Long-term outcome of surgically managed necrotizing enterocolitis in a developing country.

UNLABELLED: Necrotizing enterocolitis (NEC) is a serious condition with a high morbidity and mortality commonly affecting premature babies. Data for the impact of the long-term disease burden in developing countries are limited although poor long-term outcome of surgically managed patients has been shown in terms of increased risk of neurodevelopmental delay, increased infectious disease burden and abnormal neurological outcomes in the developed world. PURPOSE: To evaluate the long-term outcome of a pre-human immunodeficiency virus pandemic NEC cohort to characterize common risk factors and outcome in a developing world setting. METHODS: A retrospective review of medical records was carried out on a cohort of 128 premature neonates with surgical NEC (1992-1995). Morbidity, mortality and long-term outcome were evaluated. RESULTS: Data for 119 of 128 sequentially managed neonates with surgically treated NEC was available. Mean gestational age was 32 weeks and average birth weight was 1,413 g. Early (30-day postoperative) survival was 69% (n = 82) overall and 71% in the <1,500 g birth weight group (n = 68; 53%). Overwhelming sepsis (n = 16) or pan-intestinal necrosis (n = 18) accounted for most of the early deaths. Late deaths (>30 days postoperatively, n = 22) resulted from short bowel syndrome (5), sepsis (9), intraventricular hemorrhage (1) and undetermined causes (7). On follow-up (mean follow-up 39 months, 30 for >2 years), long-term mortality increased to 50%. Late surgical complications included late colonic strictures (9), incisional hernias (2) and adhesive bowel obstruction (3). Fifteen patients had short bowel syndrome, of which 10 (66%) survived. Of the long-term survivors, 8 (20%) had severe neurological deficits and 20 (49%) had significant neurodevelopmental delay. Neurological deficits included severe auditory impairment [5 (12%)] and visual impairment [4 (10%)]. Recurrent infections and gastrointestinal tract complaints requiring hospital admission occurred in 16 (39%) of survivors. CONCLUSION: Necrotizing enterocolitis in premature infants impacts morbidity and mortality considerably. A number do well in a developing country, but septic complications may be ongoing and recurrent. The high risk of neurodevelopmental and other problems continue beyond the neonatal period and patients should be "flagged" on for careful follow-up.

Phototherapy and exchange transfusion for neonatal hyperbilirubinaemia: neonatal academic hospitals' consensus guidelines for South African hospitals and primary care facilities.

The purpose of this document is to address the current lack of consensus regarding the management of hyperbilirubinaemia in neonates in South Africa. If left untreated, severe neonatal hyperbilirubinaemia may cause kernicterus and ultimately death and the severity of neonatal jaundice is often underestimated clinically. However, if phototherapy is instituted timely and at the correct intensity an exchange transfusion can usually be avoided. The literature describing intervention thresholds for phototherapy and exchange transfusion in both term and preterm infants is therefore reviewed and specific intervention thresholds that can be used throughout South Africa are proposed and presented graphically. A simplified version for use in a primary care setting is also presented. All academic heads of neonatology departments throughout South Africa were consulted in the process of drawing up this document and consensus was achieved.

Kangaroo mother care in the nursery.

Kangaroo mother care is becoming an integral part of the care of low birth weight infants worldwide. It provides economic savings to families and health care facilities and many physiologic and psychobehavioral benefits to mothers and infants, the most important of which is the promotion of successful breastfeeding. The benefits of breastfeeding, of human milk over formula, and of feeding from the breast per se, are beyond dispute, and so KMC should be actively promoted. The full impact of KMC on breastfeeding low birth weight infants is yet to be realized.

Expectant management of early onset, severe pre-eclampsia: perinatal outcome.

