RSS

Category Archives: Infection

My First Case of Congenital Cytomegalovirus Infection

I have this opportunity to demystify an infant’s case of long standing jaundice…

The mother’s prenatal course was apparently unremarkable, save for gestational diabetes that was controlled. The mother cannot remember any other symptoms such as flu-like illness, skin rashes, nor was she hypertensive during the prenatal period. Baby was delivered via repeat cesarean section, small for gestational age. He stayed quite long in the hospital because of infection. He was purely breastfeeding. His newborn metabolic screening result was normal. I was not the attending then.

At home, baby was quite fuzzy and irritable. Baby has been being attended to by the original neonatologist. He was jaundiced. In cases of purely breastfed babies, sometimes jaundice can be expected to last for about 3 months but the intensity is not that much compared to that during the first week of life. His stool color was still yellow. He developed umbilical hernia. The skin texture was fine; tongue was normal in size; hair was not coarse; there was no hypotonia; nor was there any constipation (something that is a remarkable findings among babies with hypothyroidism). Baby was worked up for possible hypothyroidism. Thyroid function test was normal. They were advised to go to a pediatric endocrinologist for evaluation.

Mother brought baby to my clinic for second opinion. I saw the laboratory result, it was normal. But what is puzzling is the jaundice that was quite intense. I could not evaluate baby well, especially the abdomen, because he is irritable. I advised mother that baby needs further test and treatment thus they agreed to be confined in the hospital.

I repeated the thyroid function test, it was normal. That reassured me baby has no congenital hypothyroidism which is one dreaded condition a baby can have because of life dependency on thyroid hormones for better quality of life and to attenuate whatever cognitive impairment it has already caused. I still called up an endocrinologist friend to confirm my understanding of baby’s thyroid function test result and she agreed baby is not a case of metabolic disorder.

I treated the baby as a case of sepsis pending work up results. Ultrasound of the abdomen showed the liver is enlarged, the biliary tree is intact. I am not afraid that this baby has biliary atresia which is another “lethal” condition that usually leads to baby’s death in a slow fashion.

Liver enzyme, alkaline phosphate and bilirubin were all elevated (it was a direct hyperbilirubinemia). I started the baby on ursodeoxycholic acid to help eliminate the bilirubin that could also cause inflammation of the liver cells.

After a week in the hospital, baby’s jaundice has significantly decreased and yet the direct hyperbilirubinemia (50%) was still persistent, and alkaline phosphatase level was still significantly elevated. I have discharged baby with instruction to undergo karyotyping and TORCH screening as I haven’t ascertained yet what was causing the baby’s jaundice.

A week later, mother brought back the results of baby’s tests. Karyotyping was NORMAL (thank God). On the other hand, TORCH panel revealed (+) IgM and IgG for cytomegalovirus. I referred the baby immediately to an ophthalmologist for chorioretinitis screening, and to a pediatric infectious disease specialist for further management. CT Scan of the head showed that there were periventricular calcifications near the parietal areas of the brain.

Baby is still jaundiced although the intensity is no longer that dark. He is on supportive treatment.

He will undergo repeat head CT scan as well as chorioretinitis screening one month after the first.

Advertisements
 
 

Tags: , , , , , ,

Service or Martyrdom?

Service or Martyrdom?.

 

Tags: , , , , , ,

Service or Martyrdom?

This is a retro-blog.

I remember one patient who was referred to me for neonatal care. It was about 4 years ago. A mother had to deliver prematurely by cesarean section because of premature rupture of membrane and uncontrolled uterine contractions.. Baby was 28 weeks gestational age. There was no more room for control of labor, and preparing the baby’s lungs for eventual delivery; the cesarean section had to be done outright. Both parents were employed at that time, so I thought there was no problem about financial resources.

Again, as for all babies being born prematurely, he needed to be administered surfactant. It was night time, banks were closed so there’s no way the father can tender cash at that time. I told him to go to another hospital, secure surfactant with my name as guarantor and sign a waiver for them to pay for the drug in 24 hours. The medicine was released to him and thus I was able to administer it immediately.

