Adverse Effects of Chloral Hydrate in Neonates: Frequency and Related Factors

PURPOSE: Chloral hydrate is a common drug frequently used for procedural sedation. But data on chloral hydrate use in the newborns are limited. This study examined the frequency of adverse effects of chloral hydrate and factors related to the adverse effects. We also examined if there were additional adverse effects when an additional sedative was used. METHODS: The medical records of 104 patients admitted to neonatal intensive care unit of Seoul St. Mary's Hospital from March 2010 to February 2011 who used chloral hydrate for procedural sedation were retrospectively reviewed. RESULTS: Adverse effects after administration of chloral hydrate were noted in 41.3% of the 104 patients. The adverse events included oxygen desaturation (18.8%), increase in apneic episodes (17.5%), increase in bradycardia (10%), and feeding intolerance (3.8%). Using oxygen at the time of chloral hydrate administration was independently associated with adverse effects (odds ratio [OR], 10.911; 95% confidence interval [CI], 2.082-57.178) and with the necessity for an additional sedative after administration of chloral hydrate (OR, 4.151; 95% CI, 1.455-11.840). Using one additional sedative agent after chloral hydrate showed no difference in adverse effects except feeding intolerance. CONCLUSION: Patients dependent on oxygen at the time of chloral hydrate administration may were found to be at higher risk for adverse effect of chloral hydrate and for an additional sedative. When an additional sedative is needed, it could be used with monitoring feeding intolerance after chloral hydrate administration.

The Relationship between the Timing of Gestational Diabetes Screening and HbA1c Level and Neonatal Outcome / 대한진단검사의학회지

BACKGROUND: The aim of this study was to observe clinical outcomes of the mother and her infant who were possibly exposed to high blood glucose at least 2-3 months in the early and midterm pregnancy by checking gestational weeks (GW) and the first HbA1c level at initial diagnosis of gestational diabetes (GDM). METHODS: A total of 107 GDM patients and their newborns were subject of this study. GDM patients were newly diagnosed at the Holy Family Hospital of Catholic University from January 2003 until December 2007 and continuously managed in the diabetes center. Patients medical records were retrospectively reviewed to evaluate GW and HbA1c level at the time of diagnosis, and clinical outcomes of mother and newborn baby. RESULTS: The proportion of subjects who had been diagnosed of having GDM according to GW was 7.5%, in less than 24th week of pregnancy; 55.1% in the 24-28th week; 28.0% in the 29-32nd week; and 9.4% 33rd week or more. There were 39 out of 107 subjects (36.4%) with HbA1c levels > or =6.5% and 26 out of 39 subjects (24.3%) with HbA1c levels > or =7.0%. In clinical outcomes of newborn by HbA1c levels, the frequency of delivery of large for gestational age (LGA) infant was higher in mothers diagnosed with GDM after 29th week of pregnancy or with HbA1c levels 7.0% or more (P<0.001). CONCLUSIONS: If the screening test for gestational DM was delayed, HbA1c level and the risk for LGA seemed to be higher, so it may be necessary to screen GDM no later than 24th week of pregnancy.

What can we do for dying neonate in NICU? / 소아과

Death is not only a medical problem; it is also an ethical problem. When doctors face a dying neonate, their knowledge of bioethics and the opinions of ethical specialists and religious leaders are helpful for them and the family of the dying baby. In recent years, due to the increase of surviving babies who have suffered from severe illness, those born too small or too early, and those with severe anomalies in neonatal intensive care unit (NICU), we have met with complicated bioethical problems frequently. To lessen the burdens of doctors and the parents of the dying baby, I reviewed medical, ethical and religious articles about bioethics in adult death. My suggestions are listed as follows: 1) regular bioethical education and activation of bioethical committees in NICU, 2) a well-controlled nationwide database, 3) a hospice unit space and programs for dying baby in NICU, and 4) social support for pregnant women and financial support for the NICU.

