Outcome of Preterm Infants With Postnatal Cytomegalovirus Infection via Breast Milk: A Two-Year Prospective Follow-Up Study

Approximately 15% of preterm infants may develop postnatal cytomegalovirus (CMV) infection from seropositive mothers via breast milk and are at risk for neurological sequelae in childhood. The aims of this study were to assess the effects and outcomes on growth, neurodevelopmental status, and hearing in very low birth weight (VLBW) premature infants with postnatal CMV infection via breast milk at the corrected age of 12 and 24 months.The prospective follow-up study population comprised all living preterm children (n = 55) with a birth weight ≤1500 g and gestational age of ≤35 weeks, who had been participated in our "postnatal CMV infection via breast milk" studies in 2000 and 2009, respectively. The cohort of children was assessed at 12 and 24 months. Clinical outcomes were documented during hospitalization and after discharge. Long-term outcomes included anthropometry, audiologic tests, gross motor quotient, Infant International Battery, and neurodevelopmental outcomes; all were assessed at postcorrected age in 12 and 24 months during follow-up visits.Of the 55 infants enrolled in the study (4 noninfected infants were excluded because their parents did not join this follow-up program later), 14 infants postnatally acquired CMV infection through breast-feeding (infected group) and were compared with 41 infants without CMV infection (control group). No significant differences were observed between the groups with regard to baseline characteristics, clinical outcomes, anthropometry, or psychomotor and mental development on the Bayley scale of infant development. None of the infants had CMV-related death or permanent sensorineural hearing loss.Transmission of CMV from seropositive mother via breast milk to preterm infants does not appear at this time to have major adverse effects on clinical outcomes, growth, neurodevelopmental status, and hearing function at 12 and 24 months corrected age.

Prolonged seasonality of respiratory syncytial virus infection among preterm infants in a subtropical climate

Objective

There is limited epidemiological data on the seasonality of respiratory syncytial virus (RSV) infection in subtropical climates, such as in Taiwan. This study aimed to assess RSV seasonality among children ≤24 months of age in Taiwan. We also assessed factors (gestational age [GA], chronologic age [CA], and bronchopulmonary dysplasia [BPD]) associated with RSV-associated hospitalization in preterm infants to confirm the appropriateness of the novel Taiwanese RSV prophylactic policy.

Study Design

From January 2000 to August 2010, 3572 children aged ≤24-months were admitted to Taipei Mackay Memorial Hospital due to RSV infection. The monthly RSV-associated hospitalization rate among children aged ≤24 months was retrospectively reviewed. Among these children, 378 were born preterm. The associations between GA, CA, and BPD and the incidence of RSV-associated hospitalization in the preterm infants were assessed.

Results

In children aged ≤24 months, the monthly distribution of RSV-associated hospitalization rates revealed a prolonged RSV season with a duration of 10 months. Infants with GAs ≤32 weeks and those who had BPD had the highest rates of RSV hospitalization (P<0.001). Preterm infants were most vulnerable to RSV infection within CA 9 months.

Conclusions

Given that Taiwan has a prolonged (10-month) RSV season, the American Academy of Pediatrics' recommendations for RSV prophylaxis are not directly applicable. The current Taiwanese guidelines for RSV prophylaxis, which specify palivizumab injection (a total six doses until CA 8–9 months) for preterm infants (those born before 28^6/7 weeks GA or before 35^6/7 weeks GA with BPD), are appropriate. This prophylaxis strategy may be applicable to other countries/regions with subtropical climates.

A novel six consecutive monthly doses of palivizumab prophylaxis protocol for the prevention of respiratory syncytial virus infection in high-risk preterm infants in Taiwan

BACKGROUND

Respiratory syncytial virus (RSV) circulates year round in Taiwan. A novel six consecutive monthly doses of palivizumab for RSV prevention protocol has been approved for high risk preterm infants since December 2010. This study aimed to determine the clinical effectiveness and safety of this novel protocol for the prevention of RSV infection.

METHODS

From April 2011 to March 2013, we enrolled infants born at ≤28 weeks gestation and infants born at ≤35 weeks gestation with chronic lung disease (CLD) who received palivizumab prophylaxis as study group and followed up for 12 months. Historic control, those who were born and followed up between July 2000 and June 2008, were retrieved for propensity score matching. Primary endpoint was RSV-related hospitalization, and secondary endpoints included the length of hospital stay and intensive care unit (ICU) care.

RESULTS

We enrolled 127 infants (108 infants born at ≤28 weeks and 19 infants born at 29-35 weeks with CLD). They completed 6-dose palivizumab as scheduled. Among the study group, the RSV-related hospitalizations were 2 (1.6%) within 6 months and 5 (3.9%) within 12 months after discharge. We matched 127 infants in the control group with 127 infants in the study group by propensity score matching. The reduction of RSV-related hospitalization rates were 86% (10.2% vs 1.6%, p = 0.002) within 6 months after discharge and 78% (15.7% vs 3.9%, p = 0.004) within 12 months after discharge. Compared to the control group, the rate of ICU care significantly decreased from 7.1% to 0.8% (p = 0.024) within 6 months after discharge and from 7.9% to 0.8% (p = 0.014) within 12 months after discharge. Adverse events were recorded in 6.4% injections.

CONCLUSIONS

Six monthly intramuscular administration of palivizumab is effective for prevention of RSV hospitalization in regions with no single seasonal peak of RSV infection such as Taiwan.

Renal calcification in very low birth weight infants

BACKGROUND

Renal calcification in preterm infants has been described frequently. The etiologic factors have not yet been fully clarified. The objective of this study was to evaluate the incidence of and risk factors for renal calcification in our population.

METHODS

We retrospectively reviewed the charts of very low birth weight preterm infants during a 1-year period. Renal ultrasound scans were performed at term or before discharge and at a corrected age of 1 year.

RESULTS

Six infants (6%) had renal calcification at term or before discharge compared with 96 who did not. Factors significantly associated with renal calcification included gestational age (26 weeks vs. 29 weeks, p=0.006), birth weight (851 g vs. 1141 g, p=0.004), duration of mechanical ventilation (69 days vs. 29 days, p=0.002), length of intensive care (72 days vs. 41 days, p=0.013), furosemide therapy (33% vs. 3%, p=0.027), and dexamethasone therapy (50% vs. 2% p=0.001). Birth weight and dexamethasone therapy had significant independent association after stepwise logistic regression analysis. Sex, oliguria, acidosis, duration of oxygen therapy, length of hospital stay, nutrition status, and nephrotoxic drugs did not differ between the two groups. Three of the six infants had spontaneous remission of renal calcification, whereas two patients without the finding in neonatal stage had renal calcification at a corrected age of 1 year.

CONCLUSION

The incidence of renal calcification in very low birth weight infants in this study was relatively low, and the calcification was transient in one-half of the infants. Extremely premature, sick infants requiring long-term ventilation, and those receiving furosemide or dexamethasone were more likely to have renal calcification. Clinicians should be aware that renal calcification may develop beyond the neonatal stage.

A twenty-year review of early and late-presenting congenital Bochdalek diaphragmatic hernia: are they different clinical spectra?

BACKGROUND

Congenital Bochdalek diaphragmatic hernia (CDH) is easily recognized if it is present shortly after birth. However, cases of delayed CDH presentation are more subtle and therefore less easily diagnosed.

METHODS

We retrospectively analyzed 85 patients who were under 18 and diagnosed with CDH between June 1987 and May 2007. Those diagnosed before 1 month of age were categorized as having early-presenting CDH and those diagnosed after 1 month were categorized as having late-presenting CDH.

RESULTS

Of the 85 cases, 68 (80%) were early-presenting and 17 (20%) were late-presenting CDH. Respiratory symptoms were more common in early-presenting CDH, while gastrointestinal complaints were more dominant in the late-presenting group, particularly in patients with left diaphragmatic defects. Late-presenting CDH, which was more likely to be associated with chronic gastrointestinal symptoms, was associated with a lower mortality than acute early-presenting CDH with respiratory symptoms, despite the more prompt diagnosis of the latter. The small bowel was the organ most commonly herniated into the thorax. Congenital heart disease was the most commonly associated malformation, but the presence of associated anomalies did not increase mortality.

CONCLUSION

Early-presenting CDH shows acute symptoms, is readily diagnosed, and requires prompt intervention to prevent death. In contrast, late-presenting CDH shows more subtle symptoms and is more difficult to diagnose. Although the late-presenting CHD has better prognosis, it still requires surgery intervention to alleviate the symptoms. Clinicians must maintain a high index of suspicion for CDH, regardless of its presentation.

High cytomegalovirus load and prolonged virus excretion in breast milk increase risk for viral acquisition by very low birth weight infants

BACKGROUND

Breast milk is the main source of postnatal human cytomegalovirus (HCMV) infection. The aim of this study was to assess the relationship between HCMV load in breast milk and viral transmission to very low birth weight (VLBW) infants.

