Frequent nasopharyngeal suctioning as a risk factor associated with neonatal coagulase-negative staphylococcal colonisation and sepsis

INTRODUCTION

This case-control study aimed to determine whether catheter use was significantly associated with coagulase-negative staphylococci (CoNS) colonisation and/or sepsis in neonates.

METHODS

Weekly swabs of the nose, umbilicus, rectum, wounds, eye discharge and intravenous catheter tips (after removal) of infants admitted to the neonatal intensive care unit of Universiti Kebangsaan Malaysia Medical Centre, Malaysia, were cultured. CoNS sepsis was diagnosed if pure growth of CoNS was cultured from the peripheral blood specimen of symptomatic infants. For each infant with CoNS colonisation or sepsis, a control infant was retrospectively and randomly selected from unaffected infants in the ward. Multivariate analyses were performed to determine whether catheter use was a significant risk factor.

RESULTS

CoNS colonisation was detected in 113 (8.7%) infants. CoNS sepsis was found in 12 (10.6%) infants with CoNS colonisation and 7 (0.6%) infants without CoNS colonisation. Multivariate analysis showed that the following were significantly associated with CoNS colonisation: conjunctivitis (adjusted odds ratio [OR] 8.2, 95% confidence interval [CI] 1.9–34.8, p = 0.005); central venous catheters (adjusted OR 5.8, 95% CI 1.9–17.8, p = 0.002); and nasopharyngeal and/or oral suctioning more than twice in the 48 hours before positive culture (adjusted OR 7.3, 95% CI 3.3–16.2, p < 0.001). Exposure to frequent nasopharyngeal and/or oral suctioning (adjusted OR 20.8, 95% CI 3.5–125.3, p = 0.001) was the only significant factor associated with CoNS sepsis.

CONCLUSION

Infants requiring more than two nasopharyngeal and/or oral suctions in the previous 48 hours were found to have a higher risk of developing CoNS colonisation and sepsis.

Brain herniation in a neonate

Brain herniation is generally thought to be unlikely to occur in newborns due to the presence of the patent fontanelles and cranial sutures. A review of the literature published from 1993 to 2008 via MEDLINE search revealed no reports on neonatal brain herniation from intracranial tumour. We report a preterm Malay male infant born via elective Caesarean section for antenatally diagnosed intracerebral tumour, which subsequently developed herniation. Cerebral magnetic resonance imaging showed features that were compatible with a large complex intracranial tumour causing mass effect and gross hydrocephalus. Tumour excision was scheduled when the infant was two weeks old. Unfortunately, on the morning of the surgery, he developed signs of brain herniation and had profuse tumour haemorrhage during the attempted excision. Histopathological examination revealed an embryonal tumour, possibly an atypical rhabdoid/teratoid tumour. This case illustrates that intracranial tumours in newborns can herniate and should therefore be closely monitored.

Inhaled nitric oxide and intravenous magnesium sulphate for the treatment of persistent pulmonary hypertension of the newborn

INTRODUCTION

The aim of this study was to compare the response and survival rates of term infants with persistent pulmonary hypertension of the newborn (PPHN) on high frequency oscillatory ventilation (HFOV) treated with either inhaled nitric oxide (iNO) or intravenous magnesium sulphate (MgSO4).

METHODS

This was a randomised controlled study. The inclusion criteria were infants with respiratory distress, oxygen index equal to or greater than 25 despite HFOV support, and echocardiographic evidence of PPHN. Infants in the MgSO4 group (n is 13) were loaded with MgSO4 200 mg/kg infused over half an hour, followed by continuous infusion at 50-150 mg/kg/hour to attain a serum magnesium level of 5.0-7.0 mmol/L. Infants in the iNO group (n is 12) were administered nitric oxide at an initial concentration of 20 ppm. Analysis was done on an intention-to-treat basis.

