Early neonatal mortality and causes of death in Ramathibodi Hospital: 1981-1990.

PIP: This study examined the trends in early neonatal mortality by birthweight during 1981-90 at Ramathibodi Hospital in Thailand. Deaths were analyzed by causes of death within the first 7 days of life. Causes included congenital malformation, immaturity, asphyxia, respiratory distress syndrome (RDS), infection, and other causes. The results showed that 71,153 births occurred during the 10 year period, an increase of 22% over the period. Low birthweight increased from 6.3% in the first five years to 7.1% in the last five years. Very low birthweight (less than 1500 g) increased from 0.47% in the first five years to 0.57% in the last five years. Early neonatal mortality decreased from 0.53% in 1981 to 0.23% in 1990, which was over a reduction of over 50%. The reduction was 60% when congenital malformations were excluded. Early neonatal mortality declined for all birthweight groups by 40-75%, with the exception of birthweights under 1000 g. 90% of early neonatal deaths were due to congenital malformation, immaturity, RDS, asphyxia, and infection. Mortality due to congenital malformation remained at a rate of about 1.3:1000 live births. Causes of death varied with birthweight group. Neonates less than 1000 g died of RDS and immaturity in both 5-year periods. Neonates between 1000-1499 g and 1500-1999 g died of congenital malformation in the most recent period; for the first period, neonatal mortality was caused by RDS and infection respectively. Congenital malformation was the primary cause over the 10-year period for births weighing 2000 and higher grams. Hospital management for delivering and postpartum women changed over the ten year period. Although there was no specific intensive care unit, equipment for intensive neonatal care management was available. The improvement in neonatal mortality occurred during a period of increased numbers of births and low birthweight babies. Neonates under 1000 g were not managed as aggressively by medical staff because of the poor chances of survival and the high cost of care. In 1990, there was a change for more aggressive management of neonates with a birthweight between 750-999 g. The incidence of infection, asphyxia, and RDS decreased or remained stable due to better management of RDS and early detection and treatment with antibiotics of infection.^ieng

Neonatal intensive care: present and future trends in Thailand.

PIP: A neonatal intensive care unit (NICU) provides the personnel, equipment, and related infrastructure necessary to support the life of a premature or sick neonate. Neonatologists, other medical specialists, nurses, and auxiliaries are on hand to treat and manage their young patients with respirators, monitors, infusion pumps, portable X-ray machines, incubators, and intensive care warmer units as required in a facility large enough to provide unrestricted working space together with pipelines and hand washing facilities. Appropriate laboratory support is needed, while complementary ultrasound, computer tomography, and magnetic resonance scanning are always welcome. Most health institutions in Thailand, however, do not have the personnel, equipment, infrastructure, and financial resources to establish and operate dedicated NICUs. Lack of financial support is the largest constraint. These institutions make do as best they can with available facilities and may be considered to have special care facilities in their nurseries which provide essential life support, but not on the scale of NICUs in the US and Europe. Thailand is two decades behind the US and Europe in terms of providing NICU services to patients in need. Experience with the small NICU established in October 1990 at Ramathibodi Hospital is described. Few would dispute the importance of and need for NICUs to decrease neonatal morbidity and mortality. Such expensive and sophisticated care should, however, be postponed in Thailand in the interest of ensuring that basic needs such as good maternal antenatal care, deliveries, and neonatal care are met. Specialized neonatal care may be encouraged in centers insofar as available resources permit. No official training program exists for neonatologists leading to a board certification by the Thai Medical Council. Moreover, Ramathibodi Hospital has the only neonatal nurse practitioner program. Perinatal training programs for doctors and nurses must be organized in stepwise fashion to prepare for a future in Thailand when NICUs will be widely established in medical schools, regional hospitals, and large private hospitals.^ieng

Neonatal lupus erythematosus in Thailand.

Systemic lupus erythematosus (SLE) is not uncommon in Thai children and adults but neonatal lupus erythematosus has never been reported in Thailand. A case of NLE born of a mother without prior history of SLE was reported. He was initially misdiagnosed as congenital self-healing histiocytosis because of seborrheic dermatitis-like lesions, petechiae, hepatosplenomegaly and thrombocytopenia. Features supporting the diagnosis of NLE in this case were presented.

Clinical trial of special premature formula for low-birth-weight infants.