METHODS

Breast-fed VLBW infants who were born to HCMV-seropositive mothers and who were managed in a neonatal intensive care unit were enrolled in the study. Blood from mothers and infants was tested for HCMV antibodies after birth. Breast milk was collected for viral culture and HCMV load measurement. Urine from the babies was obtained for HCMV-DNA detection. Symptoms of HCMV infection were recorded and evaluated by neonatologists.

RESULTS

Of the 23 evaluated mothers during a 1-year period, 19 were HCMV seropositive; 17 of the women had detectable HCMV-DNA in their breast milk whey. Of the 23 infants born to the 19 seropositive mothers, 8 infants of 8 mothers had HCMV-DNA detected in the urine, indicating that they were infected, even though the breast milk was always frozen prior to feeding. Three infected infants had symptoms. At 4 weeks after delivery, the median viral load in breast milk from mothers of the 8 infected infants was significantly higher than that from mothers of the 15 noninfected infants (P = 0.04). HCMV was detectable in breast milk for a significantly longer period in mothers of infected infants (7.5 vs. 2.6 weeks P = 0.03).

CONCLUSIONS

High HCMV load and prolonged virus excretion in breast milk are maternal risk factors for viral transmission to VLBW infants.

Concomitant rotavirus and Salmonella infections in children with acute diarrhea

BACKGROUND AND PURPOSE

The incidence of concomitant rotavirus and Salmonella infection has been reported to be 1.3% to 7.4%. We designed this study to compare the clinical manifestations in children infected with rotavirus, Salmonella, or both.

METHODS

The medical records of admitted children with acute rotavirus or Salmonella gastroenteritis in 2001 were reviewed. They were divided into group R (rotavirus), group S (Salmonella) and group C (concomitant infection with both). The differences of clinical manifestations and laboratory data among the three groups were analyzed via chi-squared, analysis of variance (ANOVA), Bonferroni and Kruskal-Wallis tests, and odds ratios with 95% confidence intervals (95% CI).

RESULTS

Among the 895 cases reviewed, 550 were group R, 312 group S, and 33 (3.7%) group C. Group C had more vomiting compared with group S (p = 0.0017). Comparing with group R, group C had more prolonged and high fever (> or = 39 degrees C) (p < 0.05), more percentage of green coloration, with mucus and blood contained in the stool (p < 0.001). The C-reactive protein (CRP) value was significantly higher in group C (9.70 +/- 11.05 mg/dL) than in group R (1.33 +/- 3.62mg/dL) or S (5.22 +/- 6.11 mg/dL) (p < 0.05). Hypokalemia was found most frequently in group C (C: 30.0%, S: 8.8%, R: 7.3%) (p = 0.0026).

CONCLUSION

Concomitant rotavirus and Salmonella infections accounted for 3.7% of cases in this study. They had higher CRP as well as incidence of hypokalemia [corrected] In a child with rotavirus gastroenteritis, concomitant infection with Salmonella should be considered if the child has sustained a high fever (> or = 39 degrees C) for over 4 days and a green stool with mucus and blood.

Bacterial tracheitis in pediatrics: 12 year experience at a medical center in Taiwan

BACKGROUND

Bacterial tracheitis may cause life-threatening airway obstruction.

METHODS

Records of patients admitted to the pediatric wards of Mackay Memorial Hospital between 1994 and 2005 with a diagnosis of bacterial tracheitis made on bronchoscopic visualization of thick membranous tracheal secretions were retrospectively reviewed.

RESULTS

A total of 40 patients (aged 1 month-8 years, 29 [73%] under 3 years old) were included. Cough, fever, dyspnea, and hoarseness were the commonest symptoms. Fourteen patients (21%) required intubation. The most frequently isolated bacteriae were alpha-hemolytic streptococcus (in 11, 38%), pseudomonas (5, 17%), and Staphylococcus aureus (4, 14%). Intubation was more frequent in patients seen between 1994 and 1999 compared with those seen later (8/12 early vs 9/28 late). In the early period alpha-hemolytic streptococcus (55%) and pseudomonas (36%) were isolated. In the later period the most frequently isolated bacteria was alpha-hemolytic streptococcus (28%), followed by S. aureus (22%). No patients died, but those with pseudomonas infection had more severe complications, including tracheal stenosis. The average hospital stay in the early period was 26.2 +/- 20.5 days versus 9.1 +/- 4.8 days in the late period. The corresponding lengths of stay in the intensive care unit were 10.5 +/- 11.5 days and 2.0 +/- 2.2 days.

CONCLUSIONS

Bacterial tracheitis requiring hospitalization of children appeared to be milder in the second half of the study period. Pseudomonas tracheitis tends to have a severe course.

Neonatal gastric perforation: report of 15 cases and review of the literature

BACKGROUND

Gastric perforation among neonates is a rare but frequently fatal condition of uncertain etiology. The aim of this study was to review the clinical course of neonatal gastric perforation and to evaluate possible prognostic factors.

METHODS

We retrospectively analyzed the medical records of 15 patients with neonatal gastric perforation over a 19-year period. Another 97 patients described in the medical literature, for whom the gestational ages and birth weights were clearly stated, were also reviewed.

RESULTS

In our series, there were three girls and 12 boys, nine of whom were full-term infants and six preterm infants. The most common initial manifestations were poor activity, abdominal distension, and respiratory distress. The overall mortality was 47% (7/15). Prematurity was the only statistically significant risk factor; 83% (5/6) of premature infants died compared with 22% (2/9) of term babies (p < 0.05). Combining our series with the patients reported in the literature, there were a total of 50 premature infants and 62 term infants. Gastric perforation occurred on postnatal days 2-7 and presented with nonspecific manifestations. The mortality was significantly higher in premature than in term infants (31/50, 62% vs. 16/62, 26%; p < 0.001). A trend towards higher mortality in infants with lower birth weights was observed (>2500 g, 28%; 1501-2500 g, 52%; 1000-1500 g, 60%; <1000 g, 100%). Infants with birth weights <2500 g had a significantly higher mortality than infants with birth weights >2500 g (32/58, 55% vs. 15/54, 28%; p<0.05).

CONCLUSION

Neonatal gastric perforation is associated with high mortality, particularly in premature infants. There is also a trend towards higher mortality in lower-birth-weight infants.

Bronchopulmonary dysplasia predicts adverse developmental and clinical outcomes in very-low-birthweight infants

This study examined the developmental and clinical outcomes in very-low-birthweight (VLBW; < or =1500g) infants with and without bronchopulmonary dysplasia (BPD) throughout infancy, and assessed if BPD predicted poor developmental outcome beyond the effects of other risk factors. One hundred and three VLBW infants (53 males, 50 females; mean gestational age 28wks [SD 2] birthweight 1041g [SD 261]) were graded for severity of BPD according to the American National Institutes of Health (NIH) consensus definition. Neuro-development was assessed using the Neonatal Neurobehavioral Examination-Chinese version, at 36 and 39 weeks' postmenstrual age, and the 2nd edition of the Bayley Scales of Infant Development at 6 and 12 months' corrected age. Clinical outcome was measured by means of rehospitalization for pulmonary causes and treatment with pulmonary medications. Compared with infants without BPD, infants with BPD had higher rates of clinical morbidity, and those with severe BPD further exhibited higher incidences of developmental delay throughout infancy. BPD predicts poor 1-year developmental and clinical outcomes in VLBW infants for which effects are well correlated to the NIH consensus definition.

Neonatal subgaleal hemorrhage: clinical presentation, treatment, and predictors of poor prognosis

BACKGROUND

Neonatal subgaleal hemorrhage (SGH) is a rare but potentially lethal medical emergency. The objective of the present retrospective study was to clarify the clinical presentation, management, and factors associated with morbidity and mortality.

METHODS

The records of all newborns from January 1995 to December 2004 were reviewed for evidence of SGH, based on the presence of a fluctuating hemorrhagic mass that crossed suture lines and extended toward the neck. Characteristics were compared between those with a poor or a good outcome.

RESULTS

Forty-two newborns with SGH were identified, 77% having had an instrumental delivery. The incidence was 0.6/1000 deliveries and 4.6/1000 vacuum-assisted deliveries. Thirteen patients (31%) had a poor outcome (five died, four had epilepsy, three with severe auditory dysfunction, two with cerebral palsy, and one with renal vein thrombosis). The group with the poor outcome had significantly more patients who had been transferred from other hospitals (P < 0.001). Those with a poor outcome had significantly more hypotension (P < 0.001) and seizures (P < 0.05). Laboratory findings associated with a poor outcome included anemia, coagulopathy, metabolic acidosis, and renal impairment. Other predictors of a poor prognosis included skull bone fracture, the need for pressors, blood transfusion, ventilator support, intensive care unit admission, and a longer hospital stay.

