Renal Tubular Necrosis and Papillary Necrosis after Gastroenteritis in Infants

Three young infants who had severe gastroenteritis developed radiological and histological features of renal tubular necrosis. Characteristically the excretion urogram showed renal enlargement with prolonged and heavy opacification of the renal parenchyma and a pronounced increase in density of the pyramids. Subsequent radiological studies showed extensive papillary necrosis. Though these infants are now apparently fit, renal damage has occurred and this may eventually give rise to features indistinguishable from chronic pyelonephritis.     

Fetal or neonatal autopsy and genetic counseling. Experience of the Human Genetic Service of Liège

From January 1976 to June 1984, 308 necropsies were performed on neonates and fetuses of various gestational age, mainly coming from hospitals of the province of Liege. 41% of the necropsied infants have at least one malformation and 34% of the malformed show multiple birth defects. There were 17 anatomo-clinic diagnoses of chromosomal aberrations but only 12 cases were confirmed by caryotype, for practical or technical reasons. One third of the parents of the necropsied infants came for genetic counselling with a high recurrence risk in 13% of the advices. For further improvement of the possibilities of diagnosis, we are pleading in favour of more frequent radiological and chromosomal fetal examinations. This must lead us to better convince obstetricians and neonatologists and get more favourable practical conditions to carry out the necropsies.     

PULMONARY INFLAMMATORY HYPERINFLATION IN INFANTS

In infants less than 3 years old pulmonary hyperinflation can be a clinical and radiological sign of acute pneumonitis. It is an early, nonspecific occurrence in the presence of inflammation. The most reliable radiologic signs include flattening and undulation of the diaphragm, mediastinal elongation and narrowing, and a cardiac outline completely visualized above the diaphragm.     

Six year follow up of infants with bacteriuria on screening.

OBJECTIVE--To determine the value of screening for bacteriuria in infants with special emphasis on the natural course of untreated asymptomatic bacteriuria, renal growth, and renal damage. DESIGN--Prospective six year follow up of infants with bacteriuria on screening in an unselected infant population. SETTING--Paediatric outpatient clinic. PATIENTS--50 Infants (14 girls, 36 boys) with bacteriuria on screening verified by suprapubic aspiration from an unselected population of 3581 infants in a defined area of Gothenburg. INTERVENTIONS--Children with asymptomatic bacteriuria and normal findings on initial urography were untreated, although other infections were treated. MAIN OUTCOME MEASURES--Culture of urine and determination of C reactive protein concentration every six weeks for the first six months after diagnosis, every three months from six months to two years, and every six months between two and three years; thereafter yearly urine culture. Evaluation of renal concentrating capacity with a desmopressin test; radiological examination, including first and follow up urography and micturition cystourethrography without antibiotic cover; and measurement of renal parenchymal thickness and renal surface area. RESULTS--Of the original 50 infants, 37 (12 girls, 25 boys) were followed up for at least six years. Two infants developed pyelonephritis within two weeks after bacteriuria was diagnosed; the others remained free of symptoms. 45 Infants were untreated; the bacteriuria cleared spontaneously in 36 and in response to antibiotics given for infections in the respiratory tract in eight. Recurrences of bacteriuria were observed in 10 of the 50 children, of whom one had pyelonephritis. No child had more than one recurrence. At follow up urography in 36 of the 50 children (9 girls, 27 boys) after a median of 32 months no child had developed renal damage. First samples tested for renal concentrating capacity showed significantly higher values than those from a reference population (mean SD score 0.50, 95% confidence interval 0.21 to 0.79; p less than 0.001), but the last samples showed no significant difference (mean SD score 0.08, -0.24 to 0.40; p greater than 0.05). CONCLUSIONS--Mass screening for bacteriuria in infancy results primarily in detection of innocent bacteriuric episodes and is not recommended.     

Incidence and duration of lactation and lactational performance among mothers of low-birth-weight and term infants.

