Clinical profile and management of symptomatic patent ductus arteriosus in premature infants

Twenty cases of symptomatic patent ductus arteriosus (PDA) in preterm inborn infants were studied retrospectively. The diagnostic criteria were a systolic or a systolodiastolic murmur, tachycardia (greater than 160 per minute), hyperdynamic precordium, collapsing arterial pulses, cardiomegaly or a need for intermittent positive pressure ventilation or continuous distending airway pressure. The incidence was found to be 2.48/1000 live births and 1.5% of SCBU admission. All babies were less than 35 weeks gestation and 18/20 weighed less than 1750 g at birth. Ten babies were treated with indomethacin (0.2 mg/kg) and two of these babies died before the course of treatment was completed. Ten babies were treated with conservative therapy. They could not be administered indomethacin because two died of fulminant sepsis soon after the diagnosis was made; two babies had sepsis and DIC but recovered from it, three had thrombocytopenia, one had azotemia, two babies had hyperbilirubinemia requiring exchange transfusion. The two groups of babies matched in respect to gestational age, sex, age at presentation, birth weight and associated illnesses. Two babies in each group died soon after diagnosis. Of the eight babies in each group, six babies closed the ductus on indomethacin therapy as against two on conservative therapy. This difference was significant (p less than 0.05). The babies who responded to indomethacin were all treated within two weeks of age. None of them showed any complication of drug therapy or recurrence of PDA. We conclude that intragastric indomethacin given early in the management of symptomatic PDA in term infants is a safe and effective modality.

Bilirubin crystals in peripheral blood smears from neonates with unconjugated hyperbilirubinaemia

Peripheral blood smears from 118 hyperbilirubinaemic neonates and 10 neonates with physiological jaundice were screened for the presence of bilirubin crystals. Smears were made from EDTA anticoagulated blood from 107 hyperbilirubinaemic neonates and capillary blood from 11 cases. In sixty-three (58.8%) of the 107 EDTA smears, yellow-coloured refractile rhomboid crystals were seen within the cytoplasm of the neutrophils, band forms, metamyelocytes, myelocytes, monocytes, and also extra-cellularly. The mean serum unconjugated bilirubin value was significantly higher (293.8 mumol/l) in neonates with crystals in their smears as compared to those without crystals (242.2 mumol/l). In septicaemic neonates the proportion of neutrophil-containing crystals was higher than in the case of other aetiological factors responsible for unconjugated hyperbilirubinaemia. None of the smears made from non-anticoagulated capillary blood showed bilirubin crystals.

Perinatal outcome in relation to maternal glycaemic control in diabetic mothers

The relationship between glycaemic control and perinatal outcome was assessed in 60 pregnant diabetic women, divided into three groups on the basis of the mean plasma glucose level. Group I, had mean plasma glucose less than 120 mg/dl (32 patients); group II, mean plasma glucose 121-140 mg/dl (13 patients); and group III, mean plasma glucose exceeding 140 mg/dl (15 patients). The degree of maternal glycaemic control appeared to affect the perinatal outcome. Neonatal morbidity was minimum in group I (31.25%) followed by group II infants (46.15%) and maximum in group III infants (66.6%). Maintenance of maternal plasma glucose level at or below 120 mg/dl was thus associated with minimum neonatal morbidity.

Polycythemia in the newborn

Polycythemia (venous PCV greater than 65%) in neonates is not an infrequent occurrence. Over the last 2 years out of approximately 1500 admissions to the Neonatal Unit, polycythemia was detected in 46 babies (3.06%). Seventeen (36%) of these babies were preterm and 29 (63%) were term. Approximately one third were small for dates while 2 babies (4%) were large for dates. Four of them had been born to mothers with gestational diabetes and 7 were twin deliveries. Severe perinatal asphyxia (5 minute Apgar score less than or equal to 5) was present in 12 cases (26%). Symptoms suggestive of polycythemia included lethargy in 15%, refusal to feed in 13%, respiratory distress in 10%, vomiting in 8% and abdominal distension in 6%. Associated hypoglycemia was seen in 5 cases (10.8%) while twelve babies (26%) had significant jaundice (bilirubin greater than or equal to 12 mg/dl). Twenty eight babies (60.8%) were given a partial plasma exchange transfusion through the umbilical route. There was 6.5% mortality in these 46 babies with polycythemia. Blood letting through a peripheral vein along with a plasma infusion may be a safer alternative to partial plasma exchange transfusion through umbilical route in babies with polycythemia.