RESULTS

There was no significant difference in the median age when the vasodilators were commenced (MgSO4 group: 14.0 hours, interquartile range [IQR]: 7.5, 27.0; iNO group: 14.8 hours, IQR: 12.5, 35.3, p is 0.8). There was no significant difference in the proportion of infants who responded primarily to either vasodilator (MgSO4: 23.3%, iNO: 33.3%, p is 1.0) . After switching over to iNO following a failed MgSO4 therapy, a significantly higher proportion (9 out of 10) of the non-respondents in the MgSO4 group recovered from PPHN and survived compared to the non-respondents in the iNO group (1 out of 8) who switched over to intravenous MgSO4 (p is less than 0.03).

CONCLUSION

Infants who were administered iNO following a failed MgSO4 therapy were associated with a better outcome than those who were administered MgSO4 following a failed iNO therapy.

The usefulness of early ultrasonography, electroencephalography and clinical parameters in predicting adverse outcomes in asphyxiated term infants

INTRODUCTION

The early identification of asphyxiated infants at high risk of adverse outcomes and the early selection of those who might benefit from neuroprotective therapies are required. A prospective observational study was conducted to determine if there were any early clinical, neuroimaging or neurophysiological parameters that might predict the outcome in term newborns with asphyxia.

METHODS

44 term newborns with acute asphyxia had a cranial ultrasonography (US), electroencephalography (EEG) and clinical examination performed between three and eight hours of life to determine the parameters that might predict outcome. US findings were classified as normal or abnormal (ventricular dilatation or compression and/or focal/diffuse echogenicities). EEG background activity was classified into two categories: normal/mildly abnormal/intermediate, or severely abnormal (low voltage activity or "suppression-burst"). An intrapartum score (based on graded abnormalities of foetal heart monitoring, umbilical arterial base deficit and five-minute Apgar score) and a hypoxic ischaemic encephalopathy (HIE) score (based on graded abnormalities of the neurological and respiratory status at 3-8 hours of life) was also obtained.

RESULTS

At one year of life, eight infants had died, six had defaulted follow-up, five had major impairment, two minor impairment and 23 were normal. On univariate analysis, poor outcome (death or major impairment) was associated with abnormal cranial US, severely abnormal EEG and a high HIE score (greater than or equal to 15). The positive predictive value was 54.5, 100 and 100 percent, respectively, while the negative predictive value was 93.8, 80.6 and 80.6 percent, respectively. Combining these factors did not improve the predictive values.

CONCLUSION

There was no added advantage in combining EEG or US parameters over a clinical neurological scoring system alone in predicting the outcome of asphyxiated term newborns.

A quality assurance study on the administration of medication by nurses in a neonatal intensive care unit

INTRODUCTION

This study aimed to determine the rates of non-adherence to standard steps of medication administration and medication administration errors committed by registered nurses in a neonatal intensive care unit before and after intervention.

METHODS

A baseline assessment of compliance with ten standard medication administration steps by neonatal intensive care unit nurses was carried out over a two-week period. Following this, a re-education programme was launched. Three months later, they were re-assessed similarly.

RESULTS

The baseline assessment showed that the nurses did not carry out at least one of the ten standard administrative steps during the administration of 188 medication doses. The most common steps omitted were having another nurse to witness drug administration (95 percent); labelling of individual medication prepared prior to administration (88 percent), checking prescription charts against patients' identification prior to administration (85 percent) and visually inspecting a patient's identification tag (71 percent) . Medication administration errors occurred in 31 percent (59/188) of doses administered, all due to imprecise timing of medication administration. There were no resultant adverse outcomes. Following implementation of remedial measures, there was a significant reduction in non-adherence of seven of the ten medication administration steps and the rate of medication administration errors (p-value is less than 0.001). However, in 94 percent of doses administered, the nurses still did not get a witness to countercheck calculations of drug dosages before administration.

CONCLUSION

Non-compliance with the standard practice of medication administration by nurses is common but can be improved by continuing re-education and monitoring, plus the implementation of a standard operating procedure.

