Heated and humidified high flow therapy (HHHFT) in extreme and very preterm neonates with respiratory distress syndrome (RDS): a retrospective cohort from a tertiary care setting in Pakistan

OBJECTIVE

To determine the role of heated humidified high flow therapy (HHHFT) as primary respiratory support in spontaneously breathing moderate-late, very and extreme preterm neonates with respiratory distress syndrome (RDS) at a tertiary care hospital from a developing country.

DESIGN

Retrospective cohort study.

SETTING

Neonatal intensive care unit of Indus Hospital and Health Network, Karachi, Pakistan.

PATIENTS

All preterm neonates with RDS and who received HHHFT as primary respiratory support were included retrospectively, while neonates with orofacial anomalies, congenital heart and lung diseases other than RDS, abdominal wall defects, encephalopathy, congenital pneumonia and received continuous positive airway pressure or invasive ventilation were excluded.

INTERVENTIONS

HHHFT as primary respiratory support for RDS.

MAIN OUTCOME MEASURES

Effectiveness, duration, failure rate and complications of HHHFT as a primary respiratory support in moderate-late, very and extremely preterm neonates were evaluated.

RESULTS

The cohort included 138 neonates during a period of 12 months. The median gestational age was 32 weeks, and the median birth weight was 1607 g. Grade 1-2 RDS was seen in 97%, surfactant instillation was done in 10.8% and HHHFT was provided in all the neonates as primary respiratory support. The total duration of HHHFT support was <1 week in 94% of neonates. Bronchopulmonary dysplasia and pneumothorax until discharge or death were observed in one neonate, haemodynamically significant Patent Ductus Artriosus (HsPDA) in two neonates and intraventricular haemorrhage Grade ≥2 in five neonates, while only one neonate died.

CONCLUSION

This study appears to show that HHHFT is a simple, safe, efficient and cheap mode of primary respiratory support that can be given to spontaneously breathing moderate-late, very and extremely preterm neonates with RDS, especially in low- or middle-income countries.

Pentoxifylline for treatment of sepsis and necrotising enterocolitis in neonates

BACKGROUND

Mortality and morbidity due to neonatal sepsis and necrotising enterocolitis (NEC) remain high despite the use of potent antimicrobial agents. Agents that modulate inflammation may improve outcomes. Pentoxifylline (PTX), a phosphodiesterase inhibitor, is one such agent. This is an update of a review first published in 2003 and updated in 2011 and 2015.

OBJECTIVES

To assess the effectiveness and safety of intravenous PTX as an adjunct to antibiotic therapy on mortality and morbidity in neonates with suspected or confirmed sepsis and neonates with NEC.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and trial registries in July 2022. We also searched the reference lists of identified clinical trials and handsearched conference abstracts.   SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs assessing the efficacy of PTX with antibiotics (any dose or duration) for treatment of suspected or confirmed sepsis or NEC in neonates. We included three comparisons: (1) PTX with antibiotics compared to placebo or no intervention with antibiotics; (2) PTX with antibiotics compared to PTX with antibiotics and adjunct treatments such as immunoglobulin M-enriched intravenous immunoglobulin (IgM-enriched IVIG); (3) PTX with antibiotics compared to adjunct treatments such as IgM-enriched IVIG with antibiotics.

DATA COLLECTION AND ANALYSIS

We reported typical risk ratio (RR) and risk difference (RD) with 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) for continuous outcomes derived from a fixed-effect model of meta-analysis. We calculated the number needed to treat for an additional beneficial outcome (NNTB) if there was a statistically significant reduction in RD.

MAIN RESULTS

We identified no new studies for this update. We included six RCTs (416 neonates). All of the included studies examined neonates with sepsis; we identified no studies on neonates with NEC. Four of the six trials had high risk of bias for at least one risk of bias domain. Comparison 1: PTX with antibiotics compared to placebo with antibiotics, or antibiotics alone, in neonates with sepsis may reduce all-cause mortality during hospital stay (typical RR 0.57, 95% CI 0.35 to 0.93; typical RD -0.08, 95% CI -0.14 to -0.01; NNTB 13, 95% CI 7 to 100; 6 studies, 416 participants, low-certainty evidence) and may decrease length of hospital stay (LOS) (MD -7.74, 95% CI -11.72 to -3.76; 2 studies, 157 participants, low-certainty evidence). The evidence is very uncertain that PTX with antibiotics compared to placebo or no intervention results in any change in chronic lung disease (CLD) (RR 1.50, 95% CI 0.45 to 5.05; 1 study, 120 participants, very low-certainty evidence), severe intraventricular haemorrhage (sIVH) (RR 0.75, 95% CI 0.28 to 2.03; 1 study, 120 participants, very low-certainty evidence), periventricular leukomalacia (PVL) (RR 0.50, 95% CI 0.10 to 2.63; 1 study, 120 participants, very low-certainty evidence), NEC (RR 0.56, 95% CI 0.29 to 1.06; 6 studies, 405 participants, very low-certainty evidence), or retinopathy of prematurity (ROP) (RR 0.40, 95% CI 0.08 to 1.98; 1 study, 120 participants, very low-certainty evidence) in neonates with sepsis. Comparison 2: the evidence is very uncertain that PTX with antibiotics compared to PTX with antibiotics and IgM-enriched IVIG has any effect on mortality (RR 0.71, 95% CI 0.24 to 2.10; 102 participants, 1 study, very low-certainty evidence) or development of NEC in neonates with sepsis (RR 1.33, 95% CI 0.31 to 5.66; 1 study, 102 participants, very low-certainty evidence). The outcomes of CLD, sIVH, PVL, LOS, and ROP were not reported. Comparison 3: the evidence is very uncertain that PTX with antibiotics compared to IgM-enriched IVIG with antibiotics has any effect on mortality (RR 1.25, 95% CI 0.36 to 4.39; 102 participants, 1 study, very low-certainty evidence) or development of NEC (RR 1.33, 95% CI 0.31 to 5.66; 102 participants, 1 study, very low-certainty evidence) in neonates with sepsis. The outcomes of CLD, sIVH, PVL, LOS, and ROP were not reported. All of the included studies evaluated adverse effects due to PTX, but none were reported in the intervention group in any of the comparisons.

