Pediatrics & Neonatology

A Feasible and Effective Lifestyle Counseling Program for Obese Children and Adolescents

Yu-Cheng Lin — 2012-03-02

Childhood obesity is now an epidemic problem worldwide. A combination of decreased physical activity, increased sedentary behavior, and consumption of excessive calories, has resulted in the increasing prevalence of childhood obesity. In Taiwan, according to Nutrition and Health Survey in Taiwan Elementary School Children (NAHSIT Children, 2001–2002), 15.5% of boys and 14.4% of girls between the ages of 6 and 12 years are overweight (≥ the 85th percentile value of body mass index), and 14.7% of boys and 9.1% of girls are obese (≥ the 95th percentile value of body mass index).

Ultrasound Diagnosis of Liver Masses in Children

Ming-Wei Lai — 2012-03-02

Ultrasound (US) is commonly used for the survey of various organs, including the liver. It is often used as the first-line image modality, due to easy accessibility and non-radiation safety. However, diagnostic accuracy depends on the familiarity of the operator, as well as the type, size, and location of the lesion. US is often arranged in two clinical scenarios: for screening of potential mass lesions in patients with chronic liver diseases such as chronic hepatitis B, biliary atresia, glycogen storage disease, etc. or for initial evaluation of symptomatic patients presenting with hepatomegaly, jaundice, right upper quadrant pain, as well as nonspecific abdominal pain or fever. Liver masses are more easily identified on US scanning when the echogenicity is different from the surrounding parenchyma, either hypoechoic or hyperechoic. When the masses are small in size (<0.5 cm), isoechoic, or located in segment 8, subtle ultrasonic clues such as refractive edge shadow, distorted venous landmarks, or abnormal Doppler patterns may suggest an otherwise unremarkable liver mass and warrant careful multiplanar scanning. For diagnosis and management of a liver mass, not only do we have to identify the lesion, but also the nature (benign or malignant, tumor type, primary origin, vascularity, or resectability). Although a hepatic mass may sometimes present a characteristic ultrasonic appearance, in general, it often requires an additional modality to get an accurate diagnosis for appropriate treatment. Computed tomography (CT) or magnetic resonance image (MRI) and invasive procedures such as aspiration and biopsy serve the purpose. Be aware of lower sensitivity and the intrinsic technical limitation of US, the clinician should never spare a repeated US or a second image modality in a symptomatic patient with an initial negative US exam, taking into consideration the high morbidity and mortality of a liver mass without timely diagnosis and proper management.

Current Status and Future Diagnostic Trends of Prenatal Illicit Drug Exposure in the Neonate

San-Nan Yang — 2012-03-02

With regards to opiate abuse, heroin has become the most common illicit drug in Taiwan. In pregnant women, opiate abuse contributes to adverse effects, such as low birth body weight, premature delivery, and life-long developmental consequences in the neonate. Clinical characteristics for opiate or poly-drug exposure in utero, resulted in neonatal withdrawal syndrome, which required clinical observation and treatment for days or even weeks in hospital. The American Academy of Pediatrics published guidelines which include the monitoring and treatment of neonatal abstinence syndrome (NAS) following in utero opiate or poly-drug exposure. Among these patients, NAS was the most observed clinical finding, and included dysfunction of the central nervous system, autonomic nervous system, gastrointestinal tract, and respiratory system. In some severe cases, NAS led to deleterious outcomes, such as diarrhea, fever, seizure, feeding intolerance, poor weight gain and even death. Moreover, poly-drug abusers, who used multiple illicit substances during pregnancy, declined; this obscured the clinical situation with regards to the treatment of their offspring. Thus, the identification of illicit drugs, while the patient suffers during the perinatal period, could provide an imperative basis for clinical diagnosis and potential management. Practically speaking, this identification should be assessed in both mothers and their newborn. Samples used in newborn drug testing included urine, meconium, hair, and umbilical cord segment. Urine testing of the neonate for illicit drugs, revealed a low biological sensitivity, as this procedure can only detect recent drug exposure. In addition, since the earliest collection of the newborn’s urine with the highest concentration of an analyzed substance was often missed, due to practical clinical difficulties, meconium drug testing was more biologically sensitive and easier to perform. However, meconium passage in a newborn may take several days; this often delayed the clinical diagnosis. Su et al measured hairs of neonates; this method was potentially more biologically sensitive and more rapid in the identification of poly-drug use. Indeed, it has been reported that hair analysis was costly and good at detecting chronic exposure, but, although it exerted a high biological sensitivity for opiate, amphetamine, and cocaine, it showed a low biological sensitivity for marijuana exposure. In addition, hair analysis provided a possible duration of illicit drug exposure, by the measurement of the hair segment. Although this technique is not widely available at present, it is a potential survey tool for use in important aspects of clinical needs. It is worth considering for unsolved issues underlying illicit drug exposure in the neonate prenatally, such as the occurrence and severity of NAS, and neonatal psychomotor behavior after poly-drug exposure.