CONCLUSIONS

SGH may be associated with serious complications and death. The condition must be recognized promptly and monitored closely. Those with poor prognostic factors should be referred for intensive care, treated aggressively, and followed in the long term.

Cri-du-chat syndrome

BACKGROUND

Cri-du-chat syndrome is a genetic disorder associated with various sized deletions of the short arm of chromosome 5. There are typical physical features, but individual phenotypes vary considerably.

METHODS

The records of 23 patients with cri-du-chat syndrome admitted to Mackay Memorial Hospital from June 1984 to February 2006 were retrospectively reviewed. Data abstracted from the records included abnormal facial features and physical findings, results of echocardiography, bronchoscopy, auditory evoked potential, visual evoked potential, brain ultrasonography, and karyotype. We examined the various clinical phenotypes to see if there was an association with specific karyotypes.

RESULTS

Among congenital heart conditions, atrial septal defect (8/15, 53%) was the most common, followed by ventricular septal defect (4/15, 26%), tricuspid regurgitation (4/15, 26%) and patent ductus arteriosus (3/15, 20%). Laryngomalacia was the most frequent airway problem (8/23, 34%) and strabismus the commonest visual disorder (1/23). A high percentage of patients had impaired hearing (5/23, 21%). There was no clear relationship found between deletion size and major clinical manifestations in this study.

CONCLUSIONS

Karyotype is not a reliable indicator of specific organ involvement in cri-du-chat syndrome. However, karyotyping is still useful, particularly if parental translocation are found to be involved. It helps for prenatal diagnosis of next pregnancy.

Clinical characteristics and survival of trisomy 13 in a medical center in Taiwan, 1985-2004

BACKGROUND

This study investigated the survival and natural history of trisomy 13 in a series of patients, comparing the management and outcome before and after the implementation of Taiwan's National Health Insurance program (NHI).

METHODS

A total of 28 cases of trisomy 13 seen at Mackay Memorial Hospital, Taipei, Taiwan, from 1985 to 2004 were retrospectively reviewed. Survival and management before (12 cases) and after (16 cases) the implementation of National Health Insurance were compared, and structural defects, imaging findings, and cytogenetic results were analyzed. The cases that were diagnosed prenatally, and finally terminated, were excluded from this study. The diagnosis of trisomy 13 was based on the postnatal chromosome analysis.

RESULTS

All patients except one with trisomy 13 translocation died in their first year because of severe malformations of the cardiovascular or central nervous system. The median survival was 9 days. After implementation of National Health Insurance, survival with trisomy 13 was significantly longer than before (P < 0.05). The three most common structural defects were abnormal auricular helices or low-set ears (89%), cryptorchidism and abnormal scrotum of male (73%) and cleft lip and/or palate (71%). Using echocardiography, the most commonly detected heart defects were patent ductus arteriosus (68%), ventricular septal defect (50%) and atrial septal defect (50%), and eight cases (36%) had complex congenital heart defects. The most common brain lesion was lenticulostriate vasculopathy (22%), followed by holoprosencephaly (17%), brain edema (13%) and subependymal cyst (13%).

CONCLUSIONS

Early diagnosis and the survival patterns from the data collected should be used to inform parents and health-care professionals to assist in decision making. Although most patients with trisomy 13 die within the first weeks after birth, it is important to recognize that a few may survive the first year. When counseling families, the long-term survival prospects of trisomy 13 patients should be included.

Prader-Willi syndrome in Taiwan

BACKGROUND

Prader-Willi syndrome (PWS) is a congenital disorder caused by absent expression of paternal genes in 15q11-13 affecting multiple systems. The information concerning the clinical features of this genetic disorder is incomplete in Taiwan.

METHODS

A retrospective analysis was carried out of 70 PWS patients (39 male, 31 females; age range, 1 month-22 years) seen in four major medical centers in Taiwan from January 1980 through June 2005. All cases were confirmed by methylation-specific polymerase chain reaction. The molecular characteristics, birth history, clinical presentation and laboratory studies were analyzed.

RESULTS

Complete genetic analysis was performed in 52 of the 70 patients with PWS. The abnormalities found included deletions in 45 (87%), maternal uniparental disomy (UPD) in five (10%), and a probable imprinting center deletion or an imprinting defect in two (4%). The average weight of the patients at birth was 2588 +/- 540 g. Bone age delay of >2 years and growth hormone (GH) deficiency were noted in 11/40 (28%) and 12/20 (60%), respectively. In the 18 in whom both bone age and GH were assessed, abnormalities of both were found in two (11%). In 2000, Taiwan instituted the Rare Diseases and Orphan Drugs Act and mandated a three-phase screening protocol for PWS. Of the 41 patients diagnosed with PWS before 2000, only four (10%) were diagnosed before the age of 3 months; in the 29 patients diagnosed after 2000, in 15 (52%) the syndrome was confirmed before 3 months of age (P < 0.001).

CONCLUSIONS

The present finding is in contrast to that of most previous reports that indicated a higher incidence of UPD in PWS. It is unclear whether this discrepancy in the incidence of UPD arises from under-diagnosis or because of ethnic differences, a question worthy of further study. The three-phase screening protocol has generated notable improvement in the early diagnosis of PWS in Taiwan.

Neurodevelopment in very low birth weight premature infants with postnatal subependymal cysts

The aim of this study was to investigate the neurodevelopmental outcome in very low birth weight infants with postnatal subependymal cysts. During a 3-year period, postnatal subependymal cysts were diagnosed by serial cranial ultrasound in 21 very low birth weight infants born prior to 33 weeks' gestation. These infants and 116 healthy very low birth weight controls were evaluated with the Bayley Scales of Infant Development at 2 years of age. Preterm infants with postnatal subependymal cysts had a significantly lower Psychomotor Development Index (P = .034) and were more likely than the normal group to have motor developmental delay (Psychomotor Development Index <70) (P = .013). The findings indicate that postnatal subependymal cyst is a significant risk factor for impaired motor development in very low birth weight infants (odds ratio 5.73, 95% confidence interval 1.57-20.97).

Genetic Variations of HLA-DRB1 and Susceptibility to Kawasaki Disease in Taiwanese Children

Although some previous studies have reported that genetic and immunologic factors play important roles in the pathogenesis of Kawasaki disease (KD), the etiologic factors of this enigmatic pediatric disease are still poorly understood. The purpose of this study was to investigate whether polymorphisms of the human leukocyte antigen DRB1 (HLA-DRB1) gene are associated with KD and the development of coronary artery lesions (CAL) in Taiwanese children. Genomic DNA was extracted from whole blood samples from 145 children with KD and 331 healthy controls. The HLA-DRB1 gene was genotyped by polymerase chain reaction (PCR) and sequence-based typing assays. We found that the distribution of HLA-DRB1 allele families and alleles in children with KD did not differ from that in healthy controls. Stratified analysis did not demonstrate any association between particular HLA-DRB1 allele families or alleles and the development of CAL in children with KD. These findings suggest that susceptibility to KD and CAL is not associated with the HLA-DRB1 gene in a Taiwanese population. If immunogenetic determinants are involved in this disease and its complications in Taiwanese children, they must involve genes other than HLA-DRB1.

Small versus large volume dilute surfactant lavage for meconium aspiration syndrome

BACKGROUND

Surfactant lavage has been used to treat neonatal meconium aspiration syndrome (MAS).

OBJECTIVE

To assess the effects of lavage with a small volume of dilute surfactant in neonates with MAS, and compare the results with those of historical controls treated with larger volumes.

METHODS

From August 2002 to June 2005, we treated 11 newborns with MAS using 20 ml of dilute surfactant at a phospholipid concentration of 10 mg/ml (SVL group). We compared the results with those of 9 infants previously treated with large-volume lavage (LVL group), using 40 ml of dilute surfactant, 5 mg/ml.

RESULTS

Both groups were similar at baseline except for a higher mean birth weight in the LVL group (3.29+/-0.36 vs 2.92+/-0.4 kg, P = 0.04). The lavage procedure was longer in the LVL than the SVL group (48.89 +/-7.41 vs. 30.91+/-5.83 mins, P <0.001). Measures of oxygenation, including mean PaO2, oxygenation index, and arterial/alveolar 02 ratio, showed no significant difference between the two groups. Adverse events in the LVL group included transient hypoxemia in 3 infants and white- out on chest x-ray in 5 cases. None of the patients in the SVL group had these findings. The peak mean airway pressure in.the LVL group was higher than that in the SVL group (16.0+/-2. 65 vs 13.3+/-3.01 cmH2O, P = 0.046).

CONCLUSIONS

SVL has the same benefits in neonatal MAS as LVL. However, SVL appears to be associated with fewer adverse events.

