A rare case of methemoglobinemia in a preterm newborn with unclear etiology

 Cyanosis is a bluish discoloration of the tissues due to increased levels of deoxygenated hemoglobin in capillaries. It is a common finding in newborn infants that can be caused by different diseases, including pulmonary, cardiac, infectious, and hematological disorders. Methemoglobinemia is a rare cause of cyanosis, in which hemoglobin is oxidized, changing its heme iron configuration from the ferrous (Fe2 +) to the ferric (Fe3 +) state, creating methemoglobin (Met-Hb), a form that does not bind oxygen, leading to decreased oxygen delivery to the tissues and cyanosis. We report a rare case of a preterm newborn, who developed cyanosis and worsening hypoxemia on day ten of life, she was found to have elevated Met-Hb percentage in blood gas analysis that required treatment with intravenous methylene blue. Her symptoms resolved after a period of maintenance treatment with oral methylene blue and ascorbic acid, and the etiology of her disease remains unclear.

Knowledge of Jordanian women of reproductive age who underwent bariatric surgery and its effect on birth outcomes: A cross-sectional study

Objectives

This study aims at exploring the knowledge of women of reproductive age who underwent bariatric surgery in Jordan regarding its effect on birth outcomes.

Methods

A cross-sectional study was conducted on 183 women (aged 15-49) who had undergone bariatric surgery at the Jordan University Hospital in Amman, Jordan, between 2016 and 2019, using telephone interviews with conveniently selected participants' samples. The survey tool obtained data on women's knowledge and other sociodemographic, obstetric health, and bariatric surgery information. Unfavorable birth outcomes include preterm delivery, small for gestational age, congenital abnormalities, low birth weight, and admission to the neonatal critical care unit.

Results

More than half of the participants did not know about the possible unfavorable birth outcomes after bariatric surgery and related practice guidelines. This is shown in their median score of 3 (interquartile range: 2-4) out of a maximum possible score of 8. Women who had a good score (>4) had received counseling about unfavorable bariatric surgery outcomes from their surgeon (p < 0.013); those who had educational qualifications higher than secondary school (p < 0.001) as well as those who were employed (p < 0.008) and believed that the surgery would affect the newborn (p < 0.001). The median score was also unfavorably associated with the parity of the participants (p < 0.003).

Conclusion

The extent of knowledge regarding the unfavorable birth outcome of bariatric surgery is low among women who underwent bariatric surgery at Jordan University Hospital in Jordan. Improving health literacy and information on bariatric surgery implications on pregnancy and birth outcomes amongst women of reproductive age is a recommendation from this study.

Children with type one diabetes who are migrants and refugees suffer from poor metabolic control and frequent acute complications, a study from Jordan, a limited resource country with high migrant/refugee population

BACKGROUND

Data from developed countries show that pediatric patients with type one diabetes (T1D) who are migrants/refugees suffer from poor metabolic control and frequent complications. Their status in developing countries is underreported.

AIM

To compare Jordanian and migrant/refugee children with T1D in terms of socio-demographic and metabolic characteristics.

METHODS

This is a questionnaire-based, cross-sectional study. It was completed using Microsoft forms and patients/caregivers were asked to consent if they agreed to answer.

RESULTS

A total of 146 children with T1D were enrolled in the study (42, 28.8% migrants/refugees). Jordanian and migrant/refugee children with T1D had poor metabolic control: average HbA1c was 8.9 ± 1.99% (74 ± 22 mmol/mol) and 9.0 ± 1.93% (75 ± 21 mmol/mol), respectively P = 0.81. Migrant children with T1D suffered from recurrent hypoglycemia more than the Jordanian group 33 (78.6%) and 56 (53.8%) respectively, p = 0.006. Although not statistically significant, recurrent attacks of DKA was reported more in the migrant/refugee group 13 (31.0%) and 18 (17.3%) respectively, p = 0.068.

CONCLUSION

Both Jordanian children with T1D and those who are refugees/migrants had poor metabolic control. However, those who are of migrant/refugee background were more likely to develop acute complications related to diabetes.

