Long-term outcome of surgically managed necrotizing enterocolitis in a developing country.

UNLABELLED: Necrotizing enterocolitis (NEC) is a serious condition with a high morbidity and mortality commonly affecting premature babies. Data for the impact of the long-term disease burden in developing countries are limited although poor long-term outcome of surgically managed patients has been shown in terms of increased risk of neurodevelopmental delay, increased infectious disease burden and abnormal neurological outcomes in the developed world. PURPOSE: To evaluate the long-term outcome of a pre-human immunodeficiency virus pandemic NEC cohort to characterize common risk factors and outcome in a developing world setting. METHODS: A retrospective review of medical records was carried out on a cohort of 128 premature neonates with surgical NEC (1992-1995). Morbidity, mortality and long-term outcome were evaluated. RESULTS: Data for 119 of 128 sequentially managed neonates with surgically treated NEC was available. Mean gestational age was 32 weeks and average birth weight was 1,413 g. Early (30-day postoperative) survival was 69% (n = 82) overall and 71% in the <1,500 g birth weight group (n = 68; 53%). Overwhelming sepsis (n = 16) or pan-intestinal necrosis (n = 18) accounted for most of the early deaths. Late deaths (>30 days postoperatively, n = 22) resulted from short bowel syndrome (5), sepsis (9), intraventricular hemorrhage (1) and undetermined causes (7). On follow-up (mean follow-up 39 months, 30 for >2 years), long-term mortality increased to 50%. Late surgical complications included late colonic strictures (9), incisional hernias (2) and adhesive bowel obstruction (3). Fifteen patients had short bowel syndrome, of which 10 (66%) survived. Of the long-term survivors, 8 (20%) had severe neurological deficits and 20 (49%) had significant neurodevelopmental delay. Neurological deficits included severe auditory impairment [5 (12%)] and visual impairment [4 (10%)]. Recurrent infections and gastrointestinal tract complaints requiring hospital admission occurred in 16 (39%) of survivors. CONCLUSION: Necrotizing enterocolitis in premature infants impacts morbidity and mortality considerably. A number do well in a developing country, but septic complications may be ongoing and recurrent. The high risk of neurodevelopmental and other problems continue beyond the neonatal period and patients should be "flagged" on for careful follow-up.

Kangaroo mother care in the nursery.

Kangaroo mother care is becoming an integral part of the care of low birth weight infants worldwide. It provides economic savings to families and health care facilities and many physiologic and psychobehavioral benefits to mothers and infants, the most important of which is the promotion of successful breastfeeding. The benefits of breastfeeding, of human milk over formula, and of feeding from the breast per se, are beyond dispute, and so KMC should be actively promoted. The full impact of KMC on breastfeeding low birth weight infants is yet to be realized.

Phototherapy and exchange transfusion for neonatal hyperbilirubinaemia: neonatal academic hospitals' consensus guidelines for South African hospitals and primary care facilities.

The purpose of this document is to address the current lack of consensus regarding the management of hyperbilirubinaemia in neonates in South Africa. If left untreated, severe neonatal hyperbilirubinaemia may cause kernicterus and ultimately death and the severity of neonatal jaundice is often underestimated clinically. However, if phototherapy is instituted timely and at the correct intensity an exchange transfusion can usually be avoided. The literature describing intervention thresholds for phototherapy and exchange transfusion in both term and preterm infants is therefore reviewed and specific intervention thresholds that can be used throughout South Africa are proposed and presented graphically. A simplified version for use in a primary care setting is also presented. All academic heads of neonatology departments throughout South Africa were consulted in the process of drawing up this document and consensus was achieved.

Tuberculosis of the skull vault: a case report.

We describe a 3-year-old boy who had fluctuating swellings of the head and an infra-orbital sinus which were due to tuberculous osteitis. On radiological examination, the lesions may be found to be multifocal, and usually appear to be circumscribed and lytic. Definitive diagnosis depends, however, on bone biopsy.

Bartter's syndrome. A case report.

A child presenting with the characteristic biochemical findings of Bartter's syndrome is described. Short-term follow-up showed a satisfactory response to a prostaglandin synthetase inhibitor.

