Hours In Infants Research Articles

Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations

To review and revise the 1987 pediatric brain death guidelines. Relevant literature was reviewed. Recommendations were developed using the GRADE system. (1) Determination of brain death in term newborns, infants and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma. Because of insufficient data in the literature, recommendations for preterm infants less than 37 weeks gestational age are not included in this guideline. (2) Hypotension, hypothermia, and metabolic disturbances should be treated and corrected and medications that can interfere with the neurologic examination and apnea testing should be discontinued allowing for adequate clearance before proceeding with these evaluations. (3) Two examinations including apnea testing with each examination separated by an observation period are required. Examinations should be performed by different attending physicians. Apnea testing may be performed by the same physician. An observation period of 24 hours for term newborns (37 weeks gestational age) to 30 days of age, and 12 hours for infants and chi (> 30 days to 18 years) is recommended. The first examination determines the child has met the accepted neurologic examination criteria for brain death. The second examination confirms brain death based on an unchanged and irreversible condition. Assessment of neurologic function following cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for 24 hours or longer if there are concerns or inconsistencies in the examination. (4) Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial Paco(2) 20 mm Hg above the baseline and ≥ 60 mm Hg with no respiratory effort during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed. (5) Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. Ancillary studies may be us d to assist the clinician in making the diagnosis of brain death (i) when components of the examination or apnea testing cannot be completed safely due to the underlying medical condition of the patient; (ii) if there is uncertainty about the results of the neurologic examination; (iii) if a medication effect may be present; or (iv) to reduce the inter-examination observation period. When ancillary studies are used, a second clinical examination and apnea test should be performed and components that can be completed must remain consistent with brain death. In this instance the observation interval may be shortened and the second neurologic examination and apnea test (or all components that are able to be completed safely) can be performed at any time thereafter. (6) Death is declared when the above criteria are fulfilled.

Comparison of the efficacy of serum amyloid A, C-reactive protein, and procalcitonin in the diagnosis and follow-up of necrotizing enterocolitis in premature infants

Purpose The aim of this study was to compare the efficacy of serum amyloid A (SAA) with that of C-reactive protein (CRP), and procalcitonin (PCT) in diagnosis and follow-up of necrotizing enterocolitis (NEC) in preterm infants. Methods A total of 152 infants were enrolled into this observational study. The infants were classified into 3 groups: group 1 (58 infants with NEC and sepsis), group 2 (54 infants with only sepsis), and group 3 (40 infants with neither sepsis nor NEC, or control group). The data including whole blood count, CRP, PCT, SAA, and cultures that were obtained at diagnosis (0 hour), at 24 and 48 hours, and at 7 and 10 days were evaluated. Results A total of 58 infants had a diagnosis of NEC. Mean CRP (7.4 ± 5.2 mg/dL) and SAA (46.2 ± 41.3 mg/dL) values of infants in group 1 at 0 hour were significantly higher than those in groups 2 and 3. Although the area under the curve of CRP was higher at 0 hour in infants with NEC, there were no significant differences between groups with respect to the areas under the curve of SAA, CRP, and PCT at all measurement times. Levels of SAA decreased earlier than CRP and PCT in the follow-up of NEC (mean SAA levels were 45.8 ± 45.2, 21.9 ± 16.6, 10.1 ± 8.3, and 7.9 ± 5.1 mg/dL at evaluation times, respectively). Levels of CRP and SAA of infants with NEC stages II and III were significantly higher than those with only sepsis and/or NEC stage I. Conclusions Serum amyloid A, CRP, and PCT all are accurate and reliable markers in diagnosis of NEC, in addition to clinical and radiographic findings. Higher CRP and SAA levels might indicate advanced stage of NEC. Serial measurements of SAA, CRP, and PCT, either alone or in combination, can be used safely in the diagnosis and follow-up of NEC.