Adverse pregnancy outcomes during the COVID-19 lockdown. A descriptive study

BACKGROUND

The ongoing spread coronavirus disease worldwide has caused major disruptions and led to lockdowns. Everyday lifestyle changes and antenatal care inaccessibility during the coronavirus disease 2019 (COVID-19) pandemic have variable results that affect pregnancy outcomes. This study aimed to assess the alterations in stillbirth, neonatal-perinatal mortality, preterm birth, and birth weight during the COVID-19 national lockdown.

METHODS

We used the data from the Jordan stillbirths and neonatal death surveillance system to compare pregnancy outcomes (gestational age, birth weight, small for gestational age, stillbirth, neonatal death, and perinatal death) between two studied periods (11 months before the pandemic (May 2019 to March 2020) vs. 9 months during the pandemic (April 2020 to March 1st 2020). Separate multinomial logistic and binary logistic regression models were used to compare the studied outcomes between the two studied periods after adjusting for the effects of mother's age, income, education, occupation, nationality, health sector, and multiplicity.

RESULTS

There were 31106 registered babies during the study period; among them, 15311 (49.2%) and 15795 (50.8%) births occurred before and during the COVID-19 lockdown, respectively. We found no significant differences in preterm birth and stillbirth rates, neonatal mortality, or perinatal mortality before and during the COVID-19 lockdown. Our findings report a significantly lower incidence of extreme low birth weight (ELBW) infants (<1kg) during the COVID-19 lockdown period than that before the lockdown (adjusted OR 0.39, 95% CI 0.3-0.5: P value <0.001) CONCLUSIONS: During the COVID-19 lockdown period, the number of infants born with extreme low birth weight (ELBW) decreased significantly. More research is needed to determine the impact of cumulative socio-environmental and maternal behavioral changes that occurred during the pandemic on the factors that contribute to ELBW infants.

Parents' Experience of Having an Infant in the Neonatal Intensive Care Unit: A Qualitative Study

INTRODUCTION

Admission to the neonatal intensive care unit (NICU) is usually unexpected and can be stressful to the parents causing strenuous psychosocial effects. Parents of these infants are subject to suffering stress, depression, and feelings of powerlessness. This study aimed at describing parents' experience of having their infant in the neonatal intensive care unit.

METHOD

 A qualitative descriptive design was used. Parents (six couples and four mothers) of infants hospitalized for at least ten days regardless of gestational age, gender, or medical diagnosis were selected from a teaching hospital in Amman, Jordan. Semi-structured interviews were conducted between June 2019 and November 2019.

RESULTS

 Thematic analysis of the data revealed four emerging themes: (1) Living the ambiguities of the admission to the NICU, (2) Living the burdens of their infants' hospitalization, (3) Coping with the stresses of a hospitalized infant, and (4) Reflecting on interactions with healthcare staff and the environment.

DISCUSSION AND CONCLUSION

 The study findings demonstrated parents' worries and needs and highlighted the use of spirituality/religiosity as a coping mechanism. The findings will guide healthcare providers and policymakers to develop caring strategies that enhance care delivered to parents of infants in intensive care units.

Assessment of Perceived Compliance and Barriers to Personal Protective Equipment Use Among Healthcare Workers During the COVID-19 Pandemic's Second Wave Surge: "Walk to Talk" Cross-Sectional Correlational Study

OBJECTIVE

This study aimed at investigating HCWs' perceptions of PPE compliance and barriers, as well as influencing factors, in order to develop methods to combat the rise in their infection rates.

METHODS

During the 'second wave' surge, a cross-sectional correlational analysis was conducted over a 1-month period. It consists of HCWs from various hospital sectors that admit COVID-19 patients using an online self-administered predesigned tool.