Persistent pulmonary hypertension of the neonate in a developing country--does extracorporeal membrane oxygenation have a role to play?

A retrospective study was undertaken of survival after conventional management of 35 infants suffering from persistent pulmonary hypertension of the neonate (PPHN). The outcome of infants weighing more than 2,000 g and who also qualified for extracorporeal membrane oxygenation (ECMO) therapy on the grounds of published criteria was assessed. The admission incidence of patients with PPHN was 1.1%. Secondary PPHN was more common than primary. The overall survival rate of 69% in this study reflects the trend in recently reported improved survival rates of infants with PPHN, treated with conventional techniques. Sixteen of 28 infants weighing more than 2,000 g qualified for ECMO therapy; 4 of them died. Had ECMO been available as an alternative mode of therapy, only 2 of the 4 might have been saved. The other 2 were considered to have conditions incompatible with a normal quality of life. We therefore assessed the requirement for ECMO in our population to be approximately 0.6/1,000 live births. Although ECMO may be promising, the introduction of this technique in developing countries should rather be delayed until more substantial data refute this. Because PPHN could be related to a potential preventable cause in almost 80% of cases, we propose the support of more cost-effective strategies such as continuing obstetric and perinatal education programmes.

The role of obstetric factors in determining fetal viability.

OBJECTIVE: To study the influence of primary obstetric complications on the survival and short-term morbidity rates of very-low-birth-weight (VLBW) babies. DESIGN: A 1-year retrospective, descriptive study. SETTING: Department of Obstetrics and Gynaecology, Tygerberg Hospital, CP. STUDY POPULATION: 257 women admitted with live singleton fetuses and who eventually delivered babies with birth weights ranging from 750 to 1,499 g. MANAGEMENT: Primary obstetric complications responsible for the delivery of the VLBW babies were clinically diagnosed. Active management was undertaken if the fetus was viable and obstetric and neonatal resuscitation were applied. Management was conservative when the fetus was considered non-viable. This decision on the initial treatment option was taken by the obstetrician who managed the case. MAIN OUTCOME MEASUREMENTS: Survival and short-term morbidity rates of the babies. RESULTS: Spontaneous preterm labour (45%) and hypertensive disorders (39%) were equally responsible for delivery of VLBW babies at Tygerberg Hospital. The only obstetric factor influencing the babies' outcome, however, was the initial management decision by the obstetrician. There was a survival rate of 160/213 (75.1%) in the actively managed group compared with only 1/44 (2.3%) in the conservatively managed group. Other factors that significantly influenced neonatal survival of VLBW babies were: birth weight, gestational age, Apgar score at 5 minutes and length of time between admission to hospital and the delivery. CONCLUSION: The obstetric complication responsible for delivery of the VLBW baby did not influence the survival rate. The major determinant of neonatal survival was the obstetrician's decision to manage the fetus either actively or conservatively. It seems that the outcome of VLBW babies is influenced primarily by the intrinsic characteristics of the neonates' gestational age, birth weight and condition at birth, and not the reason for delivery.

The transport of neonates to an intensive care unit.

OBJECTIVE: To describe the mode of transport, the type of patient transferred and outcome as defined by death or discharge from hospital. DESIGN: A retrospective study was done of all neonates transferred from outside the designated drainage area of the hospital. SETTING: The study was done at the level 3 Neonatal Intensive Care Unit at Tygerberg Hospital for the period January-September 1992. PARTICIPANTS: From a total of 58 infants 52 were enrolled; they originated over a vast area of the western and northern Cape Province. MAIN OUTCOME MEASURES: Reasons for transfer, mode of transport and survival were measured. RESULTS: None of the infants died during transport. In total 11 (21%) of the 52 died. Categorising outcome according to transport method showed 100% survival of babies transported by fixed-wing aircraft, 94% survival if transport was by helicopter, and 70% survival if transported by ambulance. The non-survivors had a higher mean gestational age (P < 0.05) than the survivors and included 8 (73%) with asphyxia-related meconium aspiration syndrome. When the primary referral diagnosis was considered, 8 (27%) of 29 infants with respiratory failure of any cause, and 2 (28%) of those with neurological problems, died. All the infants transported because of a surgical emergency survived. CONCLUSION: These results show a high survival rate in transported infants, with the highest mortality in the asphyxia-related meconium aspiration syndrome and the infants transported by ambulance. The preponderance of infants with meconium aspiration syndrome might reflect the standard of perinatal care provided in the outlying regions of the western and northern Cape.

