Lloyd Tooke

Defining hypoxic ischemic encephalopathy in newborn infants: benchmarking in a South African population.

Abstract Objectives: There are few population-based studies of hypoxic ischemic encephalopathy (HIE) in sub-Saharan Africa, and the published criteria that are used to define and grade HIE are too variable for meaningful comparisons between studies and populations. Our objectives were (1) to investigate how the incidence of HIE in our region varies with different criteria for intrapartum hypoxia and (2) to determine how encephalopathy severity varies with different grading systems. Method: We reviewed the records of infants with a diagnosis of HIE born between September 2008 and March 2009 in public facilities in the Southern Cape Peninsula, South Africa. The incidence of HIE was calculated according to four definitions of intrapartum hypoxia and graded according to three methods. Results: Depending on which defining criteria were applied, the incidence of HIE varied from 2.3 to 4.3 per 1000 live births, of mild HIE ranged from 0.4 to 1.3 per 1000 live births, and of moderate-severe HIE ranged from 1.5 to 3.7 per 1000 live births. Ninety-seven of the 110 (88%) infants reviewed had at least one intrapartum-related abnormality. Only 62 (56%) infants had a blood gas performed in the first hour of life. Conclusion: The incidence and grade of HIE can vary more than 2-fold in the same population, depending on which defining criteria are used. Consensus definitions are needed for benchmarking.

Nevirapine Concentrations in Preterm and Low Birth Weight HIV-Exposed Infants: Implications for Dosing Recommendations

World Health Organisation guidelines recommend nevirapine 2 mg/kg/d for HIV-exposed infants <2 kg, but 4–6 mg/kg/d for infants >2 kg. In 116 low birth weight infants, nevirapine 2 mg/kg/d until 14 days, and 4 mg/kg/d thereafter, was safe (1 mild possibly related rash) and achieved target plasma concentrations. Concentrations decreased with treatment duration. Routine dose increase at 14 days should be considered.

HIV Transmission to Extremely Low Birth Weight Infants

Background: Prematurity increases the perinatal HIV transmission rate compared with term infants. There is sparse literature documenting the risk of transmission of HIV to extremely low birth weight (ELBW) infants. Objective: To determine the risk of perinatal transmission of HIV to ELBW infants in a tertiary neonatal unit in South Africa. Methods: A prospective database was maintained on all inborn ELBW infants over a 1-year period from March 2010 to February 2011. Survival and DNA HIV polymerase chain reaction results at 6 weeks were recorded. Results: Of the 180 ELBW infants, 51 (28%) of these babies were HIV exposed. Of these 51 infants, 37 survived until 6 weeks of age. Polymerase chain reaction testing revealed 1 HIV-positive infant for a rate of 2.7% (95% confidence interval: 0.7–14.1%). Twenty-six (72%) of the 36 mothers received antiretroviral drugs, but only 16 (44%) had been treated for more than 1 month. Conclusions: The rate of HIV transmission in this cohort of ELBW infants is very low despite only 44% of the mothers receiving adequate antiretroviral drugs. We postulate that this is due to our high (89%) cesarean section rate, universal (100%) infant prophylactic antiretroviral drugs and the use of pasteurized breast milk.

Antiretrovirals causing severe pre-eclampsia

BACKGROUND Extremely low birth weight infants (ELBW) (⩽1000g) at our tertiary hospital have a much higher HIV exposure rate than bigger babies and are mainly delivered due to complications of pre-eclampsia. Studies investigating the effect of HIV or antiretroviral therapy on pre-eclampsia, a partially immune-mediated disease have produced contradictory results. OBJECTIVE To determine if there was an association between pre-eclampsia and HIV and/or antiretrovirals in the mothers of ELBW infants. STUDY DESIGN A prospective database was maintained for all ELBW infants born from August 2011 till January 2013. Data included maternal information such as HIV status, antiretroviral medication (duration and type) and mode and indication for delivery. RESULTS Of the 195 mothers who delivered ELBW infants, 46 (24%) were HIV positive. This is significantly different to the 17% HIV prevalence in mothers with bigger children (p=0.02). The main indication (59%) for delivery of the infant was hypertension related with the majority of these (94%) being classified as pre-eclampsia. Although HIV on its own showed no association (p=0.13), mothers who received greater than 4weeks of antiretrovirals were more likely to develop severe pre-eclampsia (p=0.007). CONCLUSION The debate about ARVs and PET is not yet over. We postulate that in a small group of susceptible women, ARVs may trigger early severe PET. It is unclear from our study if this would be due on a toxic or immune basis.

