Pediatrics & Neonatology

Three Dimensional Medical Imaging: From Dream to Reality

Hsu-Yi Chen, Shyh-Jye Chen — 2010-08-01

Protein for Preterm Infants: How Much is Needed? How Much is Enough? How Much is Too Much?

William W. Hay, Patti Thureen — 2010-08-01

Preterm infants require considerably more protein to achieve normal intrauterine growth rates than is commonly fed to them during their first postnatal days. Continuing protein nutrition to maintain normal growth rates often is not achieved until several weeks after birth. Most very preterm infants do not receive the protein necessary to produce the 2-3 kilograms of body mass over a 12-16 week period of NICU care and, as a result, end up growth restricted by term, in lean body mass more than fat. This article reviews the requirements for protein and amino acids necessary to achieve normal growth and development of preterm infants. Protein requirements at 24-30 weeks' gestation are as high as 4 g/kg/day, decreasing to 2-3 g/kg/day by term. Individual amino acids are important not just as building blocks for protein synthesis and net protein balance, but also as essential signalling molecules for normal cellular function. Perhaps most importantly, brain growth and later life cognitive function are directly related to protein intake during the neonatal period in preterm infants. Data are reviewed that document successful increase in protein balance in preterm infants achieved with higher than usual rates of amino acid and protein nutrition, noting that positive protein balance requires at least 1.5 g/kg/day, but there still is increased protein balance up to 4 g/kg/day. Further research is necessary to determine optimal amounts and mixtures of protein and amino acids for both intravenous and enteral feeding to improve growth, development, and functional capacity of preterm infants.

Clinical Manifestations of Symptomatic Intracranial Hemorrhage in Term Neonates: 18 Years of Experience in a Medical Center

2010-08-01

Background: Intracranial hemorrhage (ICH) is an uncommon but important cause of morbidity and mortality in term neonates. We conducted a retrospective analysis of the clinical characteristics and developmental outcomes of symptomatic ICH in term neonates. Methods: A retrospective chart review was conducted of all term neonates (less than 1 month old) diagnosed with ICH and admitted to the neonatal intensive care unit of Kaohsiung Chang Gung Hospital from December 1991 to December 2008. Demographic characteristics, mode of delivery, laboratory data, clinical presentation, and developmental status were recorded. Results: Data for 24 term neonates (17 boys and 7 girls) with a diagnosis of ICH were collected for analysis. The clinical manifestations of ICH included anemia (13/24, 54%), seizure (11/24, 46%), cyanosis (7/24, 29%), tachypnea (5/24, 21%), fever (1/24, 4%), hypothermia (1/24, 4%), and poor feeding (1/24, 4%). Age at symptom onset ranged from 2 hours to 11 days following birth. The most common type of ICH was subdural hemorrhage. All ICHs resolved, except in one infant, who died from hypoxicischemic encephalopathy at 25 days. Ten children with symptomatic ICH were reported to have normal development, while the remainder (13/23, 57%) showed developmental delays or disabilities. Conclusion: Unexplained anemia, seizure, and cyanosis were the major presenting signs in infants with symptomatic ICH. A diagnosis of ICH should be considered in term neonates who present with one or more of these signs. Although the mortality in term infants with symptomatic ICH was low, more than half

Effects of Flow Rate on Delivery of Bubble Continuous Positive Airway Pressure in an In Vitro Model

2010-08-01

Background: There has been concern over the effect of vigorous bubbling on the delivery pressure during the operation of the bubble nasal continuous positive airway pressure (CPAP) system. We investigated the relationship between intra-tubing pressure changes and flow rates in a closed bubble CPAP system in vitro. Methods: Using an experimental (in vitro) model, the distal connecting tube of the CPAP system was immersed under the water seal to a depth of 5 cm. Sixteen different flow rates, ranging from 2 L/min to 20 L/min, were tested. The procedure was repeated 10 times at each flow rate, and the intra-tubing pressure was recorded. Results: The intra-tubing pressure within the model increased as the air flow rates were adjusted from 2 L/min to 20 L/min. The relationship was represented by the following equation, pressure (cmH2O) = 5.37 + 0.15 × flow rate (L/min) (R2 = 0.826, p < 0.001). Conclusion: These results demonstrated that the intra-tubing pressure in a bubble CPAP system was highly correlated with flow rate in vitro.