Strategies for the Prevention of Neonatal Candidiasis

Eugene Leibovitz — 2012-03-02

Invasive fungal infections represent the third-leading cause of late-onset sepsis in very-low-birth-weight infants (VLBWI) and have a high rate of infection-associated mortality. The infants at high risk for fungal sepsis are VLBWI with presence of additional risk factors that contribute to increased colonization and concentration of fungal organisms. Colonization with Candida spp. in neonates is secondary to either maternal vertical transmission or nosocomial acquisition in the nursery. Multiple sites may become colonized and a direct correlation between fungal colonization and subsequent progression to invasive candidemia was determined. Randomized, single and multiple-center, placebo-controlled trials found intravenous fluconazole prophylaxis to be effective in decreasing fungal colonization and sepsis for at-risk preterm infants <1500 g birth weight. The prophylactic use of fluconazole was found to be safe with no significant development of fungal resistance. Fluconazole prophylaxis administered to preterm neonates with birth weight <1000 g and/or 27 weeks’ gestation or less has the potential of reducing and potentially eliminating invasive fungal infections and Candida-related mortality.

Can a Trial of Motivational Lifestyle Counseling be Effective for Controlling Childhood Obesity and the Associated Cardiometabolic Risk Factors?

2012-03-05

Objectives: This study was conducted to assess the effectiveness of a simple office-based program for encouraging healthy lifestyle on controlling childhood obesity and associated cardiometabolic risk factors.Methods: This non-randomized 24-week lifestyle modification trial was conducted among 457 obese children and adolescents, aged 2–18 years, who had at least one cardiometabolic risk factor in addition to obesity. This trial included three components of exercise, diet education and behavior modification, with all recommendations provided by a pediatrician, two general physicians and a nurse. Instead of strict inhibitory recommendations, healthier lifestyle was encouraged.Results: Overall 448 (98.04%) of enrolled children completed the trial with a mean age of 9.6 ± 2.9 years. After the trial, the mean of anthropometric measures and cardiometabolic risk factors decreased significantly, the mean high-density lipoprotein cholesterol (HDL-C) increased significantly, and the prevalence of the metabolic syndrome decreased from 20.8% to 1.8%. Triglycerides, LDL-C, diastolic blood pressure and WC had the highest decrease in all age groups, with the most prominent changes in the 14–18-year age group. By each -1SD decline in BMI and WC, risk factors had significant improvement.Conclusion: Motivational office-based counseling can be effective in treatment of childhood obesity and its associated cardio-metabolic risk factors. Such approach can be implemented in the primary health care system; and can be of special concern in low- and middle-income countries with limited human and financial resources. We suggest that expanding the roles of non-physician clinicians such as nurse practitioners can help to increase the amount of time available for such services.

Pitfalls in a Sonographic Diagnosis of Liver Abscess in Children

2012-03-05

Background: The purpose of this article is to identify the pitfalls of sonography in the diagnosis of liver abscesses, hematomas, and hepatic tumors, which appear similar and therefore are difficult to differentiate from each other.Methods: Cases were collected at the China Medical University Hospital between January 2008 and January 2010. Liver abscesses were initially diagnosed by sonograph in selected patients who were younger than 18 years.Results: There were 15 patients in whom a liver mass was diagnosed by ultrasound, but 6 of them were excluded from further study because of failure to meet any of the screening criteria. Nine patients with a mean age of 11.3 years (range 5-17 years) were initially suspected to have liver abscesses by ultrasound and were enrolled in the study. These nine patients were identified as follows: five with liver abscess, one with liver hematoma, one with hepatic lymphoma, one with perihepatic abscess, and one with undifferentiated liver sarcoma. Ultrasonography alone was sufficient for diagnosis in five patients. Four patients required abdominal CT scanning to confirm final diagnosis.Conclusion: Different liver lesions may present sonographic images similar to those of liver abscesses. Therefore, it is suggested that patients in whom liver abscesses were diagnosed by ultrasound undergo further evaluation if the clinical condition is less likely.