Outbreak of Salmonella worthington meningitis & septicaemia in a hospital at Chandigarh (north India)

During August 1988 an outbreak of hospital acquired infection due to S. worthington has been reported at the Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh. A total of seven neonates presented with the clinical features of meningitis and septicaemia during this outbreak and six babies died. S. worthington was isolated from blood and cerebrospinal fluid respectively. The same strains were isolated from the baby warmer mattress, baby cot, suction machine bottle and wall of the fridge. Samples from doctors, nurses and apparently healthy babies born during this period did not grow the above organism. This appears to be the first report on S. worthington in human beings from India. The outbreak was controlled by thorough cleaning and fumigation. The organisms were also mostly sensitive to antibiotics used, in contrast to the multiple drug resistant pattern reported from elsewhere.

Brain stem evoked response audiometry in neonates

Brain stem evoked response audiometry (BERA) was performed in 50 normal full term newborn infants (25 male, 25 female) to generate normative data base for this age group. The stimuli of 30 dB, 40 dB and 80 dB nHL (normal hearing level) intensities were delivered to each subjects. 30 dB stimulus failed to produce clear wave patterns, whereas upto six vertex positive waves were recognised among which waves I, III and V were commonly present. The absolute latencies of waves I and V at 40 dB nJL were 2.54 +/- 0.21 msec and 7.56 +/- 0.26 msec and at 80 dB nHL these were 2.06 +/- 0.15 msec and 7.09 +/- 0.17 msec respectively. I-V interpeak latencies (IPL) were 5.02 +/- 0.13 msec at 40 dB and 5.03 +/- 0.13 at 80 dB nHL. The latencies of waves I and V were decreased with the increase of intensity of stimuli with the rate of 0.012 msec/dB, bit I-V IPL, i.e., central conduction time remained almost constant. There were no statistically significant differences in the brain stem auditory evoked responses between male and female subjects. Brain stem evoked response audiometry is objective and reliable for hearing screening in neonates.

Lessons from improved neonatal survival at Chandigarh

We observed a significant fall in neonatal mortality in babies weighing less than 2 kg during 1986 as compared to 1973 (7.94% vs 12.88%; p less than 0.005), and in preterm babies the mortality fell from 26.88 to 11.5% (p less than 0.001) during 1986. This was achieved despite 2-3 fold increase in the high risk babies and without any increase in the number of neonatal special care beds or nurses. Effective utilisation of the facilities was made possible through: (a) reduction in admissions to neonatal special care unit of babies with birth weight more than 1500 g; (b) early discharge of babies to home from NSCU; (c) involvement of the mothers in the care of their high risk babies: and (d) care of babies with sucking difficulties and asymptomatic birth asphyxia outside NSCU. All babies discharged home at less than 2 kg weight, and living in Chandigarh were followed for 3 months and 98.2% were doing well. This observation highlights the judicious use of neonatal special care facilities and mothers for the care of high risk neonates.

Evaluation of Minolta jaundicemeter and icterometer for assessment of neonatal jaundice

Neonatal jaundice is an important disorder, because of its potential complication of kernicterus. Biochemical estimation of bilirubin can be unreliable with lots of interpersonal and interlaboratory variability. Minolta jaundicemeter and perspex icterometer were evaluated for their usefulness in assessment of neonatal jaundice. Thirty premature babies with hyperbilirubinemia were simultaneously studied with jaundicemeter, icterometer and their plasma bilirubin were estimated by AO Bilirubinometer. Babies were subdivided into three groups, viz., Group I upto 1500 g birth weight, Group II 1501-2500 g with gestation 33-34 weeks and Group III 1501-2500 g with gestation 35-36 weeks. There was a good correlation between minolta Jaundicemeter and plasma bilirubin with 'r' values of 0.84, 0.89 and 0.72 in Groups I, II and III, respectively. Except for Group III (r = 0.67), good correlation was found between icterometer and plasma bilirubin with 'r' value of 0.84 and 0.82 in Groups I and II, respectively.

