Regional pulmonary oxygen saturations immediately after birth

BACKGROUND

Partial oxygen saturation (SpO₂) increases within minutes during transition from the intrauterine to extrauterine life. This study aims to determine the postnatal course of pulmonary regional oxygen saturation (rSO₂) measured by Near-Infrared Spectroscopy (NIRS).

METHODS

We conducted an observational study at the delivery room in infants above 35 weeks of gestation who did not need resuscitation and did not develop respiratory distress. Preductal pulse oximetry (Covidien NellcorTM) and right pulmonary apex oxygen saturation (raSO₂) and basal oxygen saturation (rbSO₂) (Covidien INVOSTM) were measured, starting from the postnatal third minute of life, until the 15th minute. The correlations between SpO₂ and pulmonary rSO₂ were analyzed.

RESULTS

Of the 110 infants included in the study, 87 were term and 23 were late preterms. The gestational age and birth weight were 38.5 ± 1.36 weeks and 3285 ± 508 g, respectively. Median (5th-95th percentile) raSO₂ and rbSO₂ were 79% (58-95%) and 78% (46-95%) at the third minute, respectively. The rSO₂ values measured from both sides increased and reached a steady-state around postnatal 9 min, similar to SpO₂ values. The pulmonary NIRS values were significantly higher for babies born by C-Section compared to babies born by vaginal delivery (p < 0.05).

CONCLUSION

We found that rSO₂ measurements increased within minutes in the postnatal period in late preterm and term babies without respiratory distress and reached a plateau at the postnatal 9th minute. The normal values obtained from this preliminary study may be used to predict the prognosis of cases with respiratory distress.

Eltrombopag for treatment of thrombocytopenia after allogeneic hematopoietic cell transplantation in children: Single-centre experience

Delayed recovery of thrombocytopenia is a well-known complication after allogeneic HSCT. Eltrombopag (ELT), a thrombopoietin receptor agonist (TRAs), induces platelet maturation and release. Mostly conducted in adults, some of the previous studies have shown that ELT seems to enhance platelet recovery for post-allogeneic HSCT thrombocytopenia, appears efficacious, and offers transfusion independence. To evaluate the safety and efficacy of ELT in pediatric patients with prolonged isolated thrombocytopenia (PIT) or secondary failure of platelet recovery (SFPR) after alloHSCT. Retrospective analysis of childhood patients who received treatment with ELT for persistent thrombocytopenia after alloHSCT between May 2016 and August 2019. We evaluated the safety and efficacy of ELT in 18 childhood patients with PIT or SFPR after alloHSCT. Eltrombopag (50 mg/d) treatment was started in all patients, above 6 years of age and 20 kg weight, who had thrombocytopenia despite neutrophil engraftment on the 30th day of HSCT. Our objective was to decrease the need for platelet transfusion and have a platelet count of more than 50 000/µL. The overall response rate was 77.7%. The median time to achieve a platelet level above 30 000/µL and 50 000/µL was 21 and 44 days, respectively. In four patients, platelet count never reached 30 000/mm³ . In two patients, the treatment was discontinued due to grade 3 hepatotoxicity. Our study supports the efficacy and relative safety of ELT use for the treatment of PIT and SFPR seen after alloHSCT in children.

Clinical Efficacy of Ruxolitinib Monotherapy and Haploidentical Hematopoeitic Stem Cell Transplantation in a Child with Philadelphia Chromosome-like Relapsed/Refractory acute lymphoblastic leukemia

INTRODUCTION

(Ph-like) ALL is a subset of leukemia which has a gene expression profile similar to Ph+disease, but without the presence of BCR-ABL1 translocation.

CASE DESCRIPTION

We reported an exceptional case of a child with relapsed Ph-like ALL with IKZF1 gene deletion treated with high-dose ruxolitinib as monotherapy, after multi-agent chemotherapy. He remains in continued MRD-negative leukemia remission with full donor chimerism at 12 months post-HSCT.

DISCUSSION

The circumstance that makes our case featured is the usage of ruxolitinib as monotherapy. This report, we believe, is a pioneering report for a frequent disease with a high risk of failure for the outcome.

A single center cohort of 40 severe COVID-19 patients who were treated with convalescent plasma

Background/aim

A SARS-Cov2 infection which was first arised from Wuhan in December 2019 and named as COVID-19. Still there lacks either a specific treatment or a vaccine to treat COVID-19. Convalescent plasma (CP) was previously used successfully to treat SARS-CoV-1 and MERS infections. Health authority in Turkey has published a guideline to integrate this promising option in the treatment process of patients who are prone to high risk of developing severe COVID 19.

Materials and Methods

Forty consecutive patients who had received CP at our center were included in the study. Demographics, COVID-19 specific parameters, biomarkers to detect the severity of COVID-19 infection and outcome variables were collected retrospectively. The correlation between outcome variables and the independent predictors of the outcome were reported.

Results

Median age of the patients was 57.5 and 72.5% were male. At least one COVID-19 PCR test was confirmed to be positive in 75% of patients. Remaining 25% had a Chest-CT which was reported to be compatible with an ongoing COVID-19. All patients (100%) were classified as having severe COVID-19 infection. Over a half of the patients harbored an oxygen saturation of less than 90 despite of a continuous 5 L/min support of O2. 82.5% of the patients had a need for mechanical ventilation and 45.5% had a need for invasive mechanical ventilation. Nine out of 10 patients who have received CP outside ICU have totally recovered from COVID-19 at a median of 9 days, and a half of the patients who needed invasive mechanical ventilation were successfully free of mechanical ventilation support and managed to recover from COVID-19.

