Brain stem electric response audiometry in neonates with hyperbilirubinemia

Auditory evoked responses using BERA were studied in 30 newborn babies with plasma bilirubin > or = 15 mgm/dl and repeated after treatment of neonatal jaundice with bilirubin levels of < or = 10 mgm/dl. A few jaundiced babies (16.5%) showed absent BERA response at the initial/subsequent examination. After treatment, 3/30 babies showed absent wave form responses and 2 of these were clinically kernicteric. Jaundiced babies had prolonged wave peak latencies and inter peak latencies. Treated babies showed a tendency towards recovery in their BERA responses which were however not complete. Total plasma bilirubin value at the time of BERA examination and mean maximal bilirubin values had no correlation with the incidence and degree of BERA abnormalities.

Renal function in SFD and AFD preterm babies

Maturation of neonatal glomerular function as evidenced by serum creatinine and creatinine clearance was assessed in 15 preterm small for dates infants (Group I) and compared with values obtained in 15 preterm appropriate for date babies (Group II), on 3rd, 7th and 14th postnatal days. The mean gestational ages were 34.2 and 32.5 weeks and birth weights 1436 +/- 302g and 1752 +/- 422 g, respectively. The mean serum creatinine values in Group I were 1.40 +/- 0.28, 1.18 +/- 0.22 and 0.92 +/- 0.11 mg/dl and for Group II, 1.22 +/- 0.22, 1.01 +/- 0.24 and 0.82 +/- 0.17 mg/dl on days 3, 7 and 14, respectively. Glomerular filtration rates as evidenced by creatinine clearance were 16.08 +/- 3.53, 21.25 +/- 4.79 and 36.96 +/- 6.44 ml/min/1.73 m2 for Group I as compared to 21.38 +/- 6.65, 35.96 +/- 11.47 and 57.61 +/- 21.61 ml/min/1.73 m2 for Group II on these days, showing statistically significant (p < 0.001) increase in renal function in both the groups from days 3 to 14. Even though the serum creatinine values in the two groups were comparable at identical postnatal ages, creatinine clearance was shown to be statistically less (p < 0.05 on day 3, p < 0.001 on day 7 and p < 0.01 on day 14, respectively) in Group I as compared to Group II, thereby implying slower renal maturation in small for dates preterm babies.

Management of meconium stained amniotic fluid: a team approach

Passage of meconium in utero is a serious neonatal disorder carrying high morbidity and mortality. Role of planned team approach with aggressive intrapartum suctioning and intensive neonatal management was studied to evaluate its impact on neonatal morbidity and mortality. Meconium Stained Amniotic Fluid (MSAF) was found amongst 7.4% of all deliveries and among these 238 (10.5%) babies developed meconium aspiration syndrome (MAS). Ninety five per cent babies with MSAF were born at > 36 weeks of gestation and 76% were more than 2.5 kg. Passage of thick and thin meconium was seen in 44 and 56% respectively. Passage of thick meconium was significantly associated with severe asphyxia and carried a bad prognosis with increased risk of development of meconium aspiration syndrome, hypoxic schemic encephalopathy, seizures and pulmonary air leak syndrome. Aggressive team approach was responsible for lowering the mortality to 7.7%.

Persistent pulmonary arterial hypertension of the newborn

Persistent pulmonary hypertension of the newborn (PPHN) characterised by right to left shunting with intense cyanosis is difficult to manage, and in the best of centres carries a 40-60 percent mortality. We report our one year's experience of managing six neonates with PPHN. There were 5 males and 1 female with mean birth weight of 2.59 +/- 0.487 kg and gestation period 39 +/- 2.0 wks and 1 minute Apgar score 2.8 +/- 2.1. Four to six babies were born by cesarean section and 3-6 babies had aspiration pneumonia. All babies presented within 12 hours of age (mean 5.08 +/- 5 hrs) with intense cyanosis and respiratory distress. Diagnosis were confirmed in all by (a) hyperoxia test, (b) simultaneous determination of preductal and postductal paO2 (c) contrast echocardiography and (d) hyperoxia-hyperventilation test. Babies were managed with hyperventilation using mean ventilatory rates of 100 +/- 45 per minute, an inspired oxygen concentration of 100%, peak inspiratory pressures 27 +/- 9 cm of H2O, and expiratory pressures 5 +/- 1.6 cms of H2O, and mean air way pressures of 10.4 +/- 2.7 cms H2O. Alkali therapy was used in 3 of the six babies whereas low dose dopamine was infused in all six babies. Inspite of aggressive ventilatory therapy, only 3 out of 6 babies could be salvaged.

