Correlation of 25-Hydroxyvitamin D Levels in Serum vs. Breastmilk in Vitamin D-Supplementation Breastfeeding Women during Lactation: Randomized Double Blinded Control Trial.

Background: Vitamin D deficiency in pregnancy and lactation increases the risk of adverse perinatal outcomes; however, although Vitamin D supplementation during pregnancy and lactation is recommended, suggested dose ranges vary. Objective: To determine whether vitamin D31,800 IU/d supplementation in lactating mothers improves their vitamin D status and breast-feeding milk. Material and Method: This was a randomized, placebo­controlled study of Thai pregnant women in their third trimester. A total of 76 Thai lactating mothers and their breast-fed infants were studied with maternal 25 Hydroxyvitamin D 25 (OH) D levels of 10-30 ng/ml determined using Liquid Chromatography Mass Spectrometry Tandem (LC-MS/MS). One group received vitamin D3 1,800 IU/d supplementation for 6 weeks, and members of the other group were given a placebo. 25 (OH) D level of colostum and 6-week serum from breast-fed milk were measured by High Performance Liquid Chromatography (HPLC). The data from the two groups were analyzed and compared. Results: The mean (±SD) maternal age was 27.16±5.13 years, and mean body mass index (BMI) was 22.29±5.08 kg/m(2). At 6 weeks, maternal 25 (OH) D levels had increased significantly in the vitamin D group (VD) 68.30±15.40 nmol/L compared to 55.15±13.57 nmol/L in the placebo group (p<0.001) measured using the Liquid Chromatography-Mass Spectrometry Tandem (LC-MS/MS) method. Breast-fed milk did not show any significant incremental change in 25 (OH) D levels measured by High Performance Liquid Chromatography (HPLC); however, the change in 25 (OH) D levels in breast milk in the VD group was significantly different from that of the placebo group (p = 0.005).` Conclusion: Vitamin D3 supplementation during lactation can increase 25 (OH) D levels in Thai breast-fed mothers. Further work is needed to determine the duration of vitamin D supplementation to normalize breast milk and breast-fed infants' 25 (OH) D level at over 75 nmol/L.

THE BURDEN OF INVASIVE NEONATAL GROUP B STREPTOCOCCAL (GBS) DISEASE IN THAILAND AND THE PHILIPPINES.

Group B Streptococcus (GBS) is a leading cause of meningitis and sepsis in infancy, but burden of disease data are scarce for Asia. We performed two hospital-based, prospective, descriptive, observational studies using similar protocols in the Philippines and Thailand to evaluate neonatal GBS disease epidemiology. Infants aged <90 days with a GBS-positive culture from normally sterile sites using routine microbiological standards were eligible for inclusion. Awareness of GBS symptoms was raised by informing all women at delivery and follow-up for 90 days post-delivery. Infections were classified as early onset disease (EOD) if they occurred within 6 days of birth and late Onset disease (LOD) if they occurred 7-89 days after birth. Due to ethical requirements in Thailand, consent for study participation, including periodic post-discharge telephone calls, was obtained at delivery. Parents in the Philippines gave consent for study participation at case identification. The clinical outcomes of GBS infections were recorded. During the 6-month study period, two cases (one fatal) of EOD were identified among 8,409 live births at the study hospitals in Thailand and three cases (two fatal) of EOD were identified among 11,768 live births reported at the study hospitals in the Philippines. Incidence rates per 1,000 live births were 0.2 (95% CI: 0.0-0.8) and 0.3 (95% CI: 0.1-0.8) in Thailand and the Philippines, respectively. There were no cases of reported LOD. The low number of cases precluded analysis of serotype distribution and case fatality rates. Large epidemiological studies are needed to better understand the factors influencing GBS infection incidence in Asia.

Growth and development of very low birth weight infants aged 18-24 months at Queen Sirikit National Institute of Child Health.

