Umbilical cord blood gas and lactate levels as a marker of birth asphyxia in neonates with particular reference to resource limited countries

Birth asphyxia remains an important cause of neonatal mortality and morbidity in the developing world. Babies who suffer birth asphyxia may develop cerebral palsy, learning difficulties and epilepsy. Early diagnosis and prompt placement of rehabilitative measures would help to reduce the burden of complications arising as a result of birth asphyxia. Time and again effort has been made to develop markers that would help in predicting outcome of neonates who have had an asphyxial insult. One such parameter that is now routinely being used in the developed world is the measurement of umbilical cord blood lactate level measured from blood gases. This review highlights the importance of early diagnosis of birth asphyxia and the role of umbilical cord blood lactate level in identifying babies who have had birth asphyxia in resource limited countries with a particular reference to Pakistan

Neonatal sepsis in the very low birth weight preterm infants: part 1: review of patho-physiology

Over the last fifty years neonatal care has made tremendous progress; increasing survival, reducing morbidity, developing newer modalities of care and therapy for the very low birth weight [VLBW] and premature infant. However, mortality from neonatal sepsis in this group of infants has remained between 18-20% in the developed world and around 80% in the developing world for last three decades with little sign of decline. There is also clear evidence that VLBW infants who survive infection in the neonatal period are at significantly greater risk of neuro-developmental delay; making sepsis the most important cause of mortality and morbidity in this group of infants today. The objective of this review is to highlight the reasons for this lack of success in combating neonatal sepsis successfully. These can be attributed to four main reasons; 1] poor host defences, 2] clinician's inability to diagnose sepsis early and accurately [due to lack of or general availability of highly sensitive and specific markers], 3] clinician's poor understanding of the 'process' i.e. patho-physiology of neonatal sepsis, thus not being able to institute early 'goal' directed therapy, and 4] total reliance on killing the pathogen[s] with inadequate attention to correcting the consequences of the inflammatory process itself. This review presents a brief epidemiological background to neonatal infections in the VLBW infants, discusses host defence systems and how immune compromised VLBW infant combats infection by describing the pathophysiological 'process' of sepsis in detail. It is our belief that understanding the heterogeneity and complexity of host response and the defence systems is fundamental in formulating management strategies. By discussing patho-physiology, current available diagnostic tests and presenting an evidence based management 'care bundle' it is hoped to change clinician's paradigm to use more immune and molecular markers for diagnosis and monitoring of the infection process and in management considering adjunctive therapies that boost host defences. It is recognised that while this review is static i.e. it presents evidence as we understand it today, sepsis is a dynamic process. Our understanding, ability to diagnose and manage neo-natal sepsis is constantly changing and will continue to change and evolve. By presenting this review it is hoped that over a period of time more of our practices would become evidence based and dogma abandoned

Neonatal sepsis in the very low birth weight preterm infants: part 2: review of definition, diagnosis and management

Having presented brief epidemiology of neonatal infection and patho-physiology of neonatal sepsis in the first part of this review we now address the difficulties in defining, diagnosing and treating neonatal sepsis. The objective of this part of the review is firstly, to highlight the reasons for lack of consensus on the definition of neonatal sepsis despite a number of international conferences of experts on the subject. Secondly, to discuss the increasing sophistication of available laboratory tests and why they all lack the certainty desired by the clinician and thirdly to discuss the various evidence based treatment modalities available to treat neonatal sepsis. It is suggested that pragmatic definition of sepsis as suggested by us should be adopted. Greater use of biomarkers and molecular tests should be made to diagnose sepsis early and accurately. Lastly, it is hoped to change the clinician's paradigm by using evidence based management care bundle/package that includes adjunctive immune-modulatory and host defence boosting drugs

Use of intravenous immunoglobulin in the treatment of neonatal sepsis: a pragmatic review and analysis

To review literature and assess whether adjunctive therapy with polyclonal and or enriched intravenous immunoglobulin [IVIG] reduces mortality in neonates with sepsis. Data Source: MEDLINE, EMBASE and Cochrane systematic review. All studies published in English language evaluating IVIG treatment in neonatal sepsis. Data Synthesis: Effect of all cause mortality was quantified using fixed-effect meta-analysis. Fifteen studies published between 1986 and 2006 were identified of which fourteen reported mortality and were included in the analysis. Most studies involved small number of neonates, used different preparations and dosing regimens of IVIG, however, there was significant reduction in all cause mortality associated with use of IVIG in neonatal sepsis with pooled odds ratio of 0.41 [95% confidence interval 0.29-0.58] and a risk ratio of 0.52 [95% confidence interval 0.40-0.67; p < 0.00001]. There was no statistically significant difference between-study heterogeneity for the outcome of mortality in the two analyses. I2=0%. Number required to treat 7. This analysis shows that addition of polyclonal or enriched IVIG as adjunct to standard therapy significantly reduces all cause mortality in neonatal sepsis

Use of avicel and spray dried lactose in the development of levofloxacin 250mg tablets by direct compression method