Hepatobiliary Dysfunction in Very Low Birth Weight Infants Supported with Parenteral Nutrition

PURPOSE: The objective of this study was to describe the frequency of hepatobiliary dysfunction (HD) at our hospital and determine the possible risk factors and complications associated with the development of HD in very low birth weight infants (VLBWI) treated with parenteral nutrition (PN). METHODS: A retrospective study of VLBWI (n=92) that required PN between 2004 and 2008 in the NICU at the Bucheon St. Marys Hospital of Catholic University was performed. HD was defined by a direct bilirubin (DB) >2 mg and a transaminase of 60 IU/L defined cholestasis and liver injury. Groups I, II, and III were limited to cases of cholestasis, liver injury without cholestasis, and no abnormalities, respectively. The VLBWI were compared to each other. RESULTS: Thirty-six subjects (39.1%) had cholestasis and 51 (55.4%) had liver injury. In addition, 36 (39.1%), 19 (20.7%), and 37 (40.2%) subjects were classified as groups I, II, and III, respectively. The three groups showed significant differences in gestational age, 1- and 5-minute Apgar scores, use of surfactant, duration of parenteral nutrition, frequency of RBC transfusions, bronchopulmonary dysplasia (BPD), and patent ductus arteriosus (PDA) (P<0.05). The multiple regression analysis with cholestasis as the dependent variable, showed a significant correlation with gestational age, use of surfactant, frequency of RBC transfusions, and PDA. CONCLUSION: Various factors, such as birth weight, gestational age, 1- and 5-minute Apgar scores, use of surfactant for respiratory distress syndrome (RDS), frequency of RBC transfusions, BPD, and PDA may be related to hepatobiliary dysfunction in VLBWI treated with PN.

Oxygen Desaturation during Nutritive Sucking in Premature Infants with Bronchopulmonary Dysplasia: Its Effect on Feeding and Growth until 4 Months of Corrected Age

PURPOSE: This study examined the occurrence of oxygen desaturation events during nutritive sucking in premature infants with bronchopulmonary dysplasia (BPD) and its effects on feeding and growth outcomes until 4 months of corrected age (CA). METHODS: Thirty-four premature infants with BPD free from major cardiac, gastrointestinal, respiratory anomalies were included. By reviewing medical records, clinical characteristics, feeding conditions at 36 weeks of postmenstrual age (PMA), we focused on oxygen desaturation, and short-term outcomes in 14 infants with no or mild desaturation (group A) and in 20 infants with moderate or severe desaturation (group B). RESULTS: Group B had lower birth weight and shorter gestational age at birth, longer duration of hospitalization, was discharged at higher weeks of PMA, and needed ventilatory assist and oxygen supplementation longer than group A (P<0.05). Group B started nutritive sucking later, with a greater decrease in SpO2 during sucking, being more indicative of feeding problems at 40 weeks of PMA, but not at 4 months of CA. Percent of infant needing oxygen supplementation and percent of infants with growth failure were not different between groups at 40 weeks of PMA and 4 months of CA. Body weight and growth velocity differences noted at 40 weeks of PMA became insignificant at 4 months of CA. CONCLUSION: The severity of desaturation during nutritive sucking in premature infants with BPD influenced the infant's feeding and growth at 40 weeks of PMA. However, it disappeared at 4 months of CA.