OBJECTIVE: To evaluate the perinatal outcome of expectant management of early onset, severe pre-eclampsia. DESIGN: Prospective case series extending over a five-year period. SETTING: Tertiary referral centre. POPULATION: All women (n = 340) presenting with early onset, severe pre-eclampsia, where both mother and the fetus were otherwise stable. METHODS: Frequent clinical and biochemical monitoring of maternal status with careful blood pressure control. Fetal surveillance included six-hourly heart rate monitoring, weekly Doppler and ultrasound evaluation of the fetus every two weeks. All examinations were carried out in a high care obstetric ward. MAIN OUTCOME MEASURES: Prolongation of gestation, perinatal mortality rate, neonatal survival and major complications. RESULTS: A mean of 11 days were gained by expectant management. The perinatal mortality rate was 24/1,000 (> or = 1,000 g/7 days) with a neonatal survival rate of 94%. Multivariate analysis showed only gestational age at delivery to be significantly associated with neonatal outcome. Chief contributors to neonatal mortality and morbidity were pulmonary complications and sepsis. Three pregnancies (0.8%) were terminated prior to viability and only two (0.5%) intrauterine deaths occurred, both due to placental abruption. Most women (81.5%) were delivered by caesarean section with fetal distress the most common reason for delivery. Neonatal intensive care was necessary in 40.7% of cases, with these babies staying a median of six days in intensive care. CONCLUSION: Expectant management of early onset, severe pre-eclampsia and careful neonatal care led to high perinatal and neonatal survival rates. It also allowed the judicious use of neonatal intensive care facilities. Neonatal sepsis remains a cause for concern.

Infants of women with severe early pre-eclampsia: the effect of absent end-diastolic umbilical artery doppler flow velocities on neurodevelopmental outcome.

Umbilical artery Doppler flow velocity waveform studies were performed over a period of 4 y on 242 women with severe pre-eclampsia before 34 wk gestation. Sixty-eight (28%) had absent end-diastolic umbilical artery Doppler flow velocities. One hundred and ninety-three infants survived to hospital discharge and were followed at 6-monthly intervals until 48 mo of age. The mean corrected developmental quotient was 94 +/- 8 at 24 mo of age and 87 +/- 9 at 48 mo. Ninety-two percent of the infants had a developmental quotient of >80 at 24 mo and 72% at 48 mo of age. This decline is thought to be due to the impact of social circumstances. There were no differences between the developmental quotients of the infants with normal and those with absent end-diastolic umbilical artery Doppler flow velocities at either 24 or 48 mo of age. At 24 mo of age, infants with absent end-diastolic umbilical artery Doppler flow velocities scored lower in the Performance subscale test (p = 0.03). The developmental quotients of infants from poorer socioeconomic backgrounds were significantly lower than those living in more privileged circumstances. At 48 mo, 153 (97%) of the children presented with normal gross motor development. Four infants had cerebral palsy. No differences were noted in the motor outcomes between the infants of women with normal umbilical artery waveforms and those with absent end-diastolic umbilical artery Doppler flow velocities.

Necrotizing enterocolitis in infants born to women with severe early preeclampsia and absent end-diastolic umbilical artery doppler flow velocity waveforms.

The aim of this study was to determine the prevalence of necrotizing enterocolitis (NEC) in infants born to a homogeneous group of women with severe preeclampsia before 34 weeks' gestation and who had absent end-diastolic umbilical artery Doppler flow (AEDF) or normal umbilical Doppler flow velocities (NUFV). A total of 242 infants were entered into the study. The mean birth weight was 1260.5 g (SD = 339) and the mean gestational age 30.5 weeks (SD = 2.0). Sixty-eight (28%) infants had AEDF, 43 (18%) had umbilical artery Doppler flow velocities between the 95th and 99th percentile, and 131 (54%) had NUFV. Forty-one (18%) infants developed NEC, of whom 20 (8%) developed definite and advanced NEC (grade 2 and 3). Of these, 16(80%) had grade 2 and 4(20%) had grade 3. Twenty-one (8%) infants developed suspected NEC (grade 1). The mean onset of grade 1 NEC (7.2 days) occurred significantly earlier than in those with grades 2 and 3 NEC (18.7 and 23.3 days, respectively). Of the 21 infants with grade 1 NEC, 10 (48%) had AEDF and 9 (43%) had NUFV. None of the infants with grades 2 or 3 NEC had AEDF. We conclude that although chronically hypoxemic fetuses born to women with severe early onset preeclampsia and AEDF respond by redistributing blood flow to vital organs and away from the gut; the intestinal compromise is of insufficient magnitude to induce intestinal necrosis or NEC. Enteral feeding, however, should be introduced cautiously in infants with AEDF, as so-called suspected NEC developed significantly more often in these infants.

