Prophylaxis of symptomatic patent ductus arteriosus with oral ibuprofen in very low birth weight infants.

BACKGROUND: Patent ductus arteriosus (PDA) is a common cause of mortality and morbidity among very low birth weight infants. Oral ibuprofen suspension has been shown to have the same efficacy and safety as intravenous indomethacin in the prevention and treatment of symptomatic PDA. With lower dosage, the prevalence of side effects may decrease without changes in efficacy. OBJECTIVE: To evaluate the efficacy and side effects of low dose ibuprofen suspension for prevention of symptomatic PDA in very low birth weight infants. PATIENTS AND METHOD: A prospective, double blind, randomized controlled trial was conducted on premature neonates with gestational ages between 28-32 weeks, birth weight 1500 grams or less, at the Neonatal Unit, Queen Sirikit National Institute of Child Health (QSNICH) during October 2005 to October 2006. Only infants who had PDA on echocardiogram were included in the study. Three doses of ibuprofen suspension or placebo were randomly given at the dosage of 10, 5, 5 mg/kg every 24 hours. Daily physical examination, serial laboratory evaluation and echocardiogram were used to evaluate symptomatic PDA, complications and side effects. RESULTS: Sixty-two infants were recruited in the study and randomly assigned into the study and control group. The gestational age and birthweight of the 2 groups were similar The prevalence of symptomatic PDA was less in the ibuprofen group than in placebo group (9.86% vs. 35.48%; p = 0.015). There were no differences in the prevalence of complications and adverse effects between the two groups. CONCLUSION: Prophylactic oral ibuprofen suspension at lower dosage results in less symptomatic PDA without significant side-effects.

Comparison outcomes of surfactant therapy in respiratory distress syndrome in two periods.

BACKGROUND: Exogenous surfactant replacement therapy has been a part of the routine care of preterm neonates with respiratory distress syndrome (RDS) since 1990s. In Thailand, the utilization of surfactant replacement therapy had been limited due to the high cost until the National Health Insurance Policy began in 2003 which covered the cost of surfactant. Nowadays surfactant replacement therapy is more frequently used at Queen Sirikit National Institute of Child Health, so the authors were interested in evaluating its use in RDS. OBJECTIVES: To compare the outcome and complications of surfactant replacement therapy in newborns who were diagnosed with moderate to severe RDS during two times period. STUDY DESIGN: Retrospective study. MATERIAL AND METHOD: The data of infants who were diagnosed as moderate to severe RDS and treated with surfactant at Queen Sirikit National Institute of Child Health between January 1st, 2003 and December 31th, 2005 were reviewed. The outcome of this study (Group II) was compared to the previous study conducted in 1999-2002 (Group I). The complications, mortality rate, association time of start surfactant and duration of ventilation were reviewed. RESULTS: The data of ninety-one moderate to severe RDS patients who received surfactant replacement therapy were reviewed. The mean birth weight and gestational age in this group were 1250 +/- 435.57 gm and 29.38 +/- 2.2 week less than in the first group 1,344 +/- 452.37gm and 29.69 +/- 2.61 week. The second group showed statistical differences in antepartum hemorrhage (4.4%) and pregnancy induced hypertension (PIH) (17.6%) while the first group had 33.3% ofantepartum hemorrhage and 3% of PIH. In neonatal conditions, there were statistical significant differences in anemia 28.6% in group II compared to 9% in group I and patent ductus arteriosus 67% in group II compared to 39.4% in group I. Surfactant was given earlier in life (4.75 +/- 2.76 hours) in the second group compared to the first group (7.21 +/- 4.92 hour) and the overall duration ofpatients on mechanical ventilation in Group II (6 days) was shorter than in Group I (16 days). This was especially more evident in patients who received surfactant within the first six hours of life. The immediate complication, pulmonary hemorrhage was found in more cases in Group I (33.3%) than in Group II (12.1%) but bronchopulmonary dysplasia (BPD) was found to be a late complication in more cases in Group II (46.1%) than in Group I (21.2%). The mean length of admission was longer in Group II (61.23 +/- 41.08 days) compared to Group I (38.5 +/- 23.48 days) and the mortality rate in Group II was 18.7% (17 cases) lower than Group I 33.3% (11 cases). CONCLUSION: Surfactant therapy in moderate to severe RDS can shorten the duration of ventilation and decrease the mortality rate, but has no effect in decreasing the incidence of chronic lung disease. Nevertheless the earlier the surfactant therapy is started, the higher the survival rate.