Early rescue administration of surfactant and nasal continuous positive airway pressure in preterm infants <32 weeks gestation

This study reports our institutional experience on the outcome after prophylactic and early rescue endotracheal instillation of surfactant within 20 minutes of birth, followed by extubation and nasal continuous positive airway pressure (NCPAP) in preterm infants <32 weeks gestational age. A total of 142 infants were prospectively studied (42, gestational age from 23 to 27 and 100, from 28 up to 32 weeks). All infants were electively intubated for administration of 200 mg/kg porcine isolated surfactant (Curosurf, Chiesi Farmaceutici SPA, Parma, Italy) as soon as practicably possible (within 20 min after birth) and NCPAP was then initiated. Extubation and switch to NCPAP at 6 h was successful in 6/42 (14.3%) infants less than 28 weeks gestational age and 75/100 (75%) infants 28-32 weeks gestational age. Out of 81 infants that were successfully extubated, 76 (93.83%) never required re-ventilation. At 96 h of age, need for continuing intubation and ventilation was required by 6/38 (15.8%) alive infants <28 weeks gestational age and 8/100 (8%) infants 28-32 weeks gestational age. Mean duration of NCPAP post-extubation was 38±20 hours for infants 23-27 wks and 29±15 hours for infants 28-32 wks gestational age. The mortality rate was 2.81% (4/142). Implementation of prophylactic or early rescue administration of surfactant with NCPAP in infants at high risk for developing RDS in neonatal ICU is a safe modality of respiratory support in preterm infants.

The Effects of Gestational Age and Birth Weight on False-Positive Newborn-Screening Rates

Newborn-screening false-positive rates (FPRs) are disproportionately increased in preterm infants. The objective of this study was to determine variation in newborn screening FPRs according to birth weight and gestational age. Our secondary objective was to examine the effect of postnatal age on FPRs in preterm infants. The Ohio State Newborn Screening Program Database was analyzed to determine the overall and birth weight-specific FPRs for 18 analytes. Data were stratified into birth weight categories (<1000 g, 1000-1499 g, 1500-2499 g, 2500-3999 g, and >4000 g). In addition, to examine the effect of postnatal age on FPRs, we examined the 2 analytes with the highest FPRs, thyrotropin with back-up thyroxine and 17-hydroxyprogesterone, in infants whose gestational age was <32 weeks, determined on the basis of postnatal age at screening. Data from 448 766 neonates were reviewed. Infants with very low birth weight (VLBW) comprised 1.9% of the study cohort, but accounted for 18% of false-positive results. For 14 of 18 analytes studied, FPRs increased with decreasing birth weight/gestational age and were significantly increased in infants with VLBW compared with infants who weighed 2500 to 3999 g (P < .001). Thyrotropin/back-up thyroxine and 17-hydroxyprogesterone accounted for 62% of total false-positive results in VLBW infants. When blood specimens were collected at a postnatal age of ≥ 48 hours in infants born at <32 weeks, a 44% relative reduction in 17-hydroxyprogesterone false-positive results was detected. False-positive newborn-screening rates are disproportionately increased in VLBW infants. FPRs may be reduced by delaying screening of <32 weeks' gestation, preterm infants until 24 to 48 hours' postnatal age.

A Randomized, Controlled Trial of a Behavioral Intervention to Reduce Crying among Infants

To evaluate the efficacy of videotaped instruction of a behavioral intervention to reduce crying among newborns. Mothers of healthy, full-term newborns were recruited from the postpartum unit of a large community hospital for a prospective, randomized, controlled trial of an intervention to reduce infant crying. Mothers participating in the intervention viewed a videotape with instructions involving swaddling, side positioning, white noise, jiggling, and sucking. Mothers in the control group viewed a videotape with instructions for normal newborn care. Intervention was assessed by mean hours per day of infant total crying (fussing, crying, and unsoothable crying) and sleeping as recorded in a diary 3 days a week during the 1st, 4th, 6th, 8th, and 12th weeks of age; the Parenting Stress Index was also used during the 6th and 12th weeks. Fifty-one mother-infant pairs were recruited; 35 completed the study (18 intervention and 17 controls). Sixteen were lost to follow-up. There were no statistically significant differences between the groups in the hours of mean daily total crying or sleeping during the 1st, 4th, 6th, 8th, or 12th weeks of age. For example, during the 6th week of age mean daily total crying was 1.9 hours for infants in the control group versus 2.2 hours for infants in the intervention group (P = .4); sleep was 14.5 hours for infants in the control group versus 14.4 hours for infants in the intervention group (P = .8). During the 12th week mean daily total crying was 1.2 hours for infants in the control group versus 1.8 hours for infants in the intervention group (P = .8) and sleep was 14.1 hours for infants in the control group versus 14.0 hours for infants in the intervention group (P = 1.0). There was no difference between the groups in the Parenting Stress Index during the 6th week of age. The behavioral intervention, when provided via videotape, does not seem to be efficacious in decreasing total crying among normal infants.

