio inédito, y las estadísticas perinatales anuales, con el propósito de detectar las tendencias en la mortalidad de los neonatos de muy bajo peso al nacer en la institución en un período de cuatro décadas. La mortalidad disminuyó de 54% a 38% durante ese periodo de tiempo. La disminución fue mayor para los infantes que pesaban 1001-1500 g (40%) que para aquellos que pesaban ≤ 1000 g (28%). A pesar del aumento del acceso a la ventilación mecánica con el tiempo, no se produjo una disminución apreciable en la mortalidad de infantes cuyo peso era ≤ 750 g. Hubo una disminución estadísticamente significativa de la mortalidad en relación con el aumento del peso en el período de 1987-2002, p < 0.001. El peso ± SD promedio de los sobrevivientes (1.18 ± 0.24 kg) fue significativamente mayor que el de los no sobrevivientes (0.89 ± 0.21 kg) para el mismo periodo. Una ulterior disminución de la mortalidad en neonatos de muy bajo peso al nacer implicará medidas encaminadas a disminuir la mortalidad en neonatos de peso ≤ 750 g y a aumentar la disponibilidad de la nutrición parenteral y la accesibilidad de los surfactantes.

Factors associated with extreme hyperbilirubinaemia in neonates at the University Hospital of the West Indies.

AIM: To determine factors associated with extreme hyperbilirubinaemia in neonates at the University Hospital of the West Indies. METHODS: A retrospective review of all neonates with hyperbilirubinaemia requiring medical intervention at the University Hospital of the West Indies between 1 January 2006 and 30 June 2007 was performed. Factors associated with extreme hyperbilirubinaemia were determined using multiple logistic regression models. RESULTS: A total of 170 neonates fulfilled the inclusion criteria for the study and 15 (9%) of them had extreme hyperbilirubinaemia. The majority (97, 57%) were term infants and 103 (61%) were male. Exclusively breastfed neonates were more likely to have extreme hyperbilirubinaemia (OR 2.6, 95% CI 0.01-0.6). Neonates whose mothers received oxytocin during labour (OR 2.7, 95% CI 0.02-0.3) and those who were G6PD-deficient (OR 2.6, 95% CI 0.01-0.5) were more likely to have extreme hyperbilurubinaemia. CONCLUSION: Exclusive breastfeeding, oxytocin use in the mother during labour and G6PD deficiency in the infant were found to be factors associated with extreme hyperbilirubinaemia.

Myasthenia gravis in Jamaican children: a 12-year institutional review.

BACKGROUND: Myasthenia gravis is uncommon in children. The clinical characteristics in children of the English-speaking Caribbean have not been documented previously. OBJECTIVE: To describe the clinical characteristics and outcome of children with myasthenia gravis at two tertiary hospitals in Jamaica. METHODS: The case-notes of all children with a diagnosis of myasthenia gravis managed at the University Hospital of the West Indies and Bustamante Hospital for Children between January 1994 and December 2005 were reviewed. RESULTS: There were 34 children; mean age of onset of illness was 7.5 years and mean period of follow-up was 38.5 months. The male-to-female ratio was 1:1.3. Nineteen (59%) presented with ocular manifestations; 47% of these developed signs of generalised involvement. Most were treated with pyridostigmine and prednisone. Eight patients had thymectomy. Four patients (12%) entered remission. There were two deaths. CONCLUSIONS: Myasthenia gravis in Jamaican children is similar to that in other populations. It is more common in female children. Most children present with ocular manifestations and remission occurs infrequently.

Epidemiology of neonatal jaundice at the University Hospital of the West Indies / Epidemiología de la ictericia neonatal en el Hospital Universitario de West Indies

OBJECTIVE: To describe the epidemiology of neonatal jaundice at the University Hospital of the West Indies (UHWI). METHODS: A retrospective review of all neonates at the UHWI with clinically significant jaundice between January 1, 2006 and June 30, 2007 was performed. Demographic, clinical and laboratory data were collected. Descriptive analyses were performed. RESULTS: The incidence of clinically significant neonatal jaundice at the UHWI was 4.6% for the study period. There were 103 male (61%) and 67 (39%) female infants. The aetiology of jaundice in the infant was attributed to ABO incompatibility in 59 (35%), infection in 30 (18%), prematurity in 19 (11%), G6PD deficiency in 8 (5%), Rhesus incompatibility in 6 (3.5%) and no cause was identified in 16 (9%) infants. There was a low incidence (26%) of screening for G6PD deficiency although it was the most common aetiology for infants presenting from home. Nine (5%) neonates required exchange blood transfusion. Infants admitted from home had a significantly higher mean total bilirubin value at presentation, a significantly higher mean peak bilirubin level and presented significantly later than those who were admitted from the postnatal ward (p < 0.001). One patient was discharged with a diagnosis of bilirubin encephalopathy but defaulted from follow-up. Two neonates died but from causes unrelated to neonatal jaundice. Sixty-two patients (37%) were followed-up post discharge; 50% had hearing tests done, all tests were normal. Sixty-one (98%) infants had normal development at the time of the study; one patient had impaired motor development but this infant also had a myelomeningocoele. CONCLUSION: To further reduce morbidity associated with neonatal jaundice at the UHWI, there should be increased screening for G6PD deficiency; current systems in place for follow-up and monitoring of infants discharged from hospital prior to 72 hours must also be expanded and strengthened.