Conclusion

According to the results of this study, CP is an efficient conjunct to conventional therapy against COVID-19 with a favorable safety profile.

Squamous cell carcinoma development in Fanconi anemia patients who underwent hematopoietic stem cell transplantation

We examined SCC development of 24 FA patients, who received HSCT from HLA-matched relatives. In our BMT center, we applied low-dose CY + LFI + ATG (n:13) as conditioning regimen for FA patients between 1992 and 1999, and CY + BU + ATG (n:11) between 1999 and 2002. The aim of this study was to investigate SCC development after HSCT and examine features of the follow-up patients. The 10-year overall survival (OS) of the group with LFI + regimen was 43%, whereas the group without LFI regimen was 60%. There was a statistically significant relationship between infections (viral/bacterial) and overall survival (Fisher's Exact test P < .001). Five out of 13 long-term (>1 year) surviving patients developed SCC in the HNSCC (n:4) and esophagus (n:2) region (a patient with oral SCC developed a second primary esophageal SCC). The SCC rate in our FA patients was 38%, four of the SCC patients were transplanted with irradiation used conditioning regimens, three of them had acuteGvHD (Grade II-III), only one developed chronic GvHD. The interval between HSCT and SCC diagnosis was median 13 (range 6-18) years, the age for the development of cancer was median 21 (range 15-32) years. Survival after SCC was low, median 6 months (range 6-12), due to delayed SCC diagnosis, tumor progression under therapy and treatment-related toxicities of the usually reduced RT and/or CT.

Neurons from human mesenchymal stem cells display both spontaneous and stimuli responsive activity

Mesenchymal stem cells have the ability to transdifferentiate into neurons and therefore one of the potential adult stem cell source for neuronal tissue regeneration applications and understanding neurodevelopmental processes. In many studies on human mesenchymal stem cell (hMSC) derived neurons, success in neuronal differentiation was limited to neuronal protein expressions which is not statisfactory in terms of neuronal activity. Established neuronal networks seen in culture have to be investigated in terms of synaptic signal transmission ability to develop a culture model for human neurons and further studying the mechanism of neuronal differentiation and neurological pathologies. Accordingly, in this study, we analysed the functionality of bone marrow hMSCs differentiated into neurons by a single step cytokine-based induction protocol. Neurons from both primary hMSCs and hMSC cell line displayed spontaneous activity (≥75%) as demonstrated by Ca++ imaging. Furthermore, when electrically stimulated, hMSC derived neurons (hMd-Neurons) matched the response of a typical neuron in the process of maturation. Our results reveal that a combination of neuronal inducers enhance differentiation capacity of bone marrow hMSCs into high yielding functional neurons with spontaneous activity and mature into electrophysiologically active state. Conceptually, we suggest these functional hMd-Neurons to be used as a tool for disease modelling of neuropathologies and neuronal differentiation studies.

Turkish Neonatal Society guideline on nutrition of the healthy term newborn

Research shows strong evidence that breastfeeding offers many health benefits for infants and mothers, as well as potential economic and environmental benefits for communities. The World Health Organization recommends breastfeeding exclusively for up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond.

Turkish Neonatal Society guideline on enteral feeding of the preterm infant

Early initiation of enteral feeding with the own mother's milk and prevention of postnatal growth failure is the target of nutrition in preterm infants. Together with total parenteral nutrition, mouth care and minimal enteral nutrition is started with colostrum in the very early hours of life in small preterm infants. Expressed mother's milk is given via a gastric tube and gradually increased in accordance with the gestational age/birth weight and the risk factors. For infants born heavier than 1 000 grams, the aim is to reach total enteral feeding at the end of first week, and at the end of the second week for infants weighing less than 1000 grams. Supporting mothers in milk expression and kangaroo mother care, promoting non-nutritive feeding, appropriate fortification of mother' milk, and initiating and advancing breastfeeding as soon as the infant is ready are all crucial. Donor mother milk, and as a second choice, preterm formula is advised if the mother's milk is not available. Individualized post-discharge nutrition decisions can be taken in accordance with the actual growth at the time of discharge. The goal is optimal neurodevelopmental achievement together with the prevention of long-term metabolic problems. Late preterm infants, which constitute the majority of preterm infants, also need close nutritional attention and follow-up.

Turkish Neonatal Society guideline on parenteral nutrition in preterm infants

Postnatal growth failure due to inappropriate and insufficient nutrition is a risk for preterm infants, especially for very-low-birth-weight or extremely-low-birth-weight infants. This extrauterine growth failure causes negative effects on long-term neurodevelopment. Early initiation of intensive parenteral nutrition with appropriate protein and energy supply is a nutritional emergency when enteral feeding cannot be achieved. This approach prevents protein catabolism and helps achievement of positive protein balance and postnatal growth. Protein, lipid, and glucose initiation with appropriate doses that reach timely goals constitute the major elements of parenteral nutrition. The transition to enteral nutrition with the mother's milk at the earliest convenience must be targeted in parenteral nutrition.

Persistent hyperglycemia in a neonate: Is it a complication of therapeutic hypothermia?