The lactation experience of 55 mothers of 62 infants of low birth weight (2500 g or less) was prospectively compared with that of 55 mothers of 55 control infants (38 weeks'' gestation or more, birth weight more than 2500 g) born at the same institution. The incidence rates of lactation at delivery were 73% for the control group and 58% for the low-birth-weight group; 11% of the infants of low birth weight fed breast milk were never put to the breast. The mean age at first suckling was 277.3 hours in the low-birth-weight group, compared with 3.3 hours in the control group (p less than 0.0005). At first suckling 81% of the low-birth-weight infants and 25% of the control infants sucked poorly or refused the breast (p less than 0.001). At discharge 65% of the breast-milk-fed control infants were exclusively breast-fed, compared with 3% of the low-birth-weight infants fed breast milk (p less than 0.001). The incidence rates of lactation over time were similar in the control and low-birth-weight groups (51% v. 44% at 1 month, 29% v. 13% at 3 months, 13% v. 4% at 6 months and 4% v. 2% at 12 months). The mean duration of lactation was 3.2 months for the control group and 2.5 months for the low-birth-weight group. In the long term 37% of the low-birth-weight infants fed breast milk failed to breast-feed, compared with 2% of the control infants, and only 31% were exclusively breast-fed, compared with 85% of the control infants (p less than 0.001). However, the degree of satisfaction with the lactation experience was similar in the two groups. We conclude that mothers of low-birth-weight infants have good potential for lactation.     

Survival of extremely premature babies in a geographically defined population: prospective cohort study of 1994-9 compared with 2000-5

Objective To assess changes in survival for infants born before 26 completed weeks of gestation.Design Prospective cohort study in a geographically defined population.Setting Former Trent health region of the United Kingdom.Subjects All infants born at 22+0 to 25+6 weeks’ gestation to mothers living in the region. Terminations were excluded but all other births of babies alive at the onset of labour or the delivery process were included.Main outcome measures Outcome for all infants was categorised as stillbirth, death without admission to neonatal intensivecare, death before discharge from neonatal intensivecare, and survival to discharge home in two time periods: 1994-9 and 2000-5 inclusive.Results The proportion of infants dying in delivery rooms was similar in the two periods, but a significant improvement was seen in the number of infants surviving to discharge (P<0.001). Of 497 infants admitted to neonatal intensive care in 2000-5, 236 (47%) survived to discharge compared with 174/490 (36%) in 1994. These changes were attributable to substantial improvements in the survival of infants born at 24 and 25 weeks. During the 12 years of the study none of the 150 infants born at 22 weeks’ gestation survived. Of the infants born at 23 weeks who were admitted to intensive care, there was no significant improvement in survival to discharge in 2000-5 (12/65 (18%) in 2000-5 v 15/81 (19%) in 1994-9).Conclusions Survival of infants born at 24 and 25 weeks of gestation has significantly increased. Although over half the cohort of infants born at 23 weeks wasadmitted to neonatalintensive care, there was no improvement in survival at this gestation. Care for infants born at 22 weeks remained unsuccessful.     

A detection method for streak artifacts and radiological noise in a non-uniform region in a CT image

By using the CT images obtained by subtracting two CT images acquired under the same conditions and slice locations, we have devised a method for detecting streak artifacts in non-uniform regions and only radiological noise components in CT images. A chest phantom was scanned using 16- and 64-multidetector row helical CT scanners with various mAs values at 120 kVp. The upper lung slice image was employed as a target image for evaluating the streak artifacts and radiological noise. One hundred parallel line segments with a length of 80 pixels were placed on the subtracted CT image, and the largest CT value in each CT value profile was employed as a feature variable of the streak artifacts; these feature variables were analyzed with the extreme value theory (Gumbel distribution). To detect only the radiological noise, all CT values contained in the 100 line profile were plotted on normal probability paper and the standard deviation was estimated from the inclination of its fitted line for the CT value plots. The two detection methods devised in this study were able to evaluate the streak artifacts and radiological noise in the CT images with high accuracy.     

Season-of-birth and acute leukemia of infancy

Because of its short and clearly delineated latency period, acute leukemia of infancy is particularly suited to etiologic analysis. From 1950 to mid-1985, 31 infants with acute leukemia (less than 1 year of age) were registered at the University of Texas, M.D. Anderson Cancer Center at Houston. The medical records of these infants were reviewed for demographic and birth information. Of the 31 infants, 14 (45%) were Hispanic. The sex ratio was 3:1 male/female) for white infants and 5:9 for Hispanic infants. Of the white infants, half had acute lymphocytic leukemia, compared with all but one of the Hispanic infants. There was a significant excess of winter births among the infants diagnosed with acute leukemia (P less than 0.05). The significant association between season-of-birth and the occurrence of leukemia cases is suggestive of periodicity of an environmental etiologic agent, perhaps acting in concert with endogenous rhythmicities in susceptibility to that agent. This finding is deserving of further study.     

