Feeding intolerance scoring system in very preterm and very low birth weight infants using clinical and ultrasound findings.

Very preterm infants are at a high risk of developing feeding intolerance; however, there are no widely accepted definitions of feeding intolerance. This study aimed to develop a scoring system for feeding intolerance in very preterm infants by combining clinical symptoms and ultrasonography (US) findings. This prospective cohort study included very preterm and/or very low birth weight infants. We defined feeding intolerance as the inability to achieve full feeding (150 ml/kg/day) by 14 days of life. The clinical findings included vomiting, abdominal distention, and gastric fluid color. US findings included intestinal peristaltic frequency, gastric residual volume, peak systolic velocity, and the resistive index of the superior mesenteric artery. We conducted multivariate analyses to evaluate the potential predictors and developed a scoring system to predict feeding intolerance. A total of 156 infants fulfilled the eligibility criteria; however, 16 dropped out due to death. The proportion of patients with feeding intolerance was 60 (42.8%). Based on the predictive ability, predictors of feeding intolerance were determined using data from the US at 5-7 days of age. According to multivariate analysis, the final model consisted of 5 predictors: abdominal distention (score 1), hemorrhagic gastric fluid (score 2), intestinal peristaltic movement ≤18x/2 min (score 2), gastric fluid residue >25% (score 2), and resistive index >0.785 (score 2). A score equal to or above 5 indicated an increased risk of feeding intolerance with a positive predictive value of 84.4% (95% confidence interval:73.9-95.0) and a negative predictive value of 76.8% (95% confidence interval:68.4-85.3). The scoring system had good discrimination (area under the receiver operating characteristic curve:0.90) and calibration (p = 0.530) abilities. This study developed an objective, accurate, easy, and safe scoring system for predicting feeding intolerance based on clinical findings, 2D US, and color Doppler US.

Predicting Factors for Mortality in Patients After the Modified Blalock-Taussig Shunt Procedure in Developing Countries: A Retrospective Study.

Background: Blalock-Taussig (BT) is a palliative procedure that preserves blood circulation to the lungs and alleviates cyanosis in patients with congenital heart diseases and reduced pulmonary blood flow. BT shunt remains a routinely performed procedure in developing countries before definitive surgery. However, evidence on predictor factors of mortality after this procedure is still scarce in Indonesia. This study evaluated the predictive factors of mortality after the BT shunt procedure. Methods: This retrospective study evaluated the medical record data of all postoperative BT shunt patients at Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia, from 2016 to 2020. We performed univariate and multivariate analyses to identify the predictors of in-hospital mortality. Results: The total subjects in this study were 197 children, 107 (54.3%) boys and 90 (45.7%) girls. The median values for age and body weight at the time of surgery were 20 months (11 days - 32 years) and 7.9 (2.7-42) kg. The most prevalent diagnosis was the Tetralogy of Fallot, found in 80 (40.6%) patients. In-hospital postoperative mortality was 20.8% (41 patients). Based on multivariate analysis, predictors associated with mortality were weight <4.25 kg (OR 20.9; 95% CI 7.4-59.0; p < 0.0001) and emergency procedures (OR 3.5; 95% CI 1.3-9.5; p = 0.016). Conclusion: The mortality rate after BT shunt at PJT Rumah Sakit Cipto Mangunkusumo was 20.8%. Based on multivariate analysis, weight <4.25 kg and emergency procedures are two predictors of mortality in BT shunt.

Transcatheter Closure of Perimembranous Ventricular Septal Defect Using the Lifetech Konar-Multi Functional Occluder: Early to Midterm Results of the Indonesian Multicenter Study.