Özdemir H, Memişoğlu A, Alp-Unkar Z, Arcagök B, Bilgen H, Turan S, Özek E. Persistent hyperglycemia in a neonate: Is it a complication of therapeutic hypothermia? Turk J Pediatr 2017; 59: 193-196. The aim of this report is to present a newborn with persistent hyperglycemia requiring insulin therapy as a possible complication of therapeutic hypothermia. A term appropriate for gestational age (AGA) female infant, was born by emergency cesarean section due to abruption of placenta and was resuscitated and intubated in the delivery room. Whole body cooling was initiated according to standard cooling criteria. The patient`s blood glucose increased up to 250 mg/dl on a glucose perfusion rate of 6 mg/kg/min after the second day of cooling. Insulin therapy was started due to persistent hyperglycemia and continued for 17 days. As it has been reported in adults after therapeutic cooling, persistent hyperglycemia attributed to hypothermia can also complicate therapeutic hypothermia in neonates.

Comparative heel stick study showed that newborn infants who had undergone repeated painful procedures showed increased short-term pain responses

AIM

We evaluated the short-term effect of repeated pain exposure on the pain responses of newborn infants using different pain assessment methods, as this area had been under-researched.

METHODS

We compared 20 term, large for gestational age infants and 40 term, appropriate for gestational age controls. All had undergone a heel stick for a newborn screening test just before discharge, but the larger babies had also undergone at least other five painful stimuli prior to that. A pulse oximeter and a skin conductance algesimeter (SCA) were connected to the babies during the heel prick, and video recordings were made. Crying time, the Neonatal Infant Pain Scale (NIPS), heart rate, peripheral oxygen saturation (SpO₂ ) and SCA measurements were compared within and between the groups.

RESULTS

After the heel prick, the crying time (p = 0.021) and NIPS (p = 0.013) scores were significantly higher in the study group and the SpO₂ levels were significantly lower (p = 0.009), but the heart rate (p = 0.981) was not significantly different between the groups. SCA measurements did not differ significantly between the groups.

CONCLUSION

Babies who received more painful stimuli during the first few days of life showed greater pain responses during a subsequent heel prick.

The predictive value of stimulation index calculated by modified mixed lymphocyte culture in the detection of GVHD following hematopoietic stem cell transplantation

OBJECTIVE

Mixed lymphocyte culture (MLC) is one of the routine tests performed prior to hematopoietic stem cell transplantation (HSCT) as a predictive assay for assessing the quality of donor matching and graft-versus-host disease (GVHD). The stimulation index is one of the formulas of the MLC test, and it is used for evaluation of matching between donor and recipient. Modified MLC (mMLC) test is produced by adding various cytokines to the MLC test, and increased sensitivity has been reported with this modification.

METHODS

The importance of the stimulation index values in MLC and mMLC tests was evaluated in 59 patients who received HSCs from human leukocyte antigen-identical sibling donors. In the mMLC test, cytokines were added as interleukin (IL)-2, IL-2 + IL-4 and IL-2 + interferon (IFN)-gamma + tumor necrosis factor (TNF)-alpha. Stimulation index values in mMLC test were compared with stimulation index values in MLC test.

RESULTS

Twenty-three (39%) patients developed GVHD. When evaluated in terms of stimulation index >1 patients, in MLC, 55% of the patients developed GVHD (p=0.229), whereas these values were 75% in the IL-2 added mMLC test (p=0.035), 100% in the IL-2 + IL-4 added mMLC test (p=0.076) and 85.7% in the IL-2 + IFN-gamma + TNF-alpha added mMLC test (p=0.015).

CONCLUSION

mMLC increased the sensitivity of the test. The relation between the positive results and evidence of GVHD after transplantation was found significant.

Iron deficiency anemia in late-preterm infants

Iron deficiency anemia is a common problem in newborn infants. The American Academy of Pediatrics recommends iron prophylaxis at 4 months of age for term infants. There is no specific recommendation for iron prophylaxis in late-preterm infants. We aimed to establish the optimum time for iron prophylaxis in late-preterm infants. Thirty-eight late-preterm (Group 1) and 38 term (Group 2) infants born on the same day were enrolled in the study. Hemoglobin, ferritin and reticulocyte values at birth, 2nd month and 4th month were assessed. The cord ferritin, hemoglobin and reticulocyte levels did not differ significantly between groups. However, at the 2nd month, median ferritin and hemoglobin values were lower in late-preterm infants than term infants (145 mg/dl vs. 195 mg/dl, p=0.001 and 10.1 g/dl vs. 11.6 g/dl, p<0.001, respectively). Median ferritin levels were lower at the 4th month in latepreterm infants than term infants, but this difference was not significant after exclusion of three late- preterm infants who required iron therapy (49 mg/dl vs. 62 mg/dl, p=0.2). There was a tendency of higher frequency of anemia in late-preterm infants at 4 months (42.8% vs. 21.1%), but this was statistically insignificant (p=0.07). At the 2nd month of age, the median ferritin and hemoglobin levels of late-preterm infants were lower than those of term infants. Further studies with larger sample sizes are required to determine the need for earlier supplementation of iron in late-preterm infants.

JAK2 (V617F) mutation is not associated with thrombosis in Behcet syndrome

The Janus kinase 2(V617F) (JAK2 (V617F)) mutation is an acquired genetic defect that is considered to enhance thrombosis in Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs). Thrombosis is also a well-defined component of Behcet syndrome (BS). The aim of this study was to determine the frequency of JAK2 ( V617F ) mutation in BS-associated thrombosis. A total of 152 patients with BS (62 with thrombosis and 90 without thrombosis) were enrolled. An additional 186 patients with MPNs and 107 healthy blood donors were included to serve as diseased and healthy controls, respectively. None of the patients with BS and healthy controls carried the JAK2 (V617F) mutation, whereas 67% of patients with MPNs were positive for JAK2 ( V617F ). The frequency of thrombosis in patients with MPNs was not statistically different between carriers and non-carriers of JAK2 ( V617F ) mutation. Our data suggest that JAK2 (V617F) is not directly related to thrombosis in MPNs and in other thrombotic entities, such as BS.