Acute Pathophysiological Effects of Intratracheal Instillation of Budesonide and Exogenous Surfactant in a Neonatal Surfactant-depleted Piglet Model

2010-08-01

Background: Chronic lung disease continues to be a major complication in premature infants with severe respiratory distress syndrome (RDS). This is despite having advanced ventilatory care, prenatal corticosteroids, and postnatal surfactant therapies. The combined use of intratracheal corticosteroids and surfactant may not only recruit the lungs, but also alleviate pulmonary inflammation in severe RDS. Methods: Fifteen newborn piglets received repeated pulmonary saline lavage to induce surfactant-depleted lungs, mimicking neonatal RDS. They were randomly divided into three groups: control group receiving no treatment; surfactant (Surf) group, treated with standard intratracheally instilled surfactant (100 mg/kg); and Budesonide plus surfactant (Bude + Surf) group, treated with intratracheally administered mixed suspension of budesonide (0.5 mg/kg) and surfactant (100 mg/kg). Blood samples were taken every 30 minutes for 4 hours. Lung tissue was examined after the experiment. Results: Significantly better oxygenation with higher PaO2 and alveolar-arterial oxygen difference was noted in the Surf and Bude + Surf groups, compared with the control group (p < 0.05), but there were no significant differences between the Surf and Bude + Surf groups. Pulmonary histologic damage was also markedly alleviated in both the Surf and Bude + Surf groups, compared with the control group, and lung injury scores were significantly decreased in the Surf and Bude + Surf groups, compared with the control group (p < 0.05). Conclusions: Intratracheal instillation of surfactant or surfactant plus budesonide can improve oxygenation and pulmonary histologic outcome in neonatal surfactant-depleted lungs. The additional use of budesonide does not disturb the function of the exogenous surfactant. Intratracheal administration of a corticosteroid combined with surfactant may be an effective method for alleviating local pulmonary inflammation in severe RDS.

Role of Multi-slice and Three-dimensional Computed Tomography in Delineating Extracardiac Vascular Abnormalities in Neonates

2010-08-01

Background: Recent advances in multi-slice computed tomography (MSCT) and three-dimensional computed tomography (3D CT) provide good-resolution images and short scan time for complete diagnosis of congenital heart disease (CHD). In the present study, we found that MSCT rapidly provides clinically relevant information for diagnosing extracardiac vascular anatomy in neonates with CHD. It is less invasive, necessitating only minimum or no sedation and a relatively small amount of contrast material. These advantages are crucial, especially for critically ill neonates. Methods: Between January 2007 and December 2008, MSCT scans were conducted on 41 neonates who were admitted to our neonatal intensive care unit. All the neonates were suspected to have complex CHD after an initial echocardiography examination. The scans were focused on detecting extracardiac vascular anatomy and abnormalities. All the image data sets were sent to image processing workstations for multiplanar interactive viewing and 3D reconstruction. Results: High-resolution MSCT scan images were obtained from 41 patients. Reported indications and findings of extracardiac abnormalities and related structural anatomy pertaining to congenital heart disease from MSCT and 3D CT findings were confirmed by clinical and surgical findings by a team of multidisciplinary congenital heart disease specialists. Conclusion: Based on clinical and surgical confirmation of the MSCT scan results from a multidisciplinary congenital heart disease specialist team, we concluded that adequate information on CHD, specifically that regarding extracardiac abnormalities of the anatomy, can be obtained and MSCT can be used to replace cardiac catheterization.

Relationship Between Birth Weight and Time of First Deciduous Tooth Eruption in 143 Consecutively Born Infants

Negar Sajjadian, H. Shajari, Ramin Jahadi, Michael G. Barakat, Ali Sajjadian — 2010-08-01

Background: Deciduous teeth play an important role in the proper alignment, spacing and occlusion of permanent teeth. The calcification of deciduous teeth begins during the fourth prenatal month, and calcification of all deciduous teeth begin by the end of the sixth prenatal month. The eruption date varies and is genetically influenced. Delayed eruption of deciduous teeth, especially the first teeth, causes nutritional problems for the infants. It also results in parental concerns. In this study, we compared the timing of eruption of the first deciduous teeth in infants in relation to their birth weight. Methods: A total of 143 infants born at Shariati Hospital in Tehran from December 2004 to December 2005 were included in the study. Data on sex, birth weight, gestational age, and time of first tooth eruption were collected. Results: The mean birth weight was 3220 ± 420 g with 5.5% of infants weighing less than 2500 g, and 19.9% weighing more than 3500 g. Patients were monitored weekly from the third month of age until the time of first tooth eruption. The mean age of first tooth eruption was 7.68 ± 1.84 months. Conclusion: There was a negative linear correlation between the time of first deciduous tooth eruption and birth weight, suggesting that delayed tooth eruption may be related to lower birth weight.