Plasma selenium in preterm and term infants during the first 12 months of life

The goal of the present study was to prospectively assess the plasma selenium (Se) concentrations of term and preterm infants during the first year of life in relation to gestational age and nutrition.

Blood specimens were collected from orally formula-fed preterm infants (gestational age < 32 weeks, birth weight < 1500 g): 1.) in hospital and 2.) corrected for gestational age parallel to healthy term breast and formula-fed infants at the ages of 1, 4 and 12 months. All infants were fed according to a standardized nutritional concept, solids and follow-up formula were introduced at the age of 4 months.

Plasma selenium in preterm infants in hospital was 11.7 (6.5–20.8) g/l and 11.6 (8.8–16.7) g/l at 4 weeks corrected for gestational age. At the age of 4 months plasma selenium was still significantly lower than in the other groups: Preterm infants: 17.1 (10.4–30.5) g/l; formula-fed term infants: 31.3 (24.3–47.5) g/l; breast-fed term infants: 45.6 (27.1–65.1) g/l). The levels of breast-fed infants were significantly higher than those of both formula-fed groups up until the introduction of solids.

Preterm infants had significantly low plasma selenium levels up until a postnatal age of at least 6 months. The levels were lower than those of term infants fed an identical unsupplemented infant formula during the first 4 months of life. These data support routine monitoring in hospital and selenium supplementation of preterm infants, preferably in hospital before discharge.     

Recent Studies on Invasive Fungal Diseases in Children and Adolescents: an Update

The improved survival of fragile pediatric hosts such as those afflicted with primary or acquired immune deficiencies, prematurity, and surgical pathology – mainly gastrointestinal and trauma – has resulted in an increased number of children susceptible to invasive fungal infections. These infections are associated with significant morbidity and mortality. Newer, safer antifungal agents allow for preventive and empiric strategies in the management of patients at risk, such as premature infants, patients receiving chemotherapy, and bone marrow or solid-organ transplant recipients. Improved radiological and molecular techniques result in earlier diagnosis of fungal infections, allowing for preemptive therapy in these patients, minimizing exposure to antifungal agents and the risk of emergence of resistant fungal strains. A better understanding of the differences in pharmacokinetics between children and adults will allow for better utilization of existing antifungal agents and improved outcomes.     

Immunisation of neonates at high risk of hepatitis B in England and Wales: national surveillance.

The results of a voluntary programme of immunisation against hepatitis B in neonates at high risk (mother being positive for hepatitis B surface antigen and without hepatitis B e antibody or having had acute hepatitis B late in pregnancy) are reported. The programme was offered in England and Wales from November 1982. Passive immunisation alone was available in the first six months of life until 1985, after which infants received passive and active immunisation from birth; in addition, some infants received passive immunisation for six months followed by a course of hepatitis B vaccine. All but a few infants received the first immunising dose within 48 hours after birth. Blood samples for analysing markers of hepatitis B virus were available at 1 year from 147 of the 223 infants given passive immunisation, 54 of the 72 given passive followed by active immunisation, and 102 of the 155 given passive and active immunisation at birth. At 1 year 11 of the 127 (9%) infants given four or more doses of specific hepatitis B immunoglobulin were positive for hepatitis B surface antigen compared with four of the 20 given three or fewer doses; 11 had levels of hepatitis B surface antibody greater than 50 IU/l. Only one of the 54 infants given passive then active immunisation was positive for hepatitis B surface antigen at 1 year and four infants had low (less than or equal to 50 IU/l) levels of hepatitis B surface antibody. Four of the 102 infants who received passive and active immunisation at birth were positive for hepatitis B surface antigen. Two had received the fill course of vaccine, whereas in the other two vaccination was incomplete or unstated. In 79 of the 89 infants who received a complete course of vaccination the level of hepatitis B surface antibody was known, and 70 had levels at 1 year greater than 100 IU/1. Reactions to immunisation were not severe at any age. The incidence of side effects was 8% for the immunoglobulin, 11% for the vaccine, and 9% when immunoglobulin and vaccine were given together. Wider collaboration in the programme is requested.     