Inhaled nitric oxide in newborns with severe hypoxic respiratory failure.

BACKGROUND: Respiratory failure in term and near term infants is often associated with persistent pulmonary hypertension of the newborn and contributes to hypoxemia in these infants. Inhaled nitric oxide (iNO) is currently used as a pulmonary vasodilator to improve oxygenation in neonates with severe respiratory failure. OBJECTIVE: To determine outcome of administration of iNO in severe hypoxic respiratory failure. MATERIAL AND METHOD: The present study was conducted from 1999 to 2004 in the neonatal intensive care unit (NICU) at Queen Sirikit National Institute of Child Health. Patients were selected from all infants > or = 34 weeks gestational age who required high frequency oscillatory ventilation (SLE 2000 HFO, SLE, UK) or conventional mechanical ventilation for hypoxemic respiratory failure caused by PPHN. Diagnosis was confirmed by 2-D echocardiogram visualization with right to left shunt through the foramen ovale or patent ductus arteriosus. Inhaled nitric oxide was given as standard therapy in patients who had two oxygenation indices > or = 20 at least 30 minutes apart after being on a mechanical ventilator. RESULTS: Fifty-five cases were enrolled and male to female ratio was 22.2 tol. The survival rate was 76.4 percent. Inhaled nitric oxide significantly improved oxygenation index, arterial alveolar oxygen tension ratio (a/A O2), and alveolar arterial oxygen gradient in survivors at one hour after treatment. The earliest improvement in oxygen saturation was within ten minutes. Meconium aspiration syndrome was the most common underlying cause of PPHN. No acute complication was found during nitric oxide administration. Chronic lung diseases, delayed development and severe hearing loss in long-term follow up were found in 10, 5, and 2 cases, respectively. CONCLUSION: Inhaled nitric oxide should be used early in severe hypoxic respiratory failure with persistent pulmonary hypertension of newborn and can improve survival rates without any major immediate side effects.

Outcome of maternal syphilis at Rajavithi Hospital on offsprings.

