Predictive model for bacterial late-onset neonatal sepsis in a tertiary care hospital in Thailand.

BACKGROUND: Early diagnosis of neonatal sepsis is essential to prevent severe complications and avoid unnecessary use of antibiotics. The mortality of neonatal sepsis is over 18%in many countries. This study aimed to develop a predictive model for the diagnosis of bacterial late-onset neonatal sepsis. METHODS: A case-control study was conducted at Queen Sirikit National Institute of Child Health, Bangkok, Thailand. Data were derived from the medical records of 52 sepsis cases and 156 non-sepsis controls. Only proven bacterial neonatal sepsis cases were included in the sepsis group. The non-sepsis group consisted of neonates without any infection. Potential predictors consisted of risk factors, clinical conditions, laboratory data, and treatment modalities. The model was developed based on multiple logistic regression analysis. RESULTS: The incidence of late proven neonatal sepsis was 1.46%. The model had 6 significant variables: poor feeding, abnormal heart rate (outside the range 100-180 x/min), abnormal temperature (outside the range 36o-37.9 °C), abnormal oxygen saturation, abnormal leucocytes (according to Manroe's criteria by age), and abnormal pH (outside the range 7.27-7.45). The area below the Receiver Operating Characteristics (ROC) curve was 95.5%. The score had a sensitivity of 88.5% and specificity of 90.4%. CONCLUSION: A predictive model and a scoring system were developed for proven bacterial late-onset neonatal sepsis. This simpler tool is expected to somewhat replace microbiological culture, especially in resource-limited settings.

Prevalence of Sexually Transmitted Infection in Teenage Pregnancy in Rajavithi Hospital, Thailand.

BACKGROUND: Behavioral and social changes in the modern era have triggered an increase in the incidence of early sexual contact and teenage pregnancy. Since there is no routine Gonococcal & Chlamydial (GC & CT) screening in teens in antenatal clinics in Thailand, the present study was performed to find the prevalence of STI, especially Chlamydial infection, in teenage pregnancy. OBJECTIVE: To evaluate the prevalence of sexually transmitted infections (STIs), especially Chlamydial infection (CT), in teenage pregnancy and its related factors. MATERIAL AND METHOD: One hundred and twenty-one teenage pregnancies were recruited at the ANC in Rajavithi Hospital from October 2006 to May 2007. After signing informed consent forms, they were asked to answer questionnaires about baseline data, sexual information and risk factors, after which urine specimens were collected for screening for GC and CT using the PCR technique (AMPLICOR by Roche). Later, pelvic examination was per formed by the gynecologist at the STD (sexually transmitted disease) clinic. All the data and LAB results were recorded and analyzed by the SPSS program. Numbers, percentages, means with SD, Chi-squared test, Fisher's exact test and odds ratio were used. Potential risk factors were analyzed using binary logistic regression. RESULTS: The prevalence of STI in pregnant teenagers was 28.1% (CT = 19.8%, GC = 1.7%, hepatitis B = 3.3%, trichomoniasis 1.7%, Herpes simplex = 0.8% and condyloma acuminata = 0.8%). No Syphilis, chancroid or HIV were found in the present study Other non-STI like candidiasis and bacterial vaginosis were found in 45.5% of participants (candidiasis and bacterial vaginosis at 19.0% and 24.8%, respectively). The risk of CT infection was significantly related (6.9 times higher) to having previous sexual contact before the current partner (95% CI, 1.8-27.0). CONCLUSION: STI, especially Chlamydial infection, was found in a significant number of teenage pregnancies. Measures should be taken to prevent this resulting in complicated outcomes in the future.

Comparative growth outcome of preterm neonate fed post-discharge formula and breast milk after discharge.

OBJECTIVE: To evaluate the post-discharge growth, laboratory outcome, neurodevelopment and safety of post-discharge formula in comparison to breast milk. MATERIAL AND METHOD: A prospective cohort of preterm infants, who were discharged on breast milk or post-discharge formula (PDF) were studied. Demographic data, post-discharge growth, laboratory outcome, neurodevelopment and complications were recorded. These infants were followed-up at 40 weeks' postmenstrual age (PMA) 2, 4 and 6 months' corrected age. The present study was conducted for 22 months (from September 1, 2011-May 31, 2013). RESULTS: Seventeen infants were enrolled in the study, 7 in the breastfed group and 10 in the PDF group. Mean maternal age in breastfed group were significantly younger compared with PDF-fed group. PDF-fed infants were longer with statistical significantly at 40 weeks PMA and 4 months' corrected age (p < 0.05). At 2 months' corrected age, babies in breast milk group were significantly heavier compared to those in PDF group. Conversely, those in PDF group were heavier than the breastfed group at 4 months' corrected age (p < 0.05). There was no difference of head circumference between groups at follow-up. A higher serum phosphorus and lower serum alkaline phosphatase were related to improve suspected osteopenia of prematurity at 2 months' corrected age in PDF group (p = 0.007). Hematocrit was higher in the PDF group than breastfed group, which was statistically significant at 40 weeks' postmenstrual age and 6 months' corrected age. There were no significant diferences in developmental screening in both groups. CONCLUSION: Post-discharge formula may improve growth, hematocrit and reduce suspected osteopenia of prematurity. However neurodevelopment outcome and complications were similar to both groups.