Clinical characteristics and survival of trisomy 18 in a medical center in Taipei, 1988–2004

Trisomy 18 is the second most common autosomal trisomy in newborns. The birth prevalence of this disorder is approximately 1 in 3,000 to 1 in 8,000, and the life span of the majority of patients is less than 1 year. As information regarding outcome in trisomy 18 is rather fragmentary in the literature, this study is aimed at investigating the survival and natural history of trisomy 18. We also evaluated the survival age and management of trisomy 18 in two different periods, before and after the implementation of National Health Insurance (NHI) program. Thirty-nine cases of trisomy 18 were collected in Mackay Memorial Hospital in a 17-year period, from 1988 to 2004. Delivery data, survival age, management before and after the implementation of NHI program, structural defects, image findings and cytogenetic results were analyzed by medical and nurse's records. The diagnosis of trisomy 18 was based on the prenatal amniocentesis or postnatal chromosome analysis. Three patients had trisomy 18 mosaicism. Since cardiovascular and central nervous systems are the most common organ systems involved in this disorder, 31 patients received brain ultrasonography and heart ultrasonography for evaluation of their multiple anomalies after admission. All patients except one died in their first year due to severe malformations of the cardiovascular or central nervous systems. The median survival age was 6 days. We found a longer survival with female patients than with male patients (P < 0.05). Implementation of NHI program in the more recent decade of this study period was associated with longer survival of trisomy 18 (P < 0.05). The three most common structural defects were clenched hands (95%), rocker bottom feet (90%), and low set or malformed ears (90%). Low birth weight was present in 90%. By cardiac ultrasonography, the top four heart defects were ventricular septal defect (94%), patent ductus arteriosus (77%) and atrial septal defect (68%). However, ten cases (32%) had complex congenital heart defects. By brain ultrasonography, the most common brain lesion was cerebellar hypoplasia (32%), followed by brain edema (29%), enlarged cisterna magna (26%) and choroid plexus cysts (19%). Although most patients with trisomy 18 die within the first few weeks after birth, it is important to recognize that a small but notable percentage of these patients will survive the first year. When prenatal or postnatal decisions need to be made, the possibility of long-term survival should be included in any discussion to enable families to make the most appropriate decision.

Infected cephalohematoma of newborns: experience in a medical center in Taiwan

BACKGROUND

The objective of the present retrospective study was to clarify the clinical course, major pathogens, and other infections associated with infected cephalohematoma.

METHODS

From January 1978 to December 2003, records of all newborns were reviewed for evidence of an infected cephalohematoma, based either on local signs of infection or a diagnostic tap that yielded pus. Patients were divided into two groups: those seen in the early period (1978-1990) and in the late period (1991-2003).

RESULTS

Twenty-eight newborns with infected cephalohematoma were identified, 14 each in the early and late periods. The mean age at onset was 17.8 +/- 13.9 days. The most common local findings were erythema (79%), increasing size of the hematoma (68%), and a fluctuant mass (46%), while fever (64%), poor appetite (39%) and irritability (18%) were the common systemic signs. Common laboratory findings included leukocytosis (82%) and an elevated C-reactive protein (61%). Escherichia coli was the most common pathogen (16 patients, 57%) and was isolated significantly more frequently in the late period (early period: 36%, late period: 79%, P < 0.05). Staphylococcus aureus was the second common pathogen (five patients, 18%). Ten patients (36%) had other associated infection: eight had sepsis, three had meningitis, and one had osteomyelitis. In the early period three patients (11%) died.

CONCLUSIONS

Clinicians should be aware that cephalohematoma is a potential site of infection. The incidence of associated system infection is high and may result in mortality. Appropriate diagnostic and therapeutic measures should be undertaken promptly if there are infectious signs.

Cerebral hemodynamic change and intraventricular hemorrhage in very low birth weight infants with patent ductus arteriosus

The aims of this study were to assess the hemodynamics of the cerebral arteries and intraventricular hemorrhage in very-low-birthweight (VLBW) infants with and without patent ductus arteriosus (PDA) by cranial Doppler sonography. VLBW infants with significant PDA were recruited into the study (sPDA) group. Arterial blood gas analysis and complete blood counts were done near the time of the cranial sonography examination. Mechanical ventilator settings and daily fluid intake were recorded. The cranial Doppler sonographic examinations were repeated after PDA closure by indomethacin therapy and/or surgical ligation. A total of 40 preterm infants fulfilled the criteria of the study group. Another 37 preterm infants were recruited into a control group. Mean birth weight and gestational age did not differ significantly between the two groups. Differences in heart rate, blood pH, pCO2, pO2, use of surfactant therapy, mean airway pressure, ventilation index and FiO2 were statistically significant. In the sPDA group before closure of the PDA, the left atrial diameter/aorta diameter ratio demonstrated a positive relationship with resistance index (RI) and an inverse relationship with end diastolic velocities (Vd). After closure of the PDA, these changes neared those of the control group. The overall incidence of intraventricular hemorrhage (IVH) was higher in the sPDA than in the control group. There was no statistical difference in the grading and severity of IVH between the two groups. However, all preterm infants with severe IVH were found in the sPDA group, and their RIs were all higher than 0.80. Cranial Doppler sonography can be a useful tool to evaluate cerebral hemodynamic changes in VLBW infants with sPDA. Increased RI and decreased Vd of the cerebral artery may indicate a probable sPDA, and normalization of the RI and Vd may suggest closure of the sPDA.

Neonatal sepsis in the neonatal intensive care unit: characteristics of early versus late onset

Neonatal sepsis is a major cause of death in newborns despite sophisticated neonatal intensive care. This retrospective study reviewed the clinical characteristics of cases of culture-proven sepsis in a neonatal intensive care unit from January 1992 to December 2001. Patients were divided into those with onset of sepsis in the first 7 days of life (early-onset group) and those with onset after the seventh day of life (late-onset group). A total of 270 cases with 325 episodes of sepsis and 353 isolated pathogens were identified and included in the study. The male-to-female ratio was 1.4. The majority of cases of sepsis occurred in low birth weight (75.9%) and premature babies (76.7%). Late onset occurred in 71.9% of cases. Patients with late onset had a lower mortality rate than those with early onset (11.3% vs 28.9%). Coagulase-negative staphylococci (20.1%) was the most common organism isolated, but infection with Pseudomonas aeruginosa was associated with the highest morality rate (55.0%). Late-onset sepsis was significantly more common in very low birth weight and premature infants. The most frequently encountered pathogens in the early-onset group were group B streptococci (GBS) and Escherichia coli, while in the late-onset group, the organisms were coagulase-negative staphylococci and Enterobacteriaceae, including E. coli, Klebsiella pneumoniae, and Acinetobacter baumannii. GBS infection resulted in the highest mortality when the onset of sepsis was within the first 24 hours of life.

Necrotizing enterocolitis in infants: clinical outcome and influence on growth and neurodevelopment

BACKGROUND AND PURPOSE

Necrotizing enterocolitis (NEC) is a gastrointestinal emergency in neonates. Whether NEC affects infants' growth and development is controversial. The purpose of this study was to explore the clinical characteristics and outcome and to assess the effect of NEC on growth and neurodevelopment in infants.

METHODS

A total of 80 neonates admitted to the neonatal intensive care unit from January 1991 to April 2002 with definite, advanced NEC, including 48 with modified Bell's stage II and 32 with stage III. Sixty six of the patients were premature. Very low birth weight (VLBW) preterm infants without NEC were used as matching controls for the 15 infants with VLBW. The growth and neurodevelopment of patients and controls were assessed using the Bayley Scales of Infant Development-II and compared at 6 and 18 months of corrected age.

RESULTS

NEC developed an average of 27.7 days after feeding began. The most common initial signs were abdominal distension, decreased activity, hematochezia, and abdominal tenderness. Thirty four patients (43%) required surgical intervention. Three infants developed short bowel syndrome after surgical resection. The overall mortality was 24% (19/80) and was mostly associated with extensive bowel involvement and NEC-related sepsis or multiple organ failure. Of the surviving 61 infants, 12 (20%) developed intestinal strictures, 2 in the ileum, 6 in the colon, and 4 in both ileum and colon. Compared with controls, the VLBW infants with NEC were shorter and had delayed psychomotor development at 18 months of corrected age. Mental development, however, did not differ significantly.

CONCLUSIONS

Intestinal stricture was the most common gastrointestinal complication in this series of infants with NEC. Besides the bowel sequelae, VLBW infants who survive NEC are at risk for impairment of growth and neurodevelopment.

Transmission of cytomegalovirus from mothers to preterm infants by breast milk

OBJECTIVES

To assess the risk of transmission of cytomegalovirus (CMV) by breast milk from CMV-seropositive mothers to their breast-fed preterm infants and to evaluate their outcome.