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that adjunct PTX therapy in neonatal sepsis may decrease mortality and length of hospital stay without any adverse effects. The evidence is very uncertain if PTX with antibiotics compared to PTX with antibiotics and IgM-enriched IVIG, or PTX with antibiotics compared to IgM-enriched IVIG with antibiotics, has any effect on mortality or development of NEC. We encourage researchers to undertake well-designed multicentre trials to confirm or refute the effectiveness and safety of pentoxifylline in reducing mortality and morbidity in neonates with sepsis or NEC.

Outcomes of Neonates Born To Mothers Who Were COVID-19 Positive; An Observational Study from Pakistan

Objective: To assess outcomes of neonates born to mothers who were COVID-19 positive. Study Design: Prospective observational study. Place and Duration of Study: Secondary and Tertiary Care Hospitals of the Armed Forces, Pakistan, from Apr to Aug 2020. Methodology: We studied 106 pregnant women who tested positive for SARS-CoV-2. Stable asymptomatic newborn babies were kept in SARS-CoV-2 specified incubators, at specially designated areas for observation. Nasopharyngeal swabs were taken at first 24 hours and if negative, babies were handed over to clinically stable mothers who were educated regarding use of facemasks and proper hand washing. Neonates who tested positive for SARS-CoV-2 were evaluated for SARS-CoV-2 again at 48 hours and then every 48-72 hours, until found to be negative. Results: Total 106 women were found to be SARS-CoV-2 positive during the study period. All the women delivered singleton babies. Of the 106 babies, 5 (4.71%) were found to be positive for SARS-CoV-2 at 24 hours and only 1 (0.94%) baby was found to be positive at 48 hours and then tested negative at 7th day. Conclusion: Babies born to SARS-CoV-2 mothers were mostly asymptomatic and there was no increased risk of morbidity or mortality to the neonates suffering from the infection.

Pentoxifylline for treatment of sepsis and necrotizing enterocolitis in neonates

BACKGROUND

Mortality and morbidity due to neonatal sepsis and necrotizing enterocolitis (NEC) remain high despite the use of potent antimicrobial agents. Agents that modulate inflammation may improve outcomes. Pentoxifylline, a phosphodiesterase inhibitor, is one such agent.

OBJECTIVES

Our primary objectives were :1.To assess the effect of intravenous pentoxifylline as an adjunct to antibiotic therapy on mortality and morbidity in neonates with suspected or confirmed sepsis.2.To assess the effect of intravenous pentoxifylline as an adjunct to antibiotic therapy on mortality and morbidity in neonates with NEC.

SEARCH METHODS

We searched the Cochrane Neonatal Review Group Specialized Register, CENTRAL (The Cochrane Library Issue 2, 2014), EMBASE (January 1980 to May 2014), PubMed (January 1966 to May 2014), CINAHL (January 1982 to May 2014), Science Citation Index (January 1990 to May 2014), and BIOSIS (January 1992 May 2014) in May 2014. We checked references and cross-references from identified studies. We handsearched abstracts from the proceedings of the Pediatric Academic Societies Meetings (from January 1990 to May 2014). We placed no restrictions on language.

SELECTION CRITERIA

We included randomised or quasi-randomised trials assessing the efficacy of pentoxifylline as an adjunct to antibiotics for treatment of suspected or confirmed sepsis or NEC in neonates.

DATA COLLECTION AND ANALYSIS

We reported typical risk ratio (RR) and risk difference (RD) with 95% confidence intervals (CI) using fixed-effect model for dichotomous outcomes and mean difference (MD) for continuous outcomes. We calculated the number needed to treat for an additional beneficial outcome (NNTB) if there was a statistically significant reduction in RD.

