Biomedical subjects
Publications and source records attributed to S K Patole.
Patent ductus arteriosus (PDA), especially PDA with sepsis, has been reported as a risk factor for feed intolerance in preterm neonates. In this study, the start to full feeds interval was found to be longest in preterm neonates (<or=28 weeks' gestation) with sepsis, followed by that in preterm neonates with sepsis and PDA, and in those with PDA alone.
OBJECTIVE: To study serum creatinine (SCr) levels following indomethacin for patent ductus arteriosus (PDA) closure in extremely preterm neonates in relation to postnatal age at the start of treatment. METHODS: This was a retrospective (January 2000-December 2002) analysis of data on preterm neonates (gestation <29 weeks) who received indomethacin for PDA. Pre-existing renal malformation and/or impairment and high serum levels of nephrotoxic drugs were criteria for exclusion. RESULTS: Indomethacin was commenced at postnatal age <7 days and >or=7 days in 60 (group 1) and 30 (group 2) neonates, respectively. The median (Q1, Q3) gestational age and birth weight for group 1 and group 2 neonates were 25 (23, 27) vs. 25 (24, 26) weeks and 740 (620, 909) vs. 780 (663, 966) grams, respectively. Postnatal age <7 days at start of indomethacin was associated with higher baseline (0.083 (0.074, 0.090) vs. 0.073 (0.054, 0.083) mmol/L, p=0.001) and peak SCr levels (0.099 (0.089,0.109) vs. 0.090 (0.064, 0.104) mmol/L, p=0.015). Logistic regression analysis controlling for gestational age and baseline SCr level indicated that postnatal age >or=7 days was a risk factor for elevated SCr after indomethacin (OR=13.4, 95% CI: 3.8-46.6, p < 0.001). CONCLUSION: Postnatal age >or=7 days at the start of indomethacin is a predictor of a significant rise in SCr in extremely preterm neonates.
The efficacy of prophylactic carboxymethylcellulose (CMC) in reducing the time to reach full enteral feeds (FEFs) in neonates <32 weeks' gestation was studied in a clinical trial. When ready for feeds, enrolled neonates were allocated to either CMC (dose: CMC content of 12 mg oral erythromycin ethyl succinate syrup, 6 hourly) or placebo till either maximum 10 days treatment or FEF (150 ml/kg/day) was reached. A standardised regimen guided enteral feeding. Demographic characteristics of enrolled neonates (CMC, placebo: n = 35) were comparable. Median (interquartile range) gestational age and birth weight were 29 (28, 30) vs. 29 (27, 31) weeks and 1090 (905, 1390) vs. 1236 g (928, 1565) for the CMC and placebo groups, respectively. Median (interquartile range) time to reach FEF was 5 (4, 6) vs. 5 (3, 8) days for CMC and placebo group, respectively (p = 0.5). No CMC-related adverse effects occurred. Prophylactic CMC did not have a significant role in reducing time to reach FEF.
BACKGROUND: Surgical ligation of patent ductus arteriosus (PDA) is widely practised in preterm infants despite no clear evidence that this improves outcomes. Geographical isolation meant that ductal ligation was not an option in King Edward Memorial Hospital until recently. OBJECTIVE: A retrospective data analysis to test the hypothesis that outcomes of infants with persistent PDA were no worse than those of infants with no significant duct or a duct that closed after medical treatment. PATIENTS AND METHODS: A total of 252 infants (gestation < or =28 weeks) born between 1 January 2000 and 30 June 2002 were divided into three groups: group 1, no significant PDA (n = 154); group 2, significant PDA which closed after medical treatment (n = 65); group 3, significant PDA remaining patent after medical treatment (n = 33). A significant PDA was defined by a left atrium to aortic root ratio of >1.4 or a ductal diameter >1.5 mm with a left to right shunt. RESULTS: Twenty four (10%) infants died at median (interquartile range) 15.5 (9-35) days. After adjustment for gestational age, relative to group 1, the infants from group 3 were at a 4.02 times increased risk of death (95% confidence interval 1.12 to 14.51). There was no significant difference between groups in the incidence of chronic lung disease, chronic lung disease or death, necrotising enterocolitis, intraventricular haemorrhage, duration of oxygen, or hospital stay. CONCLUSION: Mortality was higher in infants with a persistent PDA, but other morbidities were not significantly different. A randomised trial is needed to determine whether surgical ligation will reduce mortality in such infants.