Therapeutic monitoring as an aid in rationalizing aminoglycoside dosage techniques in the neonate.

General pharmacokinetic parameters applicable to adults are not suitable in neonatal practice owing to wide interpatient variations in respect of fluid balance, renal clearance and metabolic rates. We attempted to determine whether acceptable blood levels of gentamicin or tobramycin are obtained with dosage regimens and dosage techniques which are generally recommended. Forty neonates receiving aminoglycosides were studied. After administration of the drug as a slow, constant intravenous infusion into the 'Y' connection of the infusion set, peak levels were found to be subtherapeutic. Trough levels were also very low. After administration of the same dose of gentamicin or tobramycin as a bolus into the butterfly connection of the infusion set, however, high therapeutic levels were obtained. We therefore recommend that gentamicin and tobramycin be administered as an intravenous bolus injection and that blood levels be monitored constantly in order to individualize therapy.

Does a nonreactive fetal heart rate pattern really mean fetal distress?

The aim of the study was to compare three different fetal heart rate (FHR) patterns, namely, a nonreactive pattern with good long-term variability (fluctuation of 5 or more beats/min), a reactive pattern, and a nonreactive pattern with poor long-term variability (less than 5 beats/min). For this purpose, nonstress tests done less than 24 hours before delivery and FHR patterns recorded during labor were separately assessed. Endpoints for comparison were 5-minute Apgar scores, intrauterine growth retardation, and umbilical blood gas values at birth. Regarding the nonstress test, the prevalence of low 5-minute Apgar scores in reactive, good variability, and in poor variability patterns were 7.2%, 5.3%, and 24%, respectively. The prevalences of small for gestational age newborns were 8%, 17.6%, and 60.6%, respectively. Blood gas values did not differ significantly. Regarding the FHR patterns during labor, using the same sequence, the prevalences of low 5-minute Apgar scores were 3.5%, 6%, and 23%, respectively. Small for gestational age babies occurred in 8.8%, 15.6%, and 80% of the different FHR patterns, respectively. Regarding umbilical artery blood gas values, the only significant difference was a lower pH in the poor variability group. No difference was found between the blood gas values of babies with a reactive pattern and a nonreactive pattern with good variability.

Expectant management of early onset, severe pre-eclampsia: perinatal outcome.

OBJECTIVE: To evaluate the perinatal outcome of expectant management of early onset, severe pre-eclampsia. DESIGN: Prospective case series extending over a five-year period. SETTING: Tertiary referral centre. POPULATION: All women (n = 340) presenting with early onset, severe pre-eclampsia, where both mother and the fetus were otherwise stable. METHODS: Frequent clinical and biochemical monitoring of maternal status with careful blood pressure control. Fetal surveillance included six-hourly heart rate monitoring, weekly Doppler and ultrasound evaluation of the fetus every two weeks. All examinations were carried out in a high care obstetric ward. MAIN OUTCOME MEASURES: Prolongation of gestation, perinatal mortality rate, neonatal survival and major complications. RESULTS: A mean of 11 days were gained by expectant management. The perinatal mortality rate was 24/1,000 (> or = 1,000 g/7 days) with a neonatal survival rate of 94%. Multivariate analysis showed only gestational age at delivery to be significantly associated with neonatal outcome. Chief contributors to neonatal mortality and morbidity were pulmonary complications and sepsis. Three pregnancies (0.8%) were terminated prior to viability and only two (0.5%) intrauterine deaths occurred, both due to placental abruption. Most women (81.5%) were delivered by caesarean section with fetal distress the most common reason for delivery. Neonatal intensive care was necessary in 40.7% of cases, with these babies staying a median of six days in intensive care. CONCLUSION: Expectant management of early onset, severe pre-eclampsia and careful neonatal care led to high perinatal and neonatal survival rates. It also allowed the judicious use of neonatal intensive care facilities. Neonatal sepsis remains a cause for concern.