MAIN RESULTS

Pentoxifylline used as an adjunct to antibiotics in neonates with sepsis decreased all-cause mortality during hospital stay (typical RR 0.57, 95% CI 0.35 to 0.93; typical RD -0.08, 95% CI -0.14 to -0.01; NNTB 13, 95% CI 7 to 100; 6 studies, 416 participants, low-quality evidence). Subgroup analyses revealed decrease in mortality in preterm infants, infants with confirmed sepsis, and infants with gram-negative sepsis (low-quality evidence, four studies). Pentoxifylline decreased length of hospital stay (MD -7.59 days, 95% CI -11.65 to -3.52; 2 studies, 148 participants, low-quality evidence). Pentoxifylline did not change the risk of development of NEC, chronic lung disease, severe intraventricular haemorrhage, retinopathy of prematurity, or periventricular leukomalacia in neonates with sepsis (one to two studies, very low-quality evidence). Pentoxifylline therapy compared to pentoxifylline and immunoglobulin M-enriched intravenous immunoglobulin or immunoglobulin M-enriched intravenous immunoglobulin alone did not change mortality or development of NEC in neonates with sepsis (one study, very low-quality evidence). We noted no adverse effects due to pentoxifylline. We identified no trials evaluating pentoxifylline treatment for NEC.

AUTHORS' CONCLUSIONS

Low-quality evidence from six small studies suggests that pentoxifylline therapy as an adjunct to antibiotics in neonatal sepsis decreases mortality without any adverse effects. We encourage researchers to undertake large, well-designed multicentre trials to confirm or refute the effectiveness of pentoxifylline in reducing mortality and morbidity in neonates with sepsis or NEC.

Pattern of Culture-Proven Neonatal Sepsis in a District General Hospital in the United Kingdom

Objective:

To determine the incidence, clinical characteristics, and risk factors associated with the first culture-proven episode of sepsis among neonates in a neonatal intensive care unit (NICU).

Setting:

Level-II NICU in the United Kingdom.

Patients:

Neonates with their first culture-proven sepsis between January 1, 1996, and December 31, 2000.

Methods:

Demographic data were obtained from the NICU database and chart review. Sepsis was considered early (EOS; < 72 hours old) or late (LOS; > 72 hours old). Data were also collected on potential risk factors.

Results:

Among 14,767 live births, 1,612 (11%) neonates were admitted to the NICU during the study period. Nine hundred eight were screened for sepsis. One hundred twenty-four had at least one positive culture (overall sepsis rate of 8.4 per 1,000 live births [1%] or 77 per 1,000 NICU admissions). Twenty-four neonates had EOS and 100 had LOS. Coagulase-negative staphylococci (CoNS) and group B Streptococcus were the most frequent organisms causing EOS, whereas CoNS and Escherichia coli most frequently caused LOS. Birth before 30 weeks' gestation and birth weight less than 1,500 g were risk factors for sepsis. Resuscitation at birth was the leading risk factor for EOS and respiratory support prior to sepsis, presence of a central or peripheral catheter, and total parenteral nutrition were leading risk factors for LOS.

Conclusions:

A strong inverse relationship existed between gestational age of 30 weeks or younger and birth weight of 1,500 g or less and LOS. Resuscitation and indwelling intravenous catheters were also risk factors.

Oral immunoglobulin for the prevention of rotavirus infection in low birth weight infants

BACKGROUND

Rotavirus is a common neonatal nosocomial viral infection and epidemics with the newer P(6)G9 strains have been reported. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in preventing rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the prevention of rotavirus infection in hospitalized low birthweight infants (birthweight < 2500 g)

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, EMBASE, CINAHL, biological Abstracts (BIOSIS), Science Citation Index for articles citing Barnes 1982 and the proceedings of the Pediatric Academic Societies from 1991 onwards were searched in July 2011. Ongoing trials were also searched at clinicaltrials.gov and controlled-trials.com

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) design: randomized or quasi-randomized controlled trials; 2) participants: hospitalized low birthweight infants; 3) intervention: oral immunoglobulin preparations for prevention of rotavirus infection compared to placebo OR no intervention; 4) at least one of the following outcomes were reported: all cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, rotavirus infection , duration of diarrhea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhea or chronic diarrhea.

DATA COLLECTION AND ANALYSIS

The two review authors independently abstracted data from the included trials.

MAIN RESULTS

One published study (Barnes 1982) was eligible for inclusion in this review. Barnes 1982 found no significant difference in the rates of rotavirus infection after oral gammaglobulin versus placebo in hospitalized low birthweight babies [RR 1.27 (95% CI 0.65 to 2.37)]. In the subset of infants who became infected with rotavirus after receiving gammaglobulin or placebo for prevention of rotavirus infection, there was no significant difference in the duration of rotavirus excretion between the group who had gammaglobulin (mean 2 days, range 1 to 4 days) and the group who had placebo (mean 3 days, range 1 to 6 days). Barnes 1982 reported no adverse effects after administration of oral immunoglobulin preparations.