Benefit and pitfalls of newborn hearing screening

The importance of universal newborn hearing screening (UNHS) in identifying hearing-impaired infants as early as possible is already well recognized. Transient evoked otoacoustic emissions (TEOAE) have been established as a reliable method for UNHS in full term infants. This is a cross sectional study between April 2003--December 2005. Thirteen thousand five hundred and ninety eight (13,598) newborns were screened for hearing loss with portable otoacoustic emission (OAE) before discharge. The initial coverage rate during the 3 years study period was 85.9% (13,598) with 89.2% (3762), 79.0% (4480) and 90.3% (5356) for 2003, 2004 and 2005 respectively. The mean age when hearing loss was diagnosed using ABR were 3.56 months old, 3.08 months old, and 2.25 months old and 3.01 months old for 2003, 2004, 2005 respectively and it was statistically significant. The defaulter rate at the third stage during the 3 years study period was 35% (21), 15.2% (7) and 18.2% (2) for 2003, 2004 and 2005 respectively. This study showed significant improvement in initial referral rate, coverage rate and age of diagnosis. However, we need to improve on high defaulter rates.

Usefulness of a semi-quantitative procalcitonin test kit for early diagnosis of neonatal sepsis

INTRODUCTION

This study was designed to determine the sensitivity and specificity of a semi-quantitative procalcitonin (PCT) test kit for the diagnosis of neonatal sepsis.

METHODS

Infants admitted to the neonatal intensive care unit with signs suggestive of sepsis were recruited into the study. Prior to commencement on antibiotics, the following investigations were carried out on each of these infants: blood culture and sensitivity, PCT semi-quantitation and C-reactive protein (CRP) estimation. Infants already on antibiotics, or who developed signs of sepsis within 72 hours of discontinuation of antibiotics, were excluded from the study.

RESULTS

Of the 87 infants recruited, 18 (20.7 percent) were confirmed to have sepsis based on positive blood culture results. At a PCT cut-off level of greater than or equal to 2 ng/ml, the sensitivity of the PCT-Q kit in detecting neonatal sepsis at the onset of symptoms was 88.9 percent and its specificity was 65.2 percent. The sensitivity of CRP for diagnosis of sepsis was 55.6 percent and its specificity was 89.9 percent.

CONCLUSION

The semi-quantitative PCT test kit is of moderate sensitivity but poor specificity for early diagnosis of neonatal sepsis. A negative PCT test result may help to "rule out", while a raised CRP result helps to "rule in", the possibility of sepsis.

Early outcome of congenital diaphragmatic hernia in a Malaysian tertiary centre

INTRODUCTION

This prospective observational study was conducted to determine the outcome of newborns with congenital diaphragmatic hernia (CDH). They were managed with a protocol of gentle ventilation to avoid barotraumas, and inhaled nitric oxide (iNO) or intravenous magnesium sulphate for treatment of persistent pulmonary hypertension of newborns (PPHN).

METHODS

All newborns with CDH admitted to neonatal intensive care unit of this hospital during the six-year study period were recruited. High frequency oscillatory ventilation was used when infants required peak inspiratory pressure of more than 25 mmHg. iNO at 20 ppm or intravenous magnesium sulphate was used when PPHN developed. Arterial blood pH was maintained between 7.35 and 7.45, and partial pressure of arterial carbon dioxide was kept above 35 mmHg. Surgery was performed when the infants' general condition and blood gases were stabilised for at least 24 hours.

RESULTS

Of 21 infants recruited (15 males and six females, median gestational age 39.0 weeks, median birth weight 2,800 grams), 52.4 percent had PPHN. 12 (57.1 percent) underwent surgery at a median age of 4.9 days. One died postoperatively due to PPHN. Out of the 21 subjects, 11 (52.4 percent) survived to discharge. There was no significant difference in the demographic characteristics, side and size of CDH defects, presence of PPHN, or type of treatment received, between infants who survived and died. However, infants who died had significantly lower mean Apgar scores at five minutes of life (p-value is 0.02), and higher mean oxygenation indexes (OI) (p-value is 0.01) than those of survivors. Two (18.2 percent) of the 11 survivors developed chronic lung disease.

