Pediatrics & Neonatology - Articles in Press

Pediatric Renal Transplantation in the Jordanian Population: The Clinical Outcome Measures During Long-term Follow-up Period - Corrected Proof

Sireen Shilbayeh, Issa Hazza — 2012-02-06

Introduction: Recently, many international studies have suggested that pediatric patients from diverse ethnic origins confront unique challenges for transplantation. Data concerning the efficacy and safety of transplantation for various pediatric renal transplant populations remains limited and are often confounded by immunosuppressive protocols. In one study, we aimed to evaluate the short- and long-term outcomes of renal transplants in Jordanian children in comparison with groups of different nationalities.Methods: We retrospectively retrieved data for 34 Jordanian children who received kidney transplants from living donors between January 2003 and January 2009. Subsequently, we continued to follow-up with these selected patients at scheduled clinic visits to prospectively collect long-term data for a period of approximately 22 months±15 months.Results: The patients included in this study ranged between 4 years and 19 years of age. The male/female ratio was 0.79. Glumerulonephritis (35.3%) was the most common cause of end-stage renal disease in the sample of this study; 23.5% had received a preemptive transplant. All patients also received triple immunosuppressive therapy, consisting of tacrolimus (TAC), prednisolone, and mycophenolate mofetil (n=26) or azathioprine (n=8). Furthermore, the rate of acute rejection episodes was lower in the sample of this study than the average rate of many previous studies. The patients’ survival rate at 1 year, 2 years and 3 years posttransplant was nearly 100%. The corresponding graft survivals were 97.1%, 94.12% and 91.2% respectively. Beyond three years, one female patient died postgraft loss. This graft loss was mainly attributed to recurrent glomerulonephritis. Strikingly, the prevalence of posttransplant diabetes (PTD) and hypertension was higher than reported international figures. Other adverse events, such as infections, were manageable.Conclusion: The average result of pediatric renal transplantation in Jordan is more successful than the average results of this procedure in many developed countries, especially in terms of early graft function, acute rejection episodes as well as long-term patient and graft survivals. However, additional studies are needed to better characterize pharmacokinetic of TAC and to fully understand those factors that lead to an increased probability of developing conditions like PTD and hypertension.

Efficacy of Intermediate-Dose Oral Erythromycin on Very Low Birth Weight Infants With Feeding Intolerance - Corrected Proof

2012-01-27

Background: Erythromycin is generally used as a prokinetic agent for the treatment of feeding intolerance in preterm infants; however, results from previous studies significantly vary due to different medication dosages, routes of administration, and therapy durations. The effectiveness and safety of intermediate-dose oral erythromycin in very low birth weight (VLBW) infants with feeding intolerance was examined in this study.Methods: Between November 2007 and August 2009, 45 VLBW infants with feeding intolerance, who were all at least 14 days old, were randomly allocated to a treatment group and administered 5mg/kg oral erythromycin every 6hours for 14 days (n=19). Another set of randomly selected infants was allocated to the control group, which was not administered erythromycin (n=26).Results: The number of days required to achieve full enteral feeding (36.5±7.4 vs. 54.7±23.3 days, respectively; p=0.01), the duration of parenteral nutrition (p<0.05), and the time required to achieve a body weight ≥2500g (p<0.05) were significantly shorter in the erythromycin group compared with the control group. The incidence of parenteral nutrition-associated cholestasis (PNAC) and necrotizing enterocolitis (NEC) ≥ stage II after 14 days of treatment were significantly lower (p<0.05) in the erythromycin group. No significant differences were observed in terms of the incidences of sepsis, bronchopulmonary dysplasia, or retinopathy of prematurity. No adverse effects were associated with erythromycin treatment.Conclusions: Intermediate-dose oral erythromycin is effective and safe for the treatment of feeding intolerance in VLBW infants. The incidences of PNAC and ≥ stage II NEC were significant lower in the erythromycin group.

Herlyn-Werner-Wunderlich Syndrome Consisting of Uterine Didelphys, Obstructed Hemivagina and Ipsilateral Renal Agenesis in a Newborn - Corrected Proof

2012-01-27

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare variant of Müllerian duct anomalies consisting of uterine didelphys, obstructed hemivagina, and ipsilateral renal agenesis. Patients with HWW syndrome are usually asymptomatic until menarche, when they present with acute lower abdominal pain. Here we report a case of a female newborn with right renal agenesis diagnosed during the pregnancy. The patient presented with a protruding mass over the vaginal introitus that was associated with an obstructed hemivagina and uterine didelphys.