PATIENTS AND METHODS

The study population comprised breast-fed preterm infants with a birth weight of <1,500 g and gestational age of <35 weeks. Venous blood samples from the mothers and infants were tested for CMV IgG and IgM antibodies on the 5th and 30th day after birth. Breast milk was obtained for CMV DNA detection by polymerase chain reaction and viral culture on the 5th day and on the 3rd, 6th and 12th week. Urine samples of the babies were collected at the same time for CMV culture. Neurodevelopmental assessment was done at 6 months of age, corrected for preterm birth.

RESULTS

Thirty-eight mothers and 42 infants (including 4 sets of twins) were enrolled in the study. A mother-infant pair was excluded because of inadequate breast milk collection. Thirty-six mothers (97.3%) were CMV-seropositive. CMV DNA of breast milk was detected in 35 seropositive mothers. Six infants of 5 mothers were infected (infected group) at a mean of 77 days after birth, and 34 infants of 31 mothers were not (noninfected group). In all the mothers of the infected group, CMV virus could be cultured from the milk whey. The average maternal CMV IgG on day 5 after delivery was higher in the infected than in the noninfected group. Sepsis-like symptoms and hyperbilirubinemia were more frequently noted in the infected infants than in the noninfected, but the difference was not statistically significant. Neurodevelopmental outcome did not significantly differ between the 2 groups.

CONCLUSIONS

The risk of CMV infection in breast-fed premature infants was highest when the mothers shed viable virus in their breast milk. These mothers had high CMV IgG, which may help identify those mother-infant pairs at risk. Inactivation of the virus in milk by freezing may be a way of reducing the transmission of this virus via breast milk.

Feeding with premature or infant formula in premature infants after discharge: comparison of growth and nutrition status

We designed this prospective randomized controlled study to evaluate the effects of premature and standard term formula on growth, nutrient intake and biochemical response in premature infants from hospital discharge to 6 months of corrected age. Premature infants with a gestational age of < or =35 weeks and a birth weight < or =1850 gm were assigned to receive premature infant formula (n = 19) or a standard term infant formula (n = 15). No differences were found between the two groups in weight, length, or head circumference at baseline or on follow-up. Infants fed premature formula had higher blood urea nitrogen and phosphorus at 3 months of corrected age. Those on the premature formula also had higher energy intake at 1 month of corrected age. We suggest that premature infants, especially very low birth weight infants, fed preterm infant formula after discharge until 6 months of corrected age tolerate the formula well and may benefit over those standard term formula.

Perinatal tuberculosis in a three-month-old infant

Perinatal tuberculosis is a rare disease with a high mortality rate and is difficult to diagnose. We report a case of perinatal tuberculosis diagnosed by postmortem study at the age of 3 months. An 83-day-old male infant presented with cough for 3 weeks and intermittent fever for 1 week. A focal tonic convulsion occurred on the day of admission. Physical examination revealed failure to thrive, tachypnea, and marked hepatosplenomegaly. Chest roentgenogram showed bilateral nodular alveolar-interstitial infiltrates. Abdominal computed tomography showed multiple nodules in the liver and spleen as well as lymphadenopathy in the hepatic portal hilum. Antituberculous therapies were prescribed on the second hospital day. The patient died from respiratory failure on the sixth hospital day. Mycobacterium tuberculosis was cultured from gastric aspirates and cerebrospinal fluid 4 weeks after inoculation. Postmortem examination revealed disseminated necrotizing granulomas in several organs and tissues, including the porta hepatis lymph nodes, a primary hepatic complex. M. tuberculosis infection was diagnosed in his mother based on positive findings of Mautoux test and chest roentgenogram. This case illustrates that tuberculosis, though rare, still should be considered in poor-weight-gain neonates with cough, fever, and/or hepatosplenomegaly. Careful maternal and other family contact history is essential to establishing the diagnosis.

Characteristics of nosocomial bacterial meningitis in children

Nosocomial meningitis is uncommon in children. We reviewed the medical records of all children who developed bacterial meningitis at least 72 hours after admission to Mackay Memorial Hospital for the period July 1992 through June 2000. Clinical manifestations, predisposing factors, pathogens, and outcomes were analyzed. Twenty-two cases of nosocomial meningitis were identified, comprising 9.2% (22/239) of all pediatric cases of bacterial meningitis during the study period. The male-to-female ratio was 14:8. All patients were younger than 6 months of age except for one, who was 7 years old. The mean duration between admission and onset of meningitis was 15.3 days (range, 3 to 58 days). Twenty-two organisms were isolated, including 13 Gram-negative bacteria (59%) and 9 Gram-positive bacteria (41%). The most common pathogen was Escherichia coli (5 cases), followed by Enterobacter cloacae (3), Staphylococcus aureus (3), and Chryseobacterium meningosepticum (3). Seventeen patients (77%) had concomitant bacteremia. Predisposing factors for acquisition of nosocomial meningitis included previous treatment with broad-spectrum antibiotics (68%), prematurity with very low birth weight (41%), and total parenteral nutrition (32%). Two patients (9%) had previous neurosurgical intervention. Four patients (18%) died, 3 of whom were low birth weight premature infants. Nine patients (41%) had sequelae, including developmental delay, hydrocephalus, hearing impairment, and epilepsy. Neurosurgery was not a significant risk factor for the development of nosocomial meningitis, while very low birth weight played an important role. Previous intraventricular hemorrhage or hydrocephalus, prematurity with very low birth weight, infection with Gram-negative bacteria, and prior broad-spectrum antibiotic administration were associated with poor outcome.

Treatment of severe meconium aspiration syndrome with dilute surfactant lavage

BACKGROUND AND PURPOSE

Despite the development of new adjuvant therapies, meconium aspiration syndrome (MAS) remains a serious respiratory disorder in neonates. Surfactant inactivation by meconium can be overcome by use of exogenous surfactant. This study sought to assess the efficacy and safety of dilute surfactant lavage at 2 different concentrations to treat severe MAS.

METHODS

We retrospectively reviewed the charts of all term infants with a diagnosis of MAS who had an oxygenation index (OI) > 20 during a 2-year period. Tracheobronchial lavage was performed with a dilute surfactant suspension (5 mg/mL or 10 mg/mL) to reach a total dose of 60 to 70 mg/kg of phospholipid, administered in aliquots of 2 mL.

RESULTS

The records of 22 patients were reviewed, of whom 12 had undergone lavage. These patients were subdivided into low-concentration (surfactant concentration, 5 mg/mL; n = 6) and high-concentration (surfactant concentration, 10 mg/mL; n = 6) subgroups. There were no significant differences in demographic characteristics between these 2 subgroups. The lavaged infants had a significantly higher arterial partial pressure of oxygen (PaO(2)) 24 hours after lavage than the infants without lavage (178.3 mm Hg vs 80.6 mm Hg, p < 0.05). The incidence of pneumothorax (1/12 vs 7/10, p < 0.05) and requirement for inhaled nitric oxide (5/12 vs 9/10, p < 0.05) were significantly lower in the lavaged group. All infants tolerated the procedure well except for 2 with transient complications. There were no significant differences in duration of lavage, response and complications between subgroups lavaged at low and high surfactant concentration.

CONCLUSIONS

Early lavage with dilute surfactant solution at a phospholipid concentration of either 5 mg/mL or 10 mg/mL is effective for the treatment of severe MAS. Further large-scale, prospective, randomized, controlled trials are necessary to establish the optimal dose, concentration, surfactant product, and instillation method of this treatment before it can be recommended for routine use.

Thyroid function in children with newly diagnosed type 1 diabetes mellitus

Evaluation of thyroid hormone indices was performed in 138 children with newly diagnosed type 1 diabetes, with their siblings serving as controls. The DKA group consisted of 76 children who had diabetic ketoacidosis (DKA) at initial diagnosis. The non-DKA group consisted of 62 children and the control group of 35. The thyroid function tests of the patients were measured within 3 days of the initial diagnosis of diabetes and at least one follow-up test one month to two years after adequate treatment of diabetes. The DKA group had significantly lower levels of T3, T4, free T4 and FTI than did the other two groups (p < 0.0001, p < 0.0001, p < 0.0001, and p < 0.0001, respectively). T3 concentration was lower in non-DKA subjects than in controls (p = 0.0003), but the two groups did not significantly differ in terms of T4, free T4, and FTI. The TSH level did not differ among the three groups. We conclude that DKA changes thyroid function measurements. In the absence of true thyroid disease, abnormal thyroid function tests are reversible after institution of good diabetic control. We suggest that thyroid function tests should be restricted to those patients suspected of having thyroid disorders at the initial diagnosis of type 1 diabetes.

Horseshoe lung with pseudo-ring-sling complex

We report on a 1-month-old boy who presented with a "horseshoe" lung, complete "O" rings of the trachea, and an unusual course of the left pulmonary artery mimicking a left pulmonary artery sling. Computed tomography, cardiac catheterization, and bronchoscopy were performed to confirm the rare coexistence of these anomalies. To our knowledge, such a combination of anomalies has not been reported in the English-language literature.