BACKGROUND: A significant and prolonged decline in the incidence of necrotising enterocolitis (NEC), nearing virtual elimination in some centres, has been observed consistently since implementation of a standardised feeding regimen. AIM: To systematically review the observational studies reporting incidence of NEC in preterm, low birth weight (LBW) neonates "before" and "after" implementation of a standardised feeding regimen. METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2002), Medline, Embase, Cinahl, and proceedings of the Pediatric Academic Societies (published in Pediatric Research from 1980) were searched in July and again in October 2003. The reference lists of identified observational studies, and personal files, were searched. No language restriction was applied. Key words were: standardised, enteral, feeding, neonates, necrotising enterocolitis. Authors were contacted for clarification of data. RESULTS: Six eligible studies (1978-2003) were identified. A significant heterogeneity was noted between the studies indicating the variations in the population characteristics and feeding practices over a period of 25 years. Meta-analysis of the six studies using a random effects model revealed a pooled risk ratio of 0.13 (95% confidence interval 0.03 to 0.50)-that is, introduction of a standardised feeding regimen reduced the incidence of NEC by 87%. CONCLUSION: Standardised feeding regimens may provide the single most important global tool to prevent/minimise NEC in preterm neonates. Randomised controlled trials are needed.
The case of a neonate with necrotizing enterocolitis (NEC) following intrauterine transfusions (IUTs) for Rhesus hemolytic disease (RHD) prompted us to undertake a retrospective study (1995-2002) to determine whether there is an association between IUT and NEC. Maternal and neonatal demographics, and details concerning IUT and definite (> or =Stage II) NEC, were collected. Chi2 tests of association were performed. In our population 281/38,200 (0.73%) pregnancies were complicated by RHD. Fetal anemia necessitated IUT in 25/281 pregnancies. Definite NEC occurred in 59/11,814 (very low birth weight=1874) neonatal admissions. Except for the index case, no other neonate developed NEC following IUT. No significant association was found between IUT and NEC.
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Persistent pulmonary hypertension of the newborn (PPHN) is a complex syndrome with multiple causes, with an incidence of 0.43-6.8/1,000 live births and a mortality of 10-20%. Survivors have high morbidity in the forms of neurodevelopmental and audiological impairment, cognitive delays, hearing loss, and a high rate of rehospitalization. The optimal approach to the management of PPHN remains controversial. Inhaled nitric oxide (iNO) is currently regarded as the gold standard therapy, but with as many as 30% of cases failing to respond, has not proven to be the single magic bullet. Given the complex pathophysiology of the disease, any such magic bullet is unlikely. A number of recent studies have suggested a role for specific phosphodiesterase (PDE) inhibitors in the management of PPHN. Sildenafil, a specific PDE5 inhibitor, appears the most promising of such agents. We aim to review the current status and limitations of iNO and the potential of PDE inhibitors in the management of PPHN. The reasons why caution is warranted before specific PDE5 inhibitors like sildenafil are labelled as potential magic bullets for PPHN will be discussed. The need for randomized-controlled trials to determine the safety, efficacy, and long-term outcome following treatment with sildenafil in PPHN is emphasized.
Necrotising enterocolitis (NEC) is the most common acquired gastrointestinal emergency in neonates. Presence of pneumatosis intestinalis is taken as evidence of definite NEC. A distinctive but rare form of NEC called "pneumatosis coli" has been described, presenting with gross blood in stools and minimal or absent local and systemic signs. Radio-graph characteristically reveal isolated colonic pneumatosis without small bowel involvement. Pneumatosis coli has a more benign course compared with definite NEC. Total parenteral nutrition, antibiotics, an appropriate duration off feeds and close observation remain the corner stones of therapy assuring a benign course.