Moderate Hypothermia to Treat Perinatal Asphyxial Encephalopathy

Whether hypothermic therapy improves neurodevelopmental outcomes in newborn infants with asphyxial encephalopathy is uncertain. We performed a randomized trial of infants who were less than 6 hours of age and had a gestational age of at least 36 weeks and perinatal asphyxial encephalopathy. We compared intensive care plus cooling of the body to 33.5 degrees C for 72 hours and intensive care alone. The primary outcome was death or severe disability at 18 months of age. Prespecified secondary outcomes included 12 neurologic outcomes and 14 other adverse outcomes. Of 325 infants enrolled, 163 underwent intensive care with cooling, and 162 underwent intensive care alone. In the cooled group, 42 infants died and 32 survived but had severe neurodevelopmental disability, whereas in the noncooled group, 44 infants died and 42 had severe disability (relative risk for either outcome, 0.86; 95% confidence interval [CI], 0.68 to 1.07; P=0.17). Infants in the cooled group had an increased rate of survival without neurologic abnormality (relative risk, 1.57; 95% CI, 1.16 to 2.12; P=0.003). Among survivors, cooling resulted in reduced risks of cerebral palsy (relative risk, 0.67; 95% CI, 0.47 to 0.96; P=0.03) and improved scores on the Mental Developmental Index and Psychomotor Developmental Index of the Bayley Scales of Infant Development II (P=0.03 for each) and the Gross Motor Function Classification System (P=0.01). Improvements in other neurologic outcomes in the cooled group were not significant. Adverse events were mostly minor and not associated with cooling. Induction of moderate hypothermia for 72 hours in infants who had perinatal asphyxia did not significantly reduce the combined rate of death or severe disability but resulted in improved neurologic outcomes in survivors. (Current Controlled Trials number, ISRCTN89547571.)

Diagnostic Spaces: Workhouse, Hospital, and Home in Mid-Victorian London

For nine weeks during the 1866 cholera epidemic, the registrar general for England and Wales published details of more than 13,000 deaths in London. Although the names of the deceased and the informant were withheld, all other information available from the death certificate was reproduced in the capital city's Weekly Returns , including registration district and subdistrict, precise address (house number and street, or institution), sex, age (sometimes down to hours for infants), occupation, cause(s) of death, and duration of final illness. Since historians' access to original death certificates in England and Wales is restricted, this source presents an opportunity to analyze systematically the practice of cause of death certification in the middle of the nineteenth century, albeit during a period of mortality crisis. Variability of diagnostic depth—that is, the listing of multiple causes and duration of final illness—is considered for three major causes: cholera, diarrhea, and respiratory tuberculosis. Deaths in workhouses and general hospitals were chronically underdocumented compared to home deaths. This finding supports the notion that the institutionalization of sickness in the nineteenth century was accompanied by a loss of the patient narrative and also points to the entrenchment of institutional cultures of record keeping and administration.

Diagnostic Spaces

For nine weeks during the 1866 cholera epidemic, the registrar general for England and Wales published details of more than 13,000 deaths in London. Although the names of the deceased and the informant were withheld, all other information available from the death certificate was reproduced in the capital city'sWeekly Returns, including registration district and subdistrict, precise address (house number and street, or institution), sex, age (sometimes down to hours for infants), occupation, cause(s) of death, and duration of final illness. Since historians’ access to original death certificates in England and Wales is restricted, this source presents an opportunity to analyze systematically the practice of cause of death certification in the middle of the nineteenth century, albeit during a period of mortality crisis. Variability of diagnostic “depth”—that is, the listing of multiple causes and duration of final illness—is considered for three major causes: cholera, diarrhea, and respiratory tuberculosis. Deaths in workhouses and general hospitals were chronically underdocumented compared to home deaths. This finding supports the notion that the institutionalization of sickness in the nineteenth century was accompanied by a loss of the “patient narrative” and also points to the entrenchment of institutional cultures of record keeping and administration.