Omphalocele and gastroschisis in Taiwan

The purpose of this study was to analyse the clinical differences between omphalocele and gastroschisis in Taiwan, with special reference to associated anomalies and outcomes. A retrospective review was conducted of 115 cases seen between January 1990 and June 2000 at two tertiary medical centres in Taiwan. Data included perinatal events and associated anomalies. Of 115 patients, 65 were classified as having gastroschisis and 50 as having omphalocele. Other anomalies were found in 24 omphalocele cases, compared with 23 gastroschisis cases. The range of anomalies associated with omphalocele varied more widely than in the gastroschisis cohort. Of patients with omphalocele and associated anomalies, six had chromosomal abnormalities compared with none of the patients with gastroschisis. In patients with gastroschisis and additional malformations, 17 had gastrointestinal anomalies, the most common of which was intestinal malrotation. A comparison of perinatal data revealed that infants with gastroschisis were more likely to be small for gestational age. Gastroschisis was associated with a younger overall maternal age than omphalocele and a lower birth weight. There was a male predominance among omphalocele patients, but this did not reach statistical significance.

CONCLUSION

Gastroschisis was frequently associated with intestinal anomalies and transient dysfunction, and outcomes were related to postoperative complications. Infants with gastroschisis more frequently required prolonged parenteral nutrition supplement, resulting in longer hospital stay. Omphalocele was often accompanied by chromosomal disorders leading to early neonatal death, so we recommend that amniocentesis should be indicated if omphalocele is suspected on fetal ultrasonography.

Metabolic disturbance in obese children: glucose, insulin levels and lipid profile

Obesity is a common nutritional disorder among children and adolescents. The purpose of this study was to investigate the biochemical changes in obese children in Taiwan, in comparison with those observed by other authors. Children with weights above 120 percent of ideal body weight were considered obese. Serum glucose, insulin, uric acid, and creatinine levels and lipid profiles of 298 obese children (mean age 11.3 +/- 2.4 years, 158 boys) and 60 controls (mean age 11.6 +/- 2.2 years, 38 boys) were determined using accepted procedures. Demographic and serum biochemical characteristics were compared between obese and control groups overall and by gender. Serum glucose, insulin, cholesterol, and triglyceride levels, known risk factors for coronary heart disease, were higher in the obese patients than in the control group. Early treatment and prevention of childhood obesity may keep the metabolic disturbance from deteriorating and becoming risk factors for coronary heart disease.

Final height of children with type 1 diabetes: the effects of age at diagnosis, metabolic control, and parental height

Normal growth is one of the major goals in the treatment of children with type 1 diabetes. We prospectively monitored the linear growth and metabolic control of 44 children (13 boys) with type 1 diabetes from the time of diagnosis to the attainment of adult height and analyzed the relationship between the height and the age at diagnosis, metabolic control, and genetic target height. At diagnosis, girls at puberty were taller (height in standard deviation score: 0.60 +/- 0.94, p = 0.022), while boys (-0.03 +/- 0.67) and prepubertal girls (0.24 +/- 0.86) were similar to the age-controlled children. During the following years, they lost height compared to their height at diagnosis (p = 0.009), but they still attained an average final height (-0.13 +/- 0.66 in boys, -0.05 +/- 0.86 in girls) correlated with their height at diagnosis (r = 0.37, p = 0.014), as well as their genetic target height (r = 0.78, p < 0.005). The final height as well as the reduction in height was not linearly correlated with the age at diagnosis. The mean HbA1c level of the 44 children was 10.33 +/- 1.74%, boys had better control compared with girls (mean HbA1c 9.45 +/- 1.28 v.s. 10.71 +/- 1.78%, p = 0.013). The final height or the reduction in height was not linearly correlated with the mean HbA1c level.

DQA1*Arg52,DQB1*nonAsp57, and DRB1*04 genotypes in Chinese children with insulin-dependent diabetes mellitus

Ethnic comparisons are extremely important and useful for studying the HLA component involved in insulin-dependent diabetes mellitus (IDDM) predisposition. To date there have been only a few reports on the association of HLA loci and IDDM in Chinese. We report here a study on DQA1*Arg52, DQB1*nonAsp57, and DRB1*04 in IDDM children and control adults among Han Chinese living in Taiwan. One hundred and fourteen unrelated children (62 boys) with IDDM were studied. Their ages at diagnosis were between 0.3 and 15.0 years (6.8 +/- 3.6 years). The control population consisted of 120 randomly selected normal adults. DQA1*Arg52(+/+), DQB1*nonAsp57(+/+), and DRB1*04(+/-) were associated with IDDM (RR = 11.50, 2.21, and 2.82; p = 1.11 x 10(-15), 2.84 x 10(-3), and 1.98 x 10(-4), respectively). DQA1*Arg52, DQB1*nonAsp57, and DRB1*04 conferred risks for IDDM (RR = 12.79, 7.11, and 2.83; pc = 8.22 x 10(-4), 5.35 x 10(-3), and 5.68 x 10(-4), respectively). Combinations of DQA1*Arg52 and DRB1*04 conferred the highest risk for IDDM (RR = 19.64, pc = 5.4 x 10(-5)). DQA1*Arg52 was associated with IDDM in subjects with DQB1*nonAsp57+ (RR = 14.87, pc = 2.41 x 10(-4)) and DQB1*nonAsp57 was also associated with IDDM in subjects with DQA1*Arg52+ (RR = 8.41, pc = 1.54 x 10(-3)), suggesting that DQA1*Arg52 and DQB1*nonAsp57 are interacting. This study demonstrates that DQA1*Arg52, DQB1*nonAsp57, and DRB1*04 confer susceptibility for IDDM to Chinese children. A combination of DQA1*Arg52 and DRB1*04 confers the highest risk and it is suggested that a susceptibility gene might be situated between DQA1*Arg52 and DRB1*04 or both are synergistic. There is an interaction between DQA1*Arg52 and DQB1*nonAsp57 and homozygosity for DQA1*Arg52/DQB1*nonAsp57, which encodes four susceptibility DQ heterodimers, confers a high risk.

Association of CTLA4 gene A-G polymorphism with type 1 diabetes in Chinese children

OBJECTIVE

The CTLA4 (cytotoxic T lymphocyte associated antigen-4) gene encodes the T cell receptor involved in the control of T cell proliferation and mediates T cell apoptosis. Thus it is a strong candidate gene for T cell-mediated autoimmune disease. There is polymorphism at position 49 in exon 1 of the CTLA4 gene, providing a A-G exchange. This polymorphism is reportedly associated with type 1 diabetes in Caucasians but not in a small data set of Chinese. We wished to test this polymorphism in a larger and more homogeneous data set of Chinese children with type 1 diabetes and normal adult controls.

DESIGN

A population-based case-control study of a CTLA4 gene 49 A-G polymorphism was performed to look for an association with type 1 diabetes in Chinese children.

PATIENTS

We analysed this polymorphism in 253 unrelated children (128 boys) with type 1 diabetes (age at diagnosis 7.1 +/- 3.7 years) and 91 randomly selected normal adults. All individuals were Han Chinese.

RESULTS

The genotype and gene frequencies of children with type 1 diabetes differed significantly from those of adult controls (P = 0.0091 and P = 0.0051, respectively). Genotype CTLA4 49 G/G and G allele conferred a risk of type 1 diabetes (RR = 2.13, 95% CI = 1.31-3.46, P = 0.0022; RR = 1.68, 95% CI = 1.17-2.43, P = 0.0051, respectively).

CONCLUSIONS

This study demonstrates that CTLA4 49 A-G polymorphism is associated with type 1 diabetes in Han Chinese children. The CTLA4 49 G allele confers an increased risk of type 1 diabetes.

Thyroid function in the sick very low-birth-weight infants

This study was undertaken to determine postnatal changes in thyroid function in very low-birth-weight (VLBW) infants. A total of one-hundred VLBW infants participated. Serial examination of serum levels of thyroxine (T4), free T4, triiodothyronine (T3), and thyroid-stimulating hormone (TSH) was performed in the neonatal period. A total of eighty-nine infants survived to discharge, while eleven died during hospitalization. Transient hypothyroxinemia was found in forty-one (46.1 percent) of the survivors. One of the surviving infants had primary hypothyroidism. His data was excluded from the analysis. In the other eighty-eight surviving infants, TSH levels were within normal limits throughout the six-week study period. T4 and free T4 values decreased after the first day of life, reaching a nadir at one week of age, followed by progressive increases. The mean cord blood T3 level was very low; the serum T3 value increased progressively in the postnatal period. We found a correlation between low T4 and free T4 values and mortality and neonatal illness. Hypothyroxinemia was associated with critical illness. In conclusion, the postnatal changes in thyroid function in VLBW infants were characteristic, with transient hypothyroxinemia being common in these infants. Further investigation of the relationship between thyroid function, death, neonatal illness, and developmental outcome is warranted.