CONCLUSION

Low Apgar scores and high OI were associated with poor outcome in infants with CDH.

Transient abnormal myelopoeisis in newborns with Down syndrome

Transient abnormal myelopoeisis (TAM) is a haematological phenomenon commonly seen in newborns with Down syndrome. Although the majority show spontaneous resolution, this condition should not be dismissed too readily as there have been associated fatalities. Furthermore, even for those who do show spontaneous resolution, a significant percentage will develop acute megakaryoblastic leukaemia within the next few years of life. We report a series of four patients with TAM who presented with hepatosplenomegaly and leucocytosis detected on preliminary investigations.

Risk factors associated with low bone mineral content in very low birth weight infants

INTRODUCTION

We report part of the findings of a study conducted to determine the correlation between bone mineral content (BMC) and biochemical bone markers in very low birth weight (VLBW) infants.

METHODS

This was a cross-sectional study, carried out between August 2001 and June 2004 in the neonatal intensive care unit of Hospital Universiti Kebangsaan Malaysia. Whole body BMC was measured by dual energy X-ray absorptiometry in 41 VLBW infants.

RESULTS

The mean BMC/kg body weight was 25.8 (standard deviation [SD] 11.2) g per kg. The BMC of these infants had significant negative correlation with their birth weight (r equals -0.31, p-value equals 0.048). There was no significant difference in the mean BMC between different races and gender. The infants were divided into two groups based on the course of prematurity: "non-complicated" and "complicated" groups because of the lack of "healthy reference population" data for normal BMC values in premature infants. The "non-complicated" group (30) had received ventilator assistance for less than seven days, tolerated full enteral nutrition before the age of two weeks, had no sepsis or necrotising enterocolitis and did not receive regular diuretic or steroid treatment. The cut-off level for a desirable BMC per kg in VLBW infants was obtained from a value corresponding to one SD below the mean of the "non-complicated" group, i.e., 17.4 g per kg. Eight (19.6 percent) infants had BMC less than this value. Multilinear regression analysis of demographical characteristics, maternal factors, neonatal complications and nutrition received revealed that heavier birth weight (p-value equals 0.007) and longer duration of parenteral nutrition (p-value equals 0.03) were associated with lower BMC.

CONCLUSION

VLBW infants who required parenteral nutrition for longer periods were at higher risk to having poorer bone mineralisation.

Unbalanced chromosomal translocation: a cause of recurrent spontaneous abortion

Recurrent spontaneous abortion, defined as three consecutive abortions, occurs in approximately 1% to 2% of couples. Although the cause is unknown in up to 50% of cases, about 5% of these couples are found to be a balanced translocation carrier. We report a case in which the mother was identified to be a translocation carrier following the birth of a baby with multiple congenital abnormalities.

Turn-around-time of radiographs in a neonatal intensive care unit

A quality assurance study was carried out prospectively in two phases at the Neonatal Intensive Care Unit (NICU) of Hospital Universiti Kebangsaan Malaysia. The objectives of the study were to determine the turn-around-time (TAT) of radiographs requested for infants undergoing intensive care treatment in the NICU and the effects of a standard operating procedure introduced based on initial findings of first phase of the study on subsequent TAT. The TAT was defined as the time taken for the radiograph to be ready for viewing after the attending doctor had requested for it to be done on an infant. During phase one of the study, none of the requested radiographs was ready to be viewed by the doctors within the standard TAT of 45 minutes. The problems identified were ward staffs delay in sending request forms to the radiology department, radiographers' delay in shooting and processing the films, and delay by NICU porter in collecting the processed films. Based on these findings, a standard operating procedure (SOP) was drawn up jointly by the staff of NICU and Department of Radiology. During phase two of the study conducted at one month after implementation of the SOP, there was a reduction of TAT by 50%. However, only 3 (4.3%) of the radiographs achieved the standard TAT. The main problems identified during phase two were delay in sending request forms and in collecting processed radiographs by the porter system. The dismal TAT of radiographs in NICU was related primarily to human behaviour. Besides continuous staff education, replacement of the porter system with electronic system may improve the TAT.

