Late Hemorrhagic Disease Research Articles

ГЕМОРРАГИЧЕСКИЕ ИНСУЛЬТЫ У ДЕТЕЙ РАННЕГО ВОЗРАСТА

To date, cerebrovascular diseases of childhood are poorly understood. The need to study hemorrhagic strokes in children is due to the high prevalence in early childhood, the difficulty in identifying the causes and the non-specificity of the first signs of pathology. At different stages of child development, the etiological significance of various pathogenic factors is not the same. The purpose of this study - to analyze the results of diagnosis and treatment of intracranial complications in late hemorrhagic disease of the newborn. Methods. 158 cases of treatment of patients with intracranial hemorrhages against the background of vitamin-K dependent hemorrhagic syndrome were chosen as the objects of the study. Among the sick boys prevailed and amounted to 76 percent. At the age of 40 days ± 2, the disease began in 129 (86.6%) patients. The results of treatment were monitored in 158 patients within the period from one to 3 months. Indicators reflecting the results of treatment were subjected to statistical analysis. Results. According to the type of hematoma, the patients were distributed as follows - 64 (41.1%) intracerebral hematoma, 31 (20.2%) were diagnosed with subdural hemorrhage, intraventricular hemorrhage was detected in 6 (3.8%) cases, mixed subduralintracerebral hemorrhage was detected in 15 (9.5%) patients. 43 (26.6%) patients were not operated on: with subarachnoid hemorrhages - 34 (21.4%) and 9 patients (5.7%) - with small intracerebral and suberal hemorrhages. Lethal outcome occurred in 29 children (18.4%), mortality after surgery in 8 (5.1%) cases. In 43% of cases, a follow-up study did not reveal a neurological deficit. Conclusions. Full-term infants with a combination of the following factors are susceptible to the occurrence of hemorrhagic disease of the newborn: lack of prophylactic administration of vitamin K preparations, breastfeeding, and transient cholestasis. Timely surgical treatment in most patients gives positive results, despite the operation in a very difficult general condition of the patient and unstable hemostasis. Residual neurological deficit was noted during the follow-up study mainly in patients with primary gross damage to the brain parenchyma and with late diagnosis of the disease.

Structural epilepsy in children who have suffered a hemorrhagic stroke

The relevance of studying the consequences of hemorrhagic strokes in young children is due to the frequency of cerebrovascular pathology, the formation of persistent neurological deficits, including post-stroke epilepsy, and high mortality. It is known that hemorrhages are diagnosed in the first 28 days of life in 6-7 out of 100,000 infants, in children from the 28th day of life to 18 years of age from 0.7 to 5.1 cases per 100 thousand children. Mortality in hemorrhagic and ischemic strokes in children ranges from 7 to 28%. Epileptic seizures of the acute and acute period of stroke are prognostically unfavorable factors of the course of the disease. The article presents brief literature data on the etiology and localization of hemorrhagic strokes, their role in the formation of pharmacoresistant epilepsy. Special attention is paid to the role of late hemorrhagic disease of newborns, accompanied by intracranial hemorrhages, in the formation of structural epilepsy in the future. The paper describes own clinical observations of 25 patients suffering from epilepsy after a hemorrhagic stroke with a description of the clinical picture, features of paroxysmal states and their therapy, neuroimaging data, electroencephalographic phenomena. A clinical example is presented in which the clinical, anamnestic, electrophysiological data of a patient with pharmacoresistant epilepsy developed as a result of a hemorrhagic stroke on the background of late hemorrhagic disease of newborns are considered.
 Structural epilepsy in children, formed after a hemorrhagic stroke, is accompanied by significant multi-regional damage, pronounced neurological deficit and is characterized by a pharmacoresistant course.