Iloprost inhalation for the treatment of severe persistent pulmonary hypertension of the newborn, experience at QSNICH.

BACKGROUND: Persistent pulmonary hypertension of the newborn (PPHN) is the most serious condition that causes high mortality in term and post term infants. The authors have an experience of using high frequency oscillatory ventilation (HFOV) and inhaled nitric oxide (iNO) for treatment of this condition with a good result. However, due to high cost of iNo, other pulmonary vasodilators have been use. Sildenafil had some side effects of systemic hypotension. Thus, inhaled iloprost was introduced for treatment of PPHN at our institute. OBJECTIVE: To evaluate the outcome of inhaled iloprost for the treatment of PPHN. MATERIAL AND METHOD: This was a retrospective study. The data from medical records of newborns, diagnosed as persistent pulmonary hypertension of the newborn and had received inhaled iloprost from October 1st, 2008-October 31st, 2012, were reviewed. RESULTS: Nineteen cases of PPHN treated with inhaled iloprost were reviewed. Male to female ratio was 1.3 7:1 (11:8). Mean birth weight and gestational age of these patients were 2,997 ± 531.63 grams and 37.9 ± 2.51 weeks, respectively. Meconium aspiration syndrome was the leading underlying cause of this condition. The mortality rate in this study was 21% (4 from 19 cases). After the addition of inhaled iloprost, the oxygen index (OI) in the survivor group decreased significantly at one hour after treatment (from 32.89 to 22.06, 18.76, 13. 76 at 1, 6, 12 hours, respectively). Oxygen saturation (SpO2) continued increasing after treatment in the survivor group (from 82.40% to 92.20%, 95.00%, 95.80% at 1, 6, 12 hours, respectively) with significant difference at one hour. There was a significant difference of OI and SpO2 between the survivor and non-survivor groups after treatment. Low Apgar score at 5 minutes and early diagnosis of PPHN were found statistically significant different in the non-survivor compared to the survivor groups. CONCLUSION: Inhaled iloprost could be used as an alternative treatment of PPHN without side effects of systemic hypotension.

Establishing of National Birth Defects Registry in Thailand.

BACKGROUND: Deaths attributed to birth defects are a major cause of infant and under-five mortality as well as lifetime disabilities among those who survive. In Thailand, birth defects contribute to 21% of neonatal deaths. There is currently no systematic registry for congenital anomalies in Thailand. Queen Sirikit National Institute of Child Health has initiated a Thailand Birth Defects Registry to capture birth defects among newborn infants. OBJECTIVE: To establish the national birth defects registry in order to determine the burden of birth defects in Thailand. MATERIAL AND METHOD: The birth defects data come from four main sources: National Birth Registry Database; National Health Security Office's reimbursement database; Online Birth Defect Registry Database designed to capture new cases that were detected later; and birth defects data from 20 participated hospitals. All data are linked by unique 13-digit national identification number and International Classification of Diseases (ICD)-10 codes. This registry includes 19 common structural birth defects conditions and pilots in 20 hospitals. The registry is hospital-based, hybrid reporting system, including only live births whose information was collected up to 1 year of age. RESULTS: 3,696 infants out of 67,813 live births (8.28% of total live births in Thailand) were diagnosed with congenital anomalies. The prevalence rate of major anomalies was 26.12 per 1,000 live births. The five most common birth defects were congenital heart defects, limb anomalies, cleft lip/cleft palate, Down syndrome, and congenital hydrocephalus respectively. CONCLUSION: The present study established the Birth Defects Registry by collecting data from four databases in Thailand. Information obtained from this registry and surveillance is essential in the planning for effective intervention programs for birth defects. The authors suggest that this program should be integrated in the existing public health system to ensure sustainability.

Comparison outcomes of sick babies born to teenage mothers with those born to adult mothers.