Background: The alternative device to close perimembranous ventricular septal defect (pmVSD) has been searched for better result, less complications and applicable for infants. However, the ideal device is still unavailable. We aimed to evaluate the effectiveness and outcome of transcatheter pmVSD closure using the KONAR-multi functional occluder (MFO). Methods: Clinical, procedural, follow-up data of pmVSD patients with symptom of heart failure or evidence of significant left to right shunt, growth failure, recurrent respiratory tract infection, and history of endocarditis who underwent transcatheter closure using the MFO were prospectively evaluated. Results: Between January 2016 and December 2017, there were complete records of 132 pmVSD children closed using MFO from eleven centers in Indonesia. The median of age was 4.5 (0.3-17.4) years; weight 14.8 (3.5-57) kg, defect size at the smallest part 3.4 (1.0-8.1) mm, flow ratio 1.6 (1.3-4.9), mean pulmonary artery pressure 18 (7-79) mmHg, fluoroscopy time 18 (3.8-91) and procedural time 75 (26-290) minutes. A retrograde approach was done in 41 (31%) patients. Procedures succeeded in first attempt in 126 (95.4%), failed in three and migration in three patients. Six of eight infants with congestive heart failure were closed successfully. Of 126 patients with successful VSD closure, 12 months follow-up were completed in all patients. The rate of complete occlusion at 1 month, 3 months, 6 months and 12 months after intervention were 95.2%, 97.6%, 99.2%, and 99.2%, respectively. New-onset aortic regurgitation and moderate tricuspid regurgitation developed only in five and three patients. Neither complete atrioventricular block, nor other complications occurred. Conclusion: Transcatheter closure of pmVSD using the MFO is safe, effective, and feasible in infants and children.

Prevalence and predicting factors of Group A beta-hemolytic Streptococcus carrier state in primary schoolchildren.

Introduction: Transmission of Group A Streptococcus from asymptomatic children to their surrounding carries a risk of acute rheumatic fever in susceptible people. Aim and Objectives: We aimed to investigate the prevalence and predictors of GAS carrier state and evaluate the antibiotic sensitivity pattern of GAS in Jakarta, Indonesia. Material and Methods: We enrolled 201 asymptomatic schoolchildren (6-12 years) using stratified random sampling from a primary school in Jakarta. None of the children had a history of rheumatic fever or rheumatic heart disease. All participants underwent physical examination, and laboratory tests include complete blood count, erythrocyte sedimentation rate, C-reactive protein, antistreptolysin O titer, and throat swab culture. Results: The prevalence of GAS carrier was 13.9% (95% confidence interval: 9.2%-18.6%) in our study. On multivariate analysis, tonsillar enlargement was found to be the only predicting factor of GAS carrier (P = 0.03). GAS was sensitive to penicillin G, erythromycin, vancomycin, clindamycin, chloramphenicol, azithromycin, and tetracycline in 100%, 89%, 86%, 75%, 68%, 68%, and 32% of patients, respectively. Conclusion: The GAS carrier state is common among school-age children affecting approximately 13.9% children. Tonsillar enlargement is a significant finding predictive of GAS carrier state. All isolates are still sensitive to penicillin and mostly sensitive to erythromycin but are increasingly resistant to tetracycline.

The corrected QT interval prolongation in adolescents with cardiac iron overload ß-thalassemia major.

BACKGROUND AND OBJECTIVES: Iron-induced cardiomyopathy remains the leading cause of mortality in ß-thalassemia major patients. The T2* magnetic resonance imaging (MRI) technique is the gold standard for iron load detection, yet it is expensive and not widely available especially in the developing countries. Some previous studies showed that QTc interval could be used as an early detection of cardiac iron overload. This study aimed to evaluate the diagnostic value of QTc interval as a marker of early detection of cardiac iron overload in adolescent beta thalassemia major patients. METHODS: We prospectively evaluated electrocardiography (ECG) parameter of QTc interval in 50 ß-thalassemia major patients aged 10-18 years. All participants had a 12-lead ECG evaluation, echocardiogram and cardiac MRI T2* examination within three months (average 15 days). They were categorized as cardiac iron overload (MRI T2* < 20 millisecond) and non-cardiac iron overload (MRI T2* > 20 millisecond). RESULTS: Of the 50 patients, the male to female ratio was 1.08:1 and the mean age was 13.7 ± 2.43 years. All participants showed normal systolic and diastolic function using conventional echocardiography. The mean QTc interval was significantly different between cardiac iron overload group (464.44 ± 20.35 ms) and noncardiac iron overload group (431.09 ± 32.29) (p= 0.001). Diagnostic study of QTc interval resulted in AUC 0.8 (p= 0.002). Calculated sensitivity and specificity of QTc interval were 0.88 and 0.73 respectively, with cut-off point of 449 ms. CONCLUSION: Cardiac iron overload is associated with QTc prolongation in adolescents. QTc interval of 449 ms could be considered as a cut-off point of cardiac iron overload.

Profile of Kawasaki Disease in Adolescents: Is It Different?