Hindmilk for procedural pain in term neonates

The aim of this study was to investigate whether repeated doses of hindmilk were effective for pain relief during routine heel stick in term neonates. Infants enrolled in this double-blind placebo-controlled study were randomly assigned to hindmilk, 12.5% sucrose and distilled water groups. Infants were given 1 ml of the test solution 1 minute prior to, immediately before and 1 minute after the heel stick. Pain responses were assessed by physiologic and behavioral parameters and also according to the Neonatal Facial Coding System (NFCS). There were significant reductions in crying time, duration of the first cry and tachycardia, time needed for return to baseline heart rate, and the average and 1- and 5-minute NFCS scores in the hindmilk group when compared with the distilled water group. When the hindmilk group was compared to the sucrose group, only the NFCS scores at 1 and 2 minutes reached statistical significance in favor of the sucrose group. Repeated dose hindmilk administration is an effective analgesic intervention in term newborns during heel stick. Although the analgesic effect of 12.5% sucrose is slightly superior, hindmilk may be considered as a physiologically suitable alternative to sucrose.

[Neonatal Candida infections and the antifungal susceptibilities of the related Candida species]

Among nosocomial infections in the newborns, the incidence of fungal infections has been rising over the last decades. Fluconazole has been a new option for treatment however, expanded use of the drug brought up the development of resistance. In this study, species of the Candida isolates from neonates with candida infections, their antifungal susceptibilities and the effectiveness of the therapy were evaluated. All the species of Candida isolates from blood, urine and sterile body fluids of 54 neonates and their antifungal susceptibilities were evaluated retrospectively over the 13-year period. Demographic characteristics, risk factors, infection foci, Candida species causing infection and their in vitro susceptibilities for fluconazole (FCZ) and amphotericin B (AMB) and treatment responses were analyzed. The antifungal susceptibility testing of isolates was performed by microdilution technique. The median birth weight and gestational age of the study groups were 1735 (660-3990) g and 33 (24-40) weeks, respectively. Among the patients, 19 (35%) were term, while 35 (65%) were preterm [< 32 weeks n = 20 (37%), < 28 weeks n = 7 (13%)]. The percentage of low birth weight infants was 65% (42% was < 1500 g, 13% was < 1000 g). Candida spp. were isolated mostly from blood samples (63%), followed by urine (46%), cerebrospinal fluid (CSF; 5%), peritoneal fluid (3%) and endotracheal aspirate (2%). Multifocal growth was determined in 10 (18%) cases. The isolated species were C.albicans (n =36) as being the most common isolate followed by C.parapsilosis (n = 12), C.tropicalis (n = 1), C.kefyr (n = 1), C.lusitaniae (n = 1), C.pelluculosa (n = 1) and Candida spp. (n = 2). Prior antibiotic use, long term hospitalization, total parenteral nutrition and use of lipid solutions, prematurity and catheter use were determined as the most frequently associated factors causing candidal infections. A congenital abnormality, mainly myeloschisis and hydrocephaly, was detected in 18 (33%) of the cases. Overall FCZ resistance rate was 5.5% and the rate of resistance according to the species was 2.8% for C.albicans and 11% for non-albicans isolates. No resistance was observed to AMB. Initial treatment was FCZ for 78% and AMB for 22% of the newborns. The treatment was switched to AMB in 15 (28%) cases because of no clinical or laboratory response to FCZ although only three of these babies showed resistance to FCZ (MIC ≥ 64 mcg/ml). Among the cases with no clinical/microbiological response, C.albicans was the most frequently (66%) isolated species followed by non-albicans species (33%). All of the isolates in the study group were susceptible to AMB and the rate of FCZ resistance was 5.5%. However, it was noted that the clinical treatment failure was higher than the resistance rate when FCZ was considered. Although antifungal susceptibility tests are helpful for guiding the therapy, in vivo and in vitro differences should be taken into account in case of treatment failure encountered with the use of in vitro effective agents.

Use of recombinant factor VIIa in a preterm infant with coagulopathy and subdural hematoma

Activated recombinant factor VIIa was administered to a preterm infant with bleeding diasthesis and a huge subdural hematoma that could not be controlled by the blood products. The coagulation tests were normalized the following day. Recombinant factor VIIa can be a choice in selected cases with intractable bleedings unesponsive to conventional replacement therapy.

Quantitative ultrasound and biochemical parameters for the assessment of osteopenia in preterm infants

OBJECTIVE

Our study aimed to evaluate the feasibility of quantitative ultrasound (QUS) evaluation in osteopenia of prematurity and to compare the results to biochemical parameters.

METHODS

QUS assessment of bone was performed at the end of the first postnatal week and at term-corrected age (CA) in premature infants (N = 30) and within the first week in full-term infants (N = 25). On the same day of measurement of QUS, the serum calcium, phosphorus (inorganic), and alkaline phosphatase (ALP) activity were measured in the preterm infants.