К вопросу о роли возможного синдрома мальабсорбции жиров при грудном вскармливании в развитии поздней геморрагической болезни новорожденного

The causes of late hemorrhagic disease of the newborn (HDN) are parenteral nutrition, severe diseases (e.g., biliary atresia, congenital or inherited diseases associated with cholestasis, short bowel syndrome), exclusive breastfeeding, and digestive disorders with malabsorption. Meanwhile, vitamin K deficiency develops in severe malabsorption and digestive disorders resulting from an irrational diet of a nursing mother or viral infections with the intestinal syndrome. Lipidogram of feces was evaluated by thin-layer chromatography in 15 children with late HDN. Lipidogram demonstrated high lipid content (on average, 77.47 μg/g). Moreover, the maximum levels of higher fatty acids, cholesterol, and phospholipids were detected in children with the most severe clinical presentations of bleeding. Clinical manifestations of hemorrhagic syndrome included umbilical cord bleeding (66.7%), gastrointestinal bleeding (28.5%), and intracranial hemorrhage (6.7%). In addition, all children have one or more clinical symptoms of digestive disorders (i.e., frequent bowel movements, excessive pooping, watery diarrhea). Occasionally, bloody streaks were reported. Education of nursing mothers to plan their diet and follow a balanced diet demonstrates that strict adherence to these recommendations significantly reduces the risks of vitamin K deficiency in newborns and late HDN. KEYWORDS: vitamin K, vitamin K deficiency bleeding, breastfeeding, children, lipidogram of feces, late hemorrhagic disease of the newborn, malabsorption. FOR CITATION: Mozzhukhina L.I., Kalgina S.E., Stroeva L.E., Teyf V.A. Role of fat malabsorption during breastfeeding in late hemorrhagic disease of the newborn. Russian Journal of Woman and Child Health. 2022;5(1):85–89 (in Russ.). DOI: 10.32364/2618- 8430-2022-5-1-85-89

Пребывают ли младенцы, которых кормят исключительно грудным молоком, в состоянии дефицита витамина К? (К 20-летию истории вопроса)

Актуальность. «Are breast-fed infants vitamin K deficient?» — этот вопрос F.R. Greer сформулировал в 2001 году в исследовании, ставшем классическим. Цель: определение концентрации субстанции Рrotein induced by vitamin K absence ІІ (PIVKA-II) и протромбинового комплекса как маркеров скрытого дефицита витамина К у детей первых 6 месяцев жизни, получающих исключительно естественное вскармливание. Материалы и методы. Всего исследованы 264 ребенка в возрасте от рождения до 6 месяцев, которые находились в удовлетворительном состоянии и не имели изменений в общих анализах крови и результатах тестов гепатобилиарной системы. Результаты. В раннем неонатальном периоде 62 (83,8 %) ребенка из 74, не получавших витамин К, имели показатели PIVKA-II больше нормы, составляющей 40 усл.ед/мл. У 17 (77,3 %) из 22 детей в возрасте от 8 до 28 суток жизни, не получавших витамин К после рождения, уровень PIVKA-II был в пределах нормы. Из 31 младенца, которые получили профилактический болюс витамина К1, на первой неделе жизни 92 % имеют показатели PIVKA-II в пределах нормы. У 12 (54,5 %) из 22 детей в возрасте от 28 до 180 дней, обследованных после лечения антибиотиками, показатели PIVKA-II были выше нормы. Применение антибиотиков у детей было ассоциировано с повышенным концентрациями РIVKA-II, что может свидетельствовать о скрытом приобретенном дефиците витамина К, или о его возобновлении после рождения. Исследование протромбинового комплекса у этих же детей установило по медианам и квартальным оценкам (Me 25–75) снижение содержания протромбина по Квику до 62 % (18–91 %), удлинение протромбинового времени до 18 с (13–22 с) и увеличение международного нормализованного отношения до 1,4 (1,1–2,6). Выводы. Таким образом, у детей указанной группы возникло состояние гипокоагуляции, при совпадении других неблагоприятных обстоятельств вполне достаточное для развития поздней геморрагической болезни.