Persistent lactic acidosis in neonatal hypoxic–ischaemic encephalopathy correlates with EEG grade and electrographic seizure burden

Background:Predicting at birth which infants with perinatal hypoxic–ischaemic injury will progress to significant encephalopathy remains a challenge.Objective:To determine whether lactic acidosis at birth in asphyxiated neonates could predict the grade...

Pharmacokinetics of Famotidine in Infants

Although famotidine pharmacokinetics are similar in adults and children older than 1 year of age, they differ in neonates owing to developmental immaturity in renal function. Little is currently known about the pharmacokinetics of famotidine in infants aged between 1 month and 1 year, a period when renal function is maturing. To characterise the pharmacokinetics of famotidine in infants. This was a two-part multicentre study with both single dose (Part I, open-label) and multiple dose (Part II, randomised) arms. Thirty-six infants (20 females and 16 males) who required treatment with famotidine and who had an indwelling arterial or venous catheter for reasons unrelated to the study. Infants in Part I were administered a single dose of famotidine 0.5 mg/kg; the dose was intravenous or oral according to the judgement of the attending physician. Infants receiving 0.5 mg/kg intravenously were divided into two groups by age, and pharmacokinetic parameters in infants 0-3 months and >3 to 12 months of age were compared. Infants in Part II were randomised to one of the following treatments: 0.25 mg/kg/dose intravenously or 0.5 mg/kg/dose orally on day 1 and subsequent days, or 0.25 mg/kg/dose intravenously or 0.5 mg/kg/dose orally on day 1 followed by doses of either 0.5 mg/kg/dose intravenously or 1 mg/kg/dose orally on subsequent days. From day 2 onwards, age-adjusted dose administration regimens (once daily in infants <3 months of age and every 12 hours in infants >3 months of age) were used; the total number of famotidine doses ranged from 3 to 11 and the total number of days of dose administration ranged from two to eight. In infants <3 months of age, plasma and renal clearance of famotidine were decreased compared with infants >3 months of age. Pharmacokinetic parameters for the older infants (i.e. those >3 months) were similar to those previously reported for children and adults. Approximate dose-proportionality, no accumulation on multiple dosing and an estimated bioavailability similar to adult values were also observed. A short course of famotidine therapy in infants appears generally well tolerated, and the characteristics of famotidine pharmacokinetics during the first year of life are explained to a great degree by the development of renal function, the primary route of elimination for this drug.

Moderate hypothermia in neonatal encephalopathy: Safety outcomes

Hypoxic-ischemic injury may cause multisystem organ damage with significant aberrations in clotting, renal, and cardiac functions. Systemic hypothermia may aggravate these medical conditions, such as bradycardia and increased clotting times, and very little safety data in neonatal hypoxic-ischemic injury is available. This study reports a multicenter, randomized, controlled pilot trial of moderate systemic hypothermia (33 degrees C) vs normothermia (37 degrees C) for 48 hours in infants with neonatal encephalopathy instituted within 6 hours of birth or hypoxic-ischemic event. The best outcome measures of safety were determined, comparing rates of adverse events between normothermia and hypothermia groups. A total of 32 hypothermia and 33 normothermia neonates were enrolled in seven centers. Adverse events and serious adverse effects were collected by the study team during the hospital admission, monitored by an independent study monitor, and reported to Institutional Review Boards and the Data and Safety Monitoring Committee. The following adverse events were observed significantly more commonly in the hypothermia group: more frequent bradycardia and lower heart rates during the period of hypothermia, longer dependence on pressors, higher prothrombin times, and lower platelet counts with more patients requiring plasma and platelet transfusions. Seizures as an adverse event were more common in the hypothermia group. These observed side effects of 48 hours of moderate systemic hypothermia were of mild to moderate severity and manageable with minor interventions.