Reply to the Letter from Dr. Lonati - ‘Carbon Monoxide Poisoning in Children’ - Corrected Proof

Chi-Hsun Cho, Nan-Chang Chiu — 2012-01-27

Dr. Lonati and colleagues pointed out the potential role of hydrogen cyanide in fire smoke inhalation. Cyanide poisoning has been related to cause mortality and morbidity in a fire-ground environment. However, the assessment of blood cyanide concentrations in fire victims has potential error because the toxic effects of cyanide on fire victims cannot be evaluated based solely on the concentration in blood. Since cyanide can be both produced and degraded in blood and tissue, interpreting blood levels can be difficult. In the review of Barillo and others, detoxification of cyanide can occur without specific antidotes with the use of aggressive supportive care. They suggested that specific assay and treatment for cyanide poisoning is rarely necessary in the treatment of victims of smoke and fire. In our series, more patients (n = 22) were exposed to a non-fire–related situation and only eight patients were exposed to a house fire. Only a few of our patients had their cyanide levels checked, but no abnormal findings were discovered. In the discussion section, we mentioned that the worse outcome of the house fire exposure group may be contributed to associated burns, lung inhalation injury, and exposure to other toxic gases in fire scene. Of course, hydrogen cyanide is an important toxic gas. We have cyanide antidote kits in our emergency department, but we do not have hydroxocobalamin. Although most of our patients have favorable prognoses, to save the lives of more fire victims as well as to decrease complications, we agree that checking serum cyanide and lactate levels and preparing newer and safer cyanide antidotes, e.g. hydroxocobalamin, may be helpful.

Clinical Characteristics and Genotypes of Rotaviruses in a Neonatal Intensive Care Unit - Corrected Proof

2012-01-25

Background: There are few reports on the symptoms of rotavirus infections in neonates. This study aims to describe clinical signs of rotavirus infections among neonates, with a particular focus on preterm infants, and to show the distribution of genotypes in a neonatal intensive care unit (NICU).Methods: A prospective observational study was conducted at a regional NICU for 1 year. Stool specimens from every infant in the NICU were collected on admission, at weekly intervals, and from infants showing symptoms. Rotavirus antigens were detected by enzyme-linked immunosorbent assay (ELISA), and genotypes were confirmed by Reverse transcription-Polymerase chain reaction (RT-PCR). The infants were divided into three groups: symptomatic preterm infants with and without rotavirus-positive stools [Preterm(rota+) and Preterm(rota–), respectively] and symptomatic full- or near-term infants with rotavirus-positive stools [FT/NT(rota+)]. Demographic and outcome data were compared among these groups.Results: A total of 702 infants were evaluated for rotaviruses and 131 infants were included in this study. The prevalence of rotavirus infections was 25.2%. Preterm(rota+) differed from Preterm(rota–) and FT/NT(rota+) with respect to frequent feeding difficulty (p = 0.047 and 0.034, respectively) and higher percentage of neutropenia (p = 0.008 and 0.011, respectively). G4P[6] was the exclusive strain in both the Preterm(rota+) (97.7%) and FT/NT(rota+) (90.2%), and it was the same for nosocomial, institutional infections, and infections acquired at home.Conclusion: Systemic illness signs such as feeding difficulty and neutropenia are specific for preterm infants with rotavirus infections. G4P[6] was exclusive, regardless of preterm birth or locations of infections. This study might be helpful in developing policies for management and prevention of rotavirus infections in NICUs.

Erythromycin for the Treatment of Feeding Intolerance in Preterm Infants - Corrected Proof

Chung-Ming Chen — 2012-01-20

Feeding intolerance is a frequent problem among preterm infants in intensive care. The condition usually manifests as a large residue of food in the stomach at the next feed, and may be associated with abdominal distension, intermittent regurgitation or vomiting. Earlier feeding can assist normal development of the gastrointestinal tract, and also avoid health problems related to feeding by intravenous lines. Slow progression to enteral feeding often predisposes preterm infants to prolonged use of parenteral nutrition, nosocomial infections, hepatic dysfunction, and prolonged hospitalization.