BACKGROUND: Adolescent period is the transitional stage of physical and mental development from childhood to adulthood. Pregnancy in teenage girls is generally classified to have a higher risk than those in adults. In many previous studies reported only the outcome of teenage mothers but no comparative outcome between sick babies born to teen mothers and adult mothers, so the authors conducted the present study. OBJECTIVE: To compare the outcomes of sick infants born to teenage mothers with those born to adult mothers (age > or = 20 years). MATERIAL AND METHOD: This prospective study was carried out from October 1st, 2006 to September 30th, 2009. The study group consisted of sick babies born to teenage mothers and admitted at Queen Sirikit National Institute of Child Health (QSNICH). These babies were compared to sick babies (control group) born to adult mothers during the same period. The demographic data of mothers and sick babies in both groups were recorded in the designed case record forms. Developmental assessment was done until two years of age. RESULTS: A total of 6,342 deliveries took place in Rajavithi Hospital during the study period of which 697 babies were born to teenage mothers. The incidence of teenage pregnancy was 10.99%. The number of sick babies from teenage mothers and adult mothers were 78 and 147 cases, respectively. There was a significantly higher mortality in the study group (7 cases, 9%) than the control group (4 cases, 2.7%). There was statistically significant difference in most of the demographic characteristics between the teenage and adult mothers except anemia, PROM and MSAF (meconium stain amniotic fluid). Although there was a trend of more cases of anemia and MSAF in teenage mothers than in adult mothers, there was no statistically significant difference. There was a shorter interval time from marriage to pregnancy in teen mothers than in adult mothers and a lower number of antenatal care visits with late antenatal care among the teenage mothers too. On comparing the data in infants, the teenage group had more males and a higher blood pressure than those in the adult group. There were significantly more preterm infants and higher cesarean section in the adult group too. Gastroschisis cases were found only in the teenage group. In follow-up cases, more than seventy percent in both groups were assessed for developmental outcome until two years of age. Divorce was found in teen mothers more than in adult mothers (17.54 vs. 3%) and more cases in teenage infants received care in rural areas by grandparents (36.6 vs. 12.6%). Delayed speech was found in more cases in the teen group than in the adult group (12.28 vs. 6%). CONCLUSION: The number of antenatal care in teenage mothers was less than in standard pregnancy care. Cesarean section rate was lower in teenage mothers than in the adult mothers. Preterm infants were found in more cases in the adult group but gastroschisis was found only in the teenage group. More cases of infants in the teenage group received care in rural areas by grandparents and divorce occurred more in teen mothers than adult mothers.

Compare severity of bronchopulmonary dysplasia in neonates with respiratory distress syndrome treated with surfactant to without surfactant.

BACKGROUND: The utilization of surfactant replacement therapy had been limited in treatment of respiratory distress syndrome (RDS) due to the high cost especially in developing countries. Nowadays, the National Health Insurance Policy has covered the cost of surfactant for the patients. Therefore, bronchopulmonary dysplasia (BPD) may be found increasing due to increased survival in patients with severe RDS. OBJECTIVE: To compare immediate treatment outcome of severity of BPD and outcome after hospital discharge in neonates with RDS who were treated with or without surfactant. STUDY DESIGN: Retrospective cohort study. MATERIAL AND METHOD: The data of 54 infants who developed BPD after RDS at Queen Sirikit National Institute of Child Health between January 1st, 2003 and December 31th, 2005 were kept in database format. The database was analyzed for difference between groups and the outcome of immediate treatment, severity of BPD and outcome after hospital discharge were compared. The study group was BPD cases from RDS treated with surfactant compared to control (BPD cases from RDS treated without surfactant) groups. RESULTS: Forty-three (80%) from fifty-four cases had completed data and were included into the present study. There was no statistically significant difference in maternal conditions and neonatal conditions between groups. Antenatal steroid was prescribed more often in RDS without surfactant group than surfactant group. The mean birth weight and gestational age in surfactant and without surfactant groups were 1,179.1 +/- 274.3 gm vs. 1,114.4 +/- 338.3 gm and 29 +/- 1.6 weeks vs. 29.2 +/- 2.7 weeks respectively, but no significant differences were observed between groups. To compare the severity of RDS, only 17.6% of moderate to severe RDS in the control group was found, whereas 100% was found in the study group. Moderate to severe BPD cases were found more often in the control group (70.6%) than in the study group (61.6%), but no statistically significant difference was shown. The immediate complications, e.g. pneumothorax (5.9%) and pneumomediastinum (5.9%) were found in the control group, but pulmonary hemorrhage occurred more often in the study group than the control group (11.5% vs. 5.9%). For long-term follow-up, the development outcome was not different between groups. CONCLUSION: The present study revealed no statistically significant difference in severity of BPD in neonates with RDS treated with and without surfactant groups. In addition, surfactant was useful in moderate to severe RDS because no early complication such as air leak syndrome was found in this group.