A Nationwide Survey of Risk Factors for Stillbirth in Taiwan, 2001–2004

2012-03-05

Objective: The purpose of this study was to evaluate the nationwide stillbirth rate and explore the potential risk factors associated with stillbirths.Patients and methods: Data from vital registrations during the time period from January 1, 2001 through to December 31, 2004 in Taiwan were used. Stillbirth was defined as fetal death with more than 20 completed weeks’ gestational age (GA) or with birth weight more than 500 g if the GA was not known.Results: There were a total of 8481 stillbirths identified nationwide between January 1, 2001 and December 31, 2004. The stillbirth rate was nine per 1000 total births in the study period, and the proportionate decline was nearly 48.8% in the most recent decade. There was a significant increase in average maternal age during this period. Advanced maternal age and teenage pregnancy were independent significant risk factors for stillbirths even after accounting for the effects of medical conditions that were more likely to occur among these particular age groups. Those fetuses that had been exposed to cord prolapse, maternal cervical incompetence and oligohydramnios/polyhydramnios were especially vulnerable. By contrast, women who had foreign nationality, fetal ultrasound surveys, fetal heart beat monitoring and hastened parturition were less likely to have stillbirth.Conclusion: The stillbirth rate in Taiwan has remained high despite advancements in medical care. Prenatal evaluation of high risk women may decrease the adverse fetal outcomes.

Perinatal Effects of Combined Use of Heroin, Methadone, and Amphetamine during Pregnancy and Quantitative Measurement of Metabolites in Hair

Pen-Hua Su, Yan-Zin Chang, Chen Yang, Yan-Yan Ng, Jia-Yuh Chen, Su-Chin Chen — 2012-03-05

Objective: There has been very limited research on the clinical features of newborns exposed to combined use of heroin, methadone, and amphetamine in the uterus. We describe a technique for the quantification of drug metabolites in neonatal hair samples.Methods: In a tertiary neonatal care center in Taiwan, three neonates whose mothers self-reported heroin abuse with methadone treatment during pregnancy were studied. Involuntary exposure to amphetamine was not suspected before the births. To assess long-term illicit drug exposure during pregnancy, a quantifying technique of gas chromatography/mass spectrometry (GC/MS) for hair samples from neonates was developed to replace current methods for urine and blood specimens.Results: All three mothers were addicted to heroin and prescribed oral methadone treatment during pregnancy. Two males and one female were born and then admitted to the neonatal intensive care unit because of apparent neonatal abstinence syndrome (NAS) after birth. Additional hypertonicity and cerebral dysfunction were also diagnosed by electroencephalography in one case. Supportive care was given to the neonates, unless special treatments were needed in responding to tachypnea, fetal distress, or withdrawal symptoms. During follow-up periods from 10 months to 15 months, the signs of NAS remained and delays in milestones of development were observed. Further follow-up on the infants’ neurobehavioral development is necessary. Measurement results of neonates’ hair samples revealed high levels of metabolites of heroin, methadone, and amphetamine, reflecting the amount of illicit drug exposure 2–3 months before delivery.Conclusion: The current study suggested the possibility of polydrug exposure, which was previously unknown in pregnant women in Taiwan. Measurement of neonatal hair samples could provide a basis for clinical evaluation and potential corresponding treatment.