Kawasaki Disease: An Update on Diagnosis and Treatment - Corrected Proof

Ho-Chang Kuo, Kuender D. Yang, Wei-Chiao Chang, Luo-Ping Ger, Kai-Sheng Hsieh — 2012-01-19

Kawasaki disease (KD) is an acute multi-system vasculitis syndrome of unknown etiology occurring mostly in infants and children younger than 5 years of age. In developed countries, it is the leading cause of acquired heart disease in children. However, KD remains a mysterious disease. Some viruses potentially causing the condition have been isolated, but the results have not been able to be reproduced. This article reviews and summarizes different aspects of KD and provides updated information on diagnosis and treatment. The supplementary criteria for incomplete presentation of KD patients suggested by the American Heart Association, treatment (including tumor necrosis factor-alpha antagonist, methylprednisolone pulse therapy, statins, plasma exchange, and cytotoxic agents) for those with intravenous immunoglobulin treatment failure, and other experiences are also included in this review.

Congenital Webs of the Gastrointestinal Tract: 20 Years of Experience From a Pediatric Care Teaching Hospital in Taiwan - Corrected Proof

2012-01-19

Background: To classify and evaluate the clinical spectrum of congenital webs in the gastrointestinal (GI) tract, including clinical courses and related factors.Methods: A retrospective chart review was performed on 37 patients with congenital GI webs at a pediatric care teaching hospital in north Taiwan. All of the related parameters were collected and analyzed.Results: Twelve patients had gastric webs, 22 had duodenal webs, and three had jejunal webs. The mean time to diagnosis was 1576 days for gastric webs, 116 days for duodenal and 230 days for jejunal webs. There was a statistically significant difference between the gastric and duodenal groups (p = 0.001). The major symptom was vomiting (78%). Patients with duodenal webs had a high association with congenital anomalies (50%). The major anomalies included cardiac (27%) and GI anomalies (18%). Endoscopy was performed in 10 gastric cases, and all of them were noted to have positive findings, including a fixed nonfolded stenotic ring following a second gastric chamber and a real pylorus. All of the patients received surgery except for three with gastric webs, and no mortality was noted. The mean postoperative days of tolerated feeding was 6 for those with gastric webs, 10 for those with duodenal and 11 for those with jejunal webs.Conclusion: The clinical course of gastrointestinal webs may be chronic or obscure. A delay from onset of symptoms to treatment may exist, especially in gastric webs. We suggest that prompt endoscopic confirmation and surgical intervention for these lesions, when suspected due to clinical and radiologic abnormalities, will decrease the morbidity of unexplained recurrent symptoms or signs of GI obstruction in these patients.

Weight Loss Percentage Prediction of Subsequent Neonatal Hyperbilirubinemia in Exclusively Breastfed Neonates - Corrected Proof

2012-01-19

Background: The incidence of neonatal hyperbilirubinemia in our hospital has increased since the implementation of breastfeeding promotion. Inadequate breastfeeding results in reduced calorie intake, weight loss and neonatal hyperbilirubinemia. Supplementary feeding is required if breastfeeding proves inadequate. However, the optimal weight loss cut-off value for supplementary feeding is unknown.Methods: We collected records for all healthy neonates with a gestational age ≥35 weeks and birth body weight (BBW) above 2500 g, born between March 2002 and July 2005, from our nursery. A total of 1979 neonates were reviewed, 874 of whom were exclusively breastfed and subsequently enrolled in this study. Only infants who were breastfed exclusively were enrolled; 219 of these infants (25.1%) presented significant hyperbilirubinemia after 72 hours of age. Infants with early-onset (<48 hours) hyperbilirubinemia or any known risk factors for neonatal hyperbilirubinemia were excluded. We analyzed the association between weight loss percentage and hyperbilirubinemia and investigated the best weight loss percentage cut-off value for the prediction of subsequent hyperbilirubinemia before 2 weeks of age.Results: Neonates with lower gestational age and greater weight loss percentage were associated with hyperbilirubinemia. By using weight loss ≥8% of BBW after 48 hours and weight loss ≥11% of BBW after 72 hours as the cut-off values for the prediction of subsequent hyperbilirubinemia, negative predictive values were 77.7% and 76.8%, respectively.Conclusion: This study documented the relationship between weight loss percentage and subsequent hyperbilirubinemia incidence. Our data provide a basis for determination of an optimal weight loss percentage cut-off value that indicates supplementary feeding.