Outcome of teenage pregnancy in Rajavithi Hospital.

OBJECTIVE: To compare maternal and neonatal outcomes between pregnant teenage girls (age <20 yrs) and pregnant adults (age 20-34 yrs). MATERIAL AND METHOD: Seven hundred and fifty pregnant teenagers admitted and delivered at Rajavithi Hospital during November 8, 2006 and December 22, 2007 were enrolled in the study. A control group included 750 pregnant adults delivered during the same period. RESULTS: Preterm labor was the significant antepartum complication in the teenage mothers while diabetes mellitus was the significant one in the adult mothers as compared to those in the other groups. Teenage mothers had significantly higher incidence of cesarean delivery than that in the adult mothers. The neonates of the teenage mothers showed higher number of complications than those of the adult mothers. CONCLUSION: Pregnant teenage girls had more maternal and neonatal complications than those of pregnant adults.

Comparison outcomes of surfactant therapy in respiratory distress syndrome in two periods.

BACKGROUND: Exogenous surfactant replacement therapy has been a part of the routine care of preterm neonates with respiratory distress syndrome (RDS) since 1990s. In Thailand, the utilization of surfactant replacement therapy had been limited due to the high cost until the National Health Insurance Policy began in 2003 which covered the cost of surfactant. Nowadays surfactant replacement therapy is more frequently used at Queen Sirikit National Institute of Child Health, so the authors were interested in evaluating its use in RDS. OBJECTIVES: To compare the outcome and complications of surfactant replacement therapy in newborns who were diagnosed with moderate to severe RDS during two times period. STUDY DESIGN: Retrospective study. MATERIAL AND METHOD: The data of infants who were diagnosed as moderate to severe RDS and treated with surfactant at Queen Sirikit National Institute of Child Health between January 1st, 2003 and December 31th, 2005 were reviewed. The outcome of this study (Group II) was compared to the previous study conducted in 1999-2002 (Group I). The complications, mortality rate, association time of start surfactant and duration of ventilation were reviewed. RESULTS: The data of ninety-one moderate to severe RDS patients who received surfactant replacement therapy were reviewed. The mean birth weight and gestational age in this group were 1250 +/- 435.57 gm and 29.38 +/- 2.2 week less than in the first group 1,344 +/- 452.37gm and 29.69 +/- 2.61 week. The second group showed statistical differences in antepartum hemorrhage (4.4%) and pregnancy induced hypertension (PIH) (17.6%) while the first group had 33.3% ofantepartum hemorrhage and 3% of PIH. In neonatal conditions, there were statistical significant differences in anemia 28.6% in group II compared to 9% in group I and patent ductus arteriosus 67% in group II compared to 39.4% in group I. Surfactant was given earlier in life (4.75 +/- 2.76 hours) in the second group compared to the first group (7.21 +/- 4.92 hour) and the overall duration ofpatients on mechanical ventilation in Group II (6 days) was shorter than in Group I (16 days). This was especially more evident in patients who received surfactant within the first six hours of life. The immediate complication, pulmonary hemorrhage was found in more cases in Group I (33.3%) than in Group II (12.1%) but bronchopulmonary dysplasia (BPD) was found to be a late complication in more cases in Group II (46.1%) than in Group I (21.2%). The mean length of admission was longer in Group II (61.23 +/- 41.08 days) compared to Group I (38.5 +/- 23.48 days) and the mortality rate in Group II was 18.7% (17 cases) lower than Group I 33.3% (11 cases). CONCLUSION: Surfactant therapy in moderate to severe RDS can shorten the duration of ventilation and decrease the mortality rate, but has no effect in decreasing the incidence of chronic lung disease. Nevertheless the earlier the surfactant therapy is started, the higher the survival rate.

A randomized trial of non-synchronized Nasopharyngeal Intermittent Mandatory Ventilation (nsNIMV) vs. Nasal Continuous Positive Airway Pressure (NCPAP) in the prevention of extubation failure in pre-term < 1,500 grams.