Smoking and alcohol use during pregnancy affects preterm infants' docosahexaenoic acid (DHA) status.

This study investigated the effect of alcohol consumption and smoking during pregnancy on the fatty acid composition of the infants. A total of 40 very-low-birth-weight (VLBW) infants, weighing between 750 and 1500 g, were enrolled in the study after being hospitalized and ventilated for respiratory distress syndrome (RDS). Maternal and infant demographic information was recorded. Questions regarding maternal smoking (none, < 10 and > or = 10 cigarettes/d) and alcohol consumption (none, occasionally, moderate and severe) were recorded. Erythrocyte membrane (EMB; n = 40) total fatty acid analyses were performed at birth (baseline) and on days 14 and 28 postnatally. During pregnancy, 42% of mothers consumed alcohol and 50% smoked. At birth, infants of mothers who smoked and consumed alcohol during pregnancy, had significantly higher blood docosahexaenoic acid (DHA; p < 0.05) than infants of mothers who abstained from both alcohol and smoking. The consequences of this finding remain unknown.

Introduction of a donor exposure reduction programme for multiple-transfused very-low-birth-weight infants.

OBJECTIVE: To conduct an audit of the frequency of red cell concentrate transfusions (RCCTs) in infants of different weight categories, the donor exposure rate (DER), in these transfused infants and the volume of blood wasted during each transfusion, and to identify from this baseline information specific categories of infants who would benefit from the introduction of a limited donor exposure programme (LDEP). STUDY SETTING: Neonatal wards and neonatal intensive care unit (NICU), Tygerberg Hospital, Western Cape. STUDY DESIGN: A prospective descriptive study and comparison with a historic control group. SUBJECTS: Information on the birth weight, age at the time of each RCCT and number of blood donors to whom an infant was exposed were collected post factum for all infants admitted to the neonatal wards and NICU between May 1993 and May 1994. During this time, the red blood cell concentrate was supplied as single paediatric bags (180 ml) transfused within 14 days of donation. An LDEP was introduced in February 1995. With this system, red blood cells were supplied as triple packs: a main unit of 250 ml with three empty satellite packs allowing up to three separate transfusions. These were assigned to a specific infant and were to be transfused within 21 days of donation. A second system where one adult blood bag was divided into two 180 ml bags and assigned to one infant to be transfused within 35 days of donation was also assessed. RESULTS: Of the 7854 infants admitted during the first 12-month audit period, 387 (4.9%) received 977 RCCTs. Of these, 183 (47.3%) received one transfusion, 72 (18.6%) two transfusions, 51 (13.2%) three transfusions, 27 (7.0%) four transfusions and 54 (13.9%) five or more transfusions. Infants (N = 188) with a birth weight below 1500 g admitted to the NICU were identified as the group with the highest prevalence of RCCTs (68.6%), and it was therefore decided that in the prospective study such infants would qualify for the LDEP. A total of 81 infants was transfused with either the double (N = 47) or the triple bags (N = 34) over a 5-month period. The decrease in the mean DER (+/-SD) was clinically significant when the triple (1.9 +/- 0.8) (P = 0.0001) and the double bags (1.6 +/- 0.8) (P = 0.0001) were compared with the previous single-bag system (4.4 +/- 3.5). Of concern was the large mean volume of concentrated red cells (118.5 +/- 12.5 ml) wasted per transfusion with the single-bag system. CONCLUSIONS: This survey confirmed a high RCCT rate as well as a very high DER in very-low-birth-weight (VLBW) infants treated at a tertiary centre. By assigning a triple or double bag of red cells from one blood donor and extending the storage of blood for small-volume RCCTs in infants from 14 days to 35 days, donor exposure was reduced significantly. We urge the introduction of the multibag blood transfusion system and extended storage period of blood for small-volume RCCT for VLBW infants in South Africa.