Necrotizing enterocolitis in infants born to women with severe early preeclampsia and absent end-diastolic umbilical artery doppler flow velocity waveforms.

The aim of this study was to determine the prevalence of necrotizing enterocolitis (NEC) in infants born to a homogeneous group of women with severe preeclampsia before 34 weeks' gestation and who had absent end-diastolic umbilical artery Doppler flow (AEDF) or normal umbilical Doppler flow velocities (NUFV). A total of 242 infants were entered into the study. The mean birth weight was 1260.5 g (SD = 339) and the mean gestational age 30.5 weeks (SD = 2.0). Sixty-eight (28%) infants had AEDF, 43 (18%) had umbilical artery Doppler flow velocities between the 95th and 99th percentile, and 131 (54%) had NUFV. Forty-one (18%) infants developed NEC, of whom 20 (8%) developed definite and advanced NEC (grade 2 and 3). Of these, 16(80%) had grade 2 and 4(20%) had grade 3. Twenty-one (8%) infants developed suspected NEC (grade 1). The mean onset of grade 1 NEC (7.2 days) occurred significantly earlier than in those with grades 2 and 3 NEC (18.7 and 23.3 days, respectively). Of the 21 infants with grade 1 NEC, 10 (48%) had AEDF and 9 (43%) had NUFV. None of the infants with grades 2 or 3 NEC had AEDF. We conclude that although chronically hypoxemic fetuses born to women with severe early onset preeclampsia and AEDF respond by redistributing blood flow to vital organs and away from the gut; the intestinal compromise is of insufficient magnitude to induce intestinal necrosis or NEC. Enteral feeding, however, should be introduced cautiously in infants with AEDF, as so-called suspected NEC developed significantly more often in these infants.

Value of C reactive protein measurement in tuberculous, bacterial, and viral meningitis.

The value of C reactive protein measurement in the differential diagnosis of meningitis was assessed in a population where tuberculous meningitis is prevalent. C reactive protein was measured serially with a sensitive radioimmunoassay in sera from 31 children with bacterial meningitis, 15 with tuberculous meningitis (6 with miliary tuberculosis), and 28 with viral meningitis. Concentrations of C reactive protein in patients with tuberculous meningitis lay between those of patients with bacterial and viral meningitis--a finding which detracts from the virtually absolute discrimination C reactive protein measurement allows between bacterial and viral meningitis. In all but two of the patients with tuberculous meningitis, C reactive protein concentrations fell rapidly after treatment began and became normal after 10 days. This fall did not, however, exclude the development of hydrocephalus as a complication. Measurement of C reactive protein remains a useful additional parameter in the diagnosis and management of the various types of meningitis.

The prevalence of iron deficiency in apparently healthy Cape coloured infants.

In order to obtain a more accurate picture of the prevalences of anaemia, iron deficiency anaemia, haematological iron deficiency and diminished iron stores, 240 Cape Coloured infants from the lower socio-economic groups were studied. Anaemia was diagnosed in 42 infants (17,5%), iron deficiency anaemia in 81 (34%), and haematological iron deficiency in 28%; 64 (27%) showed evidence of diminished iron stores. The findings indicate that iron deficiency was a common problem in the infants studied, and the same probably also applies to the community at large.

Zinc and copper levels in the breast-milk of Cape Town mothers.

Zinc and copper levels were measured longitudinally in the breast-milk of 55 healthy South African women from the middle and upper socio-economic classes. The mean foremilk zinc levels showed a significant fall (P less than 0,05) from 652,9 +/- 240,7 micrograms/dl at 3 days after delivery to 413,3 +/- 143,0 micrograms/dl at 7 days and 228,1 +/- 136,1 micrograms/dl at 6 weeks. Lower foremilk zinc levels were obtained at 36 weeks (64,3 +/- 50,0 micrograms/dl). In contrast, foremilk copper levels were low at 3 days (57,0 +/- 74,8 micrograms/dl), with a gradual decline to very low levels (28,0 +/- 29,7 micrograms/dl) at 36 weeks. No differences were detected between the fore- and hindmilk zinc and copper levels at any stage of lactation studied (P greater than 0,05).