RESULTS

Out of the 285 recruited participants, 36.1% had previously been diagnosed with COVID-19. Around 71% received training on PPE use. The perceived compliance was good for (PPE) usage (mean 2.60 ± 1.10). A significant higher compliance level was correlated with previous diagnosis with COVID-19, working with patients diagnosed with COVID-19, and having a direct contact with a family member older than 45 years old (P < 0.01). The main perceived barriers to the use of PPEs were unavailability of full PPEs (35%), interference with their ability to provide patient care (29%), not enough time to comply with the rigors of PPEs (23.2%) and working in emergency situations (22.5%). With regards to perceived barriers, those working with patients diagnosed with COVID-19 and those who reported having a direct contact with a family member older than 45 years old showed significantly higher level of barriers.

CONCLUSION

A series of measures, including prioritization of PPE acquisition, training, and monitoring to guarantee appropriate resources for IPC, are necessary to reduce transmission.

Impact of Computerized Prescription on Medication Errors and Workflow Efficiency in Neonatal Intensive Care Units: A Quasi-Experimental Three-Phase Study

BACKGROUND

Neonates are highly vulnerable to preventable medication errors due to their extensive exposure to medications in the neonatal intensive care units (NICUs). These errors, which can be made by medical, nursing, or pharmacy personnel, are costly and can be life-threatening. This study aimed to investigate the newly developed computerized neonatal pharmaceutical health care system (NPHCS) in terms of its ability to (1) minimize neonatal medication prescription errors (NMPEs) and (2) improve workflow efficiency compared with the traditional manual prescribing approach.

METHODS

A computerized neonatal medication prescription system was designed, developed, and tested successfully through a pilot clinical trial for over 6 months in 100 neonates. A three phase quasi-experimental study was then conducted using standardized monitoring checklists for the assessment of NMPEs before and after utilization of the developed prescribing system.

RESULTS

The obtained result showed a high rate of NMPEs in both systems, especially for the antibiotic drug group. However, the use of newly developed NPHCS significantly improved workflow efficacy. The identified errors were significantly more common in the manual mode than in the computerized mode (158.8 vs. 55 per 100 medications). These errors were distributed among different categories, including the documentation of patient identity, birth weight, and gestational age, as well as statements of dose, unit, interval, and diagnosis. Analysis of variance across different categories showed a p-value of <0.05.

CONCLUSION

The use of the computerized NPHCS improved patient safety in NICUs by decreasing NMPEs. It also significantly reduced the time required for dose calculation, prescription generation, and electronic documentation of medical records, compared with the traditional handwritten approach.

Esophageal atresia: Associated anomalies, mortality, and morbidity in Jordan

BACKGROUND

Esophageal atresia is a developmental disorder in which the upper and lower esophagus fail to connect. It has an estimated prevalence of 1 in 2,500-4,500 live births and has poorer outcomes in low- and middle-income countries than in high-income countries. This study focused on the disorder's epidemiology, morbidity, and mortality in Jordan to address the lack of data regarding esophageal atresia in this country.

METHODS

This was a retrospective study covering a 16-year period at a tertiary care academic hospital. Data were extracted from archived medical records and operative notes. All patients who had complete congenital esophageal atresia data were included. In total, the records of 55 patients were analyzed.

RESULTS

Of the included patients, 9% were diagnosed prenatally and 47% were diagnosed with polyhydramnios. The mean gestational age was 37 weeks, the mean birthweight was 2,550 g, and 60% of patients were male. Isolated cases of esophageal atresia were reported in 58.2% of patients. There was a high rate of associated congenital anomalies (41.8%), with cardiac lesions the most common (20%), and 5.5% were syndromic. Parental consanguinity was found in 18.2% of patients. Postoperative surgical-related morbidities included stricture (18/24; 75%) and leakage (5/24; 20.8%). Fistula recurrence occurred in one patient (4.2%). The mortality rate was 12.8%.

CONCLUSION

Esophageal atresia causes a high rate of mortality and exhibits post-operative morbidities. Moreover, associated anomalies were frequently observed. A high level of the malformation was found among offspring from consanguineous marriages.