Auditory Event-related Potentials in Children With Attention Deficit Hyperactivity Disorder

Min-Lan Tsai, Kun-Long Hung, Hui-Hua Lu — 2012-03-05

Background: Recording of event-related potentials (ERPs) from the scalp is a noninvasive technique reflecting the sensory and cognitive processes associated with attention tasks. Attention deficit hyperactivity disorder (ADHD) is a disorder involving deficits in attention and behavioral control. The aim of this study was to investigate the difference in ERPs between normal children and those with ADHD.Methods: We examined 50 children with ADHD and 51 age-matched controls. All children with ADHD met the full criteria for ADHD according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The auditory oddball paradigm was applied, and event-related long-latency components (N1, P2, N2 and P3) from Fz, Cz and Pz were measured in each test subject.Results: Children with ADHD showed a significantly longer latency and a lower amplitude of P3 compared to normal control children (p 10 years of age (p < 0.05).Conclusion: We found that the endogenous ERPs (P3 and N2) were significantly affected in children with ADHD, compared to exogenous ERPs (N1 and P2). Increased latency of P3 suggests a slower processing speed, and decreased P3 amplitude is interpreted as disruption of inhibitory control in children with ADHD. These results indicate a neurocognitive abnormality in ADHD, as presented by a reduction in ERP response.

Treatment With Propranolol for Infantile Hemangioma in 13 Taiwanese Newborns and Young Infants

2012-03-02

Background: Hemangioma in infants has a benign self-limited course, but the 10% of cases with complications need further treatment. Successful treatment with propranolol in western countries has been reported over the past few years. We evaluated the efficacy of propranolol for treating infantile hemangioma in Taiwanese newborns and young infants.Methods: Patients below 1 year of age treated with propanolol between November 2009 and March 2011 were enrolled. Demographic data, clinical features, imaging findings, treatment regimens of propranolol, and outcome were investigated.Results: Thirteen patients were treated with propranolol at a dose of 2–3 mg/kg/day. Seven (53.8%) patients had solitary hemangioma and six had multiple ones. The indications for treatment were risk of local event in nine patients, functional risk in four, local complication in one, and life-threatening complication in one. The median age for starting propranolol was 4 months (range: 1–11 months). Responses to propranolol, such as decolorization, regression in tumor size, or improvement of hemangioma-associated complications were observed in all patients within 1–2 weeks after treatment. Propranolol-associated adverse effects occurred in two patients. One infant had occasional tachypnea, and the other had occasional pale-looking appearance. The symptoms resolved after dosage tapering.Conclusion: Propranolol may be a promising therapeutic modality for infantile hemangioma. Therapeutic strategies are needed to evaluate the optimal treatment protocol and long-term adverse effects.

Clinical Impacts of Delayed Diagnosis of Hirschsprung’s Disease in Newborn Infants

2012-03-09

Background: Asian infants are at a higher risk of having Hirschsprung’s disease (HD). Although HD is surgically correctable, serious and even lethal complications such as Hirschsprung’s-associated enterocolitis (HAEC) can still occur. The aim of this study was to investigate the risk factors of HAEC, and the clinical impacts of delayed diagnosis of HD in newborn infants.Patients and methods: By review of medical charts in a medical center in Taiwan, 51 cases of neonates with HD between 2002 and 2009 were collected. Patients were divided into two groups based on the time of initial diagnosis: Group I, diagnosis made within 1 week after birth, and Group II after 1 week. Clinical features including demographic distribution, presenting features of HD, short-term and long-term complications related to HD were compared between the two groups of patients.Results: There were 25 patients in Group I and 19 in Group II. Group II patients had more severe clinical signs and symptoms of HAEC than Group I patients. The incidence of preoperative HAEC was 12% in Group I and 63% in Group II (adjusted odds ratio = 12.81, confidence interval = 2.60–62.97). Patients with preoperative HAEC were more likely to develop adhesive bowel obstruction after operation (33% vs. 3%, p = 0.013) and failure to thrive (33% vs. 3%, p = 0.013). Also, patients with long-segment or total colonic aganglionosis were at risk of developing both postoperative HAEC (85% vs. 29%, p = 0.001) and failure to thrive (39% vs. 3%, p = 0.002).Conclusion: In our study, we found that delayed diagnosis of HD beyond 1 week after birth significantly increases the risk of serious complications in neonatal patients. Patients with long-segment or total colonic aganglionosis have higher risk of postoperative HAEC and failure to thrive. Patients with preoperative HAEC are more likely to have adhesive bowel obstruction and failure to thrive.