RESULTS

The median of tibia z score at term-CA in premature infants was significantly lower compared to that of first postnatal week (-1 and 0.4, respectively; p < 0.0001) and it was also lower than that of term-matched controls (0.0; p = 0.001). Preterm infants at term-CA had lower weights and lengths in comparison to term infants. The median ALP value was 585 IU/L at the first postnatal week and 703 IU/L at term-CA in preterm infants (p = 0.003). The median tibia z score of infants with ALP >or=900 IU/L was significantly lower than that of the infants with ALP <900 IU/L (-1.4 vs. 0.1; p = 0.001). An inverse correlation was found between ALP levels and tibia z score at term-CA in preterm infants (rho = -0.61, p = 0.01).

CONCLUSIONS

Bone density of preterm infants at term-CA was lower than that at first postnatal week. Serum ALP levels increased during the first postnatal weeks. The tibia z scores were correlated to serum ALP levels. QUS is a good screening tool for the detection of osteopenia.

Noise levels in neonatal intensive care unit and use of sound absorbing panel in the isolette

OBJECTIVE

The purposes of this study were to measure the noise level of a busy neonatal intensive care unit (NICU) and to determine the effect of sound absorbing panel (SAP) on the level of noise inside the isolette.

METHODS

The sound pressure levels (SPL) of background noise, baby crying, alarms and closing of isolette's door/portholes were measured by a 2235-Brüel&Kjaer Sound Level Meter. Readings were repeated after applying SAP (3D pyramidal shaped open cell polyurethane foam) to the three lateral walls and ceiling of the isolette.

RESULTS

The median SPL of background noise inside the NICU was 56dBA and it decreased to 47dBA inside the isolette. The median SPL of monitor alarms and baby crying inside the isolette were not different than SPL measured under radiant warmer (p>0.05). With SAP, the median SPL of temperature alarm inside the isolette decreased significantly from 82 to 72dBA, monitor alarm from 64 to 56dBA, porthole closing from 81 to 74dBA, and isolette door closing from 80 to 68dBA (p<0.01). There was a significant reduction in the noise produced by baby crying when SAP was used in the isolette (79dBA vs 69dBA, respectively) (p<0.0001). There was also significant attenuation effect of panel on the environmental noise.

CONCLUSIONS

The noise level in our NICU is significantly above the universally recommended levels. Being inside the isolette protects infants from noise sources produced outside the isolette. However, very high noises are produced inside the isolette as well. Sound absorbing panel can be a simple solution and it attenuated the noise levels inside the isolette.

End-of-life decisions in the newborn period: attitudes and practices of doctors and nurses

The aim of our study was to assess the attitudes and practices of doctors and nurses about end-of-life decisions and compare our results with those observed in different European countries. The data was collected from nurses and doctors, using a standardized questionnaire adapted from the EURONIC study. A total of 250 structured questionnaires were delivered, and 135 (77%) of them were accepted for analysis. The end-of-life decision was taken in 39.4% of the hospitals and personal involvement was 40%. Although an ethical committee was present in the hospitals of 61.5% of responders, a written policy was present in only 3.1% of the units. The mean attitude score was 6.5. Seventy-five percent of the contributors agreed that everything possible should be done to ensure a neonate's survival regardless of the prognosis and 65.2% of responders believed that costs of health care should not affect nontreatment decisions. Most of the responders (65.2%) agreed that severe mental disability as an outcome was equal to or worse than death. In patients in whom medical intervention would be futile, or would not offer sufficient benefit to justify the burdens imposed, hospitals should set up a functional ethical committee in order to decide in matters of withholding or withdrawing intervention.

Percentiles of oxygen saturations in healthy term newborns in the first minutes of life

The aim of this study was to establish the reference values of preductal oxygen saturation (SpO2) in healthy infants immediately after birth. SpO2 recordings of 200 term neonates (vaginal group;n=150 and cesarean group;n=50) with regular respiratory pattern were evaluated. The median SpO2 values in the first, fifth and tenth minutes were 71, 92, and 98% in vaginal deliveries and 70, 79, and 96% in cesarean deliveries, respectively. SpO2 was significantly lower in the cesarean group at any time after the first minute of life (p<0.0001). The time needed to reach a SpO2>90% was three times longer in cesarean deliveries. Healthy neonates are poorly saturated immediately after birth. The duration to reach a SpO2>90% was longer in infants born by cesarean deliveries.

Report of three cases: congenital chylothorax and treatment modalities

Chylothorax is the most common cause of pleural effusion in the newborn. We report three patients with congenital chylothorax and discussed the clinical course and treatment options. Cases 1 and 2 with congenital chylothorax were treated by chest tube placement and total parenteral nutrition (TPN), and were fed a formula rich in medium-chain triglyceride. They were discharged home without any sequelae. Our 3rd case with chylothorax did not respond to the conventional therapies. Octreotide infusion was tried without any benefits and necessitated surgical intervention, but the infant developed chronic lung disease requiring nasal oxygen therapy until three months of age. All three patients developed complications of chylothorax treatment like chest tube dysfunction, pneumothorax, nosocomial sepsis, and cholestasis. Management of congenital chylothorax necessitates a multidisciplinary approach. Treatment options include pleural drainage, cessation of enteral feeding and initiation of TPN. Experience with octreotide treatment is limited. Surgery should be reserved for severe and refractory cases.