Respiratory Carriage of Haemophilus influenzae Associated with Hib Vaccine in Jordanian Children

Objective Haemophilus influenzae type b (Hib) is the most virulent serotype that colonizes the upper respiratory tract of children. After introducing Hib conjugate vaccine, Hib has become almost entirely replaced by nontypeable H. influenzae (NTHi) strains. This study investigated the incidence of NTHi, which may cause serious sporadic body infections.

Methods A total of 300 nasal and throat swab samples were obtained from children aged 6 to 60 months, who visited outpatient pediatric clinics of Jordan University Hospital and Al-Bashir Hospital, Amman, Jordan. Colonies resembling H. influenzae were tested by conventional laboratory tests including Gram staining and antibiotic susceptibility. The 16S rRNA and bexA (capsulation gene) were amplified from the extracted DNA. Swabs (n = 100) were delivered to the laboratory in transport media. After initial culture, DNA was extracted directly and tested by conventional polymerase chain reaction (PCR) employing actin beta primers for assessing the housekeeping gene, followed by quantitative PCR (qPCR) against Hib-specific primers.

Results A total of 31/300 (10.33%) of H. influenzae isolates were recovered by culture and confirmed by PCR for 16S rRNA; 96.77% (30/31) were NTHi, and only one isolate was Hib. This isolate was confirmed by detection region II of the cap locus of Hib gene by qualitative TaqMan real-time qPCR. Antibiotic resistance among NTHi to ampicillin and erythromycin was 50.0 and 20.0%, respectively.

Conclusion The conjugated Hib vaccine almost eliminated the occurrence of Hib in the upper respiratory tract of the Jordanian children, while NTHi colonization was found in 10% of them.

The enigma of gastroesophageal reflux disease among convalescing infants in the NICU: It is time to rethink

Gastroesophageal reflux (GER) can be a normal physiological process, or can be bothersome, when aerodigestive consequences are associated; the latter is often interpreted as GER disease (GERD). However, the distinction between these two entities remains an enigma among infants surviving after neonatal intensive care (NICU) care. Symptoms related to GERD are heterogeneous, and are often managed with changes in diet, feeding methods, and acid suppressive therapy. However, none of these approaches have been well-tested in neonates; hence practice variation is very high world-wide. In this paper, we explain the variation in diagnosis, pathophysiology of the clinical presentation, and highlight approaches to diagnosis and management.

Diversity of toxin genotypes and antimicrobial susceptibility of Clostridium perfringens isolates from feces of infants

Introduction

This study investigated the most important epidemiological characteristics of C. perfringens strains colonizing the intestine of Jordanian infants.

Methods

A total of 302 fecal samples were collected from Jordanian infants aged ≤ 1 year from patients hospitalized in the neonatal intensive care unit and from the outpatient department. Samples were cultured for detection of C. perfringens and evaluation of their antimicrobial resistance; identification of their potential toxins genes was performed using PCR.

Results

Overall the C. perfringens colonization rate was 27.2% (82/302). Infants aged ≤ 6 months showed significantly higher (p<0.004) colonization than older infants. The occurrence rates of C. perfringens isolates carrying potential specific toxin genes were as follows: alpha toxin 95.1% (78/82), beta-2 toxin 69.5% (57/82), beta toxin 14.6% (12/82), and only 2.4% (2/82) epsilon toxin. No isolate carried the iota toxin. Genotype A was the most prevalent among C. perfringens isolates (78.1%). The antimicrobial resistance rates of C. perfringens isolates were 20% to metronidazole and erythromycin, 16.7% to levofloxacin, and 6.7% to vancomycin.

Conclusions

This study demonstrates that the majority of C. perfringens isolates from feces of Jordanian infants were classified as type A, few isolates were classified as type C and type D, and all were negative for potential enterotoxin genes causing diarrhea.