Index of Suspicion In the Nursery

A 9-day-old Hispanic boy presents to the emergency department with seizures and apnea. The seizure lasts for about 3 minutes and is characterized by stiffening of the body and laryngospasm. Laboratory evaluation reveals a serum calcium concentration of 6 mg/dL (1.5 mmol/L). Hypocalcemic tetany resolves after administration of intravenous calcium. The infant also has fever of 100.4°F (37.7°C). The infant was born at term, and his birthweight was 3.2 kg. He is the fifth child born of nonconsanguineous parentage. The antenatal period was uneventful. Because the family does not have insurance, the mother had not taken prenatal vitamins and supplements. The baby has been fed with human milk and formula. On physical examination upon admission to the hospital, his temperature is 99°F (36.9°C), pulse is 186 beats/min, respiratory rate is 54 breaths/min, blood pressure is 97/64 mm Hg, and weight is 3.83 kg. He has no dysmorphic features and is normocephalic, with an open and flat anterior fontanelle without craniotabes. No cataracts or Chvostek sign are present. Cardiovascular examination reveals a regular heart rate and rhythm, with no murmurs. The lungs are clear to auscultation bilaterally, and there is no hepatosplenomegaly. Neurologic findings are normal. Laboratory evaluation reveals: sodium, 136 mEq/L (136 mmol/L); potassium, 5.2 mEq/L (5.2 mmol/L); chloride, 101 mEq/L (101 mmol/L); bicarbonate, 26 mEq/L (26 mmol/L); blood urea nitrogen, 10 mg/dL (3.57 mmol/L); creatinine, 0.3 mg/dL (26.5 mcmol/L); glucose, 109 mg/dL (6.1 mmol/L); calcium, 6.6 mg/dL (1.65 mmol/L); phosphorous, 10.5 mg/dL (3.4 mmol/L); albumin, 3.0 g/dL (30 g/L); and magnesium, 2 mg/dL (0.82 mmol/L). The white blood cell count and differential count are normal. Findings on cerebrospinal fluid evaluation are normal. However, the 25-hydroxyvitamin D concentration is less than 7 ng/mL (17.5 nmol/L) (normal, 10 to 68 ng/mL [25 to 169.7 nmol/L]), the 1,25-dihydroxyvitamin D concentration is 45 …

Surfactant synthesis and kinetics in infants with congenital diaphragmatic hernia.

In animal models of congenital diaphragmatic hernia (CDH), surfactant deficiency contributes to the pathophysiology of the disease; however, information on CDH in humans is limited. We compared surfactant disaturated phosphatidylcholine (DSPC) synthesis and metabolism, by stable isotope technology, in newborn infants with CDH and in control subjects. DSPC amount, total proteins, and surfactant protein-A (SP-A) from tracheal aspirates were also measured. DSPC and SP-A were significantly lower in 14 infants with CDH than in the eight control subjects. Mean DSPC was 2.3 +/- 1.3 mg/ml of epithelial lining fluid (ELF) in infants with CDH and 4.6 +/- 1.5 mg/ml of ELF in control subjects (p = 0.001). Mean SP-A in infants with CDH and in control subjects was 16.2 +/- 9.3 and 61.2 +/- 30.6 microg/ml of ELF, respectively (p = 0.03). DSPC kinetics was measured in 12 of 14 infants with CDH and in 5 of 8 control subjects. Secretion time was 8.3 +/- 5.5 and 8.5 +/- 2.5 hours and peak time 51.9 +/- 15.2 and 51 +/- 13 hours in infants with CDH and in control subjects, respectively. Fractional synthesis rate was not different for infants with CDH and control subjects (p = 0.4). In conclusion, surfactant DSPC synthesis and kinetics were not significantly deranged in infants with CDH compared with control subjects. Other factors, such as lower surface area or increased DSPC catabolism, may contribute to surfactant pool alteration in CDH.

FLUID AND ELECTROLYTE CONCEPTS IN NEW BORNS.

