Manar Al-lawama

Oral paracetamol versus oral ibuprofen for treatment of patent ductus arteriosus

Objective This study was performed to investigate the safety and efficacy of oral paracetamol versus oral ibuprofen in the treatment of patent ductus arteriosus (PDA) in premature infants. Methods Premature infants with PDA with a gestational age of ≤32 weeks or birth weight of ≤1500 g were included in this randomized study. Results A total of 120 premature infants fulfilled the inclusion criteria. Of these 120 infants, 34 fulfilled the treatment criteria and 22 were finally randomized. We found no significant difference in the mortality or primary closure rates between the two groups. We also found no significant difference in the short-term neonatal outcomes. Conclusions Either oral paracetamol or oral ibuprofen can be used safely and effectively to treat PDA in premature infants.

Clinical value of repeat blood cultures in neonatal patients receiving antibiotic treatment

Objective Retrospective database study to determine the clinical usefulness of repeat blood cultures in antibiotic-treated neonates. Methods Data regarding blood culture indication and findings for patients admitted to a neonatal intensive care unit (NICU) over a 2-year period were obtained from the hospital database. Repeat blood culture was defined as culture performed <7 days from initial testing in a patient receiving antibiotic treatment. Results Repeat cultures made up 21.3% of all blood cultures originating in the NICU (500/2352 cultures; 338 initial positive cultures; 210 patients). The most common indications for repeat culture were follow-up of clinically well babies with previous positive culture findings and the development of new symptoms. The majority of culture findings were negative (60.2%), with 7.2% indicating the presence of a new pathogen. Cultures repeated on day 5 were significantly more likely to reveal a new pathogen than those repeated on days 1–4. Conclusions Repeat blood cultures in neonatal patients who have developed new symptoms >4 days after initial testing may be beneficial. The use of repeat blood culture is not recommended for any other indication.

Intrauterine transmission of H1N1 disease: a theory that needs evidence!

Three pandemics of influenza in the 20th century have been described. Unfortunately, a little is known about the effect of those pandemics on newborn infants. We are reporting our experience with newborns born to mothers proved to have H1N1 illness perinatally, who presented with sepsis-like illness at birth or shortly after, and were treated as having H1N1 disease. This study will report on the clinical features, outcome and discuss diagnosis and treatment challenges and also the possibility of intrauterine H1N1 transmission. Our cases had good neonatal outcome, H1N1 intrauterine transmission still a possibility that needs further research efforts.

Fetal Intrauterine Transfusion Therapy: Neonatal Outcomes

Background and objectives: Intrauterine blood transfusion (IUT) performed for fetal anemia may be associated with adverse neonatal outcomes. This study aimed to describe the clinical outcome of surviving neonates treated with IUT in an area where detailed outcome on neonatal data is limited. Patients and methods: This prospective study included all living newborns treated with IUT at our institution between March 2004 and February 2011. During this period, 30 newborns with a mean gestation age of 35 weeks (range: 25-37 weeks) were admitted with various respiratory, hematological and gastrointestinal morbidities. Results: The survival rate on discharge was 93%. Severe fetal anemia (72.2%) was significantly associated with a low reticulocyte count at birth and the need for respiratory support after birth (P<0.05). The number of IUTs was significantly correlated with the duration of admission (P=0.034) and the presence of hyporegenerative late anemia (P=0.007), but not with other neonatal outcomes or with a low reticulocyte count at birth. Use of intravenous immunoglobulin was significantly associated with an increased rate of top-up transfusion for late anemia and a decreased duration of admission, with no additional positive effects. Conclusion: This study provides evidence on the types of potential neonatal morbidities after IUT therapy and their risk factors, and could be useful to clinicians treating fetuses with intrauterine transfusions and also for counseling parents.

Letter to the editor: Treatment of patent ductus arteriosus in premature infants

Dear Editor: I have read with pleasure the article entitled “Patent ductus arteriosus in premature infants: to treat or not to treat?” by Mohamed et al. [1]. In this paper, the authors retrospectively analyzed their data regarding PDA treatment in very low birth weight infants (VLBWI). They compared the outcomes of infants born between 2001 and 2009, where their practice was to treat PDA (treat-PDA group), and infants born after 2010 till 2014, where they changed their practice to no treatment of PDA (no-treat group). I would like to praise the authors’ efforts to improve the practice of neonatal medicine and I would like to make few comments. First of all, the process that the authors used to decide converting from the standard treatment of hemodynamically significant PDA to no treatment at all was not clear. What committees were approached to approve the change in practice outside the context of research? Were the parents of VLBWI born after 2010 aware that their babies are not getting the standard of care treatment. Did this new practice have any predetermined periods for evaluation? The respected authors might already have answers for these questions, and I am confident that they have a solid audit system for their practice more frequently than what this study represent. However, explaining the process to the readers encourage structured implementation of new practice in neonatology with continuous evaluation, especially when this change is done outside the research context. The second comment is on the no-treat group. The authors explained in the introduction of their paper that they were the suspected PDA group as no echocardiography was done to confirm or role out the clinical diagnosis. So, the two study groups were apparently different not only in the treatment offered, but also on the diagnosis of the disease of interest. What if a significant number of suspected PDA (no-treat group) had only small PDA, would they be still treated if they were born before 2010. According to the authors, before 2010 they were treating moderate to severe PDA. Also, symptoms attributed to PDA might be due to other neonatal morbidities. The no-treat group included hypothetically (because I guess we will never know as no echocardiography was done) those with no PDA and babies with small insignificant PDA, as well as the moderate to large ductus. The authors compared this heterogeneous group (no-treat group) of VLBWI with moderate to large PDA (treat group). Could the better outcome of this subgroup with no PDA and small insignificant PDA compensated for the worse outcome of VLBWI with moderate to large PDA in the no-treat group. I really appreciate the authors’ efforts to avoid causing harm by unnecessary treatment. However, I guess for the time being, it is better to encourage neonatal care providers to stop practicing prophylactic PDA treatment and early screening of asymptomatic newborns where PDA is normally present.

