A review of umbilical venous catheter-related complications at a tertiary neonatal unit in Singapore

INTRODUCTION@#Umbilical venous catheters (UVCs), commonly inserted in neonates for vascular access, are not without complications.@*METHODS@#A single-centre retrospective cohort study that reviewed complications related to UVC insertion in neonates was conducted in a tertiary neonatal unit in Singapore from January 2016 to July 2017. Ideal UVC position was defined as catheter tip within 0.5 cm above or below the diaphragm. Catheter-related sepsis was defined as clinical or biochemical abnormalities suggesting any new-onset or worsening sepsis 72 hours before or after removal of UVCs, with or without positive culture. Catheter-associated bloodstream infection (CABSI) was defined as positive microbiological growth in one or more blood cultures obtained from a symptomatic infant up to two days after UVC placement or within 48 hours of catheter removal.@*RESULTS@#108 patients had UVC insertions. Mean gestational age and birth weight were 30.4 ± 4.0 weeks and 1,536.2 g ± 788.9 g, respectively. Mean UVC duration was 6.6 days. The UVC was in an ideal position in 27 (25.0%), deep in 13 (12.0%) and short in 35 (32.4%) neonates. One-third of the UVCs (n = 33) were malpositioned. Catheter-related sepsis was observed in 16 (14.8%) neonates, with 5 (4.6%) having CABSI. The most common organism was coagulase-negative Staphylococcus. Other complications include peritoneal extravasation in 3 (2.8%) patients, with two requiring surgical intervention. Venous thrombosis occurred in 2 (1.9%) neonates and was managed conservatively.@*CONCLUSION@#Although complication rates were in line with international norms, UVCs were associated with serious complications and should be judiciously used.

Long-Term Neurodevelopmental Outcomes of Premature Infants in Singapore

INTRODUCTION@#Neonatal care advances have resulted in improved survival but have raised concerns of increase in neurodevelopmental impairment. This study looked at long-term neurodevelopmental outcomes at ages 5 and 8 years of very low birthweight infants born in the 2000s as compared to the 1990s. Neurodevelopmental assessment at 2 years old was compared to that at 5 and 8 years to determine if assessment at 2 years was predictive of later outcomes.@*MATERIALS AND METHODS@#A retrospective cohort study of consecutive infants with birthweight less than 1250 grams admitted to a tertiary centre in Singapore between January 1994 to December 1995 (Epoch I) and January 2004 to December 2005 (Epoch II) were included. Neurodevelopmental impairment was defined as having intelligence quotient (IQ) of less than 70, cerebral palsy, legal blindness, or hearing impairment requiring hearing aids.@*RESULTS@#Mean gestational age was lower for Epoch II compared to Epoch I (28.1 ± 2.5 vs 29.4 ± 2.7 weeks, = 0.004). Death or neurodevelopmental impairment rates did not differ (24.3% and 17.1% at 5 years old, = 0.398; 29.1% and 25.0% at 8 years old, = 0.709). There was improvement in visual impairment rate at 8 years in Epoch II (10.7% vs 34.0%, = 0.024). Mean IQ was better in Epoch II (109 and 107 vs 97 and 99 at 5 [ = 0.001] and 8 years [ = 0.047], respectively). All infants with no neurodevelopmental impairment at 2 years remained without impairment later on.@*CONCLUSION@#Over a decade, neurodevelopmental outcomes did not worsen despite lower mean gestational age. Long- term improvement in IQ scores and a reduction in visual impairment rates were seen. Our data suggests that children without neurodevelopmental impairment at 2 years are without impairment later on; therefore, they may need only developmental monitoring with targeted assessments instead of routine formal IQ assessments.

Neonatologist-performed point-of-care functional echocardiography in the neonatal intensive care unit

Functional echocardiography (fECHO) refers to a bedside, limited assessment of the ductus arteriosus, myocardial performance and pulmonary or systemic haemodynamics that is brief in nature and addresses a specific clinical question or management dilemma. This point-of-care ultrasonography is increasingly used internationally and locally among neonatal units to assist with management of neonatal haemodynamic conditions. This article intends to explain the modality, its indications, interpretation and implications for management, and how it impacts long-term outcomes, particularly in chronic lung disease for premature infants born before 32 weeks of gestation. This review will focus on fECHO as a clinical tool to assess the haemodynamics of sick neonates and how it assists in the logical choice for cardiovascular support. Training should be approached as a combined effort between the paediatric cardiology service and neonatology service.

Singapore Neonatal Resuscitation Guidelines 2016

We present the revised Neonatal Resuscitation Guidelines for Singapore. The 2015 International Liaison Committee on Resuscitation Neonatal Task Force's consensus on science and treatment recommendations (2015), and guidelines from the American Heart Association and European Resuscitation Council were debated and discussed. The final recommendations of the National Resuscitation Council, Singapore, were derived after the task force had carefully reviewed the current available evidence in the literature and addressed their relevance to local clinical practice.