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The complications associated with umbilical venous catheterization in neonates range from pericardial effusion, portal hypertension, and peritoneal perforation with ascites, to Wharton's jelly embolism. The case of a term neonate who developed ascites and severe hyponatraemia (serum sodium 119 mmol/L) most probably following peritoneal perforation by an umbilical venous catheter is reported. The presenting feature was convulsions associated with dilutional hyponatraemia, probably following absorption of a large quantity of ascitic fluid across the peritoneum. Conservative management was associated with gradual recovery over 24 h. The case highlights that, irrespective of the route, excessive administration of salt-free fluids can lead to dilutional hyponatraemia with adverse consequences. The present case illustrates the importance of confirming intravascular positioning of umbilical catheters by ensuring free flow of blood on aspiration, to prevent/detect inadvertent peritoneal perforation. Ideally, echocardiographic confirmation of optimal intravascular placement of such catheters is preferred as radiographic confirmation is reported to be unreliable.
The clinical course of a term neonate (birthweight 3.14 kg) who developed thrombosis of the left common and internal iliac veins on day 21 following recovery from Streptococcus mitis septicemia, with shock diagnosed on day 13, is reported. Subcutaneous low molecular weight heparin (LMWH) was commenced (1.5 mg/kg 12 hourly for 10 days) after 13 h of standard heparin infusion, due to difficulties in securing a peripheral venous access. The inflammation of the left leg was completely resolved by day 5 of LMWH therapy. Prothrombin time, activated prothrombin time and fibrinogen levels were within normal limits during LMWH therapy. Treatment-related side effects, such as thrombocytopenia and bleeding tendency were not noted. Doppler studies 6 weeks after discharge home on day 33 revealed complete resolution of the thrombus. Apart from septicaemia and shock, the presence of an indwelling central venous catheter and a history of untreated maternal diabetes were additional risk factors for thrombosis. Because it is as effective as standard heparin, LMWH may be a therapeutic option for thrombosis in high-risk neonates, particularly given its ease of administration by the subcutaneous route, predictable pharmacokinetics and reduced incidence of adverse effects such as bleeding complications.
Mortality and morbidity associated with surgical management of patent ductus arteriosus (PDA) in neonates has been reported to vary from 0% to 44%. Complications like pneumothorax, pleural effusion, recurrent nerve and phrenic nerve injury are associated with surgical closure of PDA. An extremely low birthweight neonate with diaphragmatic paralysis following phrenic nerve injury during surgical closure of PDA is reported. Delay in diaphragmatic plication for over two weeks while waiting for spontaneous recovery was associated with significant morbidity including chronic lung disease. The controversies associated with timing of diaphragmatic plication in high-risk neonates are discussed.
UNLABELLED: Addition of intravenous rifampin is reported to be useful in prompt clearance of persistent coagulase negative staphylococcal (CONS) bacteraemia in high-risk neonates. Four neonates (mean birthweight 823 g, mean gestation 25 wk) with persistent CONS bacteraemia for > 7-10 d (mean 11) were treated with i.v. rifampicin (10 mg/kg/12 h x 10 d) while continuing vancomycin (15 mg/kg/24 h). Their age at time of infection ranged from 2 to 11 d. The mean (range) vancomycin peak and trough concentrations were 29 (25-35) and 6 (4-10) microg/ml, respectively. The blood isolates were Staphylococcus epidermidis, S. hominis, and S. haemolyticus. Addition of rifampicin was associated with prompt clearance of bacteraemia within 48 h (n = 3) and 5 d (n - 1). Rifampicin-related adverse effects such as abnormal liver function tests and thrombocytopenia did not occur. CONCLUSION: Addition of i.v. rifampicin to vancomycin may optimize the outcome of persistent CONS bacteraemia and the risk of bacterial resistance related to prolonged exposure to vancomycin.
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