Perinatal Outcomes Associated with Oligohydramnios in Full-Term Neonates

PURPOSE: The purpose of this study is to identify whether oligohydramnios in uncomplicated term pregnancies has an independent effect on perinatal outcome. METHODS: From Jan 2001 to Dec 2005, all uncomplicated pregnancies between 37 and 41(+6)weeks were included. Perinatal outcome was compared between cases with amniotic fluid index (AFI) 5 (n=3,117), which is determined by measuring the vertical diameter of amniotic fluid pockets in four quadrants; an AFI less than 5 suggests oligohydramnios. Exclusion criteria were premature rupture of membranes, maternal diabetes, pregnancy induced hypertension, clinical suspicion of fetal growth restriction and fetal anomalies. Outcome measures were birth weight, small for gestational age neonates, Apgar score <7, meconium stained amniotic fluid, meconium aspiration syndrome, hospital day, NICU admission, fetal distress and use of neonatal resuscitation. RESULTS: An AFI < or =5 was reported in 7.7% of cases. No significant differences in gestational age at delivery, nulliparity and maternal age were found in both groups. An AFI < or =5 were associated with an increased risk of small for gestational age, low Apgar score, NICU admission and prolonged hospital day. The incidences of meconium stained amniotic fluid, fetal distress and neonatal resuscitation were significantly higher in the cases with AFI < or =5, whereas the association between AFI < or =5 and meconium aspiration syndrome was statistically insignificant. CONCLUSION: In our study, oligohydramnios was a poor prognostic factor for perinatal outcome in uncomplicated full-term neonates. Therefore decreased amniotic fluid should warrant proper neonatal management as well as increased antepartum surveillance.

Stroke Associated With Protein C and S deficiency in Neonate: Report of two Cases

Recently, cases of stroke with inherited disorders of blood coagulation have been reported in children. Deficiency of protein C or S predisposing to a hypercoagulable state has been associated with cerebrovascular disease. We describe here two cases of cerebral infarction in neonates presenting with respiratory distress and seizure respectively. One had decreased protein C and the other was found to have decreased protein C and S. One case had asphyxia as an additional risk factor for stroke. No specific therapy was administered in both cases. They are currently being observed in the outpatient clinic without specific events.

A Case of ARC (Arthrogryposis, Renal dysfunction and Cholestasis) Syndrome with a Dead Sibling Presenting Cholestatic Jaundice

A case of ARC syndrome was found in a newborn male with persistent cholestasis. He showed renal dysfunction, failure to thrive, and ichthyosis as well as arthrogryposis. The patient who had a dead sibling with similar symptoms has not been described previously in our country.

Quantification of endothelin-1 in human umbilical venous endothelial cell culture supernatants of small for gestational age and preeclampsia neonates / 소아과

PURPOSE: It was generally accepted now a days that the pathogenesis of preeclampsia, small for gestational age (SGA), intrauterine growth retardation and fetal origin of adult diseases were related with a endothelial cell dysfunction. The purpose of this study was to know the relation of such diseases by assessing the level of endothelin-1. METHODS: SGA babies, newborns of preeclampsia and normal control mother were included in this study. Isolated endothelial cells were centrifugated and mixed with media in 37, 5% CO2 to obtain confluent monolayer of cultured human umbilical venous endothelial cell (HUVEC). Endothelin-1 levels were determined by Endothelin-1 colorimetric (EIA) Kits. We examined the endothelin-1 level in the HUVEC supernatants from SGA baby, and newborns from preeclampsia as well as normal mother. Also, we compared the endothelin-1 level of cultured normal HUVEC incubated with serum from cord blood of SGA, babies of preeclampsia or normal control mother. RESULTS: The endothelin-1 levels in cultured HUVEC supernatants of three groups showed no significant difference but the endothelin-1 levels of cultured normal HUVEC incubated with serum from preeclampsia mother or SGA mother was significantly higher than those from newborns of control mothers (P<0.05). CONCLUSION: These findings suggest that there may be the factor which affect the endothelin-1 level in serum of cord blood from SGA and preeclampsia.

Sprengel's deformity associated with a de novo balanced translocation involving chromosome 3 and 17 / 소아과

This is the first case of a de novo balanced translocation 46, XY, t(3;17)(p12.2;q25) associated with multiple musculoskeletal abnormalities, including Sprengel's deformity (congenital undescended scapula to be reported). This translocation has not been described previously with this congenital anomaly in Korea.

Infantile Type Choledochal Cyst with Biliary Atresia: Report of two cases

Choledochal cysts in neonates and young infants take two forms: the choledochal cyst associated with biliary atresia (CCBA) and the choledochal cyst in the absence of biliary atresia (CC). Infants in both groups usually have similar clinical symptoms at presentation, but management and prognosis are different. While early portoenterostomy is required for CCBA, cyst excision with hepaticojejunostomy or choledochojejunostomy is usually performed for CC. The former shows a relatively poor prognosis, and the latter shows a better prognosis. Two infants who presented with clinical features of neonatal cholestasis, and clinically suspected to have choledochal cysts, were found on imaging studies and surgery to have extrahepatic bile duct atresia in association with choledochal cysts.