Extensive portal venous gas without obvious pneumatosis intestinalis in a preterm infant with necrotizing enterocolitis

Portal venous gas is one of the classic radiologic features of necrotizing enterocolitis and is an uncommon isolated finding because it is most commonly seen in conjunction with pneumatosis intestinalis. In this case study, we present a preterm neonate with necrotizing enterocolitis who had extensive portal venous gas without obvious pneumatosis intestinalis.

Is the attendance of paediatricians at all elective caesarean sections an effective use of resources

OBJECTIVES To determine the need for resuscitation at the birth of babies delivered by elective caesarean section (CS) and to record the time spent by doctors attending such deliveries. METHODS Data were collected prospectively on all elective CSs performed at Groote Schuur Hospital over a 3-month period. Data collected included: total time involved for paediatrician from call to leaving theatre, management of infant (requiring any form of resuscitation), Apgar scores and neonatal outcome (e.g. admission to nursery). The CSs were classified as low-risk or high-risk (multiple pregnancy, prematurity, growth restriction, abnormal lie, general anaesthetic or known congenital abnormality). RESULTS Data were recorded for 138 deliveries. Three were excluded as they were not elective CS. One hundred and fifteen deliveries were classified as uncomplicated and 20 as high-risk. Only 1 of the babies born from the 115 low-risk CSs needed brief resuscitation, whereas 9 of the 20 high-risk deliveries resulted in newborn resuscitation. The reasons for low-risk CS were: previous CS (81); infant of diabetic mother (IDM) and previous CS (16); IDM alone (6); estimated big baby (10); and other (2).The average time spent at each elective CS by the pediatrician was 37 minutes. CONCLUSION For low-risk CS, the same medical attendance (i.e. a midwife) as for an uncomplicated NVD would be appropriate; this can free a doctor for other duties, and assist in de-medicalising a low-risk procedure.

Apnoea of prematurity - discontinuation of methylxanthines in a resource-limited setting

Background. Methylxanthines such as caffeine have been proven to reduce apnoea of prematurity and are often discontinued at 35 weeks’ corrected gestational age (GA). Objective. To ascertain whether a caffeine protocol based on international guidelines is applicable in our setting, where GA is often uncertain. Methods. A prospective folder review was undertaken of all premature infants discharged home over a 2-month period. Results. Fifty-five babies were included. All babies born at less than 35 weeks’ GA were correctly started on caffeine as per protocol. GA was assigned in 85.5% of cases by Ballard scoring and in 14.5% from antenatal ultrasound findings. Caffeine was discontinued before 35 weeks in 54.5%. Discussion. The main reason for discontinuing caffeine early was the baby’s ability to feed satisfactorily, a demonstration of physiological maturity. As feeding behaviours mature significantly between 33 and 36 weeks, the ability to feed may be a good indication that caffeine therapy can be stopped.

Congenital rubella - is it nearly time to take action?

Congenital rubella syndrome (CRS) is a rare but potentially debilitating disease with lifelong consequences. Although there is no cure, it is almost completely preventable by an effective immunisation programme. We present two confirmed cases of CRS diagnosed in the neonatal unit at Groote Schuur Hospital in 2011 and discuss aspects of the disease and its prevention.

A reduction of necrotising enterocolitis at Groote Schuur Hospital nursery

Necrotising enterocolitis (NEC) is an gastro-intestinal emergency occurring almost solely in preterm, low birth weight infants. Mortality, morbidity and the complication rate are high. An increase in NEC at the Groote Schuur Hospital nursery in 2008 prompted a change of practice, resulting in a significant decrease in the condition.

Cord entanglement in monoamniotic twins

Identical twin girls were delivered by emergency caesarean birth at 32 weeks with birth weights of 1890 and 1970 g. They were known to be monoamniotic (sharing the same amniotic sac). Monoamniotic twins are extremely rare, occurring in only 1% of monochorionic twins (identical twins who share the same placenta). …