OBJECTIVE: To compare the rate of reintubation within 7 days after extubation and study the complications in premature infants who were randomized in the immediate postextubation period to either nsNIMV or NCPAP. MATERIAL AND METHOD: This study was conducted in the neonatal unit of Queen Sirikit National Institute of Child Health between June 1 and November 30, 2006. Intubated premature infants born at GA < or = 34 weeks or with birth weight < or = 1500 gm, ready to be extubated before 4 weeks of age were recruited. Infants were randomized to either nsNIMV or NCPAP after extubation. Non-synchronized NIMV setting was the same as ventilator setting before extubation and NCPAP pressure was set at the same mean airway pressure of pre extubation ventilator value. Extubation was performed after intravenous loading dose of aminophylline. Primary outcome measurement was reintubation within 7 days of initial extubation and the secondary outcome was possible complications such as apnea, abdominal distension, gastrointestinal (GI) perforation, necrotizing enterocolitis (NEC), sepsis and death. RESULTS: A total of 70 VLBW infants were admitted to the neonatal unit during the study period. A total of 57 infants were intubated of which 48 infants were recruited for the study; 24 were in the nsNIMV group and 24 were in the NCPAP group. Infants in the nsNIMV group had mean birth weight and body weight at the start of study less than that in the NCPAP group (984.8 +/- 218 vs. 1067 +/- 214 and 1185 +/- 219 vs. 1205 +/-191, p = 0.003, 0.02). The nsNIMV group also had a higher rate of RDS and antenatal steroid used when compared to the NCPAP group (19/24 vs. 12/24 and 17/24 vs. 8/24, p = 0.03, 0.01). The nsNIMV group had fewer males than in the NCPAP group (8/24 vs. 17/24, p = 0.01). Reintubation was similar in both groups but atelectasis and sepsis were statistically significant risk factor for reintubation in NCPAP group. There were no significant differences in treatment related complications between the two groups, with respect to incidence of apnea (41.7% in nsNIMV vs. 62.5% in NCPAP), abdominal distensions (8.3% in nsNIMVvs. 16.7% in NCPAP), NEC (4.2% in nsNIMVvs. 12.5 in NCPAP), sepsis (4.2% in nsNIMVvs. 8.3% NCPAP). No GI perforation was observed in both groups. CONCLUSION: Non-invasive mode of ventilation, both NIMV and NCPAP, for weaning ofpre-term infants from ventilator may reduce the rate of reintubation in this group. Both modes seem to be equally safe. We believe that the use of non-invasive ventilator techniques will significantly reduce neonatal morbidity in the future. Additional prospective evaluation of these approaches should be conducted in the future.

Inhaled iloprost for severe persistent pulmonary hypertension of the newborn.

The authors report one case of persistent pulmonary hypertension that had hypoxia although receiving treatment with high frequency oscillation, inotropic drugs, blood transfusion, and oral sildenafil for pulmonary vasodilatation. The patient developed hypotension after two doses of oral sildenafil and no response to high dose of inotropic drugs. So aerosolized iloprost was given via endotracheal tube and oxygen saturation improved within 10 minutes. Oxygen was weaned at 36 hours after treatment with this drug and no any side effect was found.

Inhaled nitric oxide in newborns with severe hypoxic respiratory failure.

BACKGROUND: Respiratory failure in term and near term infants is often associated with persistent pulmonary hypertension of the newborn and contributes to hypoxemia in these infants. Inhaled nitric oxide (iNO) is currently used as a pulmonary vasodilator to improve oxygenation in neonates with severe respiratory failure. OBJECTIVE: To determine outcome of administration of iNO in severe hypoxic respiratory failure. MATERIAL AND METHOD: The present study was conducted from 1999 to 2004 in the neonatal intensive care unit (NICU) at Queen Sirikit National Institute of Child Health. Patients were selected from all infants > or = 34 weeks gestational age who required high frequency oscillatory ventilation (SLE 2000 HFO, SLE, UK) or conventional mechanical ventilation for hypoxemic respiratory failure caused by PPHN. Diagnosis was confirmed by 2-D echocardiogram visualization with right to left shunt through the foramen ovale or patent ductus arteriosus. Inhaled nitric oxide was given as standard therapy in patients who had two oxygenation indices > or = 20 at least 30 minutes apart after being on a mechanical ventilator. RESULTS: Fifty-five cases were enrolled and male to female ratio was 22.2 tol. The survival rate was 76.4 percent. Inhaled nitric oxide significantly improved oxygenation index, arterial alveolar oxygen tension ratio (a/A O2), and alveolar arterial oxygen gradient in survivors at one hour after treatment. The earliest improvement in oxygen saturation was within ten minutes. Meconium aspiration syndrome was the most common underlying cause of PPHN. No acute complication was found during nitric oxide administration. Chronic lung diseases, delayed development and severe hearing loss in long-term follow up were found in 10, 5, and 2 cases, respectively. CONCLUSION: Inhaled nitric oxide should be used early in severe hypoxic respiratory failure with persistent pulmonary hypertension of newborn and can improve survival rates without any major immediate side effects.