Dear Editor, Effective fluid and electrolyte management involves (1) calculating the fluid and electrolyte requirement for maintaining metabolic functions; (2) replacing losses (evaporative, third space, external); and (3) considering pre-existing fluid deficit or excess. The daily fluid requirements can be approximated to 120-150ml/kg/24 hours in prematures, 100ml/kg/24 hours in neonates (term) and 1000ml+50ml/kg/24 hours in infants >10 kg of body weight Detail of fluid requirement in normal neonates based on birth weight is as follows : The estimations of daily fluid requirements should also take into consideration : (1) urinary water losses, (2) gastrointestinal losses, (3) insensible water losses, and (4) surgical losses (drains). Water represents 70-80% of the body weight of the normal neonate and premature baby respectively. Total body water (TBW) varies inversely with fat content, and prematures have less fat deposits. TBW is distributed into extracellular fluid (ECF) and intracellular fluid (ICF) compartment. The ECF compartment is one-third the TBW with sodium as principal cation and chloride and bicarbonate as anions. The ICF compartment is two third the TBW with potassium the principal cation. The newborn's metabolic rate is high and extra energy is needed for maintenance of body temperature and growth. A change in body water occurs upon entrance of the fetus to his new extrauterine existence. There is a gradual decrease in body water and the extracellular fluid compartment with a concomitant increase in the intracellular fluid compartment. This shift is interrupted with premature birth. The newborn's body surface area is relatively much greater than the adults and heat loss is a major factor. Insensible water losses are from the lung (1/3) and skin (2/3). Transepithelial (skin) water is the major component and decreases with increase in post-natal age. Insensible water loss is affected by gestational age, body temperature (radiant warmers) and phototherapy. As the relative humidity of environment increases the transpithelial water loss (TEWL) decreases. The radiant warmer exposure increases the TEWL between 50 and 140%. Similarly, the TEWL increases approximately 60% with exposure to phototherapy while the impermeable plastic covering decreases the TEWL about 50-70%. The respiratory water loss (RWL) for a new born full term infant is approximately 5 ml/kg body weight per 24h at a relative humidity of 50% and TEWL 7ml/kg in a similar environment. Thus, the insensible water loss for a full term infant in the thermoneutral environment at 50% relative humidity is 12ml/kg/24h. Neonatal renal function is generally adequate to meet the needs of the normal full-term infant but may be limited during periods of stress. The ideal urine output in neonate representing the renal water required to allow excretion of the solute load at an isotonic urine osmolality of 280 mOsmol/dl (specific gravity 1.009-1.012) is 2-4 ml/kg/hr. The older child needs about l-2ml/kg/hr and the adult 0.5-1 ml/kg/hr. The electrolyte requirement of the full term neonate is : sodium 2-3 meq/kg/day. potassium l-2meq/kg/day. chloride 3-5 meq/kg/day at a rate of fluid of 100ml/kg/24 hours for the first 10 kg of weight. Special needs of preterm babies fluid therapy are : conservative approach, consider body weight changes, sodium balance and ECF tonicity. They are susceptible to both sodium loss and sodium and volume overloading. High intravenous therapy can lead to PDA, left ventricular failure, respiratory distress syndrome, bronchopulmonary dysplasia, and necrotising enterocolitis. The degree of dehydration can be measured by clinical parameters such as body weight, tissue turgor, palpation of peripheral pulsations, depression of fontanelle, dryness of the mouth and urine output. Blood urea nitrogen, haematocrit, serum sodium, serum potassium, serum chloride levels and urine osmolality are the additional factors to monitor the response of the patient and the IV fluids are adjusted accordingly. Blood volume estimates of help during surgical blood loss are : (1) premature 85-100ml/kg, (2) term 85 ml/kg, and (3) in infant 70-80 ml/kg. Intravenous nutrition is one of the major advances in neonatal surgery and will be required when it is obvious that the period of starvation will go beyond five days. Oral feeding is the best method and breast is best source. A newborn infant requires 100-200 calories/kg/day for normal growth. This is increased during stress, cold, infection, surgery and trauma. Minimum daily requirement is 2-3gm/kg of protein, 10–15 gm/kg of carbohydrate and a small amount of essential fatty acids.