Introduction of a donor exposure reduction programme for multiple-transfused very-low-birth-weight infants.

OBJECTIVE: To conduct an audit of the frequency of red cell concentrate transfusions (RCCTs) in infants of different weight categories, the donor exposure rate (DER), in these transfused infants and the volume of blood wasted during each transfusion, and to identify from this baseline information specific categories of infants who would benefit from the introduction of a limited donor exposure programme (LDEP). STUDY SETTING: Neonatal wards and neonatal intensive care unit (NICU), Tygerberg Hospital, Western Cape. STUDY DESIGN: A prospective descriptive study and comparison with a historic control group. SUBJECTS: Information on the birth weight, age at the time of each RCCT and number of blood donors to whom an infant was exposed were collected post factum for all infants admitted to the neonatal wards and NICU between May 1993 and May 1994. During this time, the red blood cell concentrate was supplied as single paediatric bags (180 ml) transfused within 14 days of donation. An LDEP was introduced in February 1995. With this system, red blood cells were supplied as triple packs: a main unit of 250 ml with three empty satellite packs allowing up to three separate transfusions. These were assigned to a specific infant and were to be transfused within 21 days of donation. A second system where one adult blood bag was divided into two 180 ml bags and assigned to one infant to be transfused within 35 days of donation was also assessed. RESULTS: Of the 7854 infants admitted during the first 12-month audit period, 387 (4.9%) received 977 RCCTs. Of these, 183 (47.3%) received one transfusion, 72 (18.6%) two transfusions, 51 (13.2%) three transfusions, 27 (7.0%) four transfusions and 54 (13.9%) five or more transfusions. Infants (N = 188) with a birth weight below 1500 g admitted to the NICU were identified as the group with the highest prevalence of RCCTs (68.6%), and it was therefore decided that in the prospective study such infants would qualify for the LDEP. A total of 81 infants was transfused with either the double (N = 47) or the triple bags (N = 34) over a 5-month period. The decrease in the mean DER (+/-SD) was clinically significant when the triple (1.9 +/- 0.8) (P = 0.0001) and the double bags (1.6 +/- 0.8) (P = 0.0001) were compared with the previous single-bag system (4.4 +/- 3.5). Of concern was the large mean volume of concentrated red cells (118.5 +/- 12.5 ml) wasted per transfusion with the single-bag system. CONCLUSIONS: This survey confirmed a high RCCT rate as well as a very high DER in very-low-birth-weight (VLBW) infants treated at a tertiary centre. By assigning a triple or double bag of red cells from one blood donor and extending the storage of blood for small-volume RCCTs in infants from 14 days to 35 days, donor exposure was reduced significantly. We urge the introduction of the multibag blood transfusion system and extended storage period of blood for small-volume RCCT for VLBW infants in South Africa.

The necessity for T-cryptantigen activation screening in babies with necrotising enterocolitis.

OBJECTIVE: To determine the prevalence of T-cryptantigen activation (TCA) and its predictive value for severity of necrotising enterocolitis (NEC) in babies. STUDY DESIGN: Prospective descriptive. STUDY POPULATION: Thirty-four babies with NEC were prospectively screened for TCA at Tygerberg Hospital over a 6-month period. TCA screening was done by testing for red blood cell agglutination by the common peanut lectin, Arachis hypogea. Once TCA was confirmed, only washed red cells were administered to the babies and plasma-containing blood products were avoided. NEC was divided into suspected NEC (stage 1), classic NEC (stage 2) and fulminant NEC (stage 3). MAIN OUTCOME MEASURES: Prevalence of TCA in babies with various stages of NEC; the association between TCA and bowel necrosis, need for surgery and mortality. RESULTS: TCA was positive in 8 (24%) of the babies in this study. Six babies (18%) had stage 1 NEC, 10 (29%) had stage 2 NEC and 18 (53%) had fulminating or stage 3 NEC. All 18 babies with stage 3 NEC required surgery and TCA was present in 8 (47%) of them. Twelve babies (35%) died, 3 with TCA and 9 with no TCA. Babies with TCA had portal venous gas on abdominal radiographs (P = 0.037) and stage 3 NEC (P = 0.003) more often than babies with no TCA. CONCLUSIONS: A strong association was noted between TCA and the fulminant form of NEC with bowel necrosis. TCA is a baby with NEC should alert the surgeon to the possibility of severe disease and the need to avoid plasma-containing blood products. Blood banks are urged to introduce routine screening for TCA in all babies with NEC.