AUTHORS' CONCLUSIONS

Current evidence does not support the use of oral immunoglobulin preparations to prevent rotavirus infection in low birthweight infants. Researchers are encouraged to conduct well-designed neonatal trials using the newer preparations of anti-rotaviral immunoglobulins (colostrum, egg yolk immunoglobulins) and include cost effectiveness evaluations.

Pentoxifylline for treatment of sepsis and necrotizing enterocolitis in neonates

BACKGROUND

Mortality and morbidity due to neonatal sepsis and necrotizing enterocolitis (NEC) is high despite the use of potent antimicrobial agents. Agents that modulate inflammation may improve outcomes. Pentoxifylline, a phosphodiesterase inhibitor, is one such agent.

OBJECTIVES

The primary objectives were to assess the effect on mortality and the safety of intravenous pentoxifylline as an adjunct to antibiotic therapy in neonates with suspected or confirmed sepsis and NEC.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2011), MEDLINE, EMBASE and CINAHL, Science Citation Index for articles referencing Lauterbach 1996, proceedings of the Pediatric Academic Societies (1990 to 2011), BIOSIS (1992 to 2011), conference proceedings (1992 to 2011), ongoing trials and reference lists of identified RCTs were searched in July 2011.

SELECTION CRITERIA

Randomised or quasi-randomised trials assessing the efficacy of pentoxifylline as an adjunct to antibiotics for treatment of suspected or confirmed sepsis or NEC in neonates were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted information for the outcomes of interest. Typical relative risk (RR) and risk difference (RD) with 95% confidence intervals (CI) using fixed effects model are reported for dichotomous outcomes and mean differences for continuous outcomes. NNT was calculated for outcomes for which there was a statistically significant reduction in RD.

MAIN RESULTS

In four randomised controlled trials, 227 neonates with suspected or confirmed sepsis were randomised to pentoxifylline or placebo. Pentoxifylline therapy significantly decreased "all cause mortality during hospital stay" in the overall population of infants with sepsis [typical RR 0.40 (95%CI 0.20 to 0.77); typical RD -0.15 (95%CI -0.26 to -0.05); NNT 7 (95%CI 4 to 20)]. Subgroup analyses revealed significant reduction in mortality in preterm infants, infants with confirmed sepsis and gram-negative sepsis. Pentoxifylline treatment significantly decreased length of hospital stay [mean difference -11.20 [95%CI -22.09 to -0.31] but not development of NEC in neonates with sepsis [typical RR 0.29 (95%CI 0.07 to 1.24); typical RD -0.20 (95%CI -0.41 to 0.01)]. No adverse effects due to pentoxifylline were noted. No completed trial of treatment with pentoxifylline for treatment of NEC was identified.

AUTHORS' CONCLUSIONS

Current evidence from four small studies suggests that the use of pentoxifylline as an adjunct to antibiotics in neonatal sepsis decreases mortality without any adverse effects. Researchers are encouraged to undertake large well-designed multicenter trials to confirm or refute the effectiveness of pentoxifylline in reducing mortality and adverse outcomes in neonates with suspected or confirmed neonatal sepsis and NEC.

Oral immunoglobulin for the treatment of rotavirus diarrhea in low birth weight infants

BACKGROUND

Rotavirus infection is the most common neonatal nosocomial viral infection. It is a major health problem worldwide. Epidemics with the newer P(6)G9 strains have been reported in neonatal units globally. These strains can cause severe symptoms in most infected infants. Infection control measures become necessary and the utilization of hospital resources increase. Local mucosal immunity in the intestine to rotavirus is important in the resolution of infection and protection against subsequent infections. Boosting local immunity by oral administration of anti-rotaviral immunoglobulin preparations might be a useful strategy in treating rotaviral infections, especially in low birth weight babies.

OBJECTIVES

To determine the effectiveness and safety of oral immunoglobulin preparations for the treatment of rotavirus diarrhea in hospitalized low birth weight infants (birth weight less than 2500 g)

SEARCH STRATEGY

Electronic databases including The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), MEDLINE, EMBASE and CINAHL, Biological Abstracts (BIOSIS) were searched by the strategy outlined in the protocol. Science Citation Index search for all articles that referenced Barnes 1982 were searched. The proceedings of the Pediatric Academic Societies published online at 'Abstracts Online' were searched. Ongoing registered trials at www.clinicaltrials.gov and www.controlled-trials.com were searched. Authors prominent in the field were contacted for any unpublished articles and more information on published articles was sought. Reference lists of identified clinical trials and personal files were also reviewed. The above search was updated in July 2011.