Functional and structural changes in parotid glands of alcoholic cirrhotic patients

The parotid gland function and structure was studied in 30 patients with biopsy-proven alcoholic cirrhosis and in 43 age- and sex-matched alcoholic and nonalcoholic control subjects. Mean simulated parotid saliva flow rate was significantly (p less than 0.05) lower in patients with alcoholic cirrhosis as compared with alcoholic and nonalcoholic control subjects. A similar reduction was observed in mean basal parotid saliva flow rate in patients with alcoholic cirrhosis that reached statistical significance (p less than 0.05) in comparison with nonalcoholic control subjects. In addition, the concentration of sodium, bicarbonate, and total proteins in stimulated parotid saliva was significantly (p less than 0.005) lower in patients with alcoholic cirrhosis as compared with the two groups of control subjects. Sialograms in 6 patients with alcoholic cirrhosis did not reveal any obstructive lesion in the primary parotid duct or its branches. Histology of salivary tissue revealed an increase in the interstromal fatty infiltration, edema, and fibrosis without evidence of inflammatory reaction in 5 patients as compared with the control subjects. These data provide evidence for marked parotid gland dysfunction in patients with alcoholic cirrhosis presumably due to metabolic derangement and altered parotid gland structure.

Acute renal failure amongst children in a tropical environment

The pathogenetic factors leading to acute renal failure (ARF) in 223 children between the ages of 20 days and 14 years were studied. Diarrhoeal diseases were responsible for ARF in 49.8%, acute glomerulonephritis in 34.1%, drug induced intravascular hemolysis in glucose -6-phosphate dehydrogenase deficiency in 4.5%, snake bite in 4%, hemolytic uremic syndrome in 2.2%, and miscellaneous causes in 5.4%. Dialysis was instituted in 178 children and the others were treated conservatively. Renal histology in 39 out of 76 children who presented with an acute nephritic illness revealed acute endocapillary proliferative glomerulonephritis in 27 and crescentic glomerulonephritis in 12. The histology in 79 out of 147 remaining patients showed acute tubular necrosis in 64, acute cortical necrosis in 13, and acute interstitial nephritis in 2. Overall mortality was 27.4%. This high incidence of ARF due to infective diarrhoeas and dysentery reflects poor socio-economic and hygienic conditions, inadequate facilities in rural areas, delays in seeking medical advice, and lack of knowledge about fluid and electrolyte therapy amongst the staff.

Lack of association between barotrauma and air leak in hyaline membrane disease

A retrospective analysis of 632 infants with hyaline membrane disease admitted to this regional intensive care nursery between 1 July 1974 and 31 December 1982 showed that 387 (61%) received mechanical ventilation. The ventilator pressures at the time the first air leak was detected were available from the records of 120 of 154 (78%) of the infants who sustained pulmonary air leak. There was a significant downward trend in both peak and end expiratory pressure used during the study period. The downward trend in peak pressure persisted when inborn and outborn infants, boys and girls, and infants more than 27, and 23 to 27 weeks' gestation were examined separately. Despite these trends there was no reduction in the incidence of pulmonary air leak in any group. These data do not support the hypothesis, implicit in the term barotrauma, that a reduction in ventilator pressures decreases the risk of air leak.

The steatocrit: a simple method for estimating stool fat content in newborn infants

A simple micromethod is described for estimating the stool fat content of newborn babies. It is quick and reliable, requires only a small amount of stool, and can be used as a screening test for newborn babies suspected of fat malabsorption.

Acro-osteolysis (report of two cases and brief review of literature

Two siblings suffering from acro-osteolysis, a rare disorder, are discussed. Although three distinct types of acro-osteolysis, namely familial, idiopathic, and due to vinyl-chloride, are clearly defined, these patients did not fit into any category. They had intact nails, preserved tactile and sensory system, plantar ulceration and so sensory deficit. Nerve conduction studies showed prolongation of motor distal latencies in median, ulnar, posterior tibial and lateral popliteal nerves. Nerve biopsies from both patients showed severe loss of myelinated fibres of all sizes, but more so of small ones.