In present study a formulation of Levofloxacin tablet 250mg was prepared by direct compression method, using two directly compressible excepients, i.e Avicel PH101 [62.5mg] and spray dried lactose [62.5mg] with magnesium stearate [5mg] as lubricant glidant on Erweka single punch machine. These tablets are round in shape having mean weight of 373.55 +/- 8.463mg with mean diameter and thickness of 12.3 +/- 0.03mm and 2.4 +/- 0.11mm. The hardness of the tablets was 12 +/- 0.39kg. Friability of tablets were 0.67% using Roche friabilator and disintegration time was 10 min in Erweka basket rack assembly. Dissolution test was performed on USP apparatus-I and%Q was found to be 94.59. Assay results was 100.54% when performed by HPLC technique using CIS column. This formulation gives excellent results using minimal excepient and simple manufacturing procedure. This type of work gives direction to try to make formulation simple and cost effective. As direct compression method is not cheap in terms of raw materials but also produces batch in short period of time. Moreover considering biopharmaceutical aspects, tablet manufactured by direct compression dissolved rapidly in gastrointestinal tract due to prime particle dissociation as compared to that of wet granulation method

Intrauterine and fetal growth standards for Saudi Arabia and the Gulf region

As there are no standard growth charts for Arabs, we have calculated birth weight, length and head circumference centile standards for boys and girls between 24 and 42 weeks gestation from 9028 [27.6% of total births in Riyadh] singleton Saudi live births in four different hospitals in Riyadh. To the best of our knowledge these are the first growth standards which are truly representative of the Saudi and perhaps Arab live borns and we recommend that they should be used in preference to the 'Western' standards used at present

Studies on the effect of dichlorvos and 2 PAM on rat brain acetylcholinesterase

Organophosphates are powerful, widely used pesticides which distrupt normal cholinergic neural impulse transmission of the central and peripheral nervous system in vertebrates by inhibiting AChE. Effect of three graded doses of Dichlorvos [3. 0, 1.5, 0.75 mg/kg b.w., i.p. daily for 7 days] was evaluated an acetylcholinerte-rase activity of rat brain and spinal cord. A dose response curve was obtained and it was observed that the spinal cord was the most susceptible region. Administration of pyridine - 2 - aldoxime, considerably reactivated the enzyme acetylcholinesterase. Variation in the reactivation of enzyme in the discrete regions of rat CNS suggests that individual regions behave as disparate organs and the extent of toxicity depends both on the region and the dose of Dichlorvos administered

Theophylline therapy for apnea of prematurity in Saudi preterm infants: therapeutic serum level and dosage

In a controlled study, 150 Saudi preterm infants were treated with 1.5 mg/kg/day of thephyline for apnea of prematurity. In 96.8% of infants the apnea was either reduced by more than 50% or abolished completely. The effective therapeutic plasma level for these infants was 4.5 +/- 2.1 micro g/mL. a loading dose was found to be unnecessary. Theophylline at these doses appears to be effective and safe treatment for apnea of prematuity in Saudi infants

Periventrucular-intra ventricular hemorrhage in the newborn

In a retrospective study spanning 4 years[1404-1407H] and including a total of 11, 050 births, the incidence of periventricular/intraventricular hemorrhage [PVH/IVH] in infants born at King Khalid University Hospital at or before 35 weeks of gestation was 20.9% and in those weighing 1500 g or less at birth was 40.8%. Incidence, grade, associations, and outcome of infants suffering PVH/IVH were tabulated. Most common was grade 1 hemorrhage; PVH/IVH was most frequently seen in infants born between 26 and 30 week's gestation [42.5%] and in those weighing between 500 and 750[g] [42.9%] at birth. Respiratory distress syndrome was associated in 81.3% of the infants with PVH/IVH

scheme for better perinatal care in the Kingdom of Saudi Arabia

Despite great developments in the health sector within the Kingdom, maternal and perinatal mortality rates remain unacceptably high. The main reason for this is the lack of an organized and coordinated system of perinatal care. This paper reviews the current state of perinatal care in the Kingdom and the reasons for the high rates of maternal and perinatal mortality. A scheme for a regionalized perinatal care system based on three different levels of care [Level I-III] is suggested

Infant feeding practices in Riyadh, Saudi Arabia

Infant-feeding patterns were studied in 6, 653 randomly selected Saudi families living in Riyadh. The 4, 796 infants studied were under 1 year of age and were fed with breast milk plus bottle complements. Bottle-feeding was started in 27.3% of infants during the first months after birth. The mean age at which solid food was introduced was 3.45 months. The overall results suggest a decreasing incidence of breast-feeding along with diminishing length of nursing period

Perinatal mortality at King Khalid University Hospital Riyadh

One of the major goals in perinatal practice is to achieve the lowest possible perinatal mortality. We evaluated the pattern of perinatal mortality at the King Khalid University Hospital [KKUH] over four years, from 1403H through 1406H [October 1982 through August 1986]. Over this period the number of births at KKUH increased by 175%. In 1406H perinatal mortality was 14.5/1000 birth; survival of infants weighing 754 g was over 80%, and those weighing between 500 and 750 g was 30%. The likelihood of survival for an infant born at or after 27 weeks of gestation was greater than 80%

Smith-Lemli-Optiz syndrome in one Arab child: a case report

The first case of Smith-Lemli-Opitz syndrome from Saudi Arabia is described. The relevant literature is reviewed