Experience with the use of palivizumab together with infection control measures to prevent respiratory syncytial virus outbreaks in neonatal intensive care units.

Respiratory syncytial virus (RSV) frequently causes nosocomial outbreaks in general paediatric wards and occasionally in neonatal intensive care units (NICUs). Conventional infection control measures often fail to prevent the spread of RSV, and it can cause significant morbidity especially in preterm and young infants. We report our experience in preventing an outbreak on a NICU after RSV had been detected in a premature infant. The index case was a 34-day-old premature infant who presented with clinical infection and RSV was detected in a clinical specimen. There were 11 patients in the ward at the time including the index case. The RSV-positive patient was isolated, the ward closed to admissions and infection control measures were implemented. Two patients were transferred to another hospital. Palivizumab 15 mg/kg i.m. was given to all patients and no further cases occurred. All subsequent RSV tests on nasal secretions were negative. Palivizumab combined with conventional infection control measures appeared to prevent the spread of RSV in this NICU. Strategies for the prevention of RSV outbreaks on NICUs all recommend the reinforcement of routine infection control measures. Recommendations concerning the use of palivizumab range from monthly prophylaxis to all infants at risk, to prophylaxis of selected cases only. Currently there are no guidelines for the use of palivizumab in NICUs or for the control of RSV outbreaks.

Resolution of obstructive sleep apnea syndrome after adenoidectomy in congenital central hypoventilation syndrome.

We report on a 2 1/2-year-old boy who is currently ventilated at home by positive pressure ventilation through a nasal mask during the night because of congenital central hypoventilation syndrome (CCHS). Up to age 2 he had developed normally. A reevaluation was performed because of symptoms suggestive of obstructive sleep apnea syndrome (OSAS), including snoring, nocturnal sweating, frequent nighttime awakenings, speech impairment, daytime fatigue, and failure to thrive. A sleep study indicated obstructive apnea episodes lasting up to 40 s and arterial desaturations below 50% during spontaneous sleep. During mechanical ventilation snoring persisted, and capillary PCO2 rose to 60 mm Hg. Partial upper airway obstruction, leaking around the mask, and arousal movements developed on passive flexion of the neck to 20 degrees. After adenoidectomy, symptoms of OSAS resolved. There were no more obstructive apneas during spontaneous sleep, but obstructive apneas could be provoked by neck flexion to 20 degrees. During ventilation, neck flexion of 20 degrees was tolerated, but a 40 degrees flexion led to partial obstruction. In CCHS patients, the problem of upper airway obstruction is rarely noted because most patients are ventilated through a permanent tracheostomy. Today, noninvasive ventilation strategies are becoming more common. Reduced activity of upper airway muscles and impaired reflex mechanisms could lead to upper airway obstruction during face mask positive pressure ventilation in children with CCHS. Enlarged adenoids worsened this problem in our patient, leading to insufficient ventilation and OSAS. Adenoidectomy resolved symptoms of OSAS and enabled successful nasal mask ventilation. Close follow-up of the patient avoided hypoxia and sequelae from OSAS such as pulmonary hypertension.

Group B streptococci during pregnancy: a comparison of two screening and treatment protocols.

OBJECTIVE: The objective was to evaluate whether the rate of neonatal group B streptococcal infection could be reduced by screening for group B streptococci during the third trimester of pregnancy. STUDY DESIGN: Two periods in which different screening and treatment protocols were applied were compared. In period A all mothers showing high-risk factors were given peripartal antibiotic coverage. In period B vaginal and rectal smears were routinely obtained in gestational week 34 and cultured for group B streptococci. If culture results were positive, the woman received peripartal antibiotics. The incidence of group B streptococcal infections and the number of peripartal antibiotic doses were established by comparing 3700 neonates (3623 mothers) in period A with 3648 neonates (3569 mothers) in period B. RESULTS: In period A, 20 group B streptococcal infections were recorded. Of these, 5 were severe to life-threatening. In period B, 4 group B streptococcal infections were observed. Two were severe and occurred in neonates born before the mothers could be screened. Another 2 were mild and occurred in neonates whose mothers had negative screening test results. The reduction was significant by the chi2 test (chi2 = 9.19, Yates' corrected P = .0024). The rates of peripartal antibiotic treatment were 11.9% in period A and 14.5% in period B. CONCLUSION: Although no neonate died of group B streptococcal sepsis in either of the 2 periods, the protocol used in period B clearly reduced the incidence of group B streptococcal infection. The number of peripartal antibiotic doses required was not much higher than in period A. Screening for group B streptococci in week 34 seems to be a valuable contribution to further improvement of neonatal outcome.