Iron status of very-low-birth-weight infants during the first 15 months of infancy.

The adequacy of iron stores in infants of very low birth weight (defined as less than 1500 g) in Canada is unknown. We monitored the iron status of 81 such infants at 3, 6, 9, 12 and 15 months of age. All of the infants were fed formula fortified with iron (13 mg/L) for at least 6 months, starting at 2 months of age. The plasma ferritin level decreased after the formula was no longer used. Although 90% of the infants were given cereal fortified with iron (30 mg of iron per 100 g) by 9 months of age, the plasma ferritin level continued to decrease. The level was less than 10 micrograms/L in 54% of the infants at 12 months of age and in 74% at 15 months; this indicated depleted iron stores. Because of delayed development very-low-birth-weight infants eat small amounts of cereal and therefore require iron-fortified formula throughout infancy.     

The laboratory diagnosis of cytomegalovirus infection in infants in the first months of life

The detection rate of IgM, specific to cytomegalovirus (CMV), in the umbilical blood was 2.0 +/- 1.8% in infants with antenatal complications in their medical history, 8.9 +/- 1.8% in hospitalized infants aged 7 days to 6 months; simultaneously, such IgM proved to be absent in healthy infants of the same age. The maximum primary detection rate of CMV-specific IgM in hospitalized infants was registered at the age of 1.5-4 months and the minimum detection rate, at the age of 6 months, as well as at the age of 1 month and younger. In sick infants aged 0-6 months CMV-specific IgM were detected, as a rule, for 2-4 weeks. 86% of infants with CMV-specific IgM detected in their blood were found to have cytomegaloviremia; in 80% of patients the virus was excreted with saliva and in 50% the virus was detected in blood plasma.     

Altitude and infant growth in Bolivia: A longitudinal study

The growth of 79 healthy, well-nourished lowland (400 M) and highland (3600 M) Bolivian infants was analyzed in a longitudinal study through the first postnatal year. Compared to low altitude infants, the high altitude infants were found, by analysis of covariance controlling for size at the previous exam, to be significantly shorter at birth, 1 and 6 months, while they were significantly lighter only at birth and 1 year. Recumbent length gain was slower in the high altitude infants in the early months of life, while weight gain did not differ between altitudes. The observed lower weights at high altitude throughout the first year appear to be due to a persistence of lower weights seen at birth and not to postnatal growth retardation. Significantly greater triceps and subscapular skin-fold thickness measurements were found in the highland group, despite their smaller length and weight. The possible causes and implications of the greater fat accumulation in the highland infants are discussed.     

Early Interactions Between Mothers and Their Medically Fragile Infants

The purpose of this study was to examine the interactions of 56 medically fragile infants and their mothers and to determine the influence of infant age, neurological status, maternal education, ethnicity, and observation location on these interactions. The interactions were observed for about 1 hr every 2 months while in the hospital, 1 month after hospital discharge, and at 6 months corrected age. The age of the infants had the greatest effect on the interaction. As infants grew older, mothers spent less time feeding, involved, holding, in body contact, looking, rocking, gesturing, and touching. However, mothers talked more, and played more with older infants. Older medically fragile infants were alert more, vocalized more, and slept less. Only one variable was directly affected by neurological status: Mothers moved neurologically normal infants more often. The neurologically normal and compromised groups were also more similar at older ages than younger ages in the percentage of time the mother was involved and the infant vocalized. Mothers with more years of education fed their infants more and looked at them more often, and minority mothers talked to their infants less and moved them more.     