FISH detection of chimerism in pediatric hematopoietic stem cell transplantation

Allogeneic hematopoietic stem cell transplantation (HSCT) is a well-established curative therapy for various malignant and non-malignant diseases. Successful outcome after allogeneic HSCT has been associated with donor chimerism (DC). However, the detection of residual host cells or mixed hemopoietic chimerism (MC) has indicated that donor chimerism is not obligatory following HSCT. More recently, fluorescence in situ hybridization (FISH) analysis has been applied to engraftment studies for the identification of polymorphic or sex chromosomes. In this study, chimerism status was evaluated in 48 sex-mismatched HSCT pediatric patients (17 women/31 men, mean age: 9.02 +/- 3.95 years, range: 2-19) by FISH and the effect of DC or MC on outcome and long-term disease-free survival was documented. The stem cell source was bone marrow in all cases. All of the donors were human leucocyte antigen-identical siblings. FISH was performed on 156 specimens between days +13 and +1878. Donor chimerism was found in 47.9% (23/48) and MC was found in 52.1% (25/48) of the patients. Fifteen of 48 (31.25%) patients died, of whom 12 (80%) were MC and three patients (20%) were DC. The difference in chimerism status (MC or DC) was statistically significant between those patients who died and those still alive (chi(2) = 6.813; P = 0.009).

Urinary tract infection and hyperbilirubinemia

The aim of this study was to evaluate the incidence of urinary tract infection (UTI) in newborns with asymptomatic, unexplained indirect hyperbilirubinemia in the first two weeks of life. Jaundiced infants, otherwise clinically well, less than two weeks of ages, with a total bilirubin level above 15 mg/dl were eligible for the study. A bilirubin work-up including glucose-6-phosphate dehydrogenase (G-6 PD) level, as well as urinalysis and a urine culture were performed in all patients. Patients with UTI, defined as more than 10,000 colony-forming units per milliliter of a single pathogen obtained by bladder catheterization, were evaluated for sepsis. Renal function tests and renal ultrasound were performed in cases with UTI. During follow-up, voiding cystourethrogram (VCUG) and dimercaptosuccinic acid scintigraphy (DMSA) were performed as well. A total of 102 patients were enrolled. The bilirubin work-up of patients did not demonstrate any significant underlying disorder. None of the infants had a high direct bilirubin level. UTI was diagnosed in eight (8%) cases [Enterobacter aerogenes (3/8:38%), Enterococcus faecalis (2/8:25%), Klebsiella pneumoniae (2/8:25%) and Escherichia coli (1/8:12%)]. Of those eight patients, only four (50%) had pyuria. Bacteriuria was present in seven (88%) patients. The sepsis screen was negative in all but one case with a high C-reactive protein (CRP) level. None of the patients had a positive blood culture. Renal function tests were within normal levels in all patients. Renal ultrasound showed urinary tract abnormalities in three (38%) patients (hydronephrosis, n=1 and pelviectasis, n=2). VCUG was performed in all patients during the study period and one had unilateral grade 3-4 reflux, while only one patient had a diverticulum of the bladder. DMSA was performed in seven patients and none had renal scars. It is of importance that UTI can occur in asymptomatic, jaundiced infants even in the first week of life. Although it is well known that UTI is a common cause of prolonged jaundice, urine culture should be considered in the bilirubin work-up of infants older than three days of age with an unknown etiology.

Allogeneic versus autologous versus peripheral stem cell transplantation in CR1 pediatric AML patients: a single center experience

BACKGROUND

Treatment of childhood acute myelocytic leukemia (AML) in first remission, is still evolving. Allogeneic bone marrow transplantation (BMT) in patients with a donor has been well established, but the role of autologous transplantation remains of interest, particularly in the light of some encouraging results in adults.

PROCEDURE

Out of 81 pediatric patients with AML in first CR, 67 were biologically randomized for allogeneic (n = 31), autologous (n = 20), or peripheral stem cell transplant (n = 16) after completing consolidation treatment, with the remaining (n = 11) dropping out or receiving chemotherapy. Disease free survival (DFS) of these different groups were analyzed.

RESULTS

Allogeneic transplantation is not superior to autologous and autologous peripheral blood stem cell transplantation (PBSCT) (DFS in 5 years is 61%, 50%, and 75%). The 5 years DFS in the autologous PBSCT group is significantly better than in the autologous BMT group (75% vs. 50%, P < 0.05).

CONCLUSION

In pediatric AML patients without a donor, autologous BMT or autologous PBSCT appears to be an effective treatment option with low transplant related mortality especially in less privileged countries where the chemotherapy only results are still low.

Effect of foremilk and hindmilk on simple procedural pain in newborns

BACKGROUND

Infants are exposed to painful stimuli during routine medical care in the first few days of life. The aim of the present study was to compare the effect of foremilk; hindmilk, which has been known to have more fat content than foremilk; and sterile water in reducing pain in newborns undergoing minor painful procedures.

METHODS

Sixty-two healthy term infants requiring a heel prick blood sample for screening tests were randomly allocated to receive 2 mL of foremilk, hindmilk or sterile water. Median crying time, duration of the first cry, percent change in heart rate, maximum heart rate and neonatal facial coding system scores were recorded to assess the infants' response to pain.

RESULTS

Statistically significant differences between the three groups were not found in terms of crying time, duration of the first cry, percent change in heart rate or maximum heart rate (P = 0.19, P = 0.08, P = 0.22 and P = 0.91, respectively). When the mean pain scores of the groups were compared at 0, 1, 2 and 3 min, there was no statistically significant difference between the three groups (P = 0.58, P = 0.55, P = 0.58 and P = 0.84 for 0, 1, 2 and 3 min, respectively).

CONCLUSION

Although hindmilk has a minor superiority in terms of crying time, duration of the first cry and percent change in heart rate, it does not reach statistical significance. It is concluded that neither foremilk nor hindmilk is superior in relieving pain when compared to placebo.