SELECTION CRITERIA

The criteria used to select studies for inclusion were: 1) DESIGN: randomized or quasi-randomized controlled trials 2) Hospitalized low birth weight infants with rotavirus diarrhea 3) INTERVENTION: Oral immunoglobulin preparations compared to placebo or no intervention 4) At least one of the following outcomes were reported: All cause mortality during hospital stay, mortality due to rotavirus infection during hospital stay, duration of diarrhea, need for rehydration, duration of viral excretion, duration of infection control measures, length of hospital stay in days, recurrent diarrhea or chronic diarrhea

DATA COLLECTION AND ANALYSIS

The two reviewers were to independently abstract data from eligible trials. No data were available for analysis.

MAIN RESULTS

No eligible randomized controlled trials were found.

AUTHORS' CONCLUSIONS

No randomized controlled trials that assessed the effectiveness or safety of oral immunoglobulin preparations for the treatment of rotavirus diarrhea in hospitalized low birth weight infants were found. Clinical trials that address the issue of oral immunoglobulin treatment of rotavirus infection are needed.

Caesarean or vaginal delivery for preterm very-low-birth weight (≤1,250 g) infant: experience from a district general hospital in UK

OBJECTIVE

To determine whether delivery by caesarean is associated with a better neuro-developmental outcome at two years for preterm infants born weighing 1,250 g or less.

SETTING

District General Hospital, United Kingdom.

DESIGN

All inborn infants weighing <1,250 g born at St Helier University Hospital between January 1995 and December 2003 were identified from contemporaneously collected computer database. All hospital records were retrieved. Details of the mother, delivery route, Apgar score, details of resuscitation and details of the baby, neonatal progress and neuro-developmental status at two years was transcribed on a pre-designed proforma. Neuro-developmental status assessment at two years of age was carried out by an independent neurodevelopmental paediatrician. Neuro-developmental status was classified as normal, severe, moderate or mild disability.

STATISTICAL ANALYSIS

Analysis was done by creating a simple two by two table. Statistical significance was set at p = 0.05. Multivariate and univariate analysis was carried out for a number of confounding variables.

SAMPLE

Total of 411 babies were identified from the data-base. Of these 59 were still born and fourteen though born alive died in the delivery suit. 125 (37%) were excluded from analysis as they were returned to their referring hospitals prior to discharge from hospital. Information about their two-year follow-up was either incomplete or not robust enough to be included in the analysis. Analysis was carried out on 213(63%) for whom we had complete data set at two years of age (103 infants born via vaginal delivery and 110 infants were born by caesarean section).

OUTCOME MEASURE

Primary outcome measure was to compare survival at discharge and neurodevelopmental status at two years of age of this cohort. Secondary outcome included determining the incidence of grade III or IV intraventricular haemorrhage (IVH), chronic lung disease and necrotising enterocolitis (NEC).

RESULTS

The overall caesarean delivery rate for this cohort was 51.6% while the overall caesarean rate for all births at our hospital during the study period varied between 20 and 23%. Neonatal mortality for those delivered by caesarean was 12.7% compared to 14.5% for those delivered vaginally (p = ns). Overall incidence of any neuro-disability at two years of age was 46.8% for those delivered by caesarean compared to 47.7% for those delivered vaginally (p = ns). There was no difference in those with severe (23.5% vs. 25.0%), moderate (10.4% vs. 9%) or mild (12.5% vs. 13.6%) neuro-disability between the groups nor was there any difference in the number of babies with IVH, chronic lung disease and NEC. Neuro-disability was equally greater in both groups for babies born weighing 750 grams or less and/or born at 26 weeks or less gestation.

CONCLUSION

Despite the increasing tendency to deliver extremely preterm babies by caesarean, we did not find that it was associated with either reduced mortality or neuro-disability at two years of age. Therefore the method of delivery of very-low-birth weight premature infants should be based on obstetric or maternal indications rather than the perceived outcome of the baby.

Intravenous polyclonal IgM-enriched immunoglobulin therapy in sepsis: a review of clinical efficacy in relation to microbiological aetiology and severity of sepsis

The efficacy of intravenous polyclonal immunoglobulin (IVIG) as adjunct therapy in sepsis has long been debated. Clinical trials have yielded contradicting results, in part due to the varying study design and varying microbiological aetiologies. In most trials, the study drug has been IVIG containing polyclonal IgG. However, in recent reports, the efficacy of IgM-enriched IVIG as adjunct therapy in sepsis has been highlighted. Here we review studies on IgM-enriched IVIG therapy in sepsis and we discuss the clinical efficacy in relation to microbiological aetiology and severity of sepsis. The results suggest that patients most likely to benefit from IgM-enriched IVIG therapy are those with Gram-negative septic shock.

Definitions of bloodstream infection in the newborn

OBJECTIVE

To develop definitions of bloodstream infections in the newborn that would enable clinicians to identify infection early, so patients can be enrolled in clinical trials. The definitions should be useful for surveillance and epidemiologic purposes.

METHOD

Search of EMBASE, MEDLINE, and Cochrane Library using age and English language limited key words sepsis, septicemia, and shock. Extensive study of textbook of neonatology and discussions with experts in the field.