Variation in early neonatal mortality for different types of fetal growth retardation

Birth and first-48-hr death records were analyzed for 10,024 liveborn infants in Mexico City and 12,786 liveborn infants in Santa Cruz, Bolivia. The objective of the analysis was to characterize the early postnatal mortality rates for different types of fetal growth retardation and prematurity. Infants who were delivered prior to 37 weeks of gestation had 23-100 times the mortality risk of infants born at full term and normal weight. Light-for-gestational-age infants (birth weight less than 2,900 g) were further divided into proportionately growth-retarded with normal Rohrer's index (weight/height) and disproportionately growth-retarded with low Rohrer's index. The proportionately growth-retarded infant had nearly twice the mortality of the full-term, appropriate-weight infants, whereas the disproportionately growth-retarded infants had 2.9-5.7 times the mortality rate of the full-term, appropriate-weight infants. There were some differences between samples in mortality rates and prevalence of the different classes of small infants, but the pattern of mortality within samples was consistent between samples.     

Perinatal brain damage: predictive value of metabolic acidosis and the Apgar score.

To assess the predictive value for perinatal brain damage of acidosis at birth, alone or in combination with the Apgar score at 5 minutes, a cohort of 982 liveborn infants delivered over two months was studied prospectively. The umbilical cord was double clamped, and arterial acid-base values were successfully determined in 964 infants and lactate concentration in 931. Reference values defining acidosis (mean +/- 2 SD) were obtained from a subset of 127 term infants who had no complications. The incidence of a low pH was 12% (111 out of 964), high base deficit 7% (70 out of 964), high lactate concentration 9% (83 out of 931), and low Apgar score at 5 minutes (less than or equal to 7) 3% (32 out of 982). Twelve of the 111 infants (11%) with acidosis had a low Apgar score, and 12 out of 29 infants (41%) with low Apgar scores had acidosis. At one year of age 35 infants were lost to follow up and 22 had an adverse outcome unrelated to asphyxia; 883 infants showed normal development but the possible sequelae of asphyxia were four deaths, slight abnormalities in 28 infants, and clear abnormalities in 10. The sensitivity and the positive predictive value of low pH for adverse outcome were, respectively, 21 and 8%, of high lactate concentration 12 and 5%, and of low 5 minute Apgar score 12 and 19%. Metabolic acidosis determined in blood from the umbilical artery at birth is a poor predictor of perinatal brain damage.     

Staphylococcal Pneumonia and Empyema in Infants and Children

One hundred and seventy-six cases of staphylococcal pneumonia and 35 cases of empyema in infants and children have been studied. There were seven deaths, five in patients with empyema and two in patients without this complication. Early diagnosis on the basis of clinical symptoms and signs and institution of therapy without awaiting radiological or bacteriological confirmation are necessary to prevent development of empyema and to reduce the mortality rate. Chloramphenicol and erythromycin, administered systemically, were generally effective. In severely toxic subjects antitoxin appeared to be of value. Blood transfusion was used to correct the rapidly progressive anemia. A chest radiograph was essential to diagnose empyema. Treatment of this condition by closed intercostal catheter drainage was effective. Pneumatoceles were encountered, but resolved spontaneously. Although there has been no significant decrease in the number of cases of pneumonia encountered, there have been no deaths since 1958 on the treatment outlined.     

Mass screening of newborn Swedish infants for alpha antitrypsin deficiency.

During the first year of mass screening for alpha1 antitrypsin deficiency, 108,000 newborn Swedish infants were examined. The screening method and criteria used for selecting infants with alpha1 antitrypsin deficiency were reliable. The Pi Z phenotype occurred at a rate of one per 1,433 infants, and the PiZ allele frequency was .026. The Pi- allele was found in one Pi Z and one Pi S infant. The Pi- allele frequency probably was below .001.     

Urinary 3-methylhistidine derivative as indicator of nutrients intake in low-birth-weight infants

Urinary excretion levels of N-methylhistidine derivatives and N-methylhistidine/creatinine ratios were studied in a group of 20 small for date newborns, 10 premature infants and 8 normal infants, at birth and at one week of life. All infants were fed with an adapted milk formula supplying 2.8 g protein/kg body weight. 1-methyl and 3-methylhistidine urinary excretion were increased in all groups of infants from birth to the 7th day of life. Creatinine and N-methyl derivatives/creatinine ratios were also significantly increased at one week of life. The two ratios showed a higher level in small for date and premature infants than in normal infants at birth which continued relatively increased at one week of life. 3-methyl-histidine/creatinine ratio appears as a useful indicator of the turnover rate of muscular proteins in low-birth-weight infants.