Five-year thyrotropin screening for congenital hypothyroidism in Ramathibodi Hospital.

OBJECTIVES: To detect newborns with congenital hypothyroidism (CH) and to treat the affected infants as early as possible. STUDY DESIGN: Cord blood thyrotropin (TSH) screening for CH in Ramathibodi Hospital began in 1993. From October 1993 to December 1998, 35,390 neonates were screened. The infants with elevated TSH level of greater than 30 mU/L were recalled for verification of CH. Confirmation tests included total thyroxine, free thyroxine and TSH level. Thyroid scan and uptake were performed in some affected infants. RESULTS: Twelve infants with CH were detected resulting in an incidence of one in 2,949 live-births. All affected infants were asymptomatic at birth. Of 12 infants with CH, one premature neonate had a delayed TSH elevation and was diagnosed as having primary hypothyroidism at 2 months of age. The recall rate for validation of CH based on a cut-off value at serum TSH level of greater than 30 mU/L is 1.1 per cent. If the cut-off value of serum TSH level was raised to greater than 40 mU/L, the recall rate would decrease to 0.43 per cent. None of the affected infants had cord blood TSH level of less than 50 mU/L except one premature patient. Therefore, beginning in January 1997, the cut-off value of TSH was raised to 40 mU/L or greater. Pitfalls in this program include incomplete blood-specimen collection and incomplete follow-up. To strengthen the program, improvements were made in the follow-up system from 1996 onward. Therefore, the coverage for blood-specimen collection progressively increased from 84 per cent in 1994 to 96 per cent in 1998. Simultaneously, the patients' return after recalls also increased from 38 per cent to 100 per cent. CONCLUSIONS: The incidence of CH in Ramathibodi Hospital is approximately 1:3,000 live-births. The optimal cord blood TSH level for recall is 40 mU/L or greater. The intensification of follow-up strategy resulted in better response to recall and earlier treatment in the affected infants.

Neonatal polycythemia: effects of partial exchange transfusion using fresh frozen plasma, Haemaccel and normal saline.

BACKGROUND: Neonatal polycythemia remains a significant clinical problem in Thailand. Partial exchanges transfusion (PET) with fresh frozen plasma (FFP) has been the mainstay of management for this condition in Thailand. Since FFP is difficult to find in certain areas and can cause concerns of transfusion related diseases, this study was undertaken to investigate the possibility of using plasma substitute and normal saline (NSS) for PET in the newborn infant with polycythemia. OBJECTIVE: 1. To compare the rate and duration of decrease of venous hematocrit (Hct) before and after PET with FFP, Haemaccel and NSS. 2. To compare any complications from using FFP, Haemaccel and NSS such as coagulation defect, electrolytes change, etc. in PET. METHODS AND SUBJECTS: A randomized prospective trial was conducted in Neonatal Unit, Department of Pediatrics, Ramathibodi Hospital. The first phase of study: July 1, 1993 to June 30, 1994: randomized prospective trial using FFP or Haemaccel for PET in 26 newborn infants with polycythemia. The second phase of study: July 1, 1994 to June 30, 1995: consecutive enrollment trial using NSS for PET in 38 consecutive newborn infants with polycythemia. RESULTS: There was significant decrease in Hct in both groups after PET but there was no statistically significant difference in the rate of decrease of Hct. There was no significant difference in biochemical profiles in both groups of infants 24 hours after PET. In the NSS group, there was significant decrease of Hct level after PET. There was no significant change of biochemical profiles and coagulation activity in these patients 24 hours after exchange transfusion. There were 2 patients with complications related to umbilical venous catheter and PET. CONCLUSION: Haemaccel and NSS can be safely used for PET to treat neonatal polycythemia. However, the attending physician should be aware of possible complications related to umbilical venous catheterization and PET.

The benefit of the direct antiglobulin test using gel technique in ABO hemolytic disease of the newborn.

The direct antiglobulin test (DAT) using the gel technique was included in the investigation of infants with hyperbilirubinemia in the first week of life. Twelve cases were preterm and 48 cases were full term infants. The patients were divided into 2 groups: the study group comprised 22 cases of blood group A or B infants born to blood group O mothers; the control group comprised 38 cases of ABO blood groups compatible with those of their mothers. The mean +/- SD (39 +/- 26 hours) of the age at the onset of hyperbilirubinemia induced by ABO hemolytic disease of the newborn (HDN) was significantly earlier than that due to other causes. The positive rate of DAT in the ABO incompatible group was similar by both the conventional technique and the gel technique, 54.5% and 50% respectively. However, the scores by the gel technique were higher than those of the conventional technique. The gel technique is simple, reliable, involves less technical error and requires a small amount of blood sample. The grading system is clear-cut, especially grade 1 + or weak positive as compared to the conventional technique which requires examination under a microscope. Therefore, the DAT using the gel technique is beneficial to the diagnosis of ABO HDN. It should be included in the investigation of infants with hyperbilirubinemia especially in case of suspected ABO HDN.

