Hung-Yang Chang

Renal Calcification in Very Low Birth Weight Infants

BACKGROUND Renal calcification in preterm infants has been described frequently. The etiologic factors have not yet been fully clarified. The objective of this study was to evaluate the incidence of and risk factors for renal calcification in our population. METHODS We retrospectively reviewed the charts of very low birth weight preterm infants during a 1-year period. Renal ultrasound scans were performed at term or before discharge and at a corrected age of 1 year. RESULTS Six infants (6%) had renal calcification at term or before discharge compared with 96 who did not. Factors significantly associated with renal calcification included gestational age (26 weeks vs. 29 weeks, p=0.006), birth weight (851 g vs. 1141 g, p=0.004), duration of mechanical ventilation (69 days vs. 29 days, p=0.002), length of intensive care (72 days vs. 41 days, p=0.013), furosemide therapy (33% vs. 3%, p=0.027), and dexamethasone therapy (50% vs. 2% p=0.001). Birth weight and dexamethasone therapy had significant independent association after stepwise logistic regression analysis. Sex, oliguria, acidosis, duration of oxygen therapy, length of hospital stay, nutrition status, and nephrotoxic drugs did not differ between the two groups. Three of the six infants had spontaneous remission of renal calcification, whereas two patients without the finding in neonatal stage had renal calcification at a corrected age of 1 year. CONCLUSION The incidence of renal calcification in very low birth weight infants in this study was relatively low, and the calcification was transient in one-half of the infants. Extremely premature, sick infants requiring long-term ventilation, and those receiving furosemide or dexamethasone were more likely to have renal calcification. Clinicians should be aware that renal calcification may develop beyond the neonatal stage.

Treatment of severe meconium aspiration syndrome with dilute surfactant lavage

BACKGROUND AND PURPOSE Despite the development of new adjuvant therapies, meconium aspiration syndrome (MAS) remains a serious respiratory disorder in neonates. Surfactant inactivation by meconium can be overcome by use of exogenous surfactant. This study sought to assess the efficacy and safety of dilute surfactant lavage at 2 different concentrations to treat severe MAS. METHODS We retrospectively reviewed the charts of all term infants with a diagnosis of MAS who had an oxygenation index (OI) > 20 during a 2-year period. Tracheobronchial lavage was performed with a dilute surfactant suspension (5 mg/mL or 10 mg/mL) to reach a total dose of 60 to 70 mg/kg of phospholipid, administered in aliquots of 2 mL. RESULTS The records of 22 patients were reviewed, of whom 12 had undergone lavage. These patients were subdivided into low-concentration (surfactant concentration, 5 mg/mL; n = 6) and high-concentration (surfactant concentration, 10 mg/mL; n = 6) subgroups. There were no significant differences in demographic characteristics between these 2 subgroups. The lavaged infants had a significantly higher arterial partial pressure of oxygen (PaO(2)) 24 hours after lavage than the infants without lavage (178.3 mm Hg vs 80.6 mm Hg, p < 0.05). The incidence of pneumothorax (1/12 vs 7/10, p < 0.05) and requirement for inhaled nitric oxide (5/12 vs 9/10, p < 0.05) were significantly lower in the lavaged group. All infants tolerated the procedure well except for 2 with transient complications. There were no significant differences in duration of lavage, response and complications between subgroups lavaged at low and high surfactant concentration. CONCLUSIONS Early lavage with dilute surfactant solution at a phospholipid concentration of either 5 mg/mL or 10 mg/mL is effective for the treatment of severe MAS. Further large-scale, prospective, randomized, controlled trials are necessary to establish the optimal dose, concentration, surfactant product, and instillation method of this treatment before it can be recommended for routine use.

Short- and Long-Term Outcomes in Very Low Birth Weight Infants with Admission Hypothermia

Background Neonatal hypothermia remains a common problem and is related to elevated morbidities and mortality. However, the long-term neurodevelopmental effects of admission hypothermia are still unknown. This study attempted to determine the short-term and long-term consequences of admission hypothermia in VLBW preterm infants. Study Design This retrospective study measured the incidence and compared the outcomes of admission hypothermia in very low birth weight (VLBW) preterm infants in a tertiary-level neonatal intensive care unit. Infants were divided into the following groups: normothermia (36.5–37.5°C), mild hypothermia (36.0–36.4°C), moderate hypothermia (32.0–35.9°C), and severe hypothermia (< 32°C). We compared the distribution, demographic variables, short-term outcomes, and neurodevelopmental outcomes at 24 months of corrected age among groups. Results We studied 341 infants: 79 with normothermia, 100 with mild hypothermia, 162 with moderate hypothermia, and 0 with severe hypothermia. Patients in the moderate hypothermia group had significantly lower gestational ages (28.1 wk vs. 29.7 wk, P < .02) and smaller birth weight (1004 g vs. 1187 g, P < .001) compared to patients in the normothermia group. Compared to normothermic infants, moderately hypothermic infants had significantly higher incidences of 1-min Apgar score < 7 (63.6% vs. 31.6%, P < .001), respiratory distress syndrome (RDS) (58.0% vs. 39.2%, P = .006), and mortality (18.5% vs. 5.1%, P = .005). Moderate hypothermia did not affect neurodevelopmental outcomes at 2 years’ corrected age. Mild hypothermia had no effect on short-term or long-term outcomes. Conclusions Admission hypothermia was common in VLBW infants and correlated inversely with birth weight and gestational age. Although moderate hypothermia was associated with higher RDS and mortality rates, it may play a limited role among multifactorial causes of neurodevelopmental impairment.