Detection of fetal congenital heart disease in a low-risk population.

Our purpose was to evaluate the efficacy of level two ultrasound screening for the detection of congenital heart defects (CHD) in a low-risk population by using three standardized cuts. Within a period of four years a total of 6727 pregnant women of a low-risk population undertook several ultrasound examinations on the basis of screening for fetal malformations. All ultrasound examinations were performed by three experienced doctors. At every single scan three standardized cuts (apical and lateral four-chamber view, crossing over of the great arteries) were obtained in order to detect congenital heart defects. Of 87 CHDs (1.33 per cent of the examined women) 39 (43.8 per cent) were diagnosed prenatally. The detection rate was 10/48 (20.8 per cent) in the presence of VSD, ASD2 or combined ASD2 + VSD, the detection rate was 29/39 (74.3 per cent) in the presence of other forms of congenital heart disease. None of the 38 missed cases in the first group but three of the ten missed CHDs in the second group had emergency neonatological problems. Aneuploidy and/or other malformations existed in 22/87 cases of CHD. The obstetrical management was changed in nearly all cases after the diagnosis of a CHD. Twenty-two women opted for termination of pregnancy because of additional fetal malformations or chromosomal defects. Five women were transferred prenatally to a tertiary centre for neonatal cardiac surgery. Ten deliveries were performed in the presence of a neonatologist. Good detection rates for CHD can be achieved in a low-risk population on the basis of level two ultrasound screening by using the above mentioned three cuts and thus, the perinatal mortality and morbidity can be improved.

Successful closure of the patent ductus arteriosus by indomethacin in an extremely low birth weight infant of very advanced postnatal age.

Many studies demonstrate the efficacy of closure of a patent ductus arteriosus with indomethacin, but also show that success diminishes markedly with increasing postnatal age. For this reason surgical ligation is usually preferred after the first month of life. We describe the case of a male premature infant (25 weeks gestation, birth weight 680 g), in whom a PDA was successfully closed with indomethacin (0.1 mg/kg once daily intravenously for 6 days) at the age of 11 weeks. Thus it may be concluded that closure by drug may be attempted before surgical ligation even in cases of advanced postnatal age.

Prenatal diagnosis of facial malformations.

In a prospective study, 5407 pregnant women were screened by ultrasound to detect malformations of the fetal face. Of a total of 11 facial anomalies, eight were detected by prenatal ultrasound (72 per cent). Three pregnancies were terminated because of associated developmental abnormalities or aneuploidy. In all of them, the facial malformations were correctly diagnosed. When associated with other developmental abnormalities, facial malformations were picked up at a rate of 100 per cent. Isolated facial malformations, by contrast, were detected in no more than 50 per cent of cases. Eight cases with suspected facial dysmorphism ended with the delivery of normal babies (specificity 99.8 per cent). None of them prompted karyotyping or any other invasive testing. Only two correctly detected facial malformations (bilateral cleft lips/palate) had a minor influence on obstetrical management. There would not have been disadvantages for the newborns in any of the cases if the malformations had been missed.

[Effectiveness and complications of percutaneous central venous catheters in neonatal intensive care]. / Effizienz und Komplikationen zentralvenöser Einschwemmkatheter in der Intensivneonatologie.

Low birth weight babies and sick full-term babies, who require total parenteral nutrition and repeated intravenous applications of drugs, which irritate peripheral veins, very often need a reliable central venous catheter. The aim of our paper was to study prospectively the efficiency and the complications of peripheral percutaneous Silastic-catheters. Over a period of 9 month we inserted 114 central venous catheters via peripheral veins in 111 premature babies and sick full-term infants at our neonatal intensive care unit. The mean duration of use was 13.7 days, the catheter-induced septicaemia-rate was 3.5%. We never saw serious complications of a central venous catheter, the most common complication was an intravasal central obstruction, but we found no relation between the occurrence-risk of complications, the duration of use and the infusion flow rate.

[Breech presentation in nulliparous women--vaginal delivery or indications for primary section?]. / Die Beckenendlage bei Erstgebärenden--Vaginale Geburt oder Indikation zur primären Sektio?