Feeding 25 low birth weight infants during a one month period either with special premature formula or with standard formula resulted in better weight gain, nutritional efficacy, fat absorption, and lower frequency of metabolic acidosis in the special premature formula group. Various biochemical indices demonstrated excellent protein and mineral metabolization of this formula, which seem appropriate for the infants studied (1,000-1,750 g birth weight). Both formulae were well tolerated without any untoward effects.

Neonatal jaundice and glucose-6-phosphate dehydrogenase deficiency.

Ninety-six newborn aged 0-7 days with serum bilirubin of more than 15 mg/dl were studied for the G6PD status using semiquantitative and the assay method. It was found that the result of the 2 methods corresponded. The prevalence of G6PD deficiency was 12.4 per cent (there were 11 boys and one girl). Among the G6PD deficiency and the normal group, there was no difference in the age of the patient, onset of jaundice, bilirubin level, hematocrit status and the reticulocyte count. The semiquantitative method is a reliable as the assay method.

Effect of phototherapy on nutrients utilization in newborn infants with jaundice.

The effect of phototherapy on digestion and absorption of nutrients was performed in 25 male, newborn infants with hyperbilirubinemia. The infants were divided into 2 groups; one group was fed with lactose formula whereas the other group received the non-lactose formula. The quantities of daily volume, fat and energy intakes of both groups were similar. Protein intake was significantly higher in the latter group. During 72-hours of phototherapy, there were decreases in serum bilirubin in all infants and mean weight change was decreased in infants fed with non-lactose formula. Treatment by phototherapy in jaundiced infants did not affect protein, fat and energy absorption. The presence of loose stool, lower stool pH and trace in reducing substances in some subjects fed with lactose formula suggests mild lactose intolerance. Prospective study in clinical trial needs to be further assessed and clarified on other nutrients such as amino acids and riboflavin status in these infants during phototherapy.

Vitamin K prophylaxis in the neonate by the oral route and its significance in reducing infant mortality and morbidity.

PIP: Vitamin K in oral drops and intramuscular injection given at birth to Thai infants were compared to determine whether these routes and doses would influence prothrombin complex activity, mortality or morbidity at 0.5, 1 and 2 months of age. The infants were 321 normal fullterm babies born at Bangkok Adventist Hospital in 1983, exclusively breastfed during the study. Prothrombin complex (PC) was measured by the Owren capillary thrombotest method using a reagent from Nyegaard Co., Oslo. Vitamin K was given in single 1 or 2 mg oral doses, or 1 mg im, within 12 hours of delivery. Judging by the number of PC deficient children, the 1 mg im and 2 mg oral doses of vitamin K maintained clotting factors best at 2 months of age. All formulations were significantly better than no treatment at 1 month at age. No toxicity or side effects were seen. Vitamin K deficiency is a known cause of bleeding disorders, particularly fatal and handicapping intracranial hemorrhage in newborns, in developing countries where injections cannot be given by midwives. These inexpensive oral pediatric drops may provide a practical form of primary health care for routine vitamin K prophylaxis in newborns.^ieng

Immunoglobulins in maternal and umbilical cord blood of Thais.

Quantitative determination of serum immunoglobulins was carried out by radial diffusion technique in 17 mothers and 43 cord blood samples. Mean maternal serum IgG, IgM and IgA were 1471 +/- 349 mg%, 109 +/- 21 mg% and 240 +/- 62 mg% respectively, and these were equivalent to maternal levels in Thai adults. Mean umbilical cord IgG was 1571 +/- 298 mg% and IgM was 10 +/- 5 mg%. IgA was not detected in the cord blood. There were no differences in the immunoglobulin levels between male and female infants. The IgG levels in the maternal sera and those in the cord sera of the corresponding offsprings were almost identical, but those of IgM were markedly different, suggesting a placenta barrier of this latter immunoglobulin. Thus, IgM level above the normal cord blood suggest intrauterine infection.

Haemorrhage in neonatal hepatic necrosis due to herpes infection.

A case of early neonatal severe bleeding and persistent hypoglycemia with a fatal outcome is reported. The autopsy examination revealed the features of neonatal hepatic necrosis. Further study by the electron microscopy indicated the presence of herpes type particles in the nucleus and cytoplasm of the remaining liver cells. Serological study of the maternal blood, post partum, revelaed positive reaction to Herpes simplex virus type 2 at low titer. It is believed that intrauterine herpes infection was responsible for the severe hepatic damage manifesting in complex clinical findings.