Targeting Gentamicin Therapeutic Ranges During the First Week of Life in Infants in Neonatal Intensive Car

Background: The absence of published recommendations for optimum dosing of gentamicin in premature neonates led us to develop dosing schedules for the neonatal population based on post‐conceptional age, and to audit the results periodically. Our previous study results supported the use of a gentamicin loading dose as well as higher maintenance doses at longer dose intervals. However, areas for improvement were identified.Aim: To further refine gentamicin dosing schedules to improve therapeutic range targeting during the first week of life in infants in the Neonatal Intensive Care Unit.Method: A revised gentamicin dosing schedule was formulated and instituted during an 8‐month period in 1999‐2000. All infants &gt; 35 weeks gestation received a loading dose of 5 mg/kg with a maintenance dose of 4 mg/kg (increased from 3.5 mg/kg during a 7‐month period in 1999) every 48 hours for infants &gt;30 weeks gestation, and every 36 hours for those 30‐34 weeks gestation. Infants &lt;34 weeks gestation were given 4 mg/kg every 36 hours without a loading dose. Blood samples for trough concentration measurement were taken immediately before the second dose and those for peak concentration 30 minutes after the completion of the 1‐hour infusion of the second dose. As the majority of the infants received gentamicin shortly after birth, analysis was performed on the data collected during the first few days of life. The results from this dosing schedule were compared with our previous data from 1999.Results: Two hundred and eleven pairs of serum gentamicin peak and trough concentrations in 1999 and 120 pairs in 1999‐2000 were eligible for analysis. The 1999‐2000 gentamicin dosing schedule resulted in 100% of trough and 88.2% of peak concentrations falling within the targeted ranges in infants &gt;30 weeks gestation and 79.5% of trough and 88.6% of peak concentrations falling within the respective targeted ranges in infants &lt;37 weeks gestation. In infants 30‐34 weeks gestation there were similar results for both dosing schedules. Overall, 88.3% of serum gentamicin trough concentrations and 85.8% of peak concentrations were within the targeted ranges during the first postnatal week using the 1999‐2000 schedule.Conclusion: The results of this study suggest improved gentamicin therapeutic concentration targeting using the 1999‐2000 dosing schedule. A larger study is required to confirm the statistical significance of our findings.

Probiotics in the treatment and prevention of acute infectious diarrhea in infants and children: a systematic review of published randomized, double-blind, placebo-controlled trials.

This review was designed to assess the evidence from randomized controlled trials on effects of probiotics in the treatment and prevention of acute infectious diarrhea in infants and children. A systematic review of published, randomized, double-blind, placebo-controlled trials on probiotics in the treatment or prevention of acute diarrhea defined as >3 loose or watery stools per 24 hours in infants and children. The use of probiotics as compared with placebo was associated with a significantly reduced risk of diarrhea lasting >3 days. The pooled estimate risk was 0.43 (95% CI, 0.34-0.53) with a fixed-effect model, and remained significant in a random-effect model (0.40; 95% CI, 0.28-0.57). Only Lactobacillus GG showed a consistent effect. Probiotics significantly reduced the duration of diarrhea when compared with placebo, particularly in rotaviral gastroenteritis-the pooled, weighted, mean difference (WMD) assuming the random-effect model was -20.1 hours (95% CI, -26.1 to -14.2) and -24.8 (95% CI, -31.8 to -17.9) respectively. A meta-analysis of the prevention studies was not feasible because of significant clinical and statistical heterogeneity. There is evidence of a clinically significant benefit of probiotics in the treatment of acute infectious diarrhea in infants and children, particularly in rotaviral gastroenteritis. Lactobacillus GG showed the most consistent effect, although other probiotic strains may also be effective. Further research is needed. Clinical and statistical heterogeneity of the prophylactic interventions preclude drawing firm conclusions about the efficacy of probiotics in preventing acute gastroenteritis.

Probiotics in the Treatment and Prevention of Acute Infectious Diarrhea in Infants and Children: A Systematic Review of Published Randomized, Double‐Blind, Placebo‐Controlled Trials