Calcinosis Cutis Complicated by Compartment Syndrome Following Extravasation of Calcium Gluconate in a Neonate: A Case Report

Tuo-Kang Chen, Chueh-Yuan Yang, Shu-Jen Chen — 2010-08-01

Hypocalcemia most frequently occurs in premature neonates. It is usually treated by intravenous (iv) calcium supplementation. However, complications caused by extravasation of iv calcium gluconate include localized soft tissue calcification, necrosis, cellulitis, osteomyelitis, and even compartment syndrome. We present a rare case of iatrogenic calcinosis cutis complicated by compartment syndrome secondary to extravasation of iv calcium gluconate in a neonate. Emergent fasciotomy was performed twice for decompression of compartment syndrome. Histologic findings revealed necrosis and calcification. Appropriate antibiotics were administered to control secondary infection. To the best of our knowledge, there were no previous case reports of calcinosis cutis with compartment syndrome in infants. Although iatrogenic calcinosis cutis is generally a benign entity, the early recognition of the presentation of extravasation of calcium gluconate is important to avoid severe complications and possible medical malpractice disputes. This report aims to raise doctors' awareness of the presentation, course, and management of this relatively rare iatrogenic complication.

Late-onset Group B Streptococcal Meningitis in a Neonate With Early Antibiotic Prophylaxis

Ting-Jung Ko, Wu-Shiun Hsieh, Po-Ren Hsueh, Hung-Chieh Chou, Chun-Yi Lu — 2010-08-01

An otherwise healthy female baby who had received early postnatal antibiotic prophylaxis because of maternal vaginal group B streptococcal (GBS) colonization died of late-onset GBS meningitis. GBS was isolated from blood and cerebrospinal fluid. Genotyping using pulsed-field gel electrophoresis confirmed that the GBS isolates from the patient were identical to those from her mother's vagina. Susceptibility tests demonstrated no antibiotic resistance. This report provides additional microbiologic evidence indicating that early postnatal antibiotic prophylaxis is not effective in preventing late-onset GBS infections in neonates born to mothers with GBS colonization.

Neonate With Severe Heart Failure Related to Vein of Galen Malformation

2010-08-01

We report a full-term female neonate who presented with respiratory distress and severe heart failure soon after birth. Heart failure secondary to perinatal infection was initially suspected. Subsequent echocardiography revealed aortic runoff, which led to consideration of an intracranial vascular abnormality. Ultrasound and magnetic resonance imaging of the brain confirmed a diagnosis of vein of Galen aneurismal malformation (VGAM). Endovascular coil embolization of the vascular anomaly was performed, resulting in improvement of heart failure. VGAM should be considered in the differential diagnosis of neonatal congestive heart failure with a structurally normal heart. Urgent endovascular embolization and aggressive medical treatment of heart failure improve prognosis in neonatal VGAM.

Neonatal Intracranial Aneurysm Rupture Treated by Endovascular Management: A Case Report

2010-08-01

Pediatric intracranial aneurysm rupture is rare, and is traditionally managed by surgical clipping. To the best of our knowledge, endovascular embolization of aneurysms in neonates has not previously been reported in Taiwan. We report a 9-day-old boy with intracranial aneurysms who underwent endovascular embolization, representing the youngest reported case in Taiwan. The 9-day-old boy presented with non-specific symptoms of irritable crying, seizure and respiratory distress. Computed tomography disclosed intraventricular hemorrhage, subarachnoid hemorrhage and focal intracranial hemorrhage around the right cerebellum. Subsequent computed tomographic angiography showed two sequential fusiform aneurysms, measuring 3 mm, located in the right side posterior inferior cerebellar artery (PICA). The patient underwent endovascular embolization because of the high risk of aneurysm re-rupture and the impossibility of surgical clipping due to the fusiform nature of the aneurysms. A postembolization angiogram revealed complete obliteration of the right distal PICA and proximal aneurysm. The distal PICA aneurysm was revascularized from the collateral circulation, but demonstrated a slow and delayed filling pattern. The patient's condition remained stable over the following week, and he was discharged without anticonvulsant therapy. No significant developmental delay was noted at follow-up at when he was 3 months old. This case emphasizes the need for clinical practitioners to consider a diagnosis of intracranial hemorrhage in neonates with seizure and increased intracranial pressure. Neonatal intracranial aneurysms can be treated safely by endovascular treatment.