Michael E. Speer

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 International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: Neonatal resuscitation

APPROXIMATELY 10% OF newborns require some assistance to begin breathing at birth, and about 1% require extensive resuscitation. Although the vast majority of newborn infants do not require intervention to make the transition from intrauterine to extrauterine life, the large number of births worldwide means that many infants require some resuscitation. Newborn infants who are born at term, had clear amniotic fluid, and are breathing or crying and have good tone must be dried and kept warm but do not require resuscitation. All others need to be assessed for the need to receive 1 or more of the following actions in sequence:

Transient hypertrophic subaortic stenosis in infants of diabetic mothers

Three newborn infants with congestive heart failure had hemodynamic, angiographic, and echocardiographic features of hypertrophic subaortic stenosis (hypertrophic obstructive cardiomyopathy). Treatment with digitalis and diuretic drugs was ineffective, but improvement occurred when these agents were withheld in one patient, and when treatment with propranolol was begun in two patients. Echocardiography was helpful in establishing the diagnosis in two patients and showed resolution of the condition during the first six months of life. Serial cardiac catheterizations confirmed resolution of the outflow obstruction in the third patient. Family studies revealed no evidence of familial cardiomyopathy, but the mothers of two infants had insulin-dependent diabetes mellitus and the mother of the third was presumed to be prediabetic.

Fulminant neonatal sepsis and necrotizing enterocolitis associated with a “nonenteropathogenic” strain of Escherichia coli+

During 1973 a nonendemic mucoid strain of Escherichia coli entered the nursery of a hospital in Houston. This organism caused septicemia and was associated with a high incidence of necrotizing enterocolitis. The illness was fulminant and characterized by apnea, abdominal distension, and shock. Diarrhea was not a feature of the symptom complex. The epidemic organism was nontypable. Assays for invasiveness, enterotoxin production, and Kl antigen were negative. Surveillance revealed a colonization rate of 14%, an attack rate in colonized infants of 19.5%, and a mortality rate of 87.5%. These data suggest that in certain instances the specific bowel flora may increase the incidence and severity of NEC.

Posttransfusion cytomegalovirus infection in neonates: Role of saline-washed red blood cells

1. Roy RN, Chance GW, Raddle IC, et al. Late hyponatremia in very low birth weight infants (< 1.3 kilograms). Pediatr Res 1976;10:526. 2. Seccombe DW, Pudek MR, Whitfield MF, et aL Perinatal changes in a digoxin-like immunoreactive substance. Pediatr Res 1984;18:1097. 3. Valdes R, Grawers SW, Brown BA, Landt M. Endogenous substance in newborn infants causing false positive digoxin measurements. J PEDIATR 1983;102:947. 4. Ebara H, Suzuki S, Nagashima K, et al. Digoxinand digitoxin-!ike immunoreactive substances in amniotic fluid, cord blood and serum of neonates. Pediatr Res 1986; 20:28. 5. Gruber KA, whitaker JM, Buckales VM. Endogenous digitalis-like substance in plasma of Volume-expanded dogs. Nature (Lond) 1980;743:287. 6. Espinel CH. The FENa test: use in the differential diagnosis of acute renal failure. JAMA 1976;236:579. 7. Graves SW, Valdes R Jr, Brown BA, et al. Endogenous digoxin-immunoreactive substance in human pregnancies. J Cliri Endocrinol Metab 1984;58:748. 8. Sulyok E. The relationship between electrolyte and acid-base balance in the premature infant during early postnatal life. Biol Neonate 1971;17:227. 9. AI-Dahhan J, Haycock GB, Chartler C, Stimmler L. Sodium homeostasis in term and preterm neonates. I. Renal aspects. Arch Dis Child 1983;58:335. 10. Beyers AD, Spruyt LL, Seifart HI, et al. Endogenous digoxin-like material. S Afr Med J 1983;64:42.

Use of Palivizumab for prevention of hospitalization as a result of respiratory syncytial virus in infants with cystic fibrosis.