Association of ABO Incompatibility With Red Blood Cell Indices of Cord Blood Unit

2012-03-05

Background: Maternal–fetal ABO incompatibility is one of the causes of neonatal hyperbilirubinemia. We postulate that hemoglobin (Hb), hematocrit (Hct), and red blood cell (RBC) values for cord blood units (CBUs) are lower and erythroblast values higher for maternal–fetal ABO incompatible dyads than for compatible dyads.Objective: We investigated the relationship between Hb, Hct, RBC, and erythroblast CBU values and maternal–fetal ABO blood type compatibility.Methods: Mothers having blood group O who gave birth to infants with blood group A, B, or AB were classified as Group I. According to baby’s blood group, the members of Group I were further divided into AO (baby group A, mother group O), BO (baby group B, mother group O), and ABO (baby group AB, mother group O) subgroups. Mothers having blood group A who gave birth to infants with blood group B or AB and mothers having blood group B who gave birth to infants with blood group A or AB were classified as Group II. All other maternal–fetal blood type pairs were considered ABO compatible and were classified as Group III. We compared mean Hb, Hct, RBC, and erythroblast values for the infants’ CBUs among these three groups including the subgroups of Group I.Results: Group I had lower mean Hb, Hct, and RBC values than Group II and Group III (both p < 0.001). Although the mean Hb, Hct, and RBC values for Group II were lower than for Group III, the difference was not statistically significant. Mean Hb and RBC for the AO group were higher and nucleated RBC (nRBC) ratios were lower than for the BO group; however, these differences were also not statistically significant. Interestingly, the mean Hct value of the BO group was significantly lower than that of the AO group (p = 0.04).Conclusion: Group A or B neonates with a group O mother have lower mean Hb, Hct, and RBC values for CBUs than other neonates. The role of RBC indices in predicting neonatal hemolytic hyperbilirubinemia remains unclear and further studies are needed to identify the possible clinical association.

Hepatic Subcapsular Hematoma: Two Neonates With Disparate Presentations

2012-03-05

Subcapsular hematoma of the liver rarely occurs in neonates and the diagnosis is often missed or delayed. We report two babies who had this uncommon condition in the early neonatal period. In the first baby, the hematoma was associated with ventouse delivery and presented with abdominal distension and worsening jaundice. In contrast, the other baby was relatively well, with progressive pallor as the only clinical finding. The former had no other identifiable risk factors, whereas the latter was confirmed as having classical hemophilia. The literature is briefly reviewed with regards to incidence, etiology, diagnosis and management. Awareness of this unusual entity coupled with a high index of suspicion is essential for early identification and stabilization of such babies.

Nager Syndrome: A Case Report

Ju-Li Lin — 2012-03-02

Nager syndrome (preaxial acrofacial dysostosis) is rare and mostly sporadic. We present a case of Nager syndrome in Taiwan. Craniofacial findings included micrognathia, malar hypoplasia, downslanting palpebral fissures, cleft palate, and ear anomalies. Radial defects consisted of hypoplastic thumb, short forearm, and proximal radioulnar synostosis. Patent ductus arteriosus, atrial septal defect, lower limb deformities, and uncommon flat nasal bridge were noted. Nasal endotube passing through a narrowing oropharynx region or oral airway is life-saving before tracheostomy is performed on patients with Nager syndrome and restricted jaw opening and glossoptosis.

Intestinal Obstruction Caused by Potato Bezoar in Infancy: A Report of Three Cases

Hsun-Chin Chao, Kuei-Wen Chang, Chao-Jan Wang — 2012-02-27

We present a report of three young infants with unusual intestinal obstruction caused by potato bezoar. They presented with vomiting, irritable crying, and abdominal distention. Barium gastrointestinal series clearly revealed intraluminal filling defect in the duodenum in two cases and ileum in one. Those bezoars in the pylorus and duodenal bulb were all successfully retrieved endoscopically. The patient’s abdominal symptoms subsided after the bezoars were eliminated; no subsequent gastrointestinal events occurred in the following months. The authors believe that the occurrence of these cases suggest that feeding mashed potato to young infants (≤4 months) should be prohibited because it can result in bezoar formation.