Three-Dimensional Brain Images in Preterm Children With Periventricular Leukomalacia - Corrected Proof

Hsiao-Feng Chou, Ming-Fan Lin, Chia-Yuan Chen, Ein-Yiao Shen — 2012-01-19

Background: To investigate the use of three-dimensional (3D) brain magnetic resonance imaging (MRI) to evaluate in preterm children with periventricular leukomalacia.Materials and Methods: Semiautomated 3D classification of the gray and white tissues was used to reconstruct brain images of patients with confirmed periventricular leukomalacia from 2D MRI.Results: We studied 14 preterm patients. The gestational age ranged from 25–37 weeks. The corrected age ranged from 5–49 months. We reconstructed the gray matter, white matter, and ventricles in order to analyze the brain volume.Conclusion: Three-dimensional MRI is a good tool that can be used to demonstrate brain lesions in stereo and differentiate the gray matter, white matter, and ventricles. Brain volume can also be accurately evaluated.

Evaluation of a Streptococcal Pharyngitis Score in Southern Taiwan - Corrected Proof

Ching-Tang Shih, Ching-Chiang Lin, Chung-Ching Lu — 2012-01-19

Background: Group A streptococcus (GAS) pharyngitis can cause serious complications such as rheumatic heart disease. The McIsaac sore throat score is a clinical prediction score used to improve the detection rate of GAS pharyngitis. We evaluated the validity of the McIsaac sore throat score in Southern Taiwan and compared our findings to those of other studies.Methods: We retrospectively analyzed chart records from children aged 3 to 15 years old who complained of fever and sore throat. They had throat cultures collected at the outpatient pediatric clinic of Fooyin University Hospital, located in Pingtung County, Taiwan during the period between January 2007 and January 2010. Clinical characteristics were reviewed, and sore throat score was analyzed.Results: A total of 342 throat cultures met the inclusion criteria of sore throat and fever. The positive rate of GAS was 4.1%. Culture-positive cases were associated with higher odds for a skin rash [adjusted odds ratio (AOR): 14.66, 95% confidence interval (CI): 4.63–46.40, p < 0.001), lower odds for cough (AOR: 0.19, 95% CI: 0.04–0.85, p = 0.030) and having a runny nose (AOR: 0.22, 95% CI: 0.05–0.99, p = 0.048). The most common physical sign was scarlet fever rash (AOR: 57.35, 95% CI: 15.45–212.98, p < 0.001). A McIsaac score of 5 had a sensitivity of 71%, specificity of 70%, and a positive predictive value of only 9.3%.Conclusion: Pediatric streptococcal pharyngitis in Southern Taiwan is uncommon. Diagnosis of GAS pharyngitis based on the McIsaac sore throat score is unreliable among pediatric patients with febrile pharyngitis in Southern Taiwan.

Pediatric Ovarian Torsion in a Medical Center in Taiwan: Case Analysis - Corrected Proof

Jun-Kai Kao, Chun-Chien Chiu, Po-Yu Wang, Meng-Kung Yu — 2012-01-19

Background: Abdominal pain is one of the most common complaints made by patients visiting emergency departments; however, ovarian torsion is an uncommon cause of abdominal pain, especially in young children. Early diagnosis is essential in order to salvage the ovaries. We performed a retrospective analysis of patients under 18 years of age who visited Changhua Christian Hospital with adnexal torsion between June 2003 and June 2010.Methods: Medical records were reviewed for age, associated symptoms, past and present medical histories, physical findings, diagnostic tests performed, clinical course, pathological findings, and diagnoses.Results: A total of 21 patients were identified and included in the analysis; their mean (SD) age was 13.62 (3.75) years. Abdominal pain was the universal symptom. Vomiting or nausea was the second most common symptom (33.3%). The average period between symptom onset and diagnosis was 3.29 (6.39) days. Right-side adnexal torsion occurred in 14 patients, and left-side torsion in seven patients. Ovarian cysts, most often dermoid cysts (e.g., teratomas), were found in 16 patients (76%). Except for one conservatively treated case and one malignant case (adult granulose cell tumor), the other results of the pathological examination were as follows: eight dermoid cysts, two cystadenomas, one follicular cyst, and eight simple cysts.Conclusion: Although it is uncommon, adnexal torsion should be included in the differential diagnosis of lower abdominal pain in all girls, regardless of age. Sonography is helpful for making such a diagnosis. Time is a critical factor, and early laparoscopy or laparotomy may save a viable ovary.