(Image courtesy of www.nhlbi.nih.gov/health/health-topics/topics/pda/)

Baby was already being weaned from the respirator, when a new problem arose, a patent ductus arteriosus. This posed a threat as it increased the volume of blood that goes to the lungs for oxygenation and predisposing to a chronic problem: bronchopulmonary dysplasia. Oral medication given via tube to treat the problem. Then another problem set in: persistent pulmonary hypertension and renal insufficiency bordering renal failure, plus signs of systemic infection showing. I did some double volume blood exchange transfusion here besides giving respective medicines.

Baby’s persistent pulmonary hypertension responded to sildenafil. After the exchange transfusion, baby started urinating. Then the murmur disappeared. However, it took a some time to wean the baby off from the respirator because of one problem: baby developed bronchopulmonary dysplasia. I had to give cocktail of medications. Finally baby was weaned off from the respirator and was extubated but still dependent on oxygen support. There were even times when after extubation and when his BPD would exacerbate, it would require some hourly aerosolization to open up his distal airways.

When baby was almost two months, he was then discharged from the hospital, free from oxygen support, feeding well, and gaining weight daily. Due to big hospital bill, they asked if it is okay for them to sign a promisory note for their payment of my professional fee. Should I say no? I never proposed any condition at all. I just called the hospital to give my approval. They also partially paid their hospital bill.

One week from discharge, they followed up at the clinic. Few days after that, the hospital declared bankruptcy and closed. Then, my fear came true. They disappeared and never came back. They never at least had the courtesy to tell me that they can’t pay my professional fee. Nada! Boom! Ba-bye! I had their number. Sometimes I ask my secretary to remind them, but then they just say they will come to no avail. Then I recall how was I attending to that baby before, I had no car then. I would wait for a cab to visit the baby. Then during early mornings, I had to walk for about 10-15 minutes going to the main road to hail a cab to go back home. And then this is what I deserve.

The perks of a neonatologist. Other colleagues surely do have their own stories and could be worse than this.

 

Tags: , , , , ,

Feeding The Tiniest Babies

Feeding The Tiniest Babies.

 

Tags: , , , , ,

Feeding The Tiniest Babies

Photo courtesy of http://zachandalyson.blogspot.com/)

I am still overwhelmed with how my little baby is able to tolerate feeds so fast…

Background…

Just few years ago, feeding prematurely born babies took a long time before it was started. During the first few days from birth, baby was made to starve. There was no strict guideline when to start feeding them. It usually  depended on the assessment of the attending doctor if he thought the baby was safe and ready to start. Thus, some would take days, others weeks.

Consequently it was observed that delayed initiation of feeding led to difficulty of babies tolerating feeding and prolonged transition to full feeds (meaning, baby is fed entirely with milk and no supplemental intravenous/parenteral fluid). Intravenous/parenteral nutrition was maintained for a longer time to provide additional caloric and nutritional requirements of the baby.

Since the intravenous fluid had to be kept for a longer time, sometimes taking weeks, this now became a portal of entry for infection. If the baby was on central lines (eg, umbilical venous lines), the worse intravenous line-related infections was, and the offending organism was harder to treat because these microbes were already resistant to most anti-microbials regularly used in that ICU. These hospital acquired infections posed additional expenses to the family.

Regarding intravenous fluid/parenteral feeding, there was a time when incorporation of amino acid was delayed, taking days. Thus baby was initially thriving on dextrose. It was also initially given at a low dose (0.5g/kg/day or 1 g/kg/day) then gradually increased (by 0.5g/kg/day) as tolerated to a maximum of 3g/kg/day. The disadvantage of this strategy was that, since 50% of the caloric requirement of developing fetus comes from amino acids, if the intravenous fluid was unable to provide the baby’s requirements, he used up the protein that he already synthesized (inside the womb) as other source of calories, which eventually led to elevated levels of creatinine (mistaken as renal insufficiency or failure).

Then when serum creatinine determination done on a later date showed abnormal findings: incorporation of amino acid was thus withheld or decreased and adjustment of antibiotics to renal dose was done until the creatinine returned to normal levels. This was for fear of having renal problem that might be aggravated by incorporation of (high dose of) protein. This further delayed the progression of amino acid incorporation to the maximum dose.