BACKGROUND: The number of very low birth weight (VLBW) births is increasing worldwide. Despite better care in recent years, they have a high incidence of delayed growth and development. There are no previous studies regarding the growth and development of these infants at Queen Sirikit National Institute of Child Health (QSNICH). OBJECTIVE: To study growth and developmental outcome of VLBW infants, aged 18-24 months who were discharged from QSNICH. MATERIAL AND METHOD: VLBW infants who were discharged from QSNICH during the year 2007 were recruited in the study. Patients with chromosomal abnormalities, major congenital anomalies, definite congenital infections and positive maternal anti-HIV tests were excluded. At the corrected age of 18-24 months, the parents were called upon to bring their infants for complete physical examination and developmental evaluation on 2 occasions, two months apart. RESULTS: There were 111 cases of VLBW infants who were discharged from QSNICH during the year 2007. Fifty-four patients were eligible for the present study. Thirty cases (55.56%) were contacted for the first examination. During this examination, there were 3 cases (10%) with low head circumference, 1 case (3.33%) with poor weight gain, 5 cases (16.67%) with visual defect, 1 case (3.33%) with moderately severe hearing loss, 1 case (3.33%) with cerebral palsy and 7 cases (23.33%) with delayed development. Twenty-one cases could be recalled for a second evaluation. Two of the 5 cases had delayed language development. There were no cases with hydrocephalous, blindness or profound hearing loss. CONCLUSION: VLBW infants at QSNICH had much better survival during recent years. Most of these survivors had normal growth and development. Those with delayed growth and development need aggressive intervention and long-term follow-up for enhancement of quality of their lives.

Acute hematogenous osteomyelitis and septic arthritis in children: clinical characteristics and outcomes study.

OBJECTIVE: To evaluate the clinical features, causative pathogens and outcomes-related to acute hematogenous osteomyelitis and septic arthritis in pediatric patients. MATERIAL AND METHOD: The authors conducted a retrospective cohort study of patients under 15 years of age with diagnosis of acute hematogenous osteomyelitis (AHO) and/or septic arthritis (SA), treated at Queen Sirikit National Institute of Child Health from 1996 to 2006. Demographic data, clinical characteristics, bacterial spectrum, and outcomes were collected. Potential risk factors for osteoarticular sequelae in the patients who had more than 2 years of follow-up were analyzed. RESULTS: One hundred and twenty-nine patients met the diagnostic criteria which included 51 cases with SA, 35 cases with AHO and 37 cases with both SA and AHO. The patient's age ranged between 1 day and 13 years 4 months, comprising 37 (28.6%) of newborns, 28 (21.7%) of > 1-12 months, 18 (14%) of > 1-3 years and 46 (35.7%) of > 3-15 years. Causative bacteria were found in 103 of 129 patients (80%), the two most common pathogens were methicillin-sensitive Staphylococcus aureus (MSSA) in 48 (46.6%) and methicillin-resistant Staphylococcus aureus (MRSA) in 18 (17.5%) cases. The initial temperature on admission day was high (> 37.5 degrees C) in only one-third of newborns, one-half of infants and two-thirds of the older group. The duration of antibiotic administration ranged between 21 and 56 days (mean 42 days). Arthrotomy or drainage and bone or joint aspiration underwent in 62% and 17% of cases respectively. Outcomes of 79 patients who had more than 2 years of follow-up identified osteoarticular sequelae in 23 patients (29%) that consisted of avascular necrosis of epiphysis, limb-length discrepancy and pathologic fractures. Univariate analysis for potential risk factors compared between sequelae and without sequelae groups demonstrated significant association with more than 1 week duration of presenting symptoms, newborn age group, hip joint infection, infection with MRSA and more than 3 days delayed treatment with appropriate antibiotics. CONCLUSION: MSSA was the most common bacterial pathogen causing pediatric osteoarticular infections in all age groups but was second to MRSA in the newborn group. Osteoarticular sequelae were avascular necrosis of epiphysis, limb length discrepancy, and pathologic fracture which were significantly related to longer duration of presenting symptoms, newborn age group, hip joint involvement, MRSA infection and delayed administration of appropriate antibiotics.

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.

A randomized trial of non-synchronized Nasopharyngeal Intermittent Mandatory Ventilation (nsNIMV) vs. Nasal Continuous Positive Airway Pressure (NCPAP) in the prevention of extubation failure in pre-term < 1,500 grams.

