Lillian R. Blackmon

Prevention of respiratory syncytial virus infections: Indications for the use of palivizumab and update on the use of RSV-IGIV

The Food and Drug Administration recently approved the use of palivizumab (palē-vizhū-mäb), an intramuscularly administered monoclonal antibody preparation. Recommendations for its use are based on a large, randomized study demonstrating a 55% reduction in the risk of hospitalization attributable to respiratory syncytial virus (RSV) infections in high-risk pediatric patients. Infants and children with chronic lung disease (CLD), formerly designated bronchopulmonary dysplasia, as well as prematurely born infants without CLD experienced a reduced number of hospitalizations while receiving palivizumab compared with a placebo. Both palivizumab and respiratory syncytial virus immune globulin intravenous (RSV-IGIV) are available for protecting high-risk children against serious complications from RSV infections. Palivizumab is preferred for most high-risk children because of ease of administration (intramuscular), lack of interference with measles–mumps–rubella vaccine and varicella vaccine, and lack of complications associated with intravenous administration of human immune globulin products. RSV-IGIV, however, provides additional protection against other respiratory viral illnesses and may be preferred for selected high-risk children including those receiving replacement intravenous immune globulin because of underlying immune deficiency or human immuno-deficiency virus infection. For premature infants about to be discharged from hospitals during the RSV season, physicians could consider administering RSV-IGIV for the first month of prophylaxis. Most of the guidelines from the American Academy of Pediatrics for the selection of infants and children to receive RSV-prophylaxis remain unchanged. Palivizumab has been shown to provide benefit for infants who were 32 to 35 weeks of gestation at birth. RSV-IGIV is contraindicated and palivizumab is not recommended for children with cyanotic congenital heart disease. The number of patients with adverse events judged to be related to palivizumab was similar to that of the placebo group (11% vs 10%, respectively); discontinuation of injections for adverse events related to palivizumab was rare.

The association of Chlamydia trachomatis, Neisseria gonorrhoeae, and group B streptococci with preterm rupture of the membranes and pregnancy outcome

There is conflicting evidence regarding a possible causal role for Chlamydia trachomatis in the development of preterm premature rupture of the membranes. We investigated the relative prevalence of endocervical infection with C. trachomads and group B streptococci in patients with preterm premature rupture of membranes compared with a control group taken from the same obstetric population. C. trachomads was isolated from 23152 (44%) patients with preterm premature rupture of membranes versus 13184 (15%) women in the control group ( p Neisseria gonorrhoeae . Group B streptococci were isolated from 16% of the patients with preterm premature rupture of membranes versus 4% of the control population ( p C. trachomads and N. gonorrhoeae . Endocervical infection with C. trachomads did not significantly affect early maternal complication rates after delivery.

Hypothermia: A neuroprotective therapy for neonatal hypoxic-ischemic encephalopathy

In May, 2005, the National Institute of Child Health and Human Development (NICHD) convened a workshop to evaluate the status of knowledge regarding the safety and efficacy of hypothermia as a neuroprotective therapy for neonatal hypoxic-ischemic encephalopathy (HIE).1 Participants, including the current and past chairs of the American Academy of Pediatrics Committee on Fetus and Newborn, reviewed current evidence and identified gaps in knowledge and clinical implications. They agreed that current evidence supports the conclusion that mild to moderate hypothermia holds promise for the amelioration of neural injury after a perinatal hypoxic-ischemic insult. The objectives of this commentary are to review briefly the background and current knowledge regarding the therapeutic efficacy and safety of sustained mild to moderate hypothermia to prevent death and severe disability in neonates who have experienced a significant hypoxic-ischemic insult and to urge caution and restraint in the immediate implementation of this therapy before more corroborating evidence has been published. The lack of a definitive therapeutic approach for HIE remains one of the unresolved clinical frustrations of contemporary neonatal medicine. The dismal prognosis for infants who sustain a severe asphyxial insult in the perinatal period has altered little despite advances in the application of diagnostic and multiorgan life-support techniques to newborns.2–5 In part because the principal etiologies differ, therapeutic advances in the management of encephalopathy in older children and adults have not proved to be applicable to neonates.6 In addition, unlike older patients, the etiology, onset, and duration of perinatal hypoxic-ischemic injury are varied and often unknown. ### Early Studies In the 1950s and 1960s, Miller and Westin7,8 studied the physiologic basis for the neuroprotective role of hypothermia in the treatment of “asphyxia neonatorum,” first in newborn animals and then in human newborns. They and others demonstrated improved survival without cerebral … Address correspondence to Lillian R. Blackmon, MD, University of Maryland School of Medicine, Room N5W68, 22 S Greene St, Baltimore, MD 21201. E-mail: lblackmon{at}peds.umaryland.edu

Enteral Theophylline and Necrotizing Enterocolitis in the Low-Birthweight Infant

In a two-phased retrospective study, clinical factors associated with the development of necrotizing enterocolitis (NEC) in neonates were identified. The first phase found 13 infants with NEC who had been treated more frequently with enteral theophylline (P<.025) and fed higher volumes ( >150 mL/kg/day; P<.05) than controls of comparable birthweight and postnatal age. Seven of the 13 infants with NEC, weighing < 1,250 g at birth, had previously received intravenous aminophylline and been changed to enteral theophylline within six days before the onset of NEC. Prolonged rupture of membranes was more prevalent (P<.025) in infants with birthweight > 1,250 g who developed NEC in the first week of life. Maternal preeclampsia helped protect against the development of NEC (P <.05) . In the second study phase, 59 infants with birthweights < 1,250 g were evaluated for gastrointestinal disturbance within five days of the introduction of any enteral medication. The frequencies of NEC, NEC scare, and feeding intolerance were greater in infants treated with enteral theophylline than in those treated with all other enteral medications combined (P<.05). This two-phased study confirms the multifactorial etiology of NEC and indicates that the administration of enteral theophylline to young infants <1,250 g may be a predisposing factor to GI disturbances and NEC. These findings warrant a further prospective investigation.