Chelation therapy for secondary neonatal iron over load: Lessons learned from rhesus hemolytic disease

Khdair-Ahmad F, Aladily T, Khdair-Ahmad O, Badran EF. Chelation therapy for secondary neonatal iron overload: Lessons learned from rhesus hemolytic disease. Turk J Pediatr 2018; 60: 335-339. Secondary neonatal iron overload occurs with intrauterine and post-natal blood transfusions. Treatment with intravenous Deferoxamine was reported only in four cases in the literature. Herein we report a case of a patient born at 36 weeks of gestation, who had rhesus hemolytic disease. He developed secondary iron overload, causing liver injury, after a total of six blood transfusions: four intrauterine and 2 post-natal transfusion therapies. Intravenous Deferoxamine treatment was started at the age of 45 days due to a ferritin level of 40,000 mg/L, progressive rise of liver enzymes, and worsening cholestasis. Treatment resulted in marked reduction in ferritin level (down to 829 mg/L at the age of 6 months), significant improvement in the liver enzymes, and resolution of cholestasis.

Dietary factors and their association with childhood obesity in the Middle East: A systematic review

BACKGROUND:

Childhood obesity is a global epidemic that is related to environmental and genetic factors and has adverse consequences throughout life, being obese is a serious health problem in childhood and increases the risk of many co-morbidities.

AIM:

The purpose of this systematic review is to illustrate that dietary factors correlate with obesity among children studied in the Middle East area.

METHODS:

Studies were screened by searching two databases in August 2017 and considered as eligible for inclusion if they: (a) are observational studies, (b) define at least one dietary factor for obese children aged 6-12 years, (c) are undertaken in the Middle East area, and (d) are written in English. The search dependent words and terms used are: diet, nutrition, pediatric obesity, physical activity, Middle East, overweight, children, excess weight, childhood, obesity and dietary factors. Papers were initially evaluated for eligibility based on title and abstract. The full text of articles of studies that met, or appeared to meet, the inclusion criteria, were saved. Quality assessment was conducted using the NIH tool for observational cohort and cross-sectional studies. Out of 730 studies, 4 papers met the inclusion criteria and rated as good quality. These studies were from Iran ( n=2), Saudi Arabia ( n=1) and Lebanon ( n=1) during 2008 and 2016.

RESULTS:

Dietary factors identified were breakfast intake, junk-food consumption, energy intake and micronutrient intake. The present systematic review shows that several dietary behaviors such as missing breakfast, excessive fat and refined carbohydrate intake with low micronutrient intake due to low consumption of fruits, vegetables and milk/diary, are associated with obesity in children in the Middle East.

CONCLUSIONS:

A healthy diet during childhood to control weight and prevent obesity is recommended for a healthy, lifelong adulthood.

Detection of novel LAMA3 mutation in Herlitz junctional epidermolysis bullosa in a Jordanian family

The Herlitz junctional epidermolysis bullosa (H-JEB) subtype usually presents as a severe lethal inherited variant of epidermolysis bullosa (EB) caused by a homozygous mutation in the genes LAMA3, LMAB3, or LAMAC3. Each gene encodes one of the three chains of heterotrimer laminin-332 proteins (including the alpha-3 chain, beta-3 chain and gamma-2-chain) responsible for the adherence of the epidermis to the underlying dermis. The aim of this report is to add to the existing knowledge about EB by describing a novel mutation in a gene responsible for genodermatosis. A case of a Jordanian male neonate, born to healthy, first cousin consanguineous parents, who developed nonhealing blistering skin and mucous membrane lesions, crusted erosions with significant granulation tissue and dystrophic nails immediately after birth is described. The patient was diagnosed as having a novel LAMA3 mutation causing (H-JEB) by immunofluorescence mapping and molecular analysis. Both parents and this baby's sibling were shown to be heterozygous carriers of the same mutation. Pre-implantation diagnosis using molecular analysis for subsequent pregnancies in this family is crucial for managing any new pregnancy.

Effects of perinatal risk factors on common neonatal respiratory morbidities beyond 36 weeks of gestation

OBJECTIVE

To assess the incidence of respiratory morbidity (RM) in all single live neonates born more than 36 weeks of gestation, and the effects of perinatal characteristics on these morbidities.