Cardiovascular function in young patients with type 1 diabetes mellitus

Echocardiographic assessment of cardiovascular function was performed in 47 type 1 diabetic patients and 30 healthy control subjects of comparable age, height, weight, and heart rate. Indexed left ventricular mass, stroke volume, cardiac output, cardiac index, shortening fraction, indexed diastolic dimension, and indexed diastolic volume were calculated and compared between patient and control groups. Left ventricular mass and performance were slightly elevated in type 1 diabetic patients compared with 30 healthy control individuals. However, only cardiac output had borderline statistical significance (p = 0.06). The reason might be short duration (mean, 4.02 +/- 4.07 years) of diabetes in our patients group. In 18 of 47 patients the duration of type 1 diabetes was even less than two years. Relation of left ventricular mass to independent variables showed that, left ventricular mass was significantly correlated with stroke volume (p = 0.008), cardiac index (p = 0.0005), indexed systolic blood pressure (p = 0.0000199), indexed diastolic blood pressure (p = 0.0000172) and left ventricular contractility (p = 0.000273) in diabetic patients. Left ventricular contractility was also independently associated in diabetic patients with the indexed systolic and diastolic blood pressure (p = 0.0000755 and 0.000678 respectively). Albumin excretion, duration of diabetes, glycosylated hemoglobin (HbAlc), serum creatinine, and left ventricular preload did not have significant univariate correlation with left ventricular contractility.

Home oxygen therapy for chronic lung disease in very low-birth-weight infants

Prolonged hospitalization in infants suffering from chronic lung disease who require continuous oxygen therapy can be avoided by oxygen administration at home. In the period from August 1995 to September 1996, 155 very low-birth-weight (VLBW) infants were consecutively admitted to the neonatal intensive care unit of Mackay Memorial Hospital. Of the 155 infants, 72% (111/155) survived to discharge. However, 34% (38/111) of the survivors developed chronic lung disease. Twenty-three infants with chronic lung disease underwent home oxygen therapy after 107.0 +/- 43.6 days of hospitalization. The mean duration of home oxygen therapy was 4.3 +/- 3.4 months. In the first year after discharge, 91% of the patients required rehospitalization. One patient died during the fourth hospitalization. Follow-up information on growth and development at one year of corrected age was available for 19 patients. Five of the 19 patients had a body weight below the 5th percentile. Five of the 19 infants were mentally retarded and 12 of the 19 patients had significantly delayed motor development. In conclusion, carefully supervised home oxygen therapy permits safe early discharge of selected VLBW infants with chronic lung disease. Their somatic and psychomotor development should be carefully followed up.

Atrial flutter in the neonate and early infancy

Atrial flutter is a rare arrhythmia in the neonate and early infancy. We retrospectively reviewed the clinical presentations, treatment and outcome of seven patients who presented clinically with atrial flutter. The age of onset ranged from 1 day to 3 months. Atrial flutter was diagnosed in the first 3 days of life in 4. Three cases presented as atrial flutter with 2:1 atrioventricular conduction and the remaining 4 with variable AV block. Heart failure was present in 3 patients and 6 patients showed normal intracardiac structure on echocardiography. Electrical cardioversion was attempted as the first treatment in 4 cases, followed by digoxin in three of the four. Digoxin was given as an initial therapy in 2 patients. One patient recovered spontaneously without treatment. In the 6 patients who received therapy, 5 converted to normal sinus rhythm within 2 days. The remaining patient had ventricular ectopic beats for about 4 months. Only 2 cases were maintained on oral digoxin for at least 4 months after discharge. No patient had a recurrence of atrial flutter during the follow-up period which ranged from 6 months to 7 years. We conclude that there is a good long-term prognosis for atrial flutter in the neonate. Digoxin and DC cardioversion may be effective as initial therapy. Long-term digoxin prophylaxis after conversion to sinus rhythm may be not necessary.

Early postnatal dexamethasone therapy for the prevention of chronic lung disease in preterm infants with respiratory distress syndrome: a multicenter clinical trial

OBJECTIVES

To study whether early postnatal (<12 hours) dexamethasone therapy reduces the incidence of chronic lung disease in preterm infants with respiratory distress syndrome.

MATERIALS AND METHODS

A multicenter randomized, double-blind clinical trial was undertaken on 262 (saline placebo, 130; dexamethasone, 132) preterm infants (<2000 g) who had respiratory distress syndrome and required mechanical ventilation shortly after birth. The sample size was calculated based on the 50% reduction in the incidence of chronic lung disease when early dexamethasone is used, allowing a 5% chance of a type I error and a 10% chance of a type II error. For infants who received dexamethasone, the dosing schedules were: 0.25 mg/kg/dose every 12 hours intravenously on days 1 through 7; 0.12 mg/kg/dose every 12 hours intravenously on days 8 through 14; 0.05 mg/kg/dose every 12 hours intravenously on days 15 through 21; and 0. 02 mg/kg/dose every 12 hours intravenously on days 22 through 28. A standard protocol for respiratory care was followed by the participating hospitals. The protocol emphasized the criteria of initiation and weaning from mechanical ventilation. The diagnosis of chronic lung disease based on oxygen dependence and abnormal chest roentgenogram was made at 28 days of age. To assess the effect of dexamethasone on pulmonary inflammatory response, serial tracheal aspirates were assayed for cell counts, protein, leukotriene B4, and 6-keto prostaglandin F1alpha. All infants were observed for possible side effects, including hypertension, hyperglycemia, sepsis, intraventricular hemorrhage, retinopathy of prematurity, cardiomyopathy, and alterations in calcium homeostasis, protein metabolism, and somatic growth.

RESULTS

Infants in the dexamethasone group had a significantly lower incidence of chronic lung disease than infants in the placebo group either judged at 28 postnatal days (21/132 vs 40/130) or at 36 postconceptional weeks (20/132 vs 37/130). More infants in the dexamethasone group than in the placebo group were extubated during the study. There was no difference between the groups in mortality (39/130 vs 44/132); however, a higher proportion of infants in the dexamethasone group died in the late study period, probably attributable to infection or sepsis. There was no difference between the groups in duration of oxygen therapy and hospitalization. Early postnatal use of dexamethasone was associated with a significant decrease in tracheal aspirate cell counts, protein, leukotriene B4, and 6-keto prostaglandin F1alpha, suggesting a suppression of pulmonary inflammatory response. Significantly more infants in the dexamethasone group than in the placebo group had either bacteremia or clinical sepsis (43/132 vs 27/130). Other immediate, but transient, side effects observed in the dexamethasone group are: an increase in blood glucose and blood pressure, cardiac hypertrophy, hyperparathyroidism, and a transient delay in the rate of growth.

CONCLUSIONS

In preterm infants with severe respiratory distress syndrome requiring assisted ventilation shortly after birth, early postnatal dexamethasone therapy reduces the incidence of chronic lung disease, probably on the basis of decreasing the pulmonary inflammatory process during the early neonatal period. Infection or sepsis is the major side effect that may affect the immediate outcome. Other observable side effects are transient. In view of the significant side effects and the lack of overall improvement in outcome and mortality, and the lack of long term follow-up data, the routine use of early dexamethasone therapy is not yet recommended.

Frequency of associated anomalies in congenital hypoplasia of depressor anguli oris muscle: a study of 50 patients

Aside from congenital heart disease, anomalies associated with unilateral hypoplasia of the depressor anguli oris muscle have not been well-documented in large series. We evaluated the associated anomalies in 50 infants or children with this disorder (male:female = 2:1) and found accompanying anomalies in 35 (70%) of 50 cases. They included anomalies of the head and neck (48%), heart (44%), skeleton (22%), genitourinary tract (24%), central nervous system (10%), gastrointestinal tract (6%), and miscellaneous minor anomalies (8%). Nearly half of our cases (22/50) had at least 2 associated systemic anomalies. Failure to thrive and psychomotor retardation were found in 5 (10%) and 3 (6%) patients, respectively, on follow-up. Three infants died neonatally of severe heart disorders, and the other one died of central nervous system anomalies. The above findings indicate that a thorough search for associated anomalies, particularly in the cardiovascular system, should be performed in all newborns with asymmetric crying face.