RESULTS

The search identified >2,000 references. The most appropriate were selected and reviewed. Definitions of bloodstream infection were developed after consultation with an international faculty.

CONCLUSION

Current definitions of neonatal infection (and associated categories) used by neonatal clinicians and researchers have been either adapted/modified from definitions developed for adults or generated by individuals to suit their local needs or the needs of a particular study. It is clear that definitions generated for adults are not applicable to children or to newborn infants. In addition, developing and using unique definitions to suit individual or local needs make comparisons of outcome data and result of studies very difficult. This article proposes a set of definitions that are based as much as possible on current evidence. These definitions may be applicable widely for daily management of an infant with an infection and for research and epidemiologic studies.

Role of Nucleated red blood cell count in cases of birth asphyxia

Full text is available as a scanned copy of the original print version.

Physicians and Health Organization Management

Full text is available as a scanned copy of the original print version.

Painful subcutaneous fat necrosis of the newborn associated with intra-partum use of a calcium channel blocker

Subcutaneous fat necrosis of the newborn (SCFN) is a relatively uncommon condition of the skin which is said to be benign and painless. We report an infant with extremely painful SCFN which was relieved only by opiate analgesia. SCFN normally resolves spontaneously within a few weeks. This case is, therefore, also unusual in that symptoms persisted beyond 6 months.

Autopsy in a neonatal intensive care unit: utilization patterns and associations of clinicopathologic discordances

OBJECTIVES

(1) To develop methods to describe autopsy utilization patterns in a neonatal intensive care unit. (2) To identify classes of patients likely to have clinicopathologic concordance or discordance.

METHODS

Five hundred forty-five consecutive neonatal intensive care unit deaths (338 autopsied, rate 62%) in a regional tertiary/quaternary care neonatal intensive care unit for referred infants (65,000 annual births) were classified in six clinical diagnostic groups (anomalies, cardiac anomalies, hypoxic ischemic encephalopathy, prematurity and its complications, infections, and other) and rated in three levels of certainty of clinical diagnosis as "gold standard" certainty, almost complete certainty, and less certain than the latter. Clinicopathologic discordances were rated in three classes using clinical, pathologic, and multidisciplinary mortality conference records. The proportions of autopsied cases, cases with major discordances, and cases with no discordances were compared and analyzed in relation to diagnostic group and level of certainty.

RESULTS

Performance of autopsy was associated with clinical diagnostic uncertainty (p = 0.008). Major discordances with implications for outcome (Class I) were found in 3%, and without implications for outcome (Class II) in 15% of cases; 42% of cases had no discordances. Major discordance rate varied inversely with the degree of diagnostic certainty (p = 0.000) and varied among clinical groups.

CONCLUSIONS

(1) Autopsy was used most for cases with potential for high yields. (2) Clinicopathologic discordances were more frequent and important in certain clinical diagnostic groups (prematurity, other) and with high levels of diagnostic uncertainty. When the diagnostic "gold standard" is available during life, autopsy will provide little information.

Comparison of two types of intravenous immunoglobulins in the treatment of neonatal sepsis

In a prospective double-blind study, standard intravenous immunoglobulin (IVIG) was compared with an IgM-enriched IVIG in the treatment of neonatal sepsis. The two treatment groups were also compared with matched controls. One hundred and thirty babies (65 in each group) ranging from 0 to 24 days old, 480 to 4200 g in weight and born between 24 and 42 weeks of gestation who had, or were suspected of having, sepsis were given either standard IVIG or IgM-enriched IVIG (250 mg/kg per day) for 4 days in addition to supportive and antibiotic therapy. A further 65 babies who received similar supportive, antibiotic and fluids but not IVIG were used as matched controls. Mortality from infection in 'culture proven sepsis' was 3/44 (6.8%) in the IgM-enriched IVIG group, 6/42 (14.2%) in the standard IVIG group, and 11/43 (25.5%) in the control group (P = 0.017, IgM versus control, P = 0.19 standard IVIG versus control). There was no statistical difference in the outcome between the two immunoglobulin therapy groups (P = 0.25). The study indicates that IVIG improves outcome in neonatal sepsis when used as an adjunct to supportive and antibiotic therapy, but larger studies are required to confirm this.

Determinants of term intrauterine growth retardation: the Saudi experience

In a clinical study from an unselected Saudi obstetric population, the incidence of and risk factors for intrauterine growth retardation among live births were investigated. From a total study group of 4578 consecutive live births, 76 (1.7%) infants were found to be growth retarded. These infants were then compared with a randomly selected control group of 76 term newborns with appropriate birthweight for their gestational ages. Delivery at term of a growth-retarded infant was significantly associated with maternal age under 20 years, maternal body mass index less than 23, first degree consanguinity, poor housing, primiparity, and inadequate prenatal care in univariate analysis. When considered jointly in multivariate logistic regression analysis, the significant determinants were reduced to primiparity, first degree consanguinity, and poor housing. These risk factors correctly predicted 63% and 71% of the intrauterine growth-retarded infants or normal birthweight infants, respectively.