Congenital factor VII deficiency: a case report

Factor VII deficiency is a rare congenital blood disorder. Its clinical features are rather variable and ranges from epistaxis to massive intracranial haemorrhage. Treatment involves replacement therapy, which constitutes use of fresh frozen plasma, prothrombin complex concentrates or recombinant activated factor VII. Although it is a rare entity, one still needs to consider it as a probable diagnosis in a newborn with coagulopathy. We report here a case of Factor VII deficiency in a newborn who presented with subdural haemorrhage at day 4 of life.

Diffuse neonatal haemangiomatosis: a rare cause of haemorrhagic shock and refractory coagulopathy in the newborn

A term newborn infant developed hypovolaemic shock shortly after birth. She was pale with gross hepatomegaly. She required multiple boluses of intravenous fluids, blood products as well as inotropic support. Blood investigations showed persistent thrombocytopenia, anaemia and disseminated intravascular coagulopathy (DIC). She also developed heart failure. She finally succumbed on the eleventh day of life. Autopsy revealed haemangiomatosis involving the liver, lungs, gastrointestinal tract, kidneys and adrenals.

Successful clot lysis using low dose of streptokinase in 22 neonates with aortic thromboses

OBJECTIVE

To determine whether intravenous infusion of low dose of streptokinase was effective in lysing umbilical arterial catheter (UAC)-associated aortic thrombi.

METHOD

A prospective cohort study of 31 consecutive newborn infants with UAC-associated aortic thrombi which were detected by abdominal ultrasonography after removal of UAC. Twenty-two infants were treated with intravenous infusion of low dose (1000 U/h) streptokinase, while nine others were not treated due to various contra-indications. Thrombolysis occurred after a mean interval of 2.2 days (standard deviation (SD) = 1.8) in the treated infants. In the untreated infants, spontaneous thrombolysis occurred significantly later, after a mean interval of 16.9 days (SD = 14.7) (95% confidence intervals of difference between mean intervals - 26.0, - 3.4; P = 0.02). Only one treated infant developed mild bleeding directly attributed to streptokinase therapy.

CONCLUSION

Low dose streptokinase infusion was effective and safe in thrombolysing UAC-associated aortic thrombi.

Epidemiology of head injury in Malaysian children: a hospital-based study

A prospective observational study was carried out at the Emergency Department, Hospital Kuala Lumpur to determine the proportion of accidental head injury among children and the circumstances of injury. The study was carried out from November 1993 to January 1994 on all children below 14 years who presented to the Emergency Department with accidental head injury. Accidental head injury made up (4.75%) of all cases seen at the Casualty Department. The ratio of boys to girls was 2:1. The mean age of head injured children was 5.2 (S.D. 3.63) years. The leading cause of head injury was fall (63%) followed by road traffic accidents (RTA) in (30.7%) while the rest were due to 'impact' (injury caused by flying object or missiles) injuries. More than half (54.4%) of those injured in RTA were pedestrians. Pedestrian injury was particularly important in the 5-< 14 years age group, where adult supervision was lacking in two thirds of the children. None of the patients who were involved in vehicle-related injuries had used a suitable protective or restraining device. All three patients who died were from this group. This study emphasises the need for stricter enforcement of laws related to the use of protective devices and measures to decrease child pedestrian injury. The issues of lack of adult supervision, both in and outside the home need to be addressed.