The relationships between candidemia and candidal colonization and virulence factors of the colonizing strains in preterm infants

Premature infants are at high risk of developing candidal infections originating from their own normal flora or from the hospital environment. This study involves the surveillance cultures and blood cultures of candidemic preterm infants with low birth weights who have been analyzed for colonization period and status, and for virulence factors such as acid proteinase and phospholipase. Arbitrarily primed-polymerase chain reaction (AP-PCR) was applied to the blood culture isolates of the babies with candidemia and their last colonizing strains in order to determine whether the source of fungemia was the rectum. Of 65 colonized infants, 6.2% developed candidemia with identical strains originating from their rectum according to their PCR patterns. Our findings indicate that the properties of the colonizing yeasts such as increase in number--although not statistically significant because of the small sample size--and/or exhibition of strong hydrolytic enzyme activities through a long duration of colonization might contribute to the development of candidemia in preterms.

Comparison of oral glucose and sucrose solutions on pain response in neonates

In this study, we aimed to compare the analgesic effect of 30% sucrose and 10% and 30% glucose in a group of healthy term newborns. A total of 113 infants whose heels were pricked for the guthrie test were included in the study. The babies were randomized into 4 groups, receiving 2 ml of 30% sucrose, 10% glucose, 30% glucose, or distilled water. Response to pain was assessed by mean crying time, recovery time, maximum heart rate, and percent change in heart rate at 1, 2, and 3 minutes. Mean crying times were 60, 102, 95, and 105 seconds in the sucrose, 10% glucose, 30% glucose, and placebo groups, respectively (P =.02). Although mean recovery time was shorter in the sucrose group (102 seconds), there was neither a significant difference between the groups (10% glucose, 121 seconds; 30% glucose, 109 seconds; control group, 132 seconds [P =.09]), Nor was there a difference in maximum heart rate and percent change in heart rate at 1, 2, and 3 minutes after heel prick (P =.14, P =.05, P =.53 For the first, second, and third minutes, respectively ). However, a statistically borderline difference existed at the end of 2 minutes favoring sucrose (P =.05). We conclude that 30% sucrose is superior to 10% and 30% glucose solutions in relieving pain, showing its primary effect in crying time. As glucose solutions are readily available in neonatal intensive care units and easier to use in routine practice, further trials are needed to evaluate the antinociceptive effect of glucose when combined with other nonpharmacologic methods.

Comparison of sucrose, expressed breast milk, and breast-feeding on the neonatal response to heel prick

Newborns endure many heel pricks and other uncomfortable procedures during their first hospital stay. The aim of this study was to investigate the effectiveness of breast-feeding in reducing pain in newborns undergoing heel prick tests. One hundred thirty healthy term infants requiring a heel prick blood sampling for the Guthrie test were studied. Infants were randomly allocated to 1 of the following treatment groups: group 1, 25% sucrose (n = 35); group 2, breast milk (n = 33); group 3, sterile water (n = 34); and group 4, breast-feeding (n = 28). The median values of crying and recovery time and percent change in heart rate at 1, 2, and 3 minutes were recorded. A behavioral pain scale was applied according to the infant body coding system. The median crying time was 36, 62, 52, and 51 seconds in groups 1, 2, 3, and 4, respectively (P =.002). Similarly, there was a significant overall difference among groups for the duration of recovery time (P =.006) and the percent change in heart rate at 1 (P =.03), 2 (P =.01), and 3 (P =.009) minutes favoring the sucrose group. But when we compared the groups, the significance remained for the sucrose versus breast milk (P =.007) and water (P =.001) groups for the recovery time and sucrose versus all other groups for the percent change in heart rate at 3 minutes. The infant body coding system showed that babies in the sucrose group had significantly lower scores followed by the breast-fed and breast milk groups (P =.0001). Our study revealed that 25% sucrose is superior to breast-feeding in pain relief, which is reflected mainly in crying time and behavioral variables. The behavioral effects of breast-feeding did not provide any additional benefit.

Cerebral infarcts in full term neonates

Cerebral infarcts are an important cause of neonatal convulsions. We report the etiologic factors, and clinical and neuroradiologic findings of four full term neonates who presented with neonatal convulsions and had cerebral infarct. In our patients the risk factors for the cerebral infarct were perinatal asphyxia, sepsis, dehydration and catheter application. All had convulsions as the initial sign of infarct and had cranial imaging which revealed the definitive diagnosis. The patients underwent an extensive evaluation for hereditary causes of cerebral infarct that included anticoagulant factors (Proteins C and S, antithrombin III, antiphospholipid antibodies), factor V Leiden and prothrombin gene mutations, blood and urine amino acid and urine organic acid levels. The results were found to be within normal limits. In conclusion, neonatal convulsions can be the first sign of cerebral infarct. For this reason it seems preferable to include cranial imaging by computed tomography or magnetic resonance imaging (MRI) in the work-up of cases with unexplained neonatal convulsions.