The Palivizumab Outcomes Registry collected data on 19,548 high-risk infants who received ≥1 dose of palivizumab and followed prospectively from 2000 through 2004. Ninety-one children with cystic fibrosis (CF) were identified who received palivizumab off label. None of the infants with CF who received prophylaxis was hospitalized as a result of respiratory syncytial virus lower respiratory tract infection. Evaluations of palivizumab use in infants with CF could be warranted.

Preterm Infants With Congenital Heart Disease and Bronchopulmonary Dysplasia: Postoperative Course and Outcome After Cardiac Surgery

Objective. Success in treatment of premature infants has resulted in increased numbers of neonates who have bronchopulmonary dysplasia (BPD) and require surgical palliation or repair of congenital heart disease (CHD). We sought to investigate the impact of BPD on children with CHD after heart surgery. Methods. This was a retrospective, multicenter study of patients who had BPD, defined as being oxygen dependent at 28 days of age with radiographic changes, and CHD and had cardiac surgery (excluding arterial duct ligation) between January 1991 and January 2002. Forty-three infants underwent a total of 52 cardiac operations. The median gestational age at birth was 28 weeks (range: 23–35 weeks), birth weight was 1460 g (range: 431–2500 g), and age at surgery was 2.7 months (range: 1.0–11.6 months). Diagnoses included left-to-right shunts (n = 15), conotruncal abnormalities (n = 13), arch obstruction (n = 6), univentricular hearts (n = 4), semilunar valve obstruction (n = 3), Shone syndrome (n = 1), and cor triatriatum (n = 1). Results. Thirty-day survival was 84% with 6 early and 6 late postoperative deaths. Survival to hospital discharge was 68%. There was 50% mortality for patients with univentricular hearts and severe BPD. The median duration of preoperative ventilation was 76 days (range: 2–244 days) and of postoperative ventilation was 15 days (range: 1–141 days). The median duration of cardiac ICU stay was 7.5 days (range: 1–30 days) and of hospital stay was 115 days (range: 35–475 days). Current pulmonary status includes on room air (n = 14), O2 at home (n = 4), and ventilated at home (n = 4) or in hospital (n = 4), and 5 patients were lost to follow-up. Conclusions. BPD has significant implications for children who have CHD and undergo cardiac surgery, leading to prolonged ICU and hospital stays, although most survivors are not O2 dependent. Postoperative mortality was highest among patients with univentricular hearts and severe BPD. Optimal timing of surgery and strategies to improve outcome remains to be delineated.

Using Mnemonics and Visual Imagery to Teach the New Neonatal Resuscitation Program

Mnemonics have long been used to help learners remember facts in various disciplines of medicine. With the introduction of the revised Neonatal Resuscitation Program (NRP), it is vital for learners to know and remember important changes to the NRP curricula. While teaching the new curricula, we found that learners appeared confused, being unable to provide the correct sequence of answers to the questions posed during the assessment phase of the course. Mnemonics were developed to aid memory recall and optimize resuscitation skills.

Examination of the Anterior Vascular Capsule of the Lens: III. Abnormalities in Infants With Congenital Infection

The disappearance of the anterior vascular capsule of the lens (tunica vasculosa lentis) in the preterm infant has been established to be useful in accurately estimating gestational age between the twenty-seventh and thirty-fourth weeks in infants appropriate or small for gestational age. Six infants have been studied with abnormalities of the anterior vascular capsule of the lens in which congenital TORCH infection has been documented (1 toxoplasmosis, 2 rubella, 2 cytomegalovirus, and 1 herpes simplex virus). Since the anterior vascular capsule generally atrophies symmetrically and completely after the thirty-fourth week of gestation, the findings of marked asymmetry and/or persistence and hypertrophy of the anterior vascular capsule of the lens warrants initiation of TORCH studies in the newborn infant.

Candida endophthalmitis: A manifestation of candidiasis in the neonate

Candida endophthalmitis is a frequent complication of systemic candidiasis. The case reported emphasizes the usefulness of indirect ophthalmoscopy in evaluating infants suspected of having disseminated candidal infection and describes the pathologic findings of Candida endophthalmitis in the neonate.