Comparison between the conventional tube technique and the gel technique in direct antiglobulin tests.

OBJECTIVES: The direct antiglobulin test (DAT) is a diagnostic procedure demonstrating in-vivo antibody or complement coating on red cells. The gel technique (GT) for this test is sensitive and easier to do than the conventional tube technique (CTT). METHODS: We tested 52 newborns with hyperbilirubinemia and 6 children and 17 adults with autoimmune hemolytic anemia (AIHA) using the (DAT) in the form of the conventional tube technique (CTT) and the gel technique (GT) simultaneously. The gradings of the agglutination reactions of both techniques were scored as 12, 10, 8, 5, 3, 0 for 4+, 3+, 2+, 1+ and w+ and negative, respectively. RESULTS: The GT yielded higher scores than the CTT (p < 0.01). The overall sensitivity and specificity of the GT were 93.5 and 88.6%, respectively. The specificity of the DAT-positive results in newborns was determined by IgG only, while in AIHA, it was determined by IgG and/or C3d and, in only one sample, by IgM. CONCLUSION: The GT is equal to or better than the CTT. Since the GT is simple, the exposure of blood bank personnel to the blood sample is low. We highly recommend the GT, especially in areas where HIV infection is prevalent.

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

Serum bilirubin levels in breast-fed vs formula-fed infants during the first 3-5 days of life.

Breast feeding seems to be a cause of neonatal jaundice during the first five days of life; the mechanism of which needs further study. Thai infants appear to exhibit a higher level of "physiological jaundice" bilirubin level than Caucasians.

PIP: Neonatal jaundice remains the most common problem in the well baby nursery. Pediatricians and neonatologists believe that breast-fed infants have a generally increased severity of jaundice during the first week of life. The authors report findings from their study of whether healthy breast-fed Thai infants have significantly higher serum bilirubin levels than those of formula-fed infants in the first 3-5 days of life. Of 190 infants born, 130 were delivered by cesarean section. The authors studied 76 infants fed with formulated milk and 54 fed with breast milk; the study did not include infants who were delivered normally and fed with formulated milk. All mothers with normal delivery insisted upon breast feeding, while discomfort among many mothers who delivered by cesarean section led them to agree to feed their babies with formulated milk. The study found breast feeding to be an apparent cause of neonatal jaundice during the first five days of life, although more study is needed on the phenomenon. Thai infants seem to have more physiological jaundice than Caucasians.

Prevention of hepatitis B infection in infants born to hepatitis B carrier mothers: low dosage vaccination.

Two groups of newborn infants born to HBeAg positive carrier mothers were given HBIG (200 IU) immediately after birth. Subsequently, at age 2 days and at 1, 2 and 12 months, the first group received 5 microgram and the second group 2 microgram of HBV vaccines. There was no significant difference in the anti-HBs seroconversion rate (SR), and the protective efficacy rate (PER) at the age of 13 months in either group. The SR and PER of group 1 were 91.7% and 90.18%, and group II were 92.9% and 91.01%, respectively. Although the significant differences were observed in the geometric mean titers of anti-HBs in group I (526.3 mIU/ml) and group II (371.4 mIU/ml), both were above the protective level. The immune responses to the reduced dosage of HBV vaccines are satisfactory in preventing HBV in the newborn infants of HBeAg positive carrier mothers.

Long-term immunoprophylaxis of hepatitis B surface antigen carrier in infants born to hepatitis B surface antigen positive mothers using plasma derived vaccine.

Immunoprophylaxis of HBV infection using 3 doses (10 micrograms) of plasma derived HBV vaccine were given to 49 newborn infants of e-antigen negative HBs Ag carrier mothers at birth, one and 6 months of age. The protective efficacy rate was 100% during first 2 years. At 3 years of age, HBs Ag carrier was 2.63% and 89.48% of infants had anti-HBs above the protective level. Ten point fifty-two percent of total infants had anti-HBs level below 10 mIU/ml and 21.05% had anti-HBs level between 10-100 mIU/ml. Most infants who had the maximal level of antibody below 100 mIU/ml had lost all antibody within 3 years. The loss of antibody was closely related to the maximal anti-HBs titer (one year of age) which is highly predictive indicator of the longevity of anti-HBs.

Congenital self-healing reticulohistiocytosis: report of a patient with a strikingly large tumor mass.

A newborn male Thai infant had numerous brownish red nodules of various sizes scattered over both palms and soles, left thigh, abdomen, chin, and left upper eyelid. An extremely large tumor mass was present on the right sole. Many lesions showed spontaneous ulceration. No extracutaneous involvement was found. All lesions involuted spontaneously within two to three months, some with scar formation. Histology showed large numbers of mononucleated and multinucleated histiocytic cell infiltrations, 10% of which contained Birbeck's granules. Areas of necrosis and calcification were also seen in the largest tumor. No recurrence was observed after follow-up for three years.

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.