Immunotherapy in perinatal infection

Though intravenous immunoglobulin (IVIG) have been shown to be beneficial in the treatment of some perinatal viral infections like varicella and possibly cytomegalovirus. The main thrust of interest has been directed towards the prevention and treatment of perinatal bacterial infections. This paper reviews literature published thus far (October 1991) on the use of IVIG in perinatal sepsis.

Percentile curves for various hematologic measurements at birth in Arab preterm babies of different gestational ages

Percentile curves were calculated for hemoglobin; hematocrit; total red and white blood cell counts; mean corpuscular volume; mean corpuscular hemoglobin; mean corpuscular hemoglobin concentration; and platelet, neutrophil, band cell, lymphocyte, monocyte, basophil, and eosinophil counts in preterm babies of 24 through 36 weeks' gestation. The curves were derived from mainly Saudi Arabian preterm babies who were born in Riyadh, which is just above sea level. Babies born to mothers with hematologic problems or babies who themselves had any evidence of hematologic disorder, blood loss, or disorders that affect hematologic values, eg, asphyxia, were excluded from the reference population. Six hundred two newborns were included in the study; however, after exclusions, the final reference population was 550. A minimum of 50 babies were studied for each gestational age except for gestations of 24 and 25 weeks. For these two gestations, 27 and 21 babies were studied, respectively. The percentile curves should be useful as a guide to the normal range of these variables in babies, particularly those of Arab origin.

Acute renal failure in neonates: A prospective study

Babies admitted to a neonatal intensive care unit in whom acute renal failure developed were studied prospectively to determine the etiology, course, and outcome of the disorder, as well as the reliability of renal indices in distinguishing intrinsic from prerenal renal failure. The incidence of neonatal acute renal failure was 3.6% (22/603). The most frequent causes were hypotension (86%), respiratory distress syndrome (41%), sepsis (32%), and asphyxia (27%). Half of the patients were born at less than 32 weeks' gestation and had a birth weight of less than 1500 gm. There was intrinsic renal failure in 15 neonates and prerenal failure in seven. Renal indices (urine-to-plasma ratio of osmolality, fractional excretion of sodium, and renal failure index) were not reliable in differentiating between intrinsix or prerenal failure. Mortality from renal failure was high at 77%. Survivors of neonatal acute renal failure who had no underlying congenital anomalies of the urinary tract did not appear to exhibit residual renal impairment during follow-up evaluation. It is important to identify those clinical indices that can be used in determining the diagnosis and prognosis of acute renal failure in neonates, particularly in very premature, low-birth-weight babies.

Low birthweight in Riyadh, Saudi Arabia: incidence and risk factors

In a multicentre prospective study, we have determined the incidence of low birthweight (LBW) and the main predisposing risk factors. Among 4651 consecutive births over a 5-month period in five hospitals in Riyadh, the overall incidence of LBW was 8.4%. When stillbirths were excluded the incidence of LBW was 7.4% of all live births. Statistical analysis was performed among 638 births (319 LBW infants, i.e. less than or equal to 2499 g and 319 babies weighing 2500 g or more). Of the 28 antenatal risk variables analysed, 13 were found to be significant when studied separately. Of these 13 variables, six were found to be significant predictors of LBW, using stepwise multiple logistic regression. These six variables together correctly predicted 72% and 88% of the LBW babies or normal birthweight babies, respectively. The risk factors thus identified were (i) short gestation, (ii) multiple gestation, (iii) low maternal body mass index, (iv) nulliparity, (v) availability of housework help, and (vi) absence of consanguinity. Measures for reducing these factors are also discussed.

Half a decade of neonatal sepsis, Riyadh, Saudi Arabia

In a retrospective study to determine the pattern of neonatal sepsis, all cases admitted to the Neonatal Intensive Care Unit (NICU) between October 1983 and July 1988 at King Khalid University Hospital, in Riyadh were studied. During the review period there were a total of 2117 admissions to the NICU. Of those 1252 (59 per cent) underwent septic screening sometimes during their stay in the NICU. The number of babies with proven bacteremia, i.e.; positive blood and or cerebrospinal fluid culture was 190 (15 per cent). Gram-positive organisms were cultured from 132 (69 per cent) and Gram-negative organisms from 47 (25 per cent) of the babies. The single most frequent organism was Staphylococcus epidermidis accounting for 36 per cent (58/190) of all proven cases. These results differ appreciably from other studies reported previously from Riyadh as well as from some other parts of the world, and stress the need to recognize Staphylococcus epidermidis as an increasingly important pathogen in the newborn nursery.

Do gowns prevent infection in neonatal intensive care units?

In a prospective study we found that gowns had no effect when used by medical and paramedical staff, in reducing infection in a tertiary care neonatal unit. We conclude that the use of gowns in this area is an ineffective and expensive method of preventing nosocomial infection.