Клинический случай ведения поздней геморрагической болезни новорожденного. Опасности для семейного врача. Современные рекомендации по профилактике

В статье представлены клиническое течение и составляющие лечения случая геморрагического синдрома, вызванного поздним дефицитом витамина К, у доношенной девочки 28 дней жизни. Вопрос ранней профилактики кровотечений, ассоциированных с поздним дефицитом витамина К, со 2-й недели жизни до трехмесячного возраста у всех новорожденных детей, которые вскармливаются грудным молоком, актуален без преувеличения, поскольку более 50 % осложнений этих кровотечений — это острые спонтанные внутричерепные кровоизлияния с летальностью свыше 30 %. Клиническими проявлениями геморрагического синдрома, который возник у девочки в завершение неонатального периода и причиной которого, по результатам клинико-лабораторных обследований, стал поздний дефицит витамина К, были нарушения общего состояния со стабильными показателями основных жизненно важных функций (температуры тела, частоты дыхания, частоты сердечных сокращений, артериального давления), отсутствие аппетита, отказ от груди, подкожная гематома больших размеров на левом латеральном участке грудной клетки, гематома неба, кровоточивость царапины на коже лица. У ребенка наблюдалась анемия, прогрессирующая от легкой степени (гемоглобин — 105 г/л, эритроциты — 3,2 × 1012 кл/л) при поступлении до тяжелой на вторые сутки госпитализации (уровень гемоглобина — 49 г/л). Показатели коагулограммы, которые были определены у ребенка, свидетельствовали в пользу позднего дефицита витамина К: удлинение времени свертывания крови до 6 мин 45 с, протромбинового времени — до 18 с, активированного тромбопластинового времени — до 90 с; фибриноген не выходил за пределы нормы — 1,9 г/л. Диагноз позднего дефицита витамина К у младенца был установлен уже после появления стойких клинико-лабораторных признаков, в условиях детской больницы. Вопрос профилактики позднего дефицита витамина К у ребенка на грудном вскармливании врачом-неонатологом, семейным врачом не рассматривался. Именно профилактика кровотечений, ассоциированных с поздним дефицитом витамина К, которую в соответствии с современными научно-практическими рекомендациями следует начинать на второй неделе жизни и продолжать до трехмесячного возраста, должна быть обязательной для младенцев, которые вскармливаются исключительно грудным молоком.

Increasing Head Circumference and Jaundice in a 4-week-old Infant

1. Marlisa Wolf, MD* 2. Komal Desai, MD* 3. Esther Kisseih, MD*,† 4. Beena Sood, MD*,†,‡ 1. *Children’s Hospital of Michigan, 2. †Neonatology Division 3. ‡Wayne State University School of Medicine Detroit, Michigan A 4-week, full term girl presents to the NICU for jaundice present since 1 week of age and increasing head circumference for over a week. She was born after an uneventful 41-week pregnancy. Family history was significant for Gilbert disease in the father. She has been exclusively breastfed since birth. At 2 weeks of age, she was seen in the emergency department for vomiting after each feeding and jaundice. An abdominal ultrasound showed no evidence of pyloric stenosis; treatment with ranitidine was initiated for suspected gastroesophageal reflux disease. Her clinical jaundice was attributed to breastmilk, and no further laboratory evaluation was completed. At 4 weeks of age, her mother brought the infant to the referring hospital for evaluation of persistent jaundice, increasing head circumference, frequent bruising, and epistaxis. It was confirmed that her head circumference had increased from 33.5 cm (14.5%) at birth to 42 cm (99%) at 4 weeks of age. She was noted to have prolonged bleeding from her intravenous site. Liver evaluation revealed a direct hyperbilirubinemia (total bilirubin of 7.9 mg/dL [135 μ mol/L] with direct bilirubin of 3.9 mg/dL [67 μ mol/L]), and elevated enzyme levels (alanine aminotransferase 83 U/L [1.38 microkatal (ukat)/L], aspartate transaminase 163 U/L [2.7 ukat/L], and alkaline phosphatase 328 U/L [5.47 ukat/L]). She was transferred to our level IV NICU for further management. ### Patient Clinical Course The physical examination upon presentation to the NICU was remarkable for macrocephaly, a bulging anterior fontanelle, icterus, and multiple petechiae. Differential diagnoses included infection, biliary abnormalities including biliary atresia, and late onset hemorrhagic disease of the newborn for which laboratory and radiographic evaluation was initiated. Although the …