Outcome of preterm infants with postnatal cytomegalovirus infection via breast milk: A two-year prospective follow-up study

AbstractApproximately 15% of preterm infants may develop postnatal cytomegalovirus (CMV) infection from seropositive mothers via breast milk and are at risk for neurological sequelae in childhood. The aims of this study were to assess the effects and outcomes on growth, neurodevelopmental status, and hearing in very low birth weight (VLBW) premature infants with postnatal CMV infection via breast milk at the corrected age of 12 and 24 months.The prospective follow-up study population comprised all living preterm children (n = 55) with a birth weight ⩽1500 g and gestational age of ⩽35 weeks, who had been participated in our “postnatal CMV infection via breast milk” studies in 2000 and 2009, respectively. The cohort of children was assessed at 12 and 24 months. Clinical outcomes were documented during hospitalization and after discharge. Long-term outcomes included anthropometry, audiologic tests, gross motor quotient, Infant International Battery, and neurodevelopmental outcomes; all were assessed at postcorrected age in 12 and 24 months during follow-up visits.Of the 55 infants enrolled in the study (4 noninfected infants were excluded because their parents did not join this follow-up program later), 14 infants postnatally acquired CMV infection through breast-feeding (infected group) and were compared with 41 infants without CMV infection (control group). No significant differences were observed between the groups with regard to baseline characteristics, clinical outcomes, anthropometry, or psychomotor and mental development on the Bayley scale of infant development. None of the infants had CMV-related death or permanent sensorineural hearing loss.Transmission of CMV from seropositive mother via breast milk to preterm infants does not appear at this time to have major adverse effects on clinical outcomes, growth, neurodevelopmental status, and hearing function at 12 and 24 months corrected age.

Neonatal Morganella morganii sepsis: a case report and review of the literature

Neonatal sepsis remains a potentially lethal condition, especially in preterm neonates. Early-onset neonatal sepsis (EOS) occurs as a multisystemic illness in the first three days of life and is associated with the acquisition of microorganisms from the mother. The microorganisms most commonly associated with early-onset sepsis include group B Streptococcus, Escherichia coli, Haemophilus influenzae, and Listeria monocytogenes. Late-onset sepsis (LOS) syndrome occurs at 7–90 days of life and is often acquired from the environment. Organisms that have been implicated in causing LOS syndrome include coagulase-negative staphylococci, Staphylococcus aureus, E coli, Klebsiella, Pseudomonas, Enterobacter, Candida, and anaerobes. However, extensive use of intrapartum antibiotics has been associated with major changes in the spectrum of organisms involved and their susceptibility to antibiotics. Morganella morganii is rarely encountered but may cause serious invasive infection in the pregnant woman or neonate. This organism is characteristically resistant to many beta-lactam antibiotics which may lead to delays in proper treatment. We report an extremely premature infant with fatal early-onset M. morganii sepsis and provide a literature review of this disease.

Small Versus Large Volume Dilute Surfactant Lavage for Meconium Aspiration Syndrome

BACKGROUND Surfactant lavage has been used to treat neonatal meconium aspiration syndrome (MAS). OBJECTIVE To assess the effects of lavage with a small volume of dilute surfactant in neonates with MAS, and compare the results with those of historical controls treated with larger volumes. METHODS From August 2002 to June 2005, we treated 11 newborns with MAS using 20 ml of dilute surfactant at a phospholipid concentration of 10 mg/ml (SVL group). We compared the results with those of 9 infants previously treated with large-volume lavage (LVL group), using 40 ml of dilute surfactant, 5 mg/ml. RESULTS Both groups were similar at baseline except for a higher mean birth weight in the LVL group (3.29+/-0.36 vs 2.92+/-0.4 kg, P = 0.04). The lavage procedure was longer in the LVL than the SVL group (48.89 +/-7.41 vs. 30.91+/-5.83 mins, P <0.001). Measures of oxygenation, including mean PaO2, oxygenation index, and arterial/alveolar 02 ratio, showed no significant difference between the two groups. Adverse events in the LVL group included transient hypoxemia in 3 infants and white- out on chest x-ray in 5 cases. None of the patients in the SVL group had these findings. The peak mean airway pressure in.the LVL group was higher than that in the SVL group (16.0+/-2. 65 vs 13.3+/-3.01 cmH2O, P = 0.046). CONCLUSIONS SVL has the same benefits in neonatal MAS as LVL. However, SVL appears to be associated with fewer adverse events.

Neonatal infected subgaleal hematoma: an unusual complication of early-onset E. coli sepsis.