The strategy of primary Caesarean section (I. UFK) was compared to the strategy of conservative vaginal delivery (SFK) in nulliparous women with singleton breech presentation. 160 women of the I. UFK and 178 women of the SFK were entered into this retrospective study. Women with gemini, preterm delivery before 32 completed weeks of amenorrhoea, with intrauterine death and with non-viable malformations were excluded. The Caesarean section rate at the I. UFK was 85% and at the SFK 12.4%. Perinatal mortality was zero in both groups. Only 1 child (33 weeks of gestation, 1350 g) died after vaginal delivery in consequence of a wrong interpretation of a pathological CTG (I. UFK) 3 weeks post partum. In addition to this child, another 3 children (0.8%) showed late morbidity (2 after vaginal delivery, 1 after Caesarean section). Only 1 case of complete brachial palsy, which healed almost completely 4 years after delivery, can be suspected of being connected with the mode of vaginal delivery. As expected, maternal morbidity was significantly increased in the group of Caesarean section in comparison to the group of vaginal delivery in terms of fever, transfusions, and duration of hospitalisation. Life-threatening complications, however, were not seen. In conclusion, our data show, that, if performed by well experienced doctors, a conservative approach for vaginal delivery in nulliparous women with breech presentation is also a safe strategy in comparison to primary Caesarean section.

[Infection-induced pathologic change in respiratory parameters in the young infant]. / Infektinduzierte pathologische Anderung der Atemparameter beim jungen Säugling.

While many aspects related to the etiology and pathogenesis of sudden infant death remain unclear, the ultimate trigger event appears to be an acute regulatory disturbance of the cardiorespiratory neurons of the reticular formation of the brain stem. Retrospective studies have demonstrated that SIDS often occurs after infection of the upper respiratory tract. We present the case history of a 10-week old infant, where the respiratory pattern demonstrated highly pathological alterations induced by a mild infection of the upper airways, as confirmed by oxycardiorespirography. Oxycardiorespirography provides continuous recording of the respiration (transthoracic impedance) extending over several hours during sleep and during the critical phase just before going to sleep and waking up in relation to heart rate, partial oxygen pressure (measured transcutaneously) and nasal flow. The presented infant is a premature infant delivered in the 34th week of gestation according to Dubowitz (artificial respiration for 7 days due to hyalin membrane syndrome stage II). During infection periodic breathing was found to be 19.3% with partly severe hypoxemia. The longest single episode of apnea was 30 seconds. On the average, 5 episodes of bradycardia occurred (less than 100/min/measuring hour). An OCRG investigation performed at the age of 5 weeks and after disappearance of the infection at the age of 12 weeks yielded normal findings. This permits the conclusion that in out patient an infection of the upper airways may have induced a pathologic respiratory pattern, which could be a major trigger mechanism for sudden infant death.

[Hydrops fetalis caused by maternal Parvovirus B19 infection]. / Hydrops fetalis bedingt durch eine maternale Parvovirus B19-Infektion.

Maternal infection with human Parvovirus B19 during pregnancy is one of the rare reasons, which can lead to a not immunologically conditioned hydrops fetalis. We report here a case of intrauterine Parvovirus infection associated with hydrops fetalis, diagnosed by intrauterine sonography in the 29 week of gestation, one week after the outbreak of Erythema. The B19 infection of the low birth weight baby, delivered in the 30 week of gestation, was diagnosed serologically with specific IgM and IgG against B19 by ELISA. No malformation could be detected in the liveborn infant, who died on the third day of life.

[Prepartal mumps infection, a risk for the newborn infant?]. / Präpartale Mumpsinfektion, ein Risiko für das Neugeborene?

Mumps infection during pregnancy is on account of the antibody prevalence rate a rare event. With a case report and the review of the recent literature we want to show that there is no danger for the infection of the newborn child.

[Indomethacin or ligation in the treatment of persistent ductus arteriosus: a report of clinical experiences]. / Indomethacin oder Ligatur bei der Behandlung des Ductus arteriosus persistens: ein Klinischer Erfahrungsbericht.

A haemodynamically significant, patent ductus arteriosus in mechanically ventilated preterm infants can be closed by two means today, either medical or surgical. The aim of our project was to compare the efficiency of these two kinds of therapy over a period of two years in condition that the indication for closing was given in all cases according to the same principles. The PDA was closed by ligation in 16 cases, by medical means (Indomethacin) in 15 cases. The outcome was significant different. 93% of the preterm infants treated with Indomethacin survived, but only 56% of the ligation-group, the main cause of death was the broncho-pulmonary dysplasia. The reason was the posterior day of life at the time of ligation compared with the Indomethacin-group. The broncho-pulmonary dysplasia is the result of pulmonary overcirculation because of prolonged patiency of the PDA. Only preparatory reasons were responsible for the delay of the day of ligation (organisation of the paediatric surgical crew including anesthesia), whereas the beginning of the medical therapy could be decided autonomously and therefore the period of pulmonary overcirculation could be shortened.