SNAPPE II Score As a Predictor of Survival in Neonates with Congenital Diaphragmatic Hernia: A Single Center Experience.

Introduction Prediction of mortality and morbidity in newborns with congenital diaphragmatic hernia (CDH) is too complex for practical use and may not be accurate. The main objective of this study was to evaluate the usefulness of the CDH Study Group equation and Score of Neonatal Acute Physiology Perinatal Extension (SNAPPE) II score to predict short-term outcomes of newborns with CDH. Materials and Methods Fifty-two neonates were admitted with CDH at Children's Hospital of Michigan from November 2001 to July 2009. Retrospective chart analysis was performed. Predicted survival rates were calculated using the equation published by the CDH Study Group in 2001. SNAPPE II scores were also obtained within 12 hours of admission. Statistical analysis was performed using SPSS statistical package. Results Thirty out of 52 (58%) neonates survived to discharge. SNAPPE II score was significantly lower (p < 0.0001) in survivors (20 ± 15) versus nonsurvivors (41 ± 16). When neonates were stratified according to the CDH Study Group, low-risk patients had a survival rate of 68% (predicted 84%), moderate-risk patients had a survival rate of 43% (predicted 57%), and high-risk patients had a survival rate of 33% (predicted 36%). A total of 83% of the newborns who survived were operated within 48 hours of life, while only 17% of the nonsurvivors were operated within 48 hours of life. Conclusion SNAPPE II scores were better predictors of mortality than the CDH Study Group equation published in 2001. Further exploration is warranted to evaluate validity of survival advantage for those who were operated within 48 hours of life. A future study of combination of prenatal and postnatal factors may help in improved outcomes of the newborns with CDH.

Outcomes of tracheostomy in the neonatal intensive care unit: is there an optimal time?

OBJECTIVE: To compare short-term outcomes of infants who underwent early versus late tracheostomy during their initial hospitalization after birth and determine the association, if any, between tracheostomy timing and outcomes. STUDY DESIGN: Retrospective chart review of infants who underwent a tracheostomy during their initial hospitalization at a single site. RESULTS: The median (range) gestational age of our cohort (n = 127) was 28 (23-42) weeks and birth weight was 988 (390-4030) g. Tracheostomy indications included airway lesions (47%), bronchopulmonary dysplasia (25%), both (22%) and others (6%). Median postmenstrual age (PMA) at tracheostomy was 45 (35-75) weeks. Death occurred in 27 (21%) infants and 65 (51%) infants were mechanically ventilated. G-tube was present at discharge in 42 (33%) infants. Infants who underwent early tracheostomy (<45 weeks PMA) (n = 66) had significantly lower gestational ages, weights and respiratory support than the late (≥45 weeks PMA) (n = 61) group. Death (29.5% versus 14%), home ventilation (41% versus 21%) and G tube (44% versus 14%) were significantly more frequent in the late tracheostomy group. On bivariate regression, outcomes were not independently associated with tracheostomy timing, after adjustment for gestational age and respiratory support. CONCLUSIONS: Of infants who underwent tracheostomy during the initial hospitalization after birth, 21% died. On adjusted analysis, tracheostomy timing was not independently associated with outcomes.

Parental perception of functional status following tracheostomy in infancy: a single center study.

OBJECTIVE: To examine the functional outcomes of children who underwent a tracheostomy in the initial hospitalization after birth and to determine their correlates. STUDY DESIGN: We administered the validated 43-item Functional Status-II (FS-II) questionnaire by Stein and Jessop over the telephone to caregivers of surviving children. The FS-II items generated a total score, age-specific: (1) total; (2) general health (GH); and (3) responsiveness, activity, or interpersonal functioning (IPF) scores in specific age group categories. RESULTS: FS-II was administered to 51/62 (82.2%) survivors at a median (range) age of 5 (1-10) years; 27% children were on the ventilator and 43% required devices. About 40% of children had a median of 1 (1-4) hospitalization in the previous 6 months. Scores were >2 SD below means in 55%, 24%, and 55% cases for age-specific T, GH, and R/A/IPF scores respectively. The T and R/A/IPF scales were significantly higher in those with private, rather than public, maternal insurance, as were T and R/A/IPF scores for children ≥ 4 years, compared with younger children. On regression analysis, FS-II T, GH, and R/A/IPF scores were independently associated with maternal private insurance (P = .02). R/A/IPF scores were also significantly associated with corrected age at FS-II administration. CONCLUSIONS: One-third of surviving children who underwent tracheostomy during their initial hospitalization remained technology-dependent. The parental FS-II questionnaires revealed low R/A/IPF scores, especially at younger ages and in those with maternal public insurance. Further research on family-level interventions to improve functional outcomes in this population is warranted.

Staphylococcal scalded skin syndrome in a preterm newborn presenting within first 24 h of life.

A preterm neonate was noted to have diffuse blanching erythema around the mouth followed by appearance of bullous lesions on the upper back, lower neck and right scapular areas at 23 h of life. The bullae subsequently ruptured leaving an extremely tender, erythematous, denuded area of the skin, which extended over next few hours to involve most of the upper back and right shoulder regions. Nikolsky sign was positive. Clinical diagnosis of staphylococcal scalded skin syndrome was made. The throat, blood, urine and cerebrospinal fluid cultures did not yield any growth, but wound culture was positive for Staphylococcus aureus. Treatment included administration of intravenous fluids and vancomycin for 10 days. The wound area was covered with vaseline and sterile gauge dressings. On day 5 of life, epithelialisation began and was complete on the seventh day of life. She was discharged home with intact skin, without scars, on day 12 of life.

Outcomes of extremely low birth weight infants with varying doses and intervals of antenatal steroid exposure.

OBJECTIVE: To compare outcomes of extremely low birth weight (ELBW) infants exposed to no antenatal steroids (ANS); incomplete ANS and complete course of ANS at varying intervals prior to delivery. METHODS: A retrospective review was performed on 169 ELBW infants with ANS exposure at varied dose-intervals. The odds of mortality, intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD) were compared between Group 1, infants born without ANS exposure, Group 2, infants born after one dose of ANS, Group 3, infants born after two doses of ANS given within a week, and Group 4, infants born after two doses of ANS >7 days prior to delivery. RESULTS: Mortality and IVH were significantly lower in Groups 3 (30% and 10%) and 4 (15% and 30%), compared to Groups 1 (56% and 69%) and 2 (56% and 38%). Increasing gestational age and exposure to complete course of ANS were significantly associated with decrease in mortality, BPD/mortality and IVH. Infants who received one dose of ANS had significantly lower incidence of severe IVH compared to infants without ANS exposure. CONCLUSIONS: Beneficial impact of ANS on mortality and composite BPD/mortality is evident only after a complete course and persists even with its administration beyond a week from delivery.