Cost-effectiveness of cefepime + netilmicin or ceftazidime + amikacin or meropenem monotherapy in febrile neutropenic children with malignancy in Turkey

Infection remains the major cause of morbidity and mortality in immunocompromised children with malignancy. In addition, the economic impact of antibiotic treatment should always be evaluated, especially in developing countries. In our center between January 1998 and January 1999, 73 children with hematological malignancies [acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML)]; 9 children with solid tumors (rhabdomyosarcoma, neuroblastoma) had 87 febrile neutropenic episodes (related to chemotherapy). These children were randomized prospectively into three treatment groups. The first group (n: 28) received cefepime plus netilmicin, while the second group (n: 29) was treated with ceftazidime plus amikacin and the third (n: 30) with meropenem as monotherapy. The aim of the study was to compare the success rates and cost of fourth generation cephalosporin plus aminoglycoside and monotherapy of meropenem with ceftazidime plus amikacin, which is the standard therapy for febrile neutropenia. Microbiologically documented infections were 29.9%, clinically documented infections were 9.2% and 60.9% of the febrile neutropenic episodes were considered to be FUO. Gram-positive microorganisms were the most commonly isolated agents from blood cultures [MRSA (Methicillin Resistant Staphylococcus aureus) in 6 patients and MSSA (Methicillin Sensitive Staphylococcus aureus) in 4 patients]. The success rates were 78.5%, 79.3% and 73.3 % for the 1st, 2nd and 3rd groups respectively. In 4 patients (4.5%) fever responded only to amphotericin-B therapy. There was no statistically significant difference between the three treatment regimens with respect to efficacy, safety and tolerance (chi2 test, p>0.05), but while the third and fourth generation cephalosporins + aminoglycosides were comparable for cost, the monotherapy regimen was the most expensive. The main determining factors for the choice of treatment of febrile neutropenic children, especially in a developing country, are cost, presence of indwelling catheter and the bacterial flora of the unit, as well as efficacy.

Could Parvovirus B19 Induce a Rejection After Bone Marrow Transplantation in a Patient with Diamond-Blackfan Anemia?

A four year-old-girl with Diamond-Blackfan anemia (DBA) that was resistant to corticosteroid treatment and transfusion dependent underwent (bone marrow transplantation) BMT from HLA identical sibling. The patient was conditioned with busulfan and cyclophosphamide and achieved complete marrow engraftment and mixed chimerism in DNA analysis. For the following 13 months she was not transfusion dependent and had a 100% Karnofsky score. But on the 14th month she had anemia ollowing fever, rash and enteritis. Parvovirus B19 IgM seropositivity confirmed Parvovirus infection. Although intravenous immunoglobulin was administered, bone marrow morphology and DNA analysis revealed rejection. Although mixed chimerism detected shortly after the BMT procedure might raise the possibility of an ongoing slow graft rejection during the relatively stable remission period, we think that parvovirus B19 had also contributed rejection.

Comparison of sucrose and human milk on pain response in newborns

The aim of this study was to compare the analgesic effect of 2 ml 25% sucrose and human milk in a group of healthy term newborns. Healthy infants (n = 102) were randomly allocated to receive one of three solutions (sucrose, human milk, sterile water) 2 min prior to taking a heel prick blood sample. The median values of crying time, recovery time and percentage change in heart rate at 1, 2 and 3 min were recorded in response to the heel prick. Median crying times were 36, 52, and 62 s in the sucrose, placebo and human milk groups, respectively (P = 0.0009). In the sucrose group, there was a significant reduction in crying time compared to human milk and placebo groups. Similarly, the median recovery time in the sucrose group (72 s) was shorter than that in the human milk (112 s) and placebo groups (124 s) (P = 0.004). The percentage change in heart rate at 1, 2 and 3 min was also significantly lower in the sucrose group (P = 0.008, P = 0.01, P = 0.002 at 1, 2, and 3 min respectively).

CONCLUSION

The orosensorial antinociceptive effect of human milk is not as effective as an analgesic as a 25% sucrose solution.

Transcutaneous measurement of hyperbilirubinaemia: comparison of the Minolta jaundice meter and the Ingram icterometer

The effectiveness of two different non-invasive transcutaneous bilirubin measurement devices was compared with serum bilirubin levels in 96 healthy newborns. Transcutaneous measurements were obtained with the Minolta Air Shields jaundice meter and the Ingram icterometer and serum bilirubin levels were determined by a direct spectrophotometric method (Bilitron 444). A linear correlation existed between serum bilirubin values and the readings on both the Minolta jaundice meter (r = 0.83) and the Ingram icterometer (r = 0.78). The Kappa coefficient was 0.66. the sensitivity, specificity and positive and negative predictive values were 100%, 56%, 33% and 100% for the Minolta jaundice meter and 100%, 48%, 29% and 100% for the Ingram icterometer, respectively. The high sensitivity and negative predictive value of both devices render them suitable for screening neonatal hyperbilirubinaemia. However, because of its low cost, the Ingram icterometer is preferable to the more complex and expensive Minolta jaundice meter, especially in countries with a high birth rate, such as Turkey.

Evaluation of chimerism with DNA polymorphisms in bone marrow transplantation

Evaluation of chimeric status following allogenic BMT is an important tool for monitoring the replacement of host cells with donor cells and for determining the risk of relapse. Polymorphic DNA sequences can be used as powerful markers in identification of donor/recipient genotype differences, even between close relatives. Polymerase chain reaction (PCR) amplification of three variable number of tandem repeat (VNTR) loci and five single-locus polymorphisms (SLP) was used to identify chimerism in 40 recipient-donor pairs. Mixed chimerism was present in 11 patients, and complete chimerism in 29. This PCR method is a rapid and sensitive assay to detect engraftment and evaluate relapse potential, and thus is very useful in the clinical management of BMT patients.

Neonatal intracranial hemorrhage due to rupture of arteriovenous malformation

Two cases of neonatal intracerebral hemorrhage secondary to rupture of arteriovenous malformation are reported and the pertinent literature is reviewed. Despite the limited number of cases, review of the literature and our results demonstrate that the outcome of surgical removal of an arteriovenous malformation in the neonatal period is not as poor as was previously believed.