Clinical experience with early enteral feeding in very-low-birth-weight infants

The primary objective of this study was to evaluate the safety and benefit of early enteral feeding in very-low-birth-weight (VLBW) infants without parenteral nutrition. Weight gain, feeding intolerance, nosocomial infection rate and a postnatal growth curve were recorded for 61 VLBW premature infants who were admitted to the Neonatal Intensive Care Unit of Mackay Memorial Hospital from September 1, 1995 to February 28, 1997. Nine infants were unable to complete the study and three were excluded because of severe bronchopulmonary dysplasia; therefore only 49 infants could be evaluated. They were divided into two groups based on birth weight: 1001 gm to 1250 gm (Group A, mean birth weight 1153 +/- 64 gm, mean gestational age 29.0 +/- 2.2 weeks), and less than or equal to 1000 gm (Group B, mean birth weight 911 +/- 82 gm, mean gestational age 27.1 +/- 1.5 weeks). They received breast milk or premature formula by intermittent nasogastric or continuous nasogastric feeding. Growth was followed over the first 30 postnatal days. Group A reached 100 kcal/kg/day of enteral feeding at a mean age of 17 days as compared with a mean age of 20 days for group B. Infants regained their birth weight at 20 and 25 days in Groups A and B, respectively. By the 30th postnatal day, weight gain exceeded birth weight by 218.2 +/- 143.1 gm and 95.3 +/- 81.5 gm in groups A and B respectively. No definite episodes of necrotizing enterocolitis (NEC) developed. Two cases of Escherichia coli sepsis and one of Klebsiella sepsis occurred. The conclusion was that early enteral feeding in very-low-birth-weight infants does not increase the risk of NEC. It was also demonstrated that enteral feeding alone can produce biphasic postnatal growth curves in very-low-birth-weight infants. Although early enteral feeding was well tolerated in the study infants, the occurrence of feeding intolerance in some (36%) would suggest that additional parenteral nutrition may benefit some infants until full enteral feeding can be achieved.

Pancreatitis in children--experience with 43 cases

Pancreatitis in children is not common and can be associated with severe morbidity and mortality. We encountered 43 children, ranging in age from 2 to 18 years, with pancreatitis over the past 10 years. The diagnosis of pancreatitis was made in those patients who showed: (1) significant intra-operative pathology or; (2) clinical findings of pancreatic inflammation and laboratory confirmation. More than one third (16 cases) of the cases were due to trauma, other causes included systemic disease (10), structural disease (8), and toxins or drugs (4). Five cases were classified as idiopathic. Most of the patients presented with abdominal pain (95%) and vomiting (56%). Jaundice was found in 7 patients and an abdominal mass in 2. Morbidity included pseudocyst (10), relapse (4), hyperglycaemia (4) and miscellaneous problems. Eight (50%) of the patients with trauma and 6 (86%) of the patients with structural diseases required surgery. Other patients were managed conservatively with bowel rest, gastric decompression, intravenous fluid and total parenteral nutrition. One case had a fatal outcome. All the survivors did well in long term follow up. Relevant literature has been reviewed and the sensitivity of various diagnostic modalities compared and discussed. A lesser known association between pancreatitis and structural anomalies such as choledochal cyst is discussed. To our knowledge, the present review is the first on pancreatitis in Chinese children.

CONCLUSION

Pancreatitis can occur from a wide variety of causes and may result in severe complications. Early diagnosis, close monitoring and aggressive intervention are mandatory to reduce morbidity and mortality.

Neurogenic diabetes insipidus in children with hypoxic encephalopathy: six new cases and a review of the literature

Hypoxic encephalopathy is rarely mentioned as a cause of neurogenic diabetes insipidus (DI) in children. We here report six cases of DI which occurred after severe hypoxic/ischaemic brain damage and include a review of the literature on 28 paediatric cases of neurogenic DI due solely to severe hypoxia/ischaemia. Airway obstruction, haemorrhagic shock and sudden infant death syndrome are the three major causes of hypoxia/ischaemia. The ages (25/28) ranged from 0.03 to 18 years (mean 7.27 years, median 5 years). The intervals between the hypoxic insult and the onset of DI (23/28) ranged from 0.08 days (2 h) to 13 days (mean 4.07 days, median 3.5 days). Linear regression analysis revealed no significant correlation between the age and the interval. Nineteen cases (82.6%) developed DI within 6 days after the hypoxic/ischaemic insult. Only two neonates survived with developmental delay. The remaining 26 cases died.

CONCLUSION

Neurogenic DI can be caused by hypoxia/ischaemia and is an ominous sign of severe brain damage in children with hypoxic encephalopathy. It is important to recognize this potential sequel by regularly monitoring intake and output, plasma sodium level, and urine specific gravity.

Continuous infusion of vasopressin in comatose children with neurogenic diabetes insipidus

Three comatose children with neurogenic diabetes insipidus were treated with intravenous infusion of vasopressin. The infusion of vasopressin was started at a dose of 1.3 to 2.7 mU/kg/h as soon as diabetes insipidus was diagnosed. The effect (urine flow < 2 ml/kg/h with increased specific gravity) was noted in 1 to 6 hours. The infusion rate of vasopressin was adjusted according to urine flow rate which was usually kept around 65 ml/100 kcal metabolized/day. Hypernatremia was corrected 17 to 53 hours after the initiation of infusion of vasopressin. The levels of sodium stayed between 127 and 151 mmol/l during a period of 2.5 to 22 days until the patients' death due to the termination of respiratory support or cardiac decompensation. A continuous infusion of vasopressin offered the advantage of rapid onset and termination of effect and therefore could be easily titrated. It seems a rational therapy for comatose children with neurogenic diabetes insipidus.

Neonatal-onset chronic intestinal pseudo-obstruction syndrome

Between January 1985 and January 1990, six cases of neonatal-onset chronic intestinal pseudo-obstruction syndrome (CIPS) were identified. Failure to gain weight in six cases, abdominal distention in five, and vomiting in five were the most common presenting symptoms. The contrast studies of the gastrointestinal tract demonstrated delayed transit time in 6/6, jejunal or ileal dilatation in 1/6, megaduodenum in 1/6, dilatation of the colon with barium retention in 4/6, and microcolon in 1/6. Urinary tract involvement was noted in three patients. Laparotomy, performed in three patients, revealed no mechanical obstruction. Except for hypoganglionosis in Patient 4, no recognizable neuropathy or myopathy was noted histopathologically. Four patients expired within 2 months after discharge. We conclude that CIPS with neonatal onset should be suspected when infants have urinary retention and abdominal distention or constipation beginning at birth or soon after. The prognosis of CIPS presenting in the newborn period appears worse than that presenting in childhood or adulthood.

The VATER association: analysis of forty six cases without karyotyping

Forty-six patients with two or more features of the VATER association admitted to the Mackay Memorial Hospital from May, 1983 to Mar, 1992 were retrospectively enrolled in this study. We compared the incidence of major features with that reported in the literature. Imperforate anus, congenital heart disease, and renal anomalies were the three most common major features in our study. Thirteen patients died. Heart failure was the major cause of mortality. We noted many patients associated minor features, and among them there was a relatively high ratio of cleft lip, cleft palate, and hypospadius. The overall outcome and development were good among the survivals. We suggest that children who have any congenital anomaly included in the VATER association should get a careful examination and evaluation of their heart, genitourinary tract, limbs and vertebrae. Early correction if possible is indicated in such patients.

Urinary tract infection in infants less than 2 months of age

Ninety-five infants, less than 2 months of age, diagnosed as urinary tract infections, from July 1984 to June 1991, were reviewed. Their urinary cultures, obtained either by suprapubic puncture or via catheterization, all had bacterial colony counts of over 10(5)/ml. In this survey, males predominated (91.6%). Fever and gastrointestinal problems were the two most prevalent signs. E. coli was the most common causative organism, and gentamicin was the most effective antibiotic. Vesicoureteral reflux (VUR), the most common anomaly, was found in one-third (25/76) of patients on voiding cystourethrography, with 20% being high grade (Gr. IV or Gr. V). Eleven cases (11%) had bacteremia, and one case had bacterial meningitis. Sixty-seven cases were followed up in our hospital and seven of them had second infections within a year of their first UTI. The mean period between episodes was less than two months. All these patients had urinary tract anomalies and received oral chemoprophylactic drugs for variable lengths of time. Five of the seven recurrences were caused by resistant bacilli. Continuous oral antibiotic prophylaxis and regular follow-up examinations were the rules of prevention for further infection and future renal impairment. These preventive methods are especially important in young infants with UTI.

Bilious vomiting during the first week of life

From Nov. 1988 to Nov. 1991, forty-five newborns, who were admitted due to bilious vomiting within the first 7 days of life followed prospectively. Twenty-three (51.1%) required surgical intervention, and the remaining twenty-two (48.9%) had nonsurgical conditions. Clinical findings of green vomitus, abdominal distension, lethargy, irritability and abdominal tenderness are more likely to indicate the need for surgery. But the onset of vomiting and time of first stool passage are not helpful in detecting the need for surgery situation. Initial routine plain abdominal roentgenogram is helpful in distinguishing infants with surgical or nonsurgical problems. Sixteen infants with normal plain abdominal roentgenograms had nonsurgical conditions. Specific findings on the plain abdominal roentgenogram were noted in 23 infants, and 19 (82.6%) of these needed surgical intervention. Contrast studies were indicated for those without signs of complete obstruction, perforation or peritonitis, but the plain abdominal roentgenogram was abnormal and clinical condition did not improved.