Two Cases of Upper Gastrointestinal Bleeding in Healthy Full Term Neonates

Upper gastrointestinal bleeding (UGIB) secondary to gastritis or peptic ulcer is unusual in neonates and possibly related to several risk factors such as intracranial hemorrhage, intracranial hypertension, congenital heart disease, perinatal asphyxia, respiratory failure and hypovolemia. It is even more unusual that healthy full term neonates get UGIB. Upper gastrointestinal endoscopy is indicated in neonates with persistent UGIB to identify the cause and location of bleeding. We report two cases of UGIB successfully treated with injection of epinephrine by means of endoscopy in healthy full term neonates. One infant had duodenal ulcer and the other had hemorrhagic gastritis.

Appropriate Timing of the Screening Test of Gestational Diabetes / 대한주산의학회잡지

OBJECTIVE: Screening tests for Gestational diabetes (GDM) are performed during the 24~28 weeks of pregnancy. Therefore, in many cases, GDM is not detected during the first trimester of pregnancy while most of important organs are developed during this period. In this review, we performed a retrospective study by dividing GDM mothers into 3 groups: diabetic, impaired glucose tolerance (IGT) and normal. The medical records of mothers and neonates from these three groups were compared. METHODS: 136 out of 536 GDM patients in Holy Family Hospital from 1995 to 2005 took a 75 g OGTT 6 weeks after delivery. As a result, 28 were diagnosed as diabetes, 18 had impaired glucose tolerance, and 90 were normal. The antenatal and perinatal history of above groups were retrospetively compared. RESULTS: In the diabetic group, 46.4% of mothers had a positive family history of diabetes, where as 38% of IGT group, 31.8% of normal group had the history. Secondly, the abortion history rate for each group was 21.4%, 16.6%, 13.3%, and each group had an average HbA1C of 7.20, 5.82 and 5.69. Also, the rate of preterm labor for each group was 17.9%, 11.1%, and 4.45%. The Apgar score (1 min/ 5min) was 7.29/8.54, 7.75/8.75 and 7.89/8.97. Lastly the rate of preeclampsia for each group was 14.3%, 11.1% and 6.8%. CONCLUSION: Three groups had distinctive differences in their perinatal morbidity both before and after delivery. Therefore, in order to reduce the perinatal morbidity and mortality rate, the present frequency or timing of GDM screening test, should be reconsidered.

Jaundice and Hemolytic Anemia Appearing within the First 24 Hour of Life due to Glucose-6-Phosphate Dehydrogenase Deficiency / 대한주산의학회잡지

The most devastating clinical consequence of G-6-PD deficiency is neonatal hyperbilirubinemia which can be severe and result in kernicterus or even death, although glucose-6-phosphate dehydrogenase deficiency is responsible for two clinical syndromes, an episodic hemolytic anemia induced by infections or certain drugs and spontaneous chronic nonspherocytic hemolytic anemia. In the pathogenesis of neonatal hyperbilirubinemia associated with G-6-PD deficiency, decreased elimination of bilirubin has been suspected to be a key factor, because these neonates usually do not develop frank anemia even in the presence of severe hyperbilirubinemia. But, we experienced a glucose-6-phosphate dehydrogenase deficient male patient who showed jaundice and severe hemolytic anemia appearing within the first 24 hour of life. The patient had resolution of symptoms after phototherapy and transfusion. We report this case with a brief review of the related literatures.

