Incidence and risk factors of parenteral nutrition-associated liver disease in newborn infants.

BACKGROUND: The aim of the present study was to determine the incidence and risk factors of parenteral nutrition-associated liver disease (PNALD) in neonates. METHODS: A 1 year prospective cohort study was carried out at the neonatal intensive care unit and sick neonatal wards, Chiang Mai University Hospital. Newborns >1000 g, receiving >7 days of parenteral nutrition (PN), were enrolled. Liver function tests were done by the end of first, second, and fourth week, and then every 4 weeks until the PN was discontinued and the jaundice resolved. The diagnosis of PNALD relied on a history of PN, direct bilirubin >2 mg/dL, and exclusion of other causes of neonatal cholestasis. Selected patient factors and PN compositions were analyzed to determine the risks for development of PNALD. RESULTS: A total of 24 infants with a mean gestational age and birthweight of 32.5 weeks and 1840 g were enrolled. Eight of the 24 developed PNALD. Compared to those without PNALD, gastrointestinal surgery, duration of enteral starvation, duration of PN, maximum PN caloric intake, and maximum carbohydrate intake were significantly associated with the development of liver disease. Despite the lack of statistical significance, there was a trend towards cholestasis in patients with sepsis. Elevation of direct bilirubin was the earliest biochemical change, observed in the first week after PN, followed by increased transaminases. CONCLUSION: Gastrointestinal surgery, duration of enteral starvation, duration of PN, maximum caloric and carbohydrate intake in PN were significant risks of PNALD in newborn infants.

Persistent hyperinsulinemic hypoglycemia of infancy associated with congenital neuroblastoma: a case report.

The authors report a rare case of persistent hyperinsulinemic hypoglycemia of infancy (PHHI) with congenital neuroblastoma without feature(s) of Beckwith-Wiedemann syndrome. A term newborn with a birth weight of 3,900 g developed hypoglycemia one hour after birth and required up to 20 mg/kg/min of intravenous glucose infusion to maintain euglycemia. Investigations during the critical period revealed an inappropriately high insulin level. An abdominal CT scan revealed a normal pancreas, right suprarenal mass, and liver nodules. A condition of stage 4S neuroblastoma was suspected and supported by an increased ratio of urine vanillylmandelic acid to creatinine. The bone marrow smear was normal. She underwent near total pancreatectomy at the age of 2 months. The suprarenal mass and liver nodules were not found during the operation or during repeated abdominal CT scans at 3 month of age. Spontaneous regression of neuroblastoma was suspected. The pathology of the pancreas was compatible with PHHI.

"Enhanced acquisition of antibiotic-resistant intestinal E. coli during the first year of life assessed in a prospective cohort study".

Background: Increasing bacterial resistance to antibiotics is a serious problem worldwide. We sought to record the acquisition of antibiotic-resistant Escherichia coli (E. coli) in healthy infants in Northern Thailand and investigated potential determinants. Methods: Stool samples from 142 infants after birth, at ages 2wk, 2mo, 4 to 6mo, and 1y, and parent stool samples were screened for E. coli resistance to tetracycline, ampicillin, co-trimoxazole, and cefazoline by culture, and isolates were further investigated for multiresistance by disc diffusion method. Pulsed-field gel electrophoresis was performed to identify persistent and transmitted strains. Genetic comparison of resistant and transmitted strains was done by multilocus sequence typing (MLST) and strains were further investigated for extra- and intra-intestinal virulence factors by multiplex PCR. Results: Forty-seven (33%) neonatal meconium samples contained resistant E. coli. Prevalence increased continuously: After 1y, resistance proportion (tetracycline 80%, ampicillin 72%, co-trimoxazole 66%, cefazoline 35%) almost matched those in parents. In 8 infants (6%), identical E. coli strains were found in at least 3 sampling time points (suggesting persistence). Transmission of resistant E. coli from parents to child was observed in only 8 families. MLST showed high diversity. We could not identify any virulence genes or factors associated with persistence, or transmission of resistant E. coli. Full-term, vaginal birth and birth in rural hospital were identified as risk factors for early childhood colonization with resistant E. coli. Conclusion: One third of healthy Thai neonates harboured antibiotic-resistant E. coli in meconium. The proportion of resistant E. coli increased during the first year of life almost reaching the value in adults. We hypothesize that enhancement of infection control measures and cautious use of antibiotics may help to control further increase of resistance.

Efficacy and safety of gentamicin by interval and intravenous dosage adjustment based on the gestational age in Thai neonates.

OBJECTIVE: To determine the pharmacological efficacy and safety of the gentamicin regimen that adjusts intravenous dose and interval based on the gestational age (GA) in Thai neonates. MATERIAL AND METHOD: Neonates aged < or = 7 days, who had received gentamicin for clinically suspected or high risk of sepsis and had no contraindication to gentamicin usage were enrolled. They were stratified into four groups by GA as < or = 29, 30-33, 34-37 and > or = 38 weeks gestation. Gentamicin administration in each group was 5, 4.5, 4 and 4 mg/kg/dose every 48, 36, 36 and 24 hours respectively according to Neofax regimen. Peak serum gentamicin concentration (SGC), trough SGC and serum creatinine (Cr) were obtained. RESULTS: Forty-nine neonates were enrolled. Forty-four (89.7%) had peak SGC within the desirable range (5-12 mg/L). Three neonates had slightly high peak SGC. Their peak SGCs were 13.0, 12.21 and 12.20 mg/L. Two neonates had slightly low peak SGC. Their peak SGCs were 4.91 and 4.4 mg/L. All neonates had trough SGC below 2 mg/L. None had significant rising of serum Cr during the present study period. CONCLUSION: This gentamicin regimen yielded good pharmacological efficacy and safety in Thai neonates, who were in the first week of life and had no renal function impairment.

Severe upper gastrointestinal hemorrhage in the newborn.

Three infants with severe upper gastrointestinal hemorrhage with esophagogastroduodenoscopic (EGD) findings were reported. The underlying conditions of these infants included Down's syndrome, hypoplastic left heart, and diaphragmatic hernia. The precipitating factors were identified in all cases, including prenatal stress, hypoxemia, prolonged ventilatory support, and gastroesophageal reflux. The EGD findings were composed of multiple gastric ulcers and a duodenal ulcer in the first 2 cases, whereas esophagitis and gastritis were noted in the last case. These ulcers were classified as secondary peptic ulcers. All cases responded well to medical treatment, including ranitidine, sucralfate, omeprazole, cisapride, and octreotide.