BACKGROUND: Syphilis remains an important sexually transmitted disease and continues to be an important problem in Thailand. Despite the clinical efficiency of penicillin in the treatment of pregnant patients with syphilis, infants with congenital syphilis are still encountered. Congenital syphilis poses significant challenges for the clinician because infants may be asymptomatic at birth or present with a highly variable clinical picture. OBJECTIVES: To evaluate the outcomes of neonates born to syphilitic mothers, the efficacy of antepartum treatment in the prevention of congenital syphilis and treatment for congenital syphilis after delivery. MATERIAL AND METHOD: The surveillance conducted from September 1st, 2002 to December 31st, 2003, involved 63 mothers who were diagnosed with syphilis and their offsprings at Rajavithi Hospital, Bangkok, Thailand. Sixty-four infants had complete physical examination, growth, development and laboratory evaluation at Queen Sirikit National Institute of Child Health at the time of delivery and at the ages of 1, 2, 4 and 6 months. RESULTS: There were 63 mothers and 64 infants recruited in the present study. Fifty-three mothers had prenatal care (84.13%). The VDRL was positive in the first prenatal care visit in 42 mothers (66.67%) and 11 mothers (17.46%) had seroconversion later on. Maternal treatment for syphilis included adequate penicillin 23 cases (36.51%), inadequate penicillin 5 cases (7.94%), erythromycin 9 cases (14.29%) and 26 mothers (41.27%) received no treatment at all. The mean maternal age, mean gestation age at treatment for syphilis and at delivery were 30.31 +/- 5.60 years, 32.75 +/- 6. 73 weeks and 38.60 +/- 1.57 weeks respectively. Failure rate in the adequate penicillin group was 8.7%. The mean birth weight of the 64 infants was 3034 +/- 495 grams, no syphilitic stillbirth occurred. Nine infants (14.06%) were identified with presumptive congenital syphilis. The manifestation include hepatomegaly (55.56%), desquamation of palms and soles (44.44%), radiological changes (33.33%) and abnormal cerebrospinal fluid (25%). The fluorescent treponemal antibody absorption immunoglobulin M (FTA-ABS IgM) tests of the infants were positive in 2 out of 9 cases (22.22%). The range of maternal and neonatal VDRL titer were between weakly reactive to 1.32 and nonreactive to 1:32 respectively. Fifty infants (78.13%) including 9 presumptive cases were followed-up, all had normal growth. Thirty-four infants (68%) who had re-evaluation for VDRL titers, were seronegative. CONCLUSION: Penicillin is the effective treatment of pregnant patients with syphilis and infants with congenital syphilis. The high risk of congenital syphilis correlates with untreated mothers and inadequate maternal syphilis treatment.

Effect of cisapride on corrected QT interval in neonates.

OBJECTIVE: To evaluate the effect of cisapride on corrected QT (QTc) interval in neonates at the Queen Sirikit National Institute of Child Health. METHOD: A prospective study was performed to see the effects of cisapride on QTc interval in 20 neonates between 1st July 2001 and 31st January 2002. QTc interval was determined just before, 48 hours, 7 days and 15 days after the start of treatment with cisapride. QTc interval was calculated by averaging QT/square root(RR) values obtained from 5 consecutive beats in lead II of the EKG. Baseline electrolyte and calcium levels were drawn on all infants before treatment of cisapride. Drug dose ranged from 0.1-0.2 mg/kg every 6 to 8 hours. RESULTS: Twenty infants were enrolled in the survey but complete data was obtained on 18 infants only. QTc interval of > 0.45 seconds was not found in any neonate. There was no significant difference of QTc interval before and 48 hours, 7 days and 15 days after cisapride administration (p = 0.861). There were also no statistically significant effects of age at starting cisapride, weight, gestational age and dose on QTc interval (p = 0.581, 0.65, 0.8, and 0.497). There were no adverse effects such as diarrhea or jaundice during the study. CONCLUSION: Term and preterm infants using cisapride at the doses of 0.4-0.8 mg/kg/day did not develop QTc prolongation, arrhythmias or adverse effects. In the absence of risk factors, cisapride may be safe for use in neonates.

Medication errors at Queen Sirikit National Institute of Child Health.

BACKGROUND: In the past two years, medication errors have been recognized as having been unacceptably high among hospitalized patients. OBJECTIVE: To determine the incidence and type of medication errors, severity of events, patient outcomes and categories of drugs involved in the largest pediatric hospital in Thailand over a fifteen-month-period. PATIENTS AND METHOD: Retrospective review of in-patient medication errors documented in standard reporting forms from September 2001 to November 2002. Main outcome measure was the incidence of errors reported. RESULTS: Medication errors occurred in 1 per cent of admissions (322 errors of 32,105 admissions). The most common error type was prescription error (35.40%). The majority of errors were detected and prevented before the drugs were administered (76.71%). There was only one case of permanent brain damage; no deaths occurred in the study period. The most common group of drugs involved in medication errors was antibiotics and the most common route of administration was oral. CONCLUSION: Medication errors are not uncommon. There is a need to change the behaviors of recognizing and acknowledging clinical errors, including drug errors. Careful review of errors highlights the many opportunities to change how drug errors are addressed and to make them less likely.