CLINICAL CASE OF HEMORRAGIC DISEASE IN NEWBORN

Newborn hemorrhagic disease develops in 0.25-0.5% of newborns due to vitamin K deficiency. Newborn hemorrhagic disease can be early (in the first 24 hours of life), classical (1-7 days of life) and late (2-8 weeks of life, rarely - up to 6 months.). All three forms are caused by deficiency of vitamin K. Early newborn hemorrhagic disease can start prenatally, and a baby has skin hemorrhages, cephalohematomas, or intracranial hemorrhages at birth. As a manifestation of early newborn hemorrhagic disease, pulmonary hemorrhage, hemorrhage in the abdominal organs (especially often the liver, spleen, adrenal glands), and grinding are possible. Clinical manifestations of late newborn hemorrhagic disease can be widespread cutaneous ecchymosis, intracranial hemorrhage, mellitus, hematemesis.A clinical case of a late form of newborn hemorrhagic disease, which has been successfully treated with the oral form of vitamin K1, is given in the article.

Late Haemorrhagic Disease of Newborn: Can It be Prevented by Changing Prophylaxis Policy?

Background: Vitamin K deficiency can cause severe haemorrhage in the newborn and is an important cause of infant morbidity and mortality. HDN can be classified according to the time of presentation after birth into early (0–24 hours), classical (1–14 days) and late (2–12 weeks) HDN. Late HDN, which presents after the first week of life, mainly manifests as intracranial haemorrhage, depending upon the site and amount of bleeding, it either results in mortality or life long sequelae in the form of cerebral palsy and scar epilepsy with or without cognitive impairment.
 Objective: To determine the frequency of ICH about vitamin K deficiency and outcome in infants aged 2 to 24 weeks.
 Materials and Methods: From 1 September 2017 to 30 September 2019 we retrieved the retrospective data of 8 patients with late HDN admitted to Bapuji Child Health Institute and Chigateri Government General Hospital, Davangere.
 Results: Six of eight cases with late HDN had an intracranial haemorrhage, of whom 5 patients died (62%), one ended up with neurological sequelae (12%) and 2 cases had an extracranial bleed. Out of these 8 cases, 5 had not received vitamin K at birth.
 Conclusion: For neonates on strict breastfeeding, despite some with vitamin K prophylaxis, some patients still may suffer from intracranial and extracranial bleeding due to late HDN. Therefore, a change in strategy in the form of making the paediatricians and Anganwadi workers working in subcenters to give vitamin K, who have been vaccinating the babies after birth, would increase the vitamin K coverage.

INTRACEREBRAL BLEEDING IN LATE HEMORRHAGIC DISEASE OF THE NEWBORN

1 Vitamin K Ad Hoc Task Force. Controversies concerning vitamin K and the newborn. Pediatrics 1993; 91: 1001-1003. 2. Isarangkura PB, Pintadit P, Tejavej A, Siripoonya P. Chulajata C, Green GM. Vitamin K prophylaxis in the neonate by oral route and its significance in reducing infant mortality and morbidity. J Med Assoc Thai 1986; 69: 56-61. 3. Ijland MM, Pereira RR, Cornelissen EA. Incidence of late vitamin K deficiency bleeding in new-borns in the Netherlands in 2005: Evaluation of the current guideline. Eur J Paediatr 2008; 167: 165-169. 4. Waseem M. Vitamin K and hemorrhagic disease of new-borns. South Med J 2006; 99: 1199. 5. Lane PA, Hathaway WE. Vitamin K in infancy. J Pediatr 1985; 106: 351-359. 6. Singh M. Vitamin K during infancy: Current status and recommendations.Indian Pediatr 1997; 34: 708-712. 7. Bor O, Akgun N, Yakut A, et al. Late hemorrhagic disease of the new-born.Paediatr Int 2000; 42: 64-66. 8. D?Souza IE, Rao SD. Late hemorrhagic disease of new-born. Indian Paediatr 2003; 40: 226-229. 9. Flood VH, Galderisi FC, Lowas SR, et al. Hemorrhagic disease of the new-born despite vitamin K prophylaxis at birth. Paediatr Blood Cancer 2008; 50: 1075-1077. 10. Zengin E, Sarper N, Türker G, et al. Late haemorrhagic disease of the new- born. Ann Trop Paediatr 2006; 26: 225-231. 11. Sutor AH, Dagres N, Niederhoff H. Late form of vitamin K deficiency bleeding in Germany. KlinPediatr 1995; 207: 89-97