Adoption of the American Academy of Pediatrics’ neonatal hyperbilirubinemia guidelines and its effect on blood exchange transfusion rate in a tertiary care center in Amman, Jordan

Introduction Severe neonatal hyperbilirubinemia can cause mortality and serious morbidities. When phototherapy fails, neonates with severe hyperbilirubinemia should undergo double volume blood exchange transfusion (BET). As this procedure carries a significant risk of mortality and morbidity, adopting guidelines for the treatment of neonatal hyperbilirubinemia is critical to avoid hyperbilirubinemia toxicity and also the complication of an unindicated procedure. Methods This study investigated the causes, complications, and trend of BET rate in our unit over a 13-year period. The medical charts and laboratory databases of all infants who underwent BET in Jordan University Hospital between 2003 and 2015 were retrospectively reviewed. Results The rate of exchange cases decreased significantly after adopting the guidelines of American Academy of Pediatrics (P<0.0001). Most neonates were term newborns (69%). Average birth weight was 2,800 g. The most common causes of exchange transfusion were non-hemolytic conditions. Late prematurity alone accounted for 20% of the cases. Thrombocytopenia was the most commonly encountered complication (33%). Chronic neurological complications were seen in 12% of those who were followed for >12 months of age. Conclusions This study showed a clear decline in the rate of BET after implementing the guidelines of American Academy of Pediatrics. In addition to improving the strategies for the identification and follow-up of at-risk newborns, we should intensify our efforts to prevent the progression of neonatal hyperbilirubinemia to the exchange level by enhancing parents’ awareness of this potentially harmful neonatal condition.

Mortality and Short-Term Outcomes of Very Low Birth Weight Infants at a Tertiary Care Center in Jordan: Comparison with Other Countries

Purpose: Very low birth weight infants (VLBWI) are the most fragile group of neonates with high rate of mortality and morbidity. Neonatal mortality rate in Jordan is still high. This is the first study from Jordan that aims to assess VLBWI mortality rate and the factors contributed to it and to report on the short outcomes and morbidities of those newborns in comparison to other countries to identify potential areas of improvement. Methods: A prospective study of all newborns with birth weight 500-1500 g, admitted to our level three neonatal intensive care unit (NICU) at Jordan university hospital over 14 months period. The results were compared to reports from other countries. Results: The study included 71 neonates admitted to our neonatal intensive care weighing from 500-1500 g during the study period. Most of them (88.7%) were inborn infants. Gestational ages mean ± SD was 28.6 ± 2.3 week. Birth weights mean ± SD was 1086.7 ± 262 g. Mortality rate was 35.2%. Short outcomes of survivors are for CLD 4.2%, sever ROP 3.8%, proven NEC 2.8%, PVL 1.9% and sever IVH rate was 10.6%. Conclusions: Mortality rate in our cohort is high. Multiple factors are involved. The care of very low birth infants in Jordan needs a lot of efforts to decrease mortality and improve morbidities. This is a prospective single center study. A multicenter study is needed that involves all health sectors in Jordan.

How to implement medical evidence into practice in developing countries

Sackett and colleagues first defined evidence-based medicine as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”.1 Integration of the best research evidence with clinical expertise and patient values is the key element for evidence-based practice. Good judgment is crucial when it comes to evaluating the evidence and implementing it.2 Evidence-based medicine is not “one size fits all”, as the world is highly diverse concerning patterns of diseases, economy, and societal values. This article documents the peculiarities of developing countries regarding evidence-based practice and presents a simple education model for the transformation of evidence into practice for undergraduate and postgraduate students. Developing countries and evidence-based medicine Developing countries have multiple issues when it comes to evidence-based medicine. First of all, most of the evidence is imported. If we take all Arab countries as an example, their medical research production over an 18-year period is just 3% of the USA’s production.3 Therefore, the best scenario is that 97% of their practice is based on evidence that was not specifically generated for them. This is unsatisfactory as every society, ethnic group, or even culture has its unique diseases or different forms of the same disease, different responses to therapeutic modalities, different resources and personnel qualifications, and perhaps also different values and patient preferences. Secondly, critical appraisal skills are poorly developed among health care professionals4 and their incorporation into the curriculums of medical schools is limited.5 Consequently, this may result in the adoption of unnecessary practice or improper use of the evidence. Furthermore, it may lead to “jerky medicine syndrome”, the term I use when physicians frequently change their way of practice in response to their latest reading of the literature. Ideally, the medical practice should be consistent with few sudden changes, otherwise achieving competence among the staff will be very difficult and could potentially lead to increased patient morbidity. The final issue regarding practicing medicine in developing countries is that the regulatory bodies of medical practice are less well established and not as empowered. As a consequence, national guidelines are either absent, unclear, or copied from international guidelines.

Benign pneumoperitoneum in newborns: which abdomen to open and which one to observe?

Benign pneumoperitoneum in newborns is not a rare condition that should be managed conservatively. Neonatologists and surgical teams should work together to avoid unnecessary and potentially risky procedures.