ABSTRACTBackgroundThis review was designed to assess the evidence from randomized controlled trials on effects of probiotics in the treatment and prevention of acute infectious diarrhea in infants and children.MethodsA systematic review of published, randomized, double‐blind, placebo‐controlled trials on probiotics in the treatment or prevention of acute diarrhea defined as &gt;3 loose or watery stools per 24 hours in infants and children.ResultsThe use of probiotics as compared with placebo was associated with a significantly reduced risk of diarrhea lasting &gt;3 days. The pooled estimate risk was 0.43 (95% CI, 0.34–0.53) with a fixed‐effect model, and remained significant in a random‐effect model (0.40; 95% CI, 0.28–0.57). Only Lactobacillus GG showed a consistent effect. Probiotics significantly reduced the duration of diarrhea when compared with placebo, particularly in rotaviral gastroenteritis—the pooled, weighted, mean difference (WMD) assuming the random‐effect model was −20.1 hours (95% CI, −26.1 to −14.2) and −24.8 (95% CI, −31.8 to −17.9) respectively. A meta‐analysis of the prevention studies was not feasible because of significant clinical and statistical heterogeneity.ConclusionsThere is evidence of a clinically significant benefit of probiotics in the treatment of acute infectious diarrhea in infants and children, particularly in rotaviral gastroenteritis. Lactobacillus GG showed the most consistent effect, although other probiotic strains may also be effective. Further research is needed. Clinical and statistical heterogeneity of the prophylactic interventions preclude drawing firm conclusions about the efficacy of probiotics in preventing acute gastroenteritis.

Dose-response relationship and infusion requirement of cisatracurium besylate in infants and children during nitrous oxide-narcotic anesthesia.

To determine the effect of age on the dose-response relation and infusion requirement of cisatracurium besylate in pediatric patients, 32 infants (mean age, 0.7 yr; range, 0.3-1.0 yr) and 32 children (mean age, 4.9 yr; range, 3.1-9.6 yr) were studied during thiopentone-nitrous oxideoxygen-narcotic anesthesia. Potency was determined using a single-dose (20, 26, 33, or 40 microg/kg) technique. Neuromuscular block was assessed by monitoring the electromyographic response of the adductor pollicis to supramaximal train-of-four stimulation of the ulnar nerve at 2 Hz. Least-squares linear regression analysis of the log-probit transformation of dose and maximal response yielded median effective dose (ED50) and 95% effective dose (ED95) values for infants (29+/-3 microg/kg and 43+/-9 microg/kg, respectively) that were similar to those for children (29+/-2 microg/kg and 47+/-7 microg/kg, respectively). The mean infusion rate necessary to maintain 90-99% neuromuscular block during the first hour in infants (1.9+/-0.4 microg x kg(-1) x min(-1); range: 1.3-2.5 microg x kg(-1) x min(-1)) was similar to that in children (2.0+/-0.5 microg x kg(-1) x min(-1); range: 1.3-2.9 microg x kg(-1) x min(-1)). The authors conclude that cisatracurium is equipotent in infants and children when dose is referenced to body weight during balanced anesthesia.

Pharmacokinetics of amrinone in neonates and infants

Objective: To evaluate the pharmacokinetics of amrinone and its metabolites in neonates and infants after reconstructive surgery for congenital heart disease. Design: Prospective study. Setting: Pediatric intensive care unit in a university hospital. Participants: Fifteen neonates aged less than 1 month with transposition of the great arteries and 14 infants aged 2 to 6 months with complete atrioventricular septal defect. Interventions: Amrinone, loading dose of 2 mg/kg, was administered before weaning from cardiopulmonary bypass, followed by a maintenance infusion of 7.5 μkg/kg/min. Measurements and Main Results: Blood samples to determine plasma concentrations of amrinone, N-acetylamrinone, and N-glycolylamrinone were drawn before amrinone administration, frequently after the loading dose, every 6 hours during the maintenance infusion, and until 48 hours after the end of the infusion. Amrinone clearance was 2.4 ± 0.9 mL/kg/min in neonates and 3.2 ± 1.2 mL/kg/min in infants (p < 0.05). The volume of distribution at steady-state was smaller (p < 0.05) in neonates than in infants. The elimination half-life of amrinone was 10.7 ± 6.7 hours in neonates and 6.1 ± 1.4 hours in infants (p < 0.05). There was a linear correlation between the clearance of amrinone and the body surface area (r = 0.67; p < 0.05). The ratio of the plasma concentration of N-acetylamrinone to that of amrinone did not differ between neonates and infants. Conclusions: Amrinone is eliminated at a slower rate in neonates than in infants. The rate of acetylation of amrinone appears to be similar; the differences in the elimination capacity of amrinone are mainly due to the immature renal function in neonates. Copyright © 2000 by W.B. Saunders Company

Constipation and Encopresis in Childhood

Constipation and Encopresis in Childhood