IgM-enriched intravenous immunoglobulin therapy in neonatal sepsis

Despite the development of newer generation of antibiotics, mortality from neonatal sepsis remains high. In a prospective, randomized study, we investigated the use of IgM-enriched immunoglobulin therapy in neonatal sepsis. Two groups of 30 infants each (matched for gestational age, sex, weight, and other variables) were randomly allocated to receive either antibiotics alone (control group) or antibiotics plus 5 mL/kg/d for four days of IgM-enriched immunoglobulin intravenously (immunotherapy group). Mortality from sepsis in the control group was 20% (6/30), while in the immunotherapy group it was 3.3% (1/30). We conclude that IgM-enriched immunoglobulin therapy in conjunction with antibiotic therapy significantly reduces mortality from neonatal sepsis.

Intravenous immunoglobulin for prevention of sepsis in preterm and low birth weight infants

The effect of an intravenous polyvalent immunoglobulin preparation given prophylactically to prevent neonatal sepsis was tested in preterm and low birth weight infants. Infants matched for gestational age, sex and birth weight (+/- 250 g) were randomly allocated into 3 groups of 50 each, one group (Group C) being used as control. Group A received Intraglobulin (Biotest Pharma, West Germany), 120 mg/kg intravenously, within 2 to 4 hours of delivery; Group B received the same on days 1 and 8. The control group received no immunoglobulin. The frequency of infection and serum immunoglobulin concentrations were determined in each group. Infection rate in the control group was 16% (8 of 50) while in each of the treated groups it was 4% (2 of 50) (P less than 0.005). The immunoglobulin concentrations achieved in the treated group were significantly higher than the control group. No adverse effect of the therapy was noted during the study and at a 6-month follow-up. It is suggested that in nurseries where the infection rate is high, prophylactic intravenous polyvalent immunoglobulin therapy for the preterm and low birth weight infants may provide protection from infection.

Delayed recurrence of group B streptococcal infection in a newborn infant: a case report

Recurrence of neonatal group B streptococcal (GBS) sepsis in an infant aged 63 days is reported. Recurrence of GBS should be considered in an infant who "goes off" after apparent eradication of the initial infection even after the neonatal period.

Shigella flexneri bacteraemia

Shigellosis is usually a non-invasive enteric disease, rarely accompanied by extra-intestinal manifestations. Shigella septicaemia is therefore reported in a child aged 10 months. In the laboratory the organism was resistant to ampicillin and only moderately susceptible to chloramphenicol. The patient responded well to cotrimoxazole to which the organism isolated was susceptible in vitro. We recommend that blood as well as faeces should be cultured in exceptionally ill patients with suspected or otherwise confirmed shigella infection.

Isolated asternia: an independent entity

Six cases of isolated asternia are described, their case histories and progress are reviewed. The relevant literature is reviewed and suggestions made towards etiology.

Is it necessary to regraduate milk after acute gastroenteritis in children?

To assess the best possible method of reintroducing milk in children suffering from acute gastroenteritis, 150 children (76 males and 74 females) admitted with acute gastroenteritis were allocated to one of three regimens: a. clear fluids initially, followed by increasing strengths of milk, in quarter strength steps; b. clear fluids initially and then reintroducing full strength milk; c. regimen of continuing full strength milk. There was no difference between the three groups in the outcome or in the length of stay in the hospital, but those who were continued on full strength milk gained more weight. The weight gain did not attain statistical significance; it is our impression on clinical grounds that this weight gain may be important in the malnourished infant who is more prone to enteritis.

Feeding pattern of children under two years of age in Riyadh, Saudi Arabia

Mothers or other close relatives of children who were in hospital in Riyadh, were asked about their feeding practices. Sixty-four per cent of mothers of newborn babies had attended antenatal clinics, but only 10% had received any instructions on feeding. Of the hospitalized children only 27% were receiving breast milk alone by one month of age. However, of the 28% of mothers who had some education, 84% were breast feeding at three months of age. In Riyadh 36 brands of artificial milk feeds are available, and by three months of age, the average baby had been on six varieties of milk. Less than 14% of mothers intending to bottle feed could read the instructions, and of those who believed they knew how, only 18% made up the formula correctly. Educational opportunities need to be exploited and easy availability of artificial milk curbed.

Dexamethasone in the treatment of hypernatraemic dehydration

Ninety infants with severe hypernatraemic dehydration (plasma sodium greater than 150 mmol/l) were studied. Most had had a convulsion before admission. They were allocated to two treatment groups. Both groups received intravenous plasma followed by slow intravenous rehydration and correction of acidosis. In addition, one group received intramuscular phenobarbitone, the other group received dexamethasone 0.3 mg by intramuscular injection every 6 hours for 48 hours. Fewer infants receiving dexamethasone had convulsions during treatment (18% compared with 52%), and fewer (18%) of them died than in the group who did not receive dexamethasone (40%). Dexamethasone may have a role in the management of hypernatraemic dehydration in infants.