METHODS

This is a prospective hospital based study covering a 12-month period. The study took place at the Department of Pediatrics, Jordan University Hospital, Amman, Jordan, between January and December 2009. The effects of different perinatal characteristics on RM including transient tachypnea of the newborn (TTN) and respiratory distress syndrome (RDS) were analyzed.

RESULTS

A total of 2282 newborns were included. One thousand two hundred and seventy-six (55.9%) of the newborns were delivered by vaginal delivery and 1,006 (44%) by cesarean section (CS) (24.5% by emergency CS and 19.5% by elective CS). Respiratory morbidity was reported in 3.7%. The incidence of TTN was 2.9% and RDS was 0.7%. Elective CS was found to be a risk factor for RM development when the gestational age was less than 39 weeks. Maternal hypertension and diabetes mellitus, and the absence of labor were independent risk factors for RM. The emergency CS and large for gestational age babies were risk factors for TTN, while male gender and GA less than 37 0+6 weeks were risk factor for RDS.

CONCLUSION

The collaborative obstetric and neonatology responsibility helps to identify the risk factors for adverse respiratory outcome when considering the time and mode of delivery. The pregnant mother should be informed regarding this possibility if delivery by elective CS is performed before the 39 0+6 weeks of gestation.

Epidemiological characteristics of Candida species colonizing oral and rectal sites of Jordanian infants

BACKGROUND

There is evidence that Candida colonization contributes to increasing invasion of candidiasis in hospitalized neonates. Few studies investigated the epidemiology and risk factors of Candida colonization among hospitalized and non-hospitalized infants. This prospective study investigated the major epidemiological characteristics of Candida species colonizing oral and rectal sites of Jordanian infants.

METHODS

Infants aged one year or less who were examined at the pediatrics outpatient clinic or hospitalized at the Jordan University Hospital, Amman, Jordan, were included in this study. Culture swabs were collected from oral and rectal sites and inoculated on Sabouraud dextrose agar. All Candida isolates were confirmed by the Remel RapID yeast plus system, and further investigated for specific virulence factors and antifungal susceptibility MIC using E-test. Genotyping of C. albicans isolates was determined using random amplified polymorphic DNA (RAPD) analysis method.

RESULTS

A total of 61/492 (12.4%) infants were colonized with Candida species by either their oral/rectal sites or both. Rectal colonization was significantly more detected than oral colonization (64.6% verses 35.4%), particularly among hospitalized infants aged more than one month. The pattern and rates of colonization were as follows: C. albicans was the commonest species isolated from both sites and accounted for 67.1% of all isolates, followed by C.kefyr (11.4%), each C. tropicalis and C. glabrata (8.9%) and C. parapsilosis (3.8%). A various rates of Candida isolates proved to secrete putative virulence factors in vitro; asparatyl proteinase, phospholipase and hemolysin. C. albicans were associated significantly (P < 0.05) with these enzymes than other Candida species. All Candida isolates were susceptible to amphotericin B and caspofungin, whereas 97% of Candida species isolates were susceptible to fluconazole using E-test. The genetic similarity of 53 C. albicans isolates as demonstrated by dendrogram revealed the presence of 29 genotypes, and of these one genotype accounted for 22% of the isolates.

CONCLUSION

This study presents important epidemiological features of Candida colonization of Jordanian infants.

Epidemiology and clinical outcome of candidaemia among Jordanian newborns over a 10-year period

This retrospective study includes all newborn patients with culture proved candidaemia who were admitted to the neonatal intensive care unit of Jordan University Hospital through the period January 1995 to June 2006. Among 24 patients included, 13 (54.2%) died. The incidence of candidaemia was 0.27%, the mean age at diagnosis 25.9 d and the mean gestational age at birth 34.6 weeks. Species most frequently isolated were Candida albicans (50%) and C. krusei (20%). Previous gastrointestinal pathology was present in 41.7% of the cases. A comparison of cases due to C. albicans with those due to other species of Candida revealed no statistical differences in terms of demographic factors, age at onset of disease, mortality, clinical manifestations or risk factors. Based on our results, empirical antifungal therapy should be considered in neonates who have gastrointestinal pathology and other risk factors.