OBJETIVO: Describir la epidemiología de ictericia neonatal en el Hospital Universitario de West Indies (UHWI). MÉTODOS: Se llevó a cabo una revisión retrospectiva de todos los recién nacidos con ictericia clínicamente significativa, en UHWI entre el 1ero de enero de 2006 y el 30 de junio de 2007. Se recogieron datos demográficos, clínicos y de laboratorio. Se realizaron análisis descriptivos. RESULTADOS: La incidencia de la ictericia neonatal clínicamente significativa en UHWI fue de 4.6% para el periodo en estudio. Había 103 recién nacidos varones (61%) y 67 (39%) hembras. La etiología de la ictericia en los neonatos se atribuyó a la incompatibilidad de ABO en 59 (35%), infección en 30 (18%), prematuridad en 19 (11%), deficiencia de G6PD en 8 (5%), e incompatibilidad de Rhesus en 6 (3.5%). No se identificó ninguna causa en 16 (9%) de los recién nacidos. Hubo una baja incidencia (26%) de tamizaje para la deficiencia de G6PD, aún cuando ésta es la etiología más común en el caso de los infantes provenientes de casa. Nueve (5%) recién nacidos requirieron cambio de sangre mediante transfusión. Infantes ingresados desde sus casas presentaban un valor promedio de bilirrubina total significativamente mayor en el momento de su hospitalización, así como un nivel pico promedio de bilirrubina significativamente más alto, y se presentaron significativamente más tarde que aquellos ingresados directamente de las sala de atención postnatal (p < 0.001). Un paciente fue dado de alta con un diagnóstico de encefalopatía bilirrubínica, pero no se presentó a las sesiones de seguimiento. Dos recién nacidos murieron, pero por causas no relacionadas con la ictericia neonatal. Sesenta y dos pacientes (37%) tuvieron seguimiento luego del alta; al 50% se les realizó pruebas de audición; todas las pruebas arrojaron resultados normales. Sesenta y un infantes (98%) presentaban un desarrollo normal en el momento del estudio. Un paciente tenía discapacidad del desarrollo motor, pero también presentaba un mielomeningocele CONCLUSIÓN: A fin de lograr una reducción de la morbosidad asociada con la ictericia neonatal en UHWI, debe realizarse un tamizaje de la deficiencia de G6PD. Asimismo, es necesario ampliar y fortalecer los sistemas actuales establecidos para el seguimiento y monitoreo de los infantes dados de alta del hospital antes de las 72 horas.

Congenital abnormalities at a tertiary center in Jamaica: an 18-month maternal-fetal medicine experience.

OBJECTIVE: The objective of this study was to compare outcomes of patients with prenatally versus postnatally diagnosed congenital abnormalities seen during the first 18 months of a recently established MFM unit. METHODS: Hospital charts of all congenital abnormalities diagnosed between July 2008 and December 2009 were reviewed. Data collected included: maternal demographics, perinatal outcome, neonatal mortality and morbidity as defined in the Radius trial. RESULTS: Fifty-five pregnancies with 57 anomalous fetuses were identified: 13 (23%) postnatally and 44 (77%) prenatally. Most frequent postnatally diagnosed anomalies were gastrointestinal (33%), central nervous system (CNS) (16%) and cardiac (16%); whereas prenatally diagnosed were CNS (29%) and genitourinary (23%). Mothers postnatally diagnosed had a 12 kg (17%) greater mean weight; 12 (92%) had anomaly scans reported as normal; birth weight and moderate neonatal morbidity were statistically greater (2.8 vs. 2.13 kg, p < 0.02) and (9/12 vs. 11/29, p < 0.03), respectively. Neonatal morbidity was 6.2 times more likely in the postnatally diagnosed group adjusting for birth weight, gestational age and route of delivery [OR (95% CI) 6.2, (1.2-32.4), p = 0.03]. CONCLUSIONS: Most abnormalities were diagnosed prenatally; however, the majority of postnatally diagnosed had false negative anomaly scans and experienced significantly more moderate neonatal morbidity.

Pattern of pregnancy weight gain in homozygous sickle cell disease and effect on birth size.