Routine hematological values in term newborns

Routine hematological parameters were investigated in 240 term normal neonates, 40 neonates in the first week of life and 49 infants between 3 and 6 months of age. Term normal neonates were selected on the basis of well defined criteria. Cord blood Hb values of 16.2 +/- 1.5 g/dl compared well with some of the recent Indian studies and Caucasian figures. Cord blood hemoglobin was lower in the presence of low maternal hemoglobin and in newborns delivered by Cesarean section. A wide variation existed in the total and differential leucocyte counts, thus limiting the clinical utility of white cell counts in the newborn period. Platelet counts were within the adult normal range.

Itraconazole therapy for disseminated candidiasis in a very low birthweight neonate

The management of a preterm neonate with systemic candidiasis using oral itraconazole is described. Oral itraconazole was well tolerated and effected a clinical and mycological cure.

Thermoregulatory alterations as a marker for sepsis in normothermic premature neonates

To evaluate the core-peripheral temperature alterations as a marker for sepsis in normothermic premature newborns, 50 normal term neonates and 11 preterms with sepsis and 11 normal preterms (controls) were studied. Axillary, rectal and sole temperatures were recorded in all babies using a single mercury-in-glass thermometer by a single observer. There was significant widening of the rectal-sole and axillary-sole temperatures in the preterms with sepsis (p less than 0.001). There was no significant difference (p greater than 0.05) between the axillary and rectal temperatures in the term, normal preterms or those with sepsis. With an overall accuracy of 90.9%, a rectal-sole temperature difference of greater than or equal to 2.3 degrees C (100% sensitivity) or greater than or equal to 3.2 degrees C (100% specificity) is a useful marker to differentiate normothermic preterms with or without sepsis. Using the axillary-sole temperature difference, the respective values were greater than or equal to 2.2 degrees C and greater than or equal to 3.0 degrees C.

Hyponatraemia and the inappropriate ADH syndrome in pneumonia

We studied serum sodium, plasma osmolality and urinary sodium and osmolality on days 1, 3 and 5 of hospitalization of 100 children aged from 1 month to 12 years admitted with a diagnosis of pneumonia. Hyponatraemia (serum sodium concentration < or = 130 mmol/l) was found in 31 patients at the time of admission. The probable cause of hyponatraemia in 94% of cases was the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Symptoms and signs indicative of severe pneumonia were two to three times more frequent and the mean duration of tachypnoea, chest-wall retraction and hospital stay about one and a half times longer in children with hyponatraemia. Four children died (two on day 1, one on day 5 and one on day 8); all four had a serum sodium concentration < or = 125 mmol/l which persisted until death. Of the remaining 27 hyponatraemic children, serum sodium concentrations returned to normal on day 3 in 26, while in one hyponatraemia persisted until day 7. The recovery from hyponatraemia showed a good correlation with improvement in clinical signs of respiratory distress. The SIADH occurred in about one-third of the children hospitalized for pneumonia, and was associated with a more severe disease and a poorer outcome. Perhaps fluid restriction in these cases may improve the outcome.

Role of foetal echocardiography in predicting perinatal outcome

To establish foetal cardiovascular parameters as predictors of perinatal outcome in pregnancy, M-Mode, 2-D echocardiography and pulse Doppler study was performed at 24-32 weeks of gestation in 65 pregnancies. These pregnancies were followed up for perinatal outcome. The studied population included 24 normal pregnancies, 21 pregnant women with heart disease (14 rheumatic and 7 congenital heart disease) and 20 high risk pregnancies (bad obstetric history in 7, suspected intrauterine growth retardation in 4, hypertensive disease of pregnancy in 6 and diabetes mellitus in 3). There was no perinatal mortality. Two foetuses were born with complete heart block and one with a small ventricular septal defect; 6 neonates had intrauterine growth retardation and two of these had neonatal asphyxia with APGAR score less than 6 at one minute. Anatomically normal heart was correctly diagnosed in all 64 foetuses and ventricular septal defect was detected antenatally in one. Antenatal diagnosis of complete heart block was correctly made in two foetuses. One new born with complete heart block required a permanent pacemaker, which was implanted. The ratio of peak velocity across mitral valve during atrial systole (A) to peak velocity during early diastolic ventricular filling (E) was chosen to correlate with perinatal outcome. The ratio was less than 1.0 in 6 foetuses, all of whom were subsequently confirmed to have intrauterine growth retardation. In normal pregnancies A/E ratio was more than 1.0. We conclude that foetal echocardiography is a useful tool for predicting perinatal outcome and may be helpful in screening patients who require specific perinatal management.

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.