OBJECTIVE: To compare the rate of reintubation within 7 days after extubation and study the complications in premature infants who were randomized in the immediate postextubation period to either nsNIMV or NCPAP. MATERIAL AND METHOD: This study was conducted in the neonatal unit of Queen Sirikit National Institute of Child Health between June 1 and November 30, 2006. Intubated premature infants born at GA < or = 34 weeks or with birth weight < or = 1500 gm, ready to be extubated before 4 weeks of age were recruited. Infants were randomized to either nsNIMV or NCPAP after extubation. Non-synchronized NIMV setting was the same as ventilator setting before extubation and NCPAP pressure was set at the same mean airway pressure of pre extubation ventilator value. Extubation was performed after intravenous loading dose of aminophylline. Primary outcome measurement was reintubation within 7 days of initial extubation and the secondary outcome was possible complications such as apnea, abdominal distension, gastrointestinal (GI) perforation, necrotizing enterocolitis (NEC), sepsis and death. RESULTS: A total of 70 VLBW infants were admitted to the neonatal unit during the study period. A total of 57 infants were intubated of which 48 infants were recruited for the study; 24 were in the nsNIMV group and 24 were in the NCPAP group. Infants in the nsNIMV group had mean birth weight and body weight at the start of study less than that in the NCPAP group (984.8 +/- 218 vs. 1067 +/- 214 and 1185 +/- 219 vs. 1205 +/-191, p = 0.003, 0.02). The nsNIMV group also had a higher rate of RDS and antenatal steroid used when compared to the NCPAP group (19/24 vs. 12/24 and 17/24 vs. 8/24, p = 0.03, 0.01). The nsNIMV group had fewer males than in the NCPAP group (8/24 vs. 17/24, p = 0.01). Reintubation was similar in both groups but atelectasis and sepsis were statistically significant risk factor for reintubation in NCPAP group. There were no significant differences in treatment related complications between the two groups, with respect to incidence of apnea (41.7% in nsNIMV vs. 62.5% in NCPAP), abdominal distensions (8.3% in nsNIMVvs. 16.7% in NCPAP), NEC (4.2% in nsNIMVvs. 12.5 in NCPAP), sepsis (4.2% in nsNIMVvs. 8.3% NCPAP). No GI perforation was observed in both groups. CONCLUSION: Non-invasive mode of ventilation, both NIMV and NCPAP, for weaning ofpre-term infants from ventilator may reduce the rate of reintubation in this group. Both modes seem to be equally safe. We believe that the use of non-invasive ventilator techniques will significantly reduce neonatal morbidity in the future. Additional prospective evaluation of these approaches should be conducted in the future.

A neonate with petechiae and pancytopenia at birth as uncommon presentation of congenital HIV infection.

The authors describe a Thai newborn boy who was presented with petechiae, hepatosplenomegaly and pancytopenia at birth caused by congenital HIV infection. His clinical presentations were appeared on the early onset after birth. The bone marrow finding has shown hypocellularity which was also rare in HIV-infected children.

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.

Maple syrup urine disease in Thai infants.

Maple syrup urine disease (MSUD) is a rare inborn error of metabolism, caused by a deficiency in activity of the branched chain alpha-keto acid dehydrogenase impairing the degradation of the branched-chain amino acids (leucine, isoleucine and valine). Classic MSUD usually manifests in the neonatal period with poor feeding, vomiting, lethargy, muscular hypertonicity, seizure, coma and death. Thirteen cases of classic MSUD were diagnosed from 1997-2007 at the Queen Sirikit National Institute of Child Health. All cases presented in the neonatal period. The onset of symptoms ranged from 3 to 20 days (median 8 days). The time taken to make the diagnosis ranged from 18 to 356 days (median 55 days). The diagnosis was accomplished by clinical diagnosis and confirmed by detecting abnormal levels of amino acids in the blood and organic acids in the urine. Clinical manifestations were non-specific such as poor suck, weak cry, drowsiness and seizures. Majority of cases were initially diagnosed as sepsis and/or meningitis. All patients had neurological sequelae and psychomotor retardation. This results show the need for increase awareness of metabolic disorder such as MSUD and the requirement for early detection and treatment to ensure a better outcome.

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.

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.

Congenital tuberculosis.

This is a retrospective study of congenital tuberculosis in Queen Sirikit National Institute of Child Health from 1979 to 1998. There were 9 patients with a mean birth weight of 2,500 grams (range 1,800-3,300). The onset of symptoms and age of diagnosis ranged from 7 to 42 (mean, 21) days and 14 to 75 (mean, 54) days after birth, respectively. The presenting signs and symptoms were fever (100%), poor feeding (100%), irritability (100%), failure to gain weight (100%), hepatomegaly (100%), splenomegaly (77.8%), cough (88.9%), respiratory distress (66.7%) and abdominal distension (77.8%). The tuberculin skin test reaction with > or = 10 mm induration was found in 2 of 8 patients. Their abnormal chest radiographs revealed bronchopneumonia 66.7 per cent, miliary pattern 33.3 per cent and multiple cystic lesion 11.1 per cent. The bacteriological study from gastric aspirate content for acid-fast bacilli (AFB) staining and culture were positive in 62.5 and 71.4 per cent respectively. Fatality rate was 33.3 per cent with no sequele found in the survivors. Congenital tuberculosis is a rare entity and difficult to give an early diagnosis. There should be a high index of suspicion for tuberculosis in those who had pneumonia and were unresponsive to aggressive antibiotics or had unexplained etiology.