A comparison of oral ibuprofen and intravenous indomethacin for closure of patent ductus arteriosus in preterm infants.

BACKGROUND: Indomethacin is widely accepted as the treatment for patent ductus arteriosus (PDA) in preterm infants but it has various side effects. Ibuprofen is the alternative treatment and believed to be less likely to induce side effects. OBJECTIVE: To compare efficacy and side effects of ibuprofen versus indomethacin treatment for symptomatic patent ductus arteriosus (PDA) in preterm infants. METHOD: The authors studied 30 infants (gestational age < or = 35 weeks, aged < or = 10 days) who were diagnosed as having symptomatic PDA confirmed by echocardiogram. The infants were randomly assigned to receive three intravenous doses of indomethacin given at 12-hour intervals or three doses of ibuprofen given at 24-hour intervals, starting within ten days of life. The demographic data, rate of clinical closure, need for additional treatment, side effects, complications and the infants' clinical course were recorded within 28 days. RESULTS: The rate of ductal closure was similar with the two treatment regimes. Ductal closure occurred in 7 of 15 infants given ibuprofen (46.67%) and 10 of 15 infants given indomethacin (66.67%). (Relative risk 0.669; 95% confidence interval, 0.328 to 1.364; p = 0.462) The number of infants who needed a second pharmacologic treatment was not significantly different between the two groups, (6 cases in the ibuprofen group, 5 cases in the indomethacin group) but surgical ligation was performed in two cases in the indomethacin group. There was a significant difference in using the diuretic drug (furosemide) in the indomethacin group (11 cases), compared to the ibuprofen group (3 cases), (p = 0.009). More cases of necrotizing enterocolitis were seen in the indomethacin group (66.67% compared to 40% in the ibuprofen group) but there was no statistically significant difference. CONCLUSION: Ibuprofen has the same efficiency as indomethacin for the treatment of symptomatic patent ductus arteriosus in preterm infants and less likely to induce necrotizing enterocolitis and renal toxicity than indomethacin.

Vertical transmission of dengue infection in Thai infants: two case reports.

Dengue infection is hyperendemic in tropical countries especially in Thailand. Most dengue infections occur during childhood but some adults may remain susceptible to infection. About 30 per cent of dengue infection are reported in patients > 15 years old. Some pregnant women may also be susceptible to dengue and if they experience dengue infection, they can transmit the dengue viruses to their babies. The authors report two babies who developed mild dengue illness, dengue hemorrhagic fever (DHF) grade II, beginning on their 6th day of life. Both of them had low grade fever, hepatomegaly and generalized petechial rash. The first baby had Hct ranging from 46 to 40 per cent with minimal right pleural effusion. The lowest platelet count was 19,000 cells/mm3. His mother had dengue shock syndrome with masssive post partum bleeding. The second baby had dengue 2 infection while his mother had dengue fever. His Hct had also risen from 52 per cent to 61 per cent with right pleural effusion. His lowest platelet count was 7,000 cells/mm3. Both mothers and their babies had a complete recovery although the first baby had prolonged thrombocytopenia for two months.

Outcome of neonates with persistent pulmonary hypertension of the newborn treated with inhaled nitric oxide.

OBJECTIVE: This study assessed the outcome of nitric oxide treatment in infants with persistent pulmonary hypertension of the newborn (PPHN) who failed high frequency oscillatory ventilation (HFOV). METHOD: This study was conducted from July 1, 2000 to June 30, 2001 at the neonatal intensive care unit of Queen Sirikit National Institute of Child Health. Nitric oxide was administered to 20 infants, > or = 34 weeks gestational age who were diagnosed with PPHN and had two oxygenation index > or = 20 at least 30 minutes apart after HFOV treatment. RESULTS: Nitric oxide inhalation significantly improved the oxygenation index, a/A ratio, A-a gradient (p<0.05) and directly measured partial pressure arterial oxygenation. Oxygen saturation improved within ten minutes after nitric oxide inhalation. The survival rate was 85 per cent. Meconium aspiration syndrome was the most common cause of PPHN. No acute complication was found during nitric oxide administration. CONCLUSION: Inhalation of nitric oxide increased the blood oxygen tension of infants with PPHN without using a surfactant and ECMO. The authors suggest that inhalation nitric oxide is a useful adjunctive therapy for these patients.

Effect of cisapride on corrected QT interval in neonates.