BACKGROUND: there is clearly growing population of young adults with potentially important coronary artery disease after Kawasaki disease (KD) during childhood, and cardiologist must be prepared to take care for them. As Kawasaki disease in adolescent and adult is rare and under-recognized, it is important to study data on patient presentations which may permit development of diagnostic criteria and treatment guidelines for this age group.This study aimed to compare the clinical profile of KD between adolescents (>10 years of age) and children ≤10 years. METHODS: This is a cross sectional study. A total of 1150 KD cases (age 1-192 months) during the period of January 2003-December 2016 were analyzed. The clinical profile of subjects aged >10 years (adolescents) and  ≤10 years (children) at acute phase of KD were compared. RESULTS: we found 17 cases of KD in adolescents among 1150 total cases (1.5%). Incomplete KD was more often seen in adolescents compared to children ≤ 10 years of age (59% vs. 29%). Some clinical features were more frequently seen in children than in adolescents, e.g. conjunctivitis (85% in ≤ 10 years of age vs. 65% in > 10 years), mucosal changes (94% vs. 77%), rash (86% vs. 59%), and hand/foot changes (68% vs. 41%). While other clinical features were more often seen in adolescents, e.g., cervical lymphadenopathy (82% vs. 39%) and coronary dilatation (47% vs. 29%). Laboratory results (hemoglobin, leukocytes, erythrocyte sedimentation rate and C-reactive protein) did not differ much between the two groups. CONCLUSION: Kawasaki disease in adolescents has some different clinical profile from that of younger age. Majority of adolescent patients have incomplete presentation. Some clinical features such as conjunctivitis, mucosal changes, rash, and hand/foot changes are more often seen in children ≤ 10 years compared to in adolescents, while cervical lymphadenopathy and coronary dilatation are more frequently seen in adolescents. The ratio of male to female is much higher in adolescents.

N-terminal-pro-b-type natriuretic peptide levels and cardiac hemosiderosis in adolescent ß-thalassemia major patients.

BACKGROUND: Iron-induced cardiomyopathy remains the leading cause of mortality in patients with ß-thalassemia major. Iron overload cardiomyopathy, which may be reversible through iron chelation, is characterized by early diastolic dysfunction. Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is a sensitive biomarker of diastolic dysfunction. AIM: The aim of the study is to evaluate the diagnostic value of NT-proBNP as a surrogate marker of iron overload examined with magnetic resonance imaging T2-star (MRI T2*). METHODS: Sixty-eight ß-thalassemia major patients (10-18 years) with no signs of heart failure underwent NT-proBNP measurement before routine transfusion. All participants prospectively underwent cardiac MRI T2* examination within 3 months (median 19 days). Patients were divided as cardiac hemosiderosis (cardiac MRI T2* <20 ms) and nonhemosiderosis (cardiac MRI T2* >20 ms). RESULTS: Of 68 patients, the male-to-female ratio was 1:1.1 and the median age was 14.1 years (range: 10-17.8 years). NT-proBNP levels were not different between hemosiderosis and nonhemosiderosis patients (P = 0.233). Further receiver operating characteristic analysis resulted in no significant correlation of NT-proBNP and MRI T2* (area under the curve 0.393, P = 0.233). CONCLUSION: Measurement of NT-proBNP levels cannot be used for early detection of cardiac iron overload in adolescent with ß-thalassemia major.

Outcome of pediatric cardiac surgery and predictors of major complication in a developing country.

BACKGROUND: Evaluating outcome and identifying predictors of major complications among children undergoing cardiac surgery are essential to improve care. We evaluated short-term outcomes of postcardiac surgery and predictors of major complications in a national referral hospital in Indonesia. METHODS: A prospective cohort study was conducted from April 2014 to March 2015 on all children undergoing cardiac surgery. Participants were followed up from the time of surgery until hospital discharge and 30-day mortality. We performed univariate and multivariate logistic regression using STATA 12-1 to identify predictors of postsurgical major complications. RESULTS: A total of 257 patients (median age: 36 months) were recruited; 217 (84.1%) had complications, including low cardiac output syndrome (19.8%), arrhythmia (18.6%), sepsis (17.4%), and pleural effusion (14.8%). Forty-nine (19%) patients had major complications, including cardiac arrest (5%), need for emergency chest opening (3.9%), and multiple organ failure (7.4%). 12.8% died during hospital stay, and 30-day mortality was 13.6%. Predictors of major complications were cyanotic congenital heart disease (odds ratio [OR]: 4.6, 95% confidence interval [CI]: 1.5-14.2), longer duration of cardiopulmonary bypass (CPB, OR: 4.4, 95% CI: 1.5-13.4), high inotropes (OR: 13.1, 95% CI: 3.2-54.2), and increase in lactate >0.75 mmol/L/h or more in the first 24 h (OR: 37.1, 95% CI: 10.1-136.3). CONCLUSION: One-fifth of children undergoing cardiac surgery experienced major complications with around 13% mortality. Cyanotic congenital heart disease, longer duration of CPB, high inotropes on leaving operating theater, and increase in blood lactate are associated with major complications in children after cardiac surgery.