Bronchopulmonary dysplasia in infants with respiratory distress syndrome in a developing country: a prospective single centre-based study.

UNLABELLED: The aim of this prospective study was to determine the incidence of bronchopulmonary dysplasia (BPD) in and the outcome of neonates ventilated for respiratory distress syndrome (RDS). The study was conducted in a developing country prior to the use of surfactant replacement therapy and the results are compared to published reports from the developed world. BPD was defined as oxygen dependency beyond day 28 of life. The incidence of BPD over a 9-month-period was 8.2% of all neonates requiring ventilation (n = 169) and 41% (n = 38) of neonates ventilated for RDS (n = 92). Of those neonates who developed BPD, 26% were still being ventilated on day 28. Of the infants, 21 (55%) developed type 1 BPD and 17 (45%) type 2 BPD. There was no statistical difference in the severity of lung disease on any of the study days between type 1 and type 2 BPD although neonates with type 2 BPD required assisted ventilation and supplemental oxygen for a longer period: 30 versus 12 days and 95 versus 49 days, respectively. Of those neonates who developed BPD, 8 (21%) died prior to discharge from hospital and a further 5 infants (17%) died subsequent to discharge. Of the latter five, three died from treatable causes (gastroenteritis n = 2, pneumonia n = 1). Of the 25 (83%) children seen at follow up, 68% were developing normally, 20% were classified as having suspect development and 12% had developed cerebral palsy at corrected postnatal ages of 12-24 months. None of the results differed significantly from those of neonates being ventilated in the developed world, except for the causes of post-discharge deaths. CONCLUSION: Health services providing ventilation for neonates in the developing world will have to take the needs of children with BPD into account when planning a neonatal service which should include among others a widely available and easily accessible primary health care system.

The necessity for T-cryptantigen activation screening in babies with necrotising enterocolitis.

OBJECTIVE: To determine the prevalence of T-cryptantigen activation (TCA) and its predictive value for severity of necrotising enterocolitis (NEC) in babies. STUDY DESIGN: Prospective descriptive. STUDY POPULATION: Thirty-four babies with NEC were prospectively screened for TCA at Tygerberg Hospital over a 6-month period. TCA screening was done by testing for red blood cell agglutination by the common peanut lectin, Arachis hypogea. Once TCA was confirmed, only washed red cells were administered to the babies and plasma-containing blood products were avoided. NEC was divided into suspected NEC (stage 1), classic NEC (stage 2) and fulminant NEC (stage 3). MAIN OUTCOME MEASURES: Prevalence of TCA in babies with various stages of NEC; the association between TCA and bowel necrosis, need for surgery and mortality. RESULTS: TCA was positive in 8 (24%) of the babies in this study. Six babies (18%) had stage 1 NEC, 10 (29%) had stage 2 NEC and 18 (53%) had fulminating or stage 3 NEC. All 18 babies with stage 3 NEC required surgery and TCA was present in 8 (47%) of them. Twelve babies (35%) died, 3 with TCA and 9 with no TCA. Babies with TCA had portal venous gas on abdominal radiographs (P = 0.037) and stage 3 NEC (P = 0.003) more often than babies with no TCA. CONCLUSIONS: A strong association was noted between TCA and the fulminant form of NEC with bowel necrosis. TCA is a baby with NEC should alert the surgeon to the possibility of severe disease and the need to avoid plasma-containing blood products. Blood banks are urged to introduce routine screening for TCA in all babies with NEC.

Improved perinatal mortality rates in 1001 patients with severe pre-eclampsia.