OBJECTIVE: To evaluate the effect of cisapride on corrected QT (QTc) interval in neonates at the Queen Sirikit National Institute of Child Health. METHOD: A prospective study was performed to see the effects of cisapride on QTc interval in 20 neonates between 1st July 2001 and 31st January 2002. QTc interval was determined just before, 48 hours, 7 days and 15 days after the start of treatment with cisapride. QTc interval was calculated by averaging QT/square root(RR) values obtained from 5 consecutive beats in lead II of the EKG. Baseline electrolyte and calcium levels were drawn on all infants before treatment of cisapride. Drug dose ranged from 0.1-0.2 mg/kg every 6 to 8 hours. RESULTS: Twenty infants were enrolled in the survey but complete data was obtained on 18 infants only. QTc interval of > 0.45 seconds was not found in any neonate. There was no significant difference of QTc interval before and 48 hours, 7 days and 15 days after cisapride administration (p = 0.861). There were also no statistically significant effects of age at starting cisapride, weight, gestational age and dose on QTc interval (p = 0.581, 0.65, 0.8, and 0.497). There were no adverse effects such as diarrhea or jaundice during the study. CONCLUSION: Term and preterm infants using cisapride at the doses of 0.4-0.8 mg/kg/day did not develop QTc prolongation, arrhythmias or adverse effects. In the absence of risk factors, cisapride may be safe for use in neonates.

Comparison outcomes of surfactant therapy in respiratory distress syndrome in two periods.

BACKGROUND: Exogenous surfactant replacement therapy has been a part of the routine care of preterm neonates with respiratory distress syndrome (RDS) since 1990s. In Thailand, the utilization of surfactant replacement therapy had been limited due to the high cost until the National Health Insurance Policy began in 2003 which covered the cost of surfactant. Nowadays surfactant replacement therapy is more frequently used at Queen Sirikit National Institute of Child Health, so the authors were interested in evaluating its use in RDS. OBJECTIVES: To compare the outcome and complications of surfactant replacement therapy in newborns who were diagnosed with moderate to severe RDS during two times period. STUDY DESIGN: Retrospective study. MATERIAL AND METHOD: The data of infants who were diagnosed as moderate to severe RDS and treated with surfactant at Queen Sirikit National Institute of Child Health between January 1st, 2003 and December 31th, 2005 were reviewed. The outcome of this study (Group II) was compared to the previous study conducted in 1999-2002 (Group I). The complications, mortality rate, association time of start surfactant and duration of ventilation were reviewed. RESULTS: The data of ninety-one moderate to severe RDS patients who received surfactant replacement therapy were reviewed. The mean birth weight and gestational age in this group were 1250 +/- 435.57 gm and 29.38 +/- 2.2 week less than in the first group 1,344 +/- 452.37gm and 29.69 +/- 2.61 week. The second group showed statistical differences in antepartum hemorrhage (4.4%) and pregnancy induced hypertension (PIH) (17.6%) while the first group had 33.3% ofantepartum hemorrhage and 3% of PIH. In neonatal conditions, there were statistical significant differences in anemia 28.6% in group II compared to 9% in group I and patent ductus arteriosus 67% in group II compared to 39.4% in group I. Surfactant was given earlier in life (4.75 +/- 2.76 hours) in the second group compared to the first group (7.21 +/- 4.92 hour) and the overall duration ofpatients on mechanical ventilation in Group II (6 days) was shorter than in Group I (16 days). This was especially more evident in patients who received surfactant within the first six hours of life. The immediate complication, pulmonary hemorrhage was found in more cases in Group I (33.3%) than in Group II (12.1%) but bronchopulmonary dysplasia (BPD) was found to be a late complication in more cases in Group II (46.1%) than in Group I (21.2%). The mean length of admission was longer in Group II (61.23 +/- 41.08 days) compared to Group I (38.5 +/- 23.48 days) and the mortality rate in Group II was 18.7% (17 cases) lower than Group I 33.3% (11 cases). CONCLUSION: Surfactant therapy in moderate to severe RDS can shorten the duration of ventilation and decrease the mortality rate, but has no effect in decreasing the incidence of chronic lung disease. Nevertheless the earlier the surfactant therapy is started, the higher the survival rate.

A randomized trial of non-synchronized Nasopharyngeal Intermittent Mandatory Ventilation (nsNIMV) vs. Nasal Continuous Positive Airway Pressure (NCPAP) in the prevention of extubation failure in pre-term < 1,500 grams.