OBJECTIVE: To assess pregnancy weight gain and newborn anthropometry in mothers with homozygous sickle cell (SS) disease and normal controls. METHODS: An eleven-year retrospective review at the University Hospital of the West Indies, Kingston, Jamaica, revealed 128 singleton deliveries in women with SS disease who were matched by maternal age and birth date with 128 controls with a normal AA phenotype. Restriction to those commencing antenatal care before 16 weeks gestation resulted in the final study group of 80 SS patients and 115 AA controls. Weight and height were measured at first antenatal visit and weight at 20, 25, 30, 35 and 38 weeks gestation. Longitudinal regression used mothers'weight as the outcome, genotype as a predictor and gestational age as a random effect. Regression analyses of maternal weight on childhood anthropometry were repeated in separate maternal genotypes. Neonatal indices included gestational age, birthweight, head circumference and crown-heel length. RESULTS: Mothers with SS disease had lower weight and body mass index at first antenatal clinic visit (p < 0.001). Total weight gain was 6.9 kg for SS women and 10.4 kg for AA controls (p < 0.001) and weekly weight gain 0.263 kg (95% CI 0.224, 0.301) and 0.396 kg (95% CI 0.364, 0.427) respectively. A significant relationship occurred between birthweight and maternal weight gain at 25-30 weeks gestation in AA controls but this relationship appears delayed in SS disease. CONCLUSION: Different patterns of maternal weight gain in SS mothers and normal controls may have significance for the lower birthweight in SS mothers.

Pattern of pregnancy weight gain in homozygous sickle cell disease and effect on birth size / Patrones de ganancia de peso gestacional y tamaño al nacer en los casos de anemia de células falciformes

OBJECTIVES: To assess pregnancy weight gain and newborn anthropometry in mothers with homozygous sickle cell (SS) disease and normal controls. METHODS: An eleven-year retrospective review at the University Hospital of the West Indies, Kingston, Jamaica, revealed 128 singleton deliveries in women with SS disease who were matched by maternal age and birth date with 128 controls with a normal AA phenotype. Restriction to those commencing antenatal care before 16 weeks gestation resulted in the final study group of 80 SS patients and 115 AA controls. Weight and height were measured at first antenatal visit and weight at 20, 25, 30, 35 and 38 weeks gestation. Longitudinal regression used mothers'weight as the outcome, genotype as a predictor and gestational age as a random effect. Regression analyses ofmaternal weight on childhood anthropometry were repeated in separate maternal genotypes. Neonatal indices included gestational age, birthweight, head circumference and crown-heel length. RESULTS: Mothers with SS disease had lower weight and body mass index at first antenatal clinic visit (p < 0.001). Total weight gain was 6.9 kg for SS women and 10.4 kg for AA controls (p < 0.001) and weekly weight gain 0.263 kg (95% CI 0.224, 0.301) and 0.396 kg (95% CI 0.364, 0.427) respectively. A significant relationship occurred between birthweight and maternal weight gain at 25-30 weeks gestation in AA controls but this relationship appears delayed in SS disease. CONCLUSION: Different patterns of maternal weight gain in SS mothers and normal controls may have significance for the lower birthweight in SS mothers.

OBJETIVO: Evaluar la ganancia de peso gestacional y la antropometría neonatal en madres con anemia de células falciformes (CF) homocigóticas y en controles normales. MÉTODO: Un examen retrospectivo de once años en el Hospital Universitario de West Indies West Indies, Kingston, Jamaica, reveló la ocurrencia de 128 partos únicos (e.d. de un solo bebé) en mujeres con la enfermedad de CF, que fueron comparadas sobre la base de la edad materna y la fecha de nacimiento, con 128 controles de fenotipo AA normal. A partir de restricciones a las gestantes que comenzaron el cuidado prenatal antes de las 16 semanas de gestación, se llegó finalmente al grupo de estudio de 80 pacientes con CF y 115 controles con AA. El peso y la altura se midieron en la primera visita prenatal, y el peso a las 20, 25, 30, 35 y 38 semanas de gestación. La regresión longitudinal usó el peso de las madres como resultado, el genotipo como predictor, y la edad gestacional como efecto aleatorio. Los análisis de la regresión de peso materno sobre la antropometría fueron repetidos en genotipos maternos separados. Los índices neonatales incluyeron la edad gestacional, el peso al nacer y la circunferencia cefálica. RESULTADOS: Las madres con la enfermedad de CF tenían más bajo peso e índice de masa corporal en la primera visita clínica prenatal (p < 0.001). La ganancia de peso total fue 6.9 kg para las mujeres con CF y 10.4 kg para los controles AA (p < 0.001) y la ganancia de peso semanal 0.263 kg (95% CI 0.224-0.301) y 0.396 kg (95% CI 0.364-0.427) respectivamente. Una relación significativa tuvo lugar entre el peso al nacer y la ganancia de peso materna en las semanas 25-30 de gestación en los controles AA, pero esta relación parece demorada en la enfermedad de CF. CONCLUSION: Los patrones diferentes de ganancia de peso materno en las madres con CF y los controles normales, pueden tener importancia significativa para las madres con CF.