OBJECTIVE: To ascertain the change in perinatal mortality (PNM) rate over a period of 10 years in 1001 patients with severe pre-eclampsia. METHODS: Patients with severe pre-eclampsia before a gestational age of 34 weeks were managed expectantly. Initial treatment consisted of the administration of magnesium sulphate to prevent convulsions and dihydralazine to reduce blood pressure. Methyldopa alone or in combination with other oral antihypertensive drugs was started soon after admission. In order to prevent fetal death from abruptio placentae, the fetal heart rate was monitored at least four times per day. Patients were delivered either at 34 weeks' gestation or when fetal or maternal indications for immediate delivery were present. The 10-year study was divided into four successive time periods and the PNM rate was calculated separately for each of these time periods. RESULTS: Perinatal survival was low if patients were delivered before or at 26 weeks' gestation but improved rapidly if delivered thereafter. There were only 33 intrauterine deaths of babies who weighed 1000 g or more. The majority of these deaths were due to abruptio placentae which had occurred prior to admission to hospital. The PNM rate for babies of 1000 g or more decreased from 61 in the first time phase and 83 in the second to 19 in the last. The overall PNM rate during the 10-year study was 62. CONCLUSION: Improved knowledge about the management of patients with severe pre-eclampsia in early pregnancy resulted in a decline in the PNM rate. Although the exact cause of this reduction towards the end of the study is not known, several factors probably played a role. They are expectant management with a little gain in the gestational age, better fetal monitoring before and during labour, earlier detection of fetal distress, earlier referral to the tertiary hospital and improved neonatal care.

The outcome of babies of mothers with severe rhesus incompatibility treated at Tygerberg Hospital, 1980-1993.

OBJECTIVE: To determine the outcome of babies of mothers with severe rhesus (Rh) incompatibility treated by elective delivery when the amniotic optical density at 450 nm crossed Whitfield's action line (group 1), by plasmapheresis and immunotherapy (group 2) or by means of intra-uterine intravascular transfusions (group 3). STUDY DESIGN: A retrospective study of 55 mothers and their 57 fetuses with severe Rh incompatibility at < 34 weeks' pregnancy duration. MAIN OUTCOME PARAMETERS: Number of mothers in each treatment group, prevalence of intra-uterine death, hydrops, intra-uterine intravascular transfusions, cord haematocrit, cord bilirubin, number of liveborn babies, birth weight, neonatal death, hyaline membrane disease (HMD) and exchange transfusions. STUDY POPULATION AND SETTING: All mothers and babies with severe Rh incompatibility (defined as an amniotic optical density of 450 nm in the upper and upper-mid zone on the Liley chart at < 34 weeks' pregnancy duration, previous fetal hydrops or Rh-related intra-uterine death (IUD), fetal hydrops on ultrasound or a fetal haematocrit < 30% at cordocentesis) treated at Tygerberg Hospital between January 1980 and January 1993. There were 20 fetuses each in groups 1 and 3, and 17 in group 2. RESULTS: A total of 48 babies (84%) were liveborn and of these 74% survived the neonatal period. (ABSTRACT TRUNCATED AT 250 WORDS)

The outcome at 12 months of very-low-birth-weight infants ventilated at Tygerberg Hospital.