Creation and validation of the Singapore birth nomograms for birth weight, length and head circumference based on a 12-year birth cohort

<p><b>INTRODUCTION</b>Both gestation and birth weight have significant impact on mortality and morbidity in newborn infants. Nomograms at birth allow classification of infants into small for gestational age (SGA) and large for gestational age (LGA) categories, for risk stratification and more intensive monitoring. To date, the growth charts for preterm newborn infants in Singapore are based on the Fenton growth charts, which are constructed based on combining data from various Western growth cohorts. Hence, we aim to create Singapore nomograms for birth weight, length and head circumference at birth, which would reflect the norms and challenges faced by local infants.</p><p><b>MATERIALS AND METHODS</b>Growth parameters of all babies born or admitted to our unit from 2001 to 2012 were retrieved. Following exclusion of outliers, nomograms for 3 percentiles of 10th, 50th, and 90th were generated for the gestational age (GA) ranges of 25 to 42 weeks using quantile regression (QR) combined with the use of restricted cubic splines. Various polynomial models (second to third degrees) were investigated for suitability of fit. The optimum QR model was found to be a third degree polynomial with a single knotted cubic spline in the mid-point of the GA range, at 33.5 weeks. Check for goodness of fit was done by visual inspection first. Next, check was performed to ensure the correct proportion: 10% of all cases fall above the upper 90th percentile and 10% fall below the lower 10th percentile. Furthermore, an alternative formula-based method of nomogram construction, using mean, standard deviation (SD) and assumption of normality at each gestational age, was used for counterchecking.</p><p><b>RESULTS</b>A total of 13,403 newborns were included in the analysis. The new infant-foetal growth charts with respect to birth weight, heel-crown length and occipitofrontal circumference from 25 to 42 weeks gestations with the 10th, 50th and 90th were presented.</p><p><b>CONCLUSION</b>Nomograms for birth weight, length and head circumference at birth had significant impact on neonatal practice and validation of the Singapore birth nomograms against Fenton growth charts showed better sensitivity and comparable specificity, positive and negative predictive values.</p>

A Comparison of the Short-term Morbidity and Mortality Between Late Preterm and Term Newborns

<p><b>INTRODUCTION</b>Late preterm babies are defined as those born between 34 to 36 completed weeks. There has been a recent increased awareness that this group of babies has a higher incidence of morbidity as compared to term babies. The aim of this study was to evaluate the short-term morbidities occurring in this group of babies managed in the neonatal unit at Singapore General Hospital (SGH).</p><p><b>MATERIALS AND METHODS</b>A retrospective study was done of babies managed in the neonatal unit at SGH from January 2005 to December 2008. Maternal, perinatal and neonatal data were obtained from the departmental database. The outcomes of late preterm infants were compared with term infants.</p><p><b>RESULTS</b>A total of 6826 babies were admitted. Ten percent (681 out of 6826) of babies were late preterm babies, making up 63% (681 out of 1081) of all preterm babies. Late preterm babies had significantly greater need for resuscitation at birth. They also had statistically significant increased risks of developing hyaline membrane disease (2.5% vs 0.1%), transient tachypnoea of the newborn (TTN) (8.1% vs 1.7%), pneumonia (7.0% vs 2.8%), patent ductus arteriosus (PDA) (4.3% vs 1.1%), hypotension (0.7% vs 0%), apnoea (3.7% vs 0%), gastrointestinal (GI) bleeding (1.5% vs 0.3%), polycythaemia (2.2% vs 1.0%), anaemia (3.4% vs 1.2%), thrombocytopenia (3.2% vs 0.6%), hypoglycaemia (6.6% vs 1.7%), neonatal jaundice requiring phototherapy (41.1% vs 12.2%) and sepsis (1.7% vs 0.6%).</p><p><b>CONCLUSION</b>Late preterm infants are indeed a vulnerable group of infants with significant morbidities that need to be addressed and treated. Despite their relatively large size and being almost term, the understanding that late preterm infants are not similar to term infants is important to both obstetricians and neonatologists.</p>

Short- and long-term outcomes at 2, 5 and 8 years old for neonates at borderline viability--an 11-year experience

<p><b>INTRODUCTION</b>Neurodevelopmental outcome of borderline viability neonates have lagged behind improvement in survival figures. Accurate figures based on local outcome allow us to better counsel parents and to prognosticate with greater accuracy on both short- and longterm outcomes.</p><p><b>MATERIALS AND METHODS</b>A retrospective cohort study of 101 consecutively born neonates, born from 21 to 26 weeks gestation over an 11-year period from 1 January 1994 to 31 December 2005 was conducted. Long-term outcomes were assessed at 2, 5 and 8 years of age in terms of mental developmental index (MDI) or intelligence quotient (IQ) scores, hearing and visual impairments, handicaps and impairments, school placement and interventions required.</p><p><b>RESULTS</b>Survival rates were 20.0%, 60.9%, 70.4% and 73.2% for neonates born at 21 to 23, 24, 25 and 26 weeks gestation respectively. Factors that predicted increased mortality included higher alveolar-arterial oxygen difference (AaDO2) with odds ratio (OR) 1.005 and lower birth weight OR 0.993. Rates of severe retinopathy of prematurity (ROP) (stage 3 or worse) were 100%, 57.1%, 42.1% and 26.7% for 21 to 23, 24, 25 and 26 weeks gestation respectively. Rates of bronchopulmonary dysplasia (BPD) were 100.0%, 57.1%, 63.2% and 60.0% respectively. Rates of severe intraventricular haemorrhage (IVH) were 0%, 7.1%, 5.3% and 10.0% respectively. Moderate to severe disability rates at 2 years old were 100%, 44.4%, 33.3% and 30.4% respectively. At 5 years old, moderate to severe disability rates were 16.7%, 22.2% and 14.3% respectively for those born at 24, 25 and 26 weeks gestation. Interpretation at 8 years was limited by small numbers.</p><p><b>CONCLUSION</b>Our results indicated that local figures for mortality and morbidity remained high at the limits of viability, although they were comparable to outcomes for large scale studies in advanced countries.</p>