A Case of Ring Chromosome 13 Syndrome with Jejunal Atresia and Hearing Loss

A ring chromosome 13 was found in newborn female with multiple congenital anomalies suggestive of 13q-syndrome. She presented with intrauterine growth retardation, agenesis of thumbs, craniofacial anomalies, congenital heart diseases, CNS, gastrointestinal anomalies which are imperforate anus and jejunal atresia and sensorineural hearing loss. To our knowledge, there have been several reports on 13q-syndrome with congenital megacolon or imperforate anus at home and abroad. However, the case presenting with jejunal atresia and hearing loss has not been described previously in the country. We report this case with a brief review of the correlation between clinical features and the observed chromosome abberation.

Effects of Insulin-like Growth Factor-I and 1,25-(OH)2 Vitamin D3 Concentration on Intrauterine Growth of Newborns from Mothers with Preeclampsia / 소아과

PURPOSE: This study was undertaken to observe the blood levels of IGF-I and 1,25-(OH)2 Vit. D3 in maternal and neonatal compartments and the effects of IGF-I concentration on intrauterine fetal growth and 1,25-(OH)2 Vit. D3 metabolism in the presence of preeclampsia. METHODS: Thirty-four full-term pregnant women with preeclampsia and their newborns(preeclampsia group) and 10 normotensive full-term pregnant women and their newborns(normotensive group) were observed. IGF-I and 1,25-(OH)2 Vit. D3 concentrations in maternal and umbilical cord blood were analysed. RESULTS: Maternal and umbilical cord blood levels of IGF-I and 1,25-(OH)2 Vit. D3 were significantly lower in the preeclampsia group than in the normotensive group. In the preeclampsia group, maternal and cord blood levels of IGF-I of small-for-gestational age newborns were significantly lower than those of appropriate-for-gestational age newborns. The birth weight and length of newborns correlated with IGF-I concentrations of maternal and umbilical cord blood in small-for-gestational age newborns of preeclampsia group. The correlation between IGF-I and 1,25-(OH)2 Vit. D3 was significant in the umbilical cord blood of preeclampsia group, but only in appropriate-for-gestational age newborns. CONCLUSION: It is suggested that the lower level of IGF-I is the primary factor of intrauterine growth retardation in preeclampsia, and the effect of IGF-I on the metabolism of 1,25-(OH)2 Vit. D3 is different according to the presence of preeclampsia and intrauterine fetal growth retardation.

The Effect of Preeclampsia Mother's Serum and Her Neonatal Cord Blood on the Activity of Soluble Adhesion Molecules (sICAM-1) and Apoptosis in Cultured Human Umbilical Venous Endothelial Cells (HUVEC)

PURPOSE: It is proposed that endothelial cell dysfunction, a central pathogenic feature of preeclampsia is caused by circulating unknown factors produced by placenta in the blood of women with preeclampsia. In this study we investigated the effect of such factors in the serum from preeclamptic mother or her neonatal umbilical vein on the activity of sICAM-1 and apoptosis in cultured human umbilical venous endothelial cells. METHOD: Quantitive determinations of sICAM-1 and apoptosis were detected from isolated and cultured HUVEC supernatants which were incubated with serum samples for 48hours. The serum samples were collected from preeclamptic mother and her neonatal cord blood in pairs according to gestational age and were compaired to nonpreeclamptic control groups. RESULTS: sICAM-1 level was significantly higher in the maternal groups compared to corresponding cord groups (P<0.001). The preterm maternal group showed higher level than term maternal group (P<0.001). The preeclamptic preterm mother groups showed elevated level compared to other mother groups and the existence of preterm delivery affects sICAM-1 level more importantly than the existence of preeclampsia. In TUNEL stain preeclamptic preterm mother group showed increased number of apoptotic nuclei compared to other groups. The neonatal cord group of preterm preeclampsia showed no apoptotic body on cultured HUVEC. CONCLUSIONS: Unknown circulating factors in preeclamptic preterm mother activate expression of sICAM-1 and apoptosis in cultured human umbilical venous endothelial cells. But the fetal circulation may not be affected by the factor (s) that lead to disturbed endothelial cell function in women with preterm preeclampsia.