Unfortunately, this feeding technique led prematures to become malnourished after birth. (As a rule, the baby usually lose weight immediately after birth, then regains his birth weight by the end of 2 weeks.) Preterm babies who were fed in this manner took longer time to regain their birth weight. Then, when these preterm babies were already able to achieve full feeds, as they were malnourished, the care provider’s tendency was to feed them aggressively to catch up and achieve their expected weight for age. Unfortunately, if genetic programming has already occurred during the malnutrition state, and then they were all of a sudden fed aggressively, this made the babies go haywire and eventually ended up with metabolic syndrome during adult life.


THE EVOLUTION…

Latest studies have highlighted the necessity to feed the baby aggressively, starting immediately after birth.

When it comes to oral feeding, within first few hours after birth, minimal enteral feeding should be commenced as long as baby has been stabilized from his respiratory distress. Again there is no strict guideline how to carry out this.

When to start feeding…

Some of my textbook authors say start as early as eight hours after birth. Personally, I do it at sixth hour after birth.

How much to give…

As to the volume, again, there is no strict guideline. Some of our foreign counterparts give 1 mL. What I do is compute it first at 20 mL/kg/day, then divide it by the number of times I will expect to feed the baby. (For example, the baby is between 1-1.2 kg, I usually feed this population every 2 hours, thus that will be 12x/24 hours; for babies who are less than 1 kg, I usually feed them every 1.5 hours or that would be 16x in 24 hours). Then, for example the computed volume is 1.2 mL, then I first give the milk every six hours on the first 24 hours. The purpose of this minimal enteral feeding/nutrition is to prime and stimulate the baby’s gut. This maneuver enables the stomach to release hormones and enzyme that will facilitate peristalsis of the intestines and gastric emptying time (a protective mechanism against infectious agents that might have been swallowed).

How to progress oral feeding…

The safest as it seems is to increase the feeds by 10 to 20 mL/kg/day. I usually give it at increments of 20 mL/kg/day. But first, what I do is increase the frequency until I will be able to reach the usual frequency I assigned according to their birth weight. So on 2nd day, from every 6 hours, I make it first every 4 hours. On the 3rd day, I increase it to every 2 hours/1.5 hours. After achieving the desired frequency, then that is when I increase the volume daily now by 20 mL/kg/day. As I increase the volume of feeding, I start to decrease the intravenous fluid that I infuse. (This is to prevent fluid overloading that will might open up the ductus arteriosus, that will impose another problem to the baby’s lungs, especially bronchopulmonary dysplasia). On the average, when the baby is able to tolerate 100 mL/kg/day of milk feedings, I already discontinue intravenous fluid. Usually, this is achieved by 7th day of life. So in general, most of my preterm babies are already free of IVF at 7th day of life.

What to give…

Certainly, in the first few days of the preterm baby’s life, breastmilk is the ideal food to give as it also contains antibodies that the baby will need to combat infection. However, admittedly, even as a breastfeeding advocate, pure breast milk feeding beyond the second week of life will not be able to sustain growth of the baby, and baby may again end up malnourished. We will need to FORTIFY the breastmilk for additional calories and electrolytes, and thus sustain baby’s caloric requirements for promote growth.

As far as the intravenous or parenteral fluid, newer data supports that protein incorporation should be started at 3 g/kg/day. Then if the baby is more premature, then you may increase it further to 4 g/kg/day. This strategy, together with aggressive oral feeding has precluded severe postnatal malnutrition, an earlier time to return to birthweight and faster weight gain, faster transition to full feeds and thus faster weaning from intravenous fluid. This strategy has decreased the incidence of complications of prolonged intravenous fluid such as thrombophlebitis, blood-borne infections and necrotizing enterocolitis. Overall, babies don’t stay longer in the ICU, which also reduces their exposure to potential harmful microbes inside the NICU, an earlier discharge date and lesser hospital bills for the parents.

The potential adverse outcome of this feeding strategy so far is the baby’s tendency to become overweight, but with a preserved and better neurologic status and mental faculty.

For now, we remain observant for the long term outcome of this newer feeding strategy among these infants.

 
Leave a comment

Posted by on July 1, 2012 in Infection, neonates, Prematurity

 

Tags: , , , , ,

Are You Aware? New Global Causes of Child Mortality & Breastfeeding

Are You Aware? New Global Causes of Child Mortality & Breastfeeding.

 

Tags: , , , , , , , , , , , , , , ,

Beinte-Cinco: Quatro

Beinte-Cinco: Quatro.

 

Tags: , , , , , , , , , , , ,