Subgaleal hematoma (SGH) is an uncommon but potentially lethal medical emergency in newborns. Delay in diagnosis may lead to mortality and morbidity. Infection of an SGH is extremely rare. We report an infected SGH with abscess formation as a complication of early-onset Escherichia coli sepsis in a term neonate. The patient was discovered to have SGH soon after birth. Early-onset E. coli sepsis developed on Day 3 of life. The SGH became infected, with abscess formation 1 week later. The infected SGH was probably due to direct hematogenous spreading of sepsis. The patient was successfully treated without complications. Clinicians should be aware that SGH is a potential site of infection and infection may be caused either by direct hematogenous extension or from traumatic scalp lesions. Appropriate antibiotic treatment and surgical debridement are necessary when an infected SGH occurs.

Hemodynamic Effects of Nasal Intermittent Positive Pressure Ventilation in Preterm Infants

AbstractNasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway pressure (NCPAP) have proven to be effective modes of noninvasive respiratory support in preterm infants. Although they are increasingly used in neonatal intensive care, their hemodynamic consequences have not been fully evaluated. The aim of this study was to investigate the hemodynamic changes between NIPPV and NCPAP in preterm infants.This prospective observational study enrolled clinically stable preterm infants requiring respiratory support received NCPAP and nonsynchronized NIPPV at 40/minute for 30 minutes each, in random order. Cardiac function and cerebral hemodynamics were assessed by ultrasonography after each study period. The patients continued the study ventilation during measurements.Twenty infants with a mean gestational age of 27 weeks (range, 25–32 weeks) and birth weight of 974 g were examined at a median postnatal age of 20 days (range, 9–28 days). There were no significant differences between the NCPAP and NIPPV groups in right (302 vs 292 mL/kg/min, respectively) and left ventricular output (310 vs 319 mL/kg/min, respectively), superior vena cava flow (103 vs 111 mL/kg/min, respectively), or anterior cerebral artery flow velocity.NIPPV did not have a significant effect on the hemodynamics of stable preterm infants. Future studies assessing the effect of NIPPV on circulation should focus on less stable and very preterm infants.

Comparative effectiveness of azithromycin for treating scrub typhus: A PRISMA-compliant systematic review and meta-analysis.

Background: Scrub typhus is a zoonotic disease that remains an important health threat in endemic areas. Appropriate anti-rickettsial treatment ensures a successful recovery. Doxycycline is a recommended drug, but it is contraindicated in pregnant women and young children. Azithromycin is a safer alternative drug, but its effectiveness remains largely unclear. Herein, we conducted a systematic review and meta-analysis to determine the effectiveness of azithromycin. Methods: Studies that investigated azithromycin in treating scrub typhus were systematically identified from electronic databases up to December 2016. Information regarding study population, disease severity, treatment protocols, and responses was extracted and analyzed. Results: In this review, 5 studies were included, which comprised a total of 427 patients. When comparing the treatment failure rate, we observed a favorable outcome in patients treated with azithromycin (risk ratio [RR] 0.83, 95% confidence interval [CI] 0.23–2.98). However, patients in the azithromycin group had longer time to defervescence (mean difference 4.38 hours, 95% CI −2.51 to 11.27) and higher rate of fever for more than 48 hours (RR 1.31, 95% CI 0.81–2.12). Moreover, patients treated with azithromycin had less adverse effects (RR 0.8, 95% CI 0.42–1.52). Conclusions: Azithromycin is as effective as other anti-rickettsial drugs with higher treatment success rates, lower frequency of adverse effects, and longer time to defervescence (GRADE 2B). Therefore, it is reasonable to use azithromycin as the first-line treatment against scrub typhus. Further studies are warranted to elucidate the effectiveness of azithromycin in specific patient groups, at high dose and influence of drug resistance.

Increase the risk of intellectual disability in children with scabies: A nationwide population-based cohort study

Abstract Scabies is a common and distressing disease caused by the mite Sarcoptes scabiei var. hominis. Psychiatric disorder in childhood is an important disease and easily neglected. There are several similarities in scabies and psychiatric disorders in childhood (PDC). Both of them may present with pruritus. They are relatively common in patients with lower socioeconomic status and crowded environment. Furthermore, immune-mediated inflammatory processes play a role in the pathophysiology in both diseases. An association between scabies and psychiatric disorders may exist. This nationwide population-based cohort study utilized data from the National Health Insurance Research Database to investigate the relationship between scabies and PDC. A total of 2137 children with scabies were identified as the study group and 8548 age- and sex-matched children were selected as the control group. A total of 607 (5.68%) children developed PDC during the 7-year follow-up period. The overall incidences of PDC are similar but patients with scabies had a higher risk of developing intellectual disability (ID) (scabies group vs control group: 1.3% vs 0.6%, adjusted hazard ratio: 2.04 and 95% confidence interval: 1.25–3.32). The immune-mediated inflammatory processes of both diseases were reviewed and may contribute to the 104% increased risk of interleukin in patients with scabies. We suggest a more comprehensive management in treating patients with scabies or ID. Early and comprehensive treatment of scabies and other risk factors may decrease the risk of subsequent ID. When we approach patients with ID, concurrent evaluation of scabies and other risk factors may contribute to successful management.