The Activity of sICAM-1 and sVCAM-1 in Plasma of Preeclamptic Mother and Neonatal Cord Blood

PURPOSE: Current concepts of preeclampsia have been focused on dysfunction of the maternal vascular endothelium, a central pathogenetic feature of the disease. But it is uncertain whether maternal preeclampsia has a harmful effect on fetal or neonatal vascular endothelium. In this study, plasma levels of endothelial adhesion molecules in preeclamptic mother and cord blood were determined to delineate vascular effects of preeclampsia on neonates. METHOD: Quantitative determinations of sICAM-1 and sVCAM-1 were measured from plasma of preeclamptic mother and neonatal cord blood in pairs according to gestational age and was compared to nonpreeclamptic control groups. RESULTS: Plasma ICAM-1 level was significantly higher in the maternal groups compared to corresponding cord groups (P<0.001). Preeclamptic maternal groups showed significantly higher sICAM-1 level compared to control maternal groups (P<0.001) and preterm maternal groups showed higher levels than term maternal groups (P<0.001). The level of sICAM-1 was significantly elevated in preeclamptic preterm cord groups than other cord groups (P<0.001). In respect to plasma sVCAM-1 level, higher value was observed in the preeclamptic preterm cord groups than preeclamptic preterm maternal groups. CONCLUSIONS: Elevation of the plasma sICAM-1 level caused by factors including vascular endotherial damage in preeclamptic mothers was observed in their neonates but with much lesser degree than their mothers. Factors associated with preterm labor other than maternal preeclampsia may seem to influence vascular endothelial injury in the cord blood.

Effects of Intestinal Ischemia on Intestinal Mucosal Damage and Effects of Interleukin-10 in Young Murine Model / 소아과

PURPOSE: Intestinal vascular ischemia is the most probable pathogenesis in the development of necrotizing enterocolitis in prematures. The authors studied the histology of intestinal mucosal damage by clamping the superior mesenteric artery in 35 rats, and, analyzed the histologic scores between young rats(I) and adult rats(II) groups according to clamping times(15, 30 and 60 minutes) and compared the effect of interleukin-10(IL-10) in five subjects. METHODS: The superior mesenteric artery supplying the small intestine was clamped by a small vessel clamp. IL-10 was applied subcutaneously every three days. All rats were killed on the third day after clamping, and were evaluated pathologically by histologic scoring scale adapted from Chiu, et al. RESULTS: The histologic score of group I was significantly higher than that of group II(P<0.05). When groups I & II were compared in terms of ischemic time, histologic scores showed significant statistical differences in the 60 minute group(9.2+/-1.304, 6.6+/-1.14, respectively, P<0.05). In young rats, the histologic score of the 30 minute group was significantly higher than that of the 15 minute group(P<0.05). Also in adult rats, the histologic score of the 60 minute group was significantly higher than that of the 30 minute group(P<0.05). The histologic score of the IL-10 treated-group was significantly lower than that of the non-treated group(P<0.05). CONCLUSION: More rapid and severe mucosal damage by ischemia was found in young rats than adult rats. We also expect that IL-10 may have an effect on treatment and prevention of ischemic change, but more extensive study is required.

The Effect of Preeclampsia on Neonatal Outcome of Premature Infants Delivered before 35 Weeks Gestation / 대한주산의학회잡지

OBJECTIVE: The purpose of this study was to determine neonatal outcomes according to laboratory and clinical features in preeclampsia before 35 weeks gestation. METHODS: The medical records of all patients delivered at the hospital from January 1, 1996 through March 31, 2002 were reviewed for the occurrence of preeclampsia before 35 weeks gestation. We compared their maternal medical and obstetric courses and neonatal outcomes with those in a group of non preeclamptic patients who delivered at similar gestational ages. RESULTS: The preeclampsia group had lower mean birth weight, 1-minute Apgar score and umbilical arterial pH. But there were no difference in the incidence of neonatal death, respiratory distress syndrome, grade 3 and 4 intraventricular hemorrhage, and culture-proven sepsis. Results were similar when analysis was limited to infants born before 32 weeks. CONCLUSION: Maternal preeclampsia does not improve neonatal outcome of infants born before 35 weeks gestation.