Pulmonary Sequestration and Diaphragmatic Eventration in a 6-month-old Infant - Corrected Proof

Hsing-Ching Kuo, Chich-Yang Chang, Joseph-Hang Leung — 2012-01-19

A congenital pulmonary malformation, such as pulmonary sequestration or congenital cystic adenomatoid malformation, should be suspected in infants with recurrent lower respiratory symptoms or unifocal infiltrations. The possibility of congenital pulmonary malformation associated with additional abnormalities, such as diaphragmatic hernia, is relatively high and can lead to misdiagnosis. We report a case of a 6-month-old girl who presented with relapsing respiratory infection and hematemesis. Computerized axial tomography scan and barium swallowing study were performed, revealing a suspected intralobar pulmonary sequestration associated with sliding gastric hernia. Since the patient’s condition was complicated by sliding hernia, pneumonia and pleural effusion, a surgical procedure instead of cardiac catheterization with coil embolization was performed. During surgery, the absence of a sliding gastric hernia but a diaphragmatic eventration was noted. Only a partial portion of the left-side diaphragm was relaxing, making the barium swallowing study difficult to interpret. This case serves as a reminder that if pulmonary sequestration is suspected, a full work-up with a complete set of imaging studies should be ordered for the possible detection of associated gastrointestinal, respiratory and thoracic abnormalities.

Congenital Central Hypoventilation Syndrome in a Full-Term Baby Presenting With Repeated Extubation Failure - Corrected Proof

Lin-Chi Huang, Jui-Hsing Chang, Nein-Lu Wang — 2012-01-19

Congenital central hypoventilation syndrome (CCHS) is a rare condition. The main characteristic is respiratory insufficiency during sleep. Patients who have CCHS need varying degrees of ventilation support during sleep, or even all day long, according to its severity. We report a term baby with repeated extubation failure, CCHS and Hirschsprung’s disease diagnosed at 1 month of age. This patient was discharged at 5 months old with a home ventilator and reached normal developmental milestones.

Carbon Monoxide Poisoning in Children - Corrected Proof

Davide Lonati, Andrea Giampreti, Carlo Alessandro Locatelli — 2012-01-19

We read with great interest the retrospective study by Cho and colleagues describing the clinical features of 30 pediatric patients with carbon monoxide (CO) poisoning in Taiwan. The acute clinical manifestations and delayed neurologic sequelae, severity of poisoning (initial Glasgow Coma Scale and HbCO, presence of severe metabolic acidosis, and seizure), therapeutic management (mechanical ventilation, inotropic therapy, and normobaric/hyperbaric antidotical treatment) and patient outcome [consciousness recovery time, hospital, and intensive care unit (ICU) stay] has been accurately and extensively described.

Rotavirus in the Neonatal Intensive Care Unit: Different Clinical Characteristics in Premature Neonates - Corrected Proof

Luan-Yin Chang — 2012-01-16

Rotavirus is one of the most common causes of diarrhea in infants and young children. In children, the most common clinical features of rotavirus infection are diarrhea and vomiting. However, the symptoms and signs of rotavirus infection may be different from those in children.

A Novel Mitochondrial DNA 8597T>C Mutation of Leigh Syndrome: Report of One Case - Corrected Proof

Jeng-Dau Tsai, Chin-San Liu, Teng-Fu Tsao, Ji-Nan Sheu — 2012-01-16

Leigh syndrome is an early-onset progressive neurodegenerative disorder with a characteristic neuropathology consisting of focal, bilateral lesions in one or more areas of the central nervous system. The brain images of Leigh syndrome are characterized by markedly symmetrical involvement, most frequently of the putamen. We report a 2-year-old girl with Leigh syndrome manifested as acute onset of altered level of consciousness. Brain magnetic resonance images showed abnormal signal intensity over the bilateral basal ganglia and cerebellar dentate nuclei. Despite normal biochemical studies, in particular serum lactate levels, magnetic resonance spectroscopy demonstrated a downward doublet lactate peak. The diagnosis of Leigh syndrome was subsequently confirmed by genetic study which showed a novel mutation at 8597T>C of the mitochondrial ATPase6 gene.