OBJECTIVE: To compare the rate of reintubation within 7 days after extubation and study the complications in premature infants who were randomized in the immediate postextubation period to either nsNIMV or NCPAP. MATERIAL AND METHOD: This study was conducted in the neonatal unit of Queen Sirikit National Institute of Child Health between June 1 and November 30, 2006. Intubated premature infants born at GA < or = 34 weeks or with birth weight < or = 1500 gm, ready to be extubated before 4 weeks of age were recruited. Infants were randomized to either nsNIMV or NCPAP after extubation. Non-synchronized NIMV setting was the same as ventilator setting before extubation and NCPAP pressure was set at the same mean airway pressure of pre extubation ventilator value. Extubation was performed after intravenous loading dose of aminophylline. Primary outcome measurement was reintubation within 7 days of initial extubation and the secondary outcome was possible complications such as apnea, abdominal distension, gastrointestinal (GI) perforation, necrotizing enterocolitis (NEC), sepsis and death. RESULTS: A total of 70 VLBW infants were admitted to the neonatal unit during the study period. A total of 57 infants were intubated of which 48 infants were recruited for the study; 24 were in the nsNIMV group and 24 were in the NCPAP group. Infants in the nsNIMV group had mean birth weight and body weight at the start of study less than that in the NCPAP group (984.8 +/- 218 vs. 1067 +/- 214 and 1185 +/- 219 vs. 1205 +/-191, p = 0.003, 0.02). The nsNIMV group also had a higher rate of RDS and antenatal steroid used when compared to the NCPAP group (19/24 vs. 12/24 and 17/24 vs. 8/24, p = 0.03, 0.01). The nsNIMV group had fewer males than in the NCPAP group (8/24 vs. 17/24, p = 0.01). Reintubation was similar in both groups but atelectasis and sepsis were statistically significant risk factor for reintubation in NCPAP group. There were no significant differences in treatment related complications between the two groups, with respect to incidence of apnea (41.7% in nsNIMV vs. 62.5% in NCPAP), abdominal distensions (8.3% in nsNIMVvs. 16.7% in NCPAP), NEC (4.2% in nsNIMVvs. 12.5 in NCPAP), sepsis (4.2% in nsNIMVvs. 8.3% NCPAP). No GI perforation was observed in both groups. CONCLUSION: Non-invasive mode of ventilation, both NIMV and NCPAP, for weaning ofpre-term infants from ventilator may reduce the rate of reintubation in this group. Both modes seem to be equally safe. We believe that the use of non-invasive ventilator techniques will significantly reduce neonatal morbidity in the future. Additional prospective evaluation of these approaches should be conducted in the future.

Inhaled iloprost for severe persistent pulmonary hypertension of the newborn.

The authors report one case of persistent pulmonary hypertension that had hypoxia although receiving treatment with high frequency oscillation, inotropic drugs, blood transfusion, and oral sildenafil for pulmonary vasodilatation. The patient developed hypotension after two doses of oral sildenafil and no response to high dose of inotropic drugs. So aerosolized iloprost was given via endotracheal tube and oxygen saturation improved within 10 minutes. Oxygen was weaned at 36 hours after treatment with this drug and no any side effect was found.

Inhaled nitric oxide in newborns with severe hypoxic respiratory failure.

BACKGROUND: Respiratory failure in term and near term infants is often associated with persistent pulmonary hypertension of the newborn and contributes to hypoxemia in these infants. Inhaled nitric oxide (iNO) is currently used as a pulmonary vasodilator to improve oxygenation in neonates with severe respiratory failure. OBJECTIVE: To determine outcome of administration of iNO in severe hypoxic respiratory failure. MATERIAL AND METHOD: The present study was conducted from 1999 to 2004 in the neonatal intensive care unit (NICU) at Queen Sirikit National Institute of Child Health. Patients were selected from all infants > or = 34 weeks gestational age who required high frequency oscillatory ventilation (SLE 2000 HFO, SLE, UK) or conventional mechanical ventilation for hypoxemic respiratory failure caused by PPHN. Diagnosis was confirmed by 2-D echocardiogram visualization with right to left shunt through the foramen ovale or patent ductus arteriosus. Inhaled nitric oxide was given as standard therapy in patients who had two oxygenation indices > or = 20 at least 30 minutes apart after being on a mechanical ventilator. RESULTS: Fifty-five cases were enrolled and male to female ratio was 22.2 tol. The survival rate was 76.4 percent. Inhaled nitric oxide significantly improved oxygenation index, arterial alveolar oxygen tension ratio (a/A O2), and alveolar arterial oxygen gradient in survivors at one hour after treatment. The earliest improvement in oxygen saturation was within ten minutes. Meconium aspiration syndrome was the most common underlying cause of PPHN. No acute complication was found during nitric oxide administration. Chronic lung diseases, delayed development and severe hearing loss in long-term follow up were found in 10, 5, and 2 cases, respectively. CONCLUSION: Inhaled nitric oxide should be used early in severe hypoxic respiratory failure with persistent pulmonary hypertension of newborn and can improve survival rates without any major immediate side effects.