The outcome at 12 months of very-low-birth-weight infants ventilated at Tygerberg Hospital.

OBJECTIVE: To determine the outcome at 1 year of age of a group of very-low-birth-weight (VLBW) infants, from urban and rural communities, ventilated at Tygerberg Hospital, W. Cape. STUDY DESIGN: Prospective descriptive study in which the prevalence of bronchopulmonary dysplasia (BPD), sensorineural deafness, intraventricular haemorrhage (IVH), retinopathy of prematurity (ROP) and abnormal motor developmental outcomes were determined in 153 ventilated VLBW infants from rural and urban areas. Of these, 69% were from lower socio-economic backgrounds. MAIN OUTCOME MEASURES: Attrition rates for rural and urban babies, BPD, ROP, IVH and abnormal motor development. STUDY POPULATION AND SETTING: All ventilated VLBW infants discharged from the neonatal intensive care unit at Tygerberg Hospital over a 1-year period were followed up at 3-monthly intervals for 12 months. RESULTS: BPD was diagnosed in 19% of the babies, with significantly more babies with birth weights under 1,000 g and gestational ages under 28 weeks having BPD. Of the babies with BPD, 25% had abnormal motor development at 1 year of age. Seven per cent of the babies had grade 3 or 4 ROP and 2.6% had sensorineural hearing loss. One hundred and seventeen (79%) of the infants attended the follow-up clinic until 12 months of age (corrected for prematurity). There were no significant differences in the number of babies followed up from rural or urban areas. Fourteen (11.9%) of the babies had abnormal motor development. A disturbing finding was that so many babies had spastic quadriplegia (8; 57%) versus diplegia (6; 43%). The incidence of abnormal motor development in the babies from the rural areas and in those with birth weights under 1,000 g from rural areas was high--a further cause for concern. CONCLUSION: The prevalence of the major complications associated with ventilated VLBW infants correlated well with those reported for similar infants from First-World countries. The poor motor developmental outcome of the babies from rural areas with birth weights under 1,000 g and high attrition rates for infants with serious complications such as BPD, IVH and ROP are distressing.

Serum zinc and copper levels in the 1st year of life.

Zinc and copper concentrations in the serum of 240 healthy infants aged 1-12 months were measured by the atomic absorption spectrophotometric method. The study was designed so that on completion there would be 20 infants in each of 12 groups according to age by month. The mean serum zinc levels remained fairly constant in all the age groups except for a significant fall from levels at 1 month (77,11 +/- 12,85 micrograms/dl) to those at 2 months of age (66,60 +/- 15,18 micrograms/dl) (P less than 0,025). Another significant decline in serum zinc levels was present between 4 and 5 months of age (P less than 0,05), which was followed by a significant increase between 5 and 6 months of age (P less than 0,05). The infants' mean serum zinc levels were lower than those of normal adults at all ages (P less than 0,05). The mean serum copper levels were low at 1 month of age (71,17 +/- 17,30 micrograms/dl), and increased significantly between 1 and 2 months (P less than 0,001) and 3 and 4 months of age (P less than 0,02). Mean serum copper levels similar to those of adults were reached at 4 months of age. These levels remained fairly constant from 5 months of age onwards, the only significant decline being noted at between 7 and 8 months of age (P less than 0,05). The present study substantiates previous findings that a specific pattern of change in serum copper concentrations which differs from the trend in serum zinc levels occurs in infants after birth. To detect zinc and copper depletion it is important to interpret serum concentrations in relation to normal values for age.