Long-term outcome of coronary artery dilatation in Kawasaki disease.

BACKGROUND: Kawasaki disease (KD) is an acute systemic vasculitis syndrome with a high incidence of coronary aneurysms in untreated children. The majority of aneurysms resulting from KD are known to regress with time. AIMS: This study aimed to determine the course and outcome of coronary artery dilatation in patients with KD and ascertain whether there are any differences in the outcomes in the different branches. SETTING AND DESIGN: This is a retrospective cohort study of patients diagnosed with KD with midterm follow-up data. METHODS: Serial echocardiography was performed in all KD patients with coronary dilatation for 1-10½ years. The Kaplan-Meier curve was used for statistical analysis. RESULTS: There were 154 patients with coronary dilatation studied. The frequency of coronary dilatation in acute phase was 33.3% and decreased to 7.9% 6-8 weeks later. Each patient could have dilatations at more than one branch, so the total number of dilatations was 245. The median time needed for regression was 2.6 months (mean: 10.5 months) while the median of follow-up duration was 41 months (mean: 23 months). Small- and medium-sized dilatations had more favorable outcomes compared to the giant ones. Location of dilatation did not influence the outcome. CONCLUSIONS: The majority (77.4%) of small- and medium-sized dilatations regress within 2 years, but giant aneurysms tend to persist. The outcome of coronary dilatation is determined by the diameter and not by the location. Regression rate is faster in smaller dilatations. Left main coronary artery is the most frequent location for dilatation.

Domperidone versus cisapride in the treatment of infant regurgitation and increased acid gastro-oesophageal reflux: a pilot study.

AIM: Although domperidone is used frequently to treat infant regurgitation, efficacy data are scarce. Cisapride was previously used in the same indication. METHODS: Domperidone and cisapride were compared in an investigator-blinded, prospective comparative trial by evaluating (a) the frequency of regurgitation, (b) acid reflux and (c) cardiac side effects in infants regurgitating >4 times/day since >2 weeks and with reflux-associated symptoms of discomfort, after conservative treatment failure. RESULTS: Within the first treatment week, the frequency of regurgitation decreased in both groups, more rapidly in the cisapride group: the median regurgitation decreased from 6.22 to 3.50 in the cisapride group versus from 4.80 to 3.70 in the domperidone group. The decrease in regurgitation was still significant after 1 month: cisapride from 6.22 to 1.55 versus domperidone from 4.80 to 1.25. However, the natural decrease in the incidence of regurgitation induced by age should also be considered. The median reflux index decreased after 1 month in the cisapride group from 3.60 to 1.75 versus from 2.70 to 2.45 in the domperidone group. One child treated with cisapride developed a significant QT prolongation. CONCLUSION: The decrease in regurgitation was comparable in both groups, although acid reflux decreased more in the cisapride group. Cisapride induced QT prolongation in one infant.

Innocent murmurs: the perception of the parents versus that of the child.

Innocent murmurs in childhood are common, and often they do not reflect cardiac disease. We have performed a prospective review, by means of a questionnaire, to clarify the parental perception of the innocent murmur identified in their child. Whenever possible, depending on age, we also sought the input of the child. Of a cohort of 63 infants and children with innocent murmurs, a response was obtained from 40 parents and 8 children to an initial questionnaire, with 26 parents replying to a second questionnaire a year later. No parent reported any symptoms in their children, or had imposed any restrictions. Of the parents, however three sets considered regular review was necessary. We conclude that the diagnosis of an innocent murmur by a paediatric cardiologist, aided by investigations including cross-sectional echocardiography, and an opportunity for explanation and reassurance, led to the child being treated normally.