OBJECTIVE: To determine the outcome at 1 year of age of a group of very-low-birth-weight (VLBW) infants, from urban and rural communities, ventilated at Tygerberg Hospital, W. Cape. STUDY DESIGN: Prospective descriptive study in which the prevalence of bronchopulmonary dysplasia (BPD), sensorineural deafness, intraventricular haemorrhage (IVH), retinopathy of prematurity (ROP) and abnormal motor developmental outcomes were determined in 153 ventilated VLBW infants from rural and urban areas. Of these, 69% were from lower socio-economic backgrounds. MAIN OUTCOME MEASURES: Attrition rates for rural and urban babies, BPD, ROP, IVH and abnormal motor development. STUDY POPULATION AND SETTING: All ventilated VLBW infants discharged from the neonatal intensive care unit at Tygerberg Hospital over a 1-year period were followed up at 3-monthly intervals for 12 months. RESULTS: BPD was diagnosed in 19% of the babies, with significantly more babies with birth weights under 1,000 g and gestational ages under 28 weeks having BPD. Of the babies with BPD, 25% had abnormal motor development at 1 year of age. Seven per cent of the babies had grade 3 or 4 ROP and 2.6% had sensorineural hearing loss. One hundred and seventeen (79%) of the infants attended the follow-up clinic until 12 months of age (corrected for prematurity). There were no significant differences in the number of babies followed up from rural or urban areas. Fourteen (11.9%) of the babies had abnormal motor development. A disturbing finding was that so many babies had spastic quadriplegia (8; 57%) versus diplegia (6; 43%). The incidence of abnormal motor development in the babies from the rural areas and in those with birth weights under 1,000 g from rural areas was high--a further cause for concern. CONCLUSION: The prevalence of the major complications associated with ventilated VLBW infants correlated well with those reported for similar infants from First-World countries. The poor motor developmental outcome of the babies from rural areas with birth weights under 1,000 g and high attrition rates for infants with serious complications such as BPD, IVH and ROP are distressing.

Chest radiographs of neonates with respiratory failure caused by congenital syphilis.

Congenital syphilis still occurs in newborn babies and the prevalence has increased in recent years, especially in developing countries. This has led to an increase in the number of babies with congenital syphilis requiring intensive care for respiratory failure. The early recognition of this disease could lead to the institution of timely and appropriate treatment. In this study the radiological picture of syphilitic pneumonitis is described in 20 neonates admitted to our neonatal intensive care unit requiring ventilation for respiratory failure. The radiological picture of the babies with syphilis was compared to 20 babies with other causes of respiratory distress. The radiological picture in 17 babies demonstrated a coarse nodular pattern in addition to band-like opacities radiating from the hilar regions. The nodular opacities became confluent on follow-up radiographs. In 13 cases, the proximal humeri showed changes typical of congenital syphilis. Two of the three babies with syphilis who did not have the typical chest radiological picture had bony involvement visible on the chest radiograph. Both the sensitivity and specificity of radiographic diagnosis were 75% with a positive and negative predictive value of 75%. The diagnosis of congenital syphilitic pneumonitis can therefore be suspected on chest radiographs and should be included in the differential diagnosis of any baby who presents with an interstitial pattern on chest radiography.

The transport of neonates to an intensive care unit.

OBJECTIVE: To describe the mode of transport, the type of patient transferred and outcome as defined by death or discharge from hospital. DESIGN: A retrospective study was done of all neonates transferred from outside the designated drainage area of the hospital. SETTING: The study was done at the level 3 Neonatal Intensive Care Unit at Tygerberg Hospital for the period January-September 1992. PARTICIPANTS: From a total of 58 infants 52 were enrolled; they originated over a vast area of the western and northern Cape Province. MAIN OUTCOME MEASURES: Reasons for transfer, mode of transport and survival were measured. RESULTS: None of the infants died during transport. In total 11 (21%) of the 52 died. Categorising outcome according to transport method showed 100% survival of babies transported by fixed-wing aircraft, 94% survival if transport was by helicopter, and 70% survival if transported by ambulance. The non-survivors had a higher mean gestational age (P < 0.05) than the survivors and included 8 (73%) with asphyxia-related meconium aspiration syndrome. When the primary referral diagnosis was considered, 8 (27%) of 29 infants with respiratory failure of any cause, and 2 (28%) of those with neurological problems, died. All the infants transported because of a surgical emergency survived. CONCLUSION: These results show a high survival rate in transported infants, with the highest mortality in the asphyxia-related meconium aspiration syndrome and the infants transported by ambulance. The preponderance of infants with meconium aspiration syndrome might reflect the standard of perinatal care provided in the outlying regions of the western and northern Cape.