Pediatric Stroke: A Single-Center Experience.

The aim of this study was to evaluate the clinical characteristics, risk factors, treatment, and outcomes of pediatric stroke cases. A total of 118 patients diagnosed with arterial ischemic stroke (AIS), hemorrhagic stroke, and sinovenous thrombosis (SVT) between January 2000 and December 2011 were included. Neonatal cases were excluded. Demographic and clinical findings were retrospectively examined from medical records. We identified 118 patients with stroke. The age of the patients ranged from 1 to 215 months (17.92 y), with a mean age of 5.19±5.25 years. AIS accounted for the majority of cases (n=69, 58.5%), and the major etiology was cardiac disease (17%). Hemorrhagic stroke accounted for 19.5% (n=23) of the cases, and late hemorrhagic disease of the newborn was the major etiology (43%, n=10). SVT accounted for 22% (n=26) of the cases, and the major etiology was otitis media-mastoiditis (27%, n=7). Hemiplegia and headache were the most frequent symptoms for AIS and SVT, respectively. Stroke is rare in children compared with adults; however, it is detected more frequently with better imaging techniques and increased awareness. We found that children with AIS presented more commonly with hemiplegia and children with SVT with headache and strabismus. We did not find an association between thrombophilia and stroke.

INTRACEREBRAL BLEEDING IN LATE HEMORRHAGIC DISEASE OF THE NEWBORN

Late onset HDN can present as bleeding from any site of the body but more commonly from intracranial vessels. It is diagnosed if bleeding occurs after 7th day of life with normal platelet count, prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), associated with stopping of bleeding and PT/PTTreturning to normal after giving vitamin K. Among the types of intracranial bleeding in late hemorrhagic disease of newborn, intracerebral parenchymal bleeding is least common.

Intensive care needs and predictors of in hospital mortality following spontaneous intracranial hemorrhage in children - A ten year single centre retrospective study

Objective: To study the clinical profile, intensive care needs and predictors of in hospital mortality in children with Spontaneous Intracranial Hemorrhage (SICH). Material and methods: Retrospective observational study in a tertiary care pediatric intensive care unit (PICU) of a teaching and referral hospital where 105 children aged > 1 month to 12 years with SICH admitted between January 2009 and May 2018 were assessed for in-hospital mortality as primary outcome. Survivors and non-survivors were compared to determine predictors of outcome. Results: The median (IQR) age of study subjects was 6 (2.25, 70) months, with 76 (72.4%) boys. Altered sensorium (n=87, 82.9%) and seizures (n=73, 69.5%), and pallor (n=66, 62.9%) and bulging anterior fontanelle (n=52, 49.5) were common presenting symptoms and signs respectively. Median (IQR) Glasgow Coma Scale (GCS) at admission was 10 (6,13) with features of herniation in 27 (25.7%). Arteriovenous malformation was the commonest cause of bleed among older children whereas late hemorrhagic disease of newborn was predominant cause among infants. Commonest site of bleed was intracerebral (n=47, 44.8%) followed by subdural (n=26; 24.8%). Sixteen (15.2%) children died during hospital stay. On univariate analysis, GCS<8, higher PRISM-III (>20), need for intubation at admission, development of shock and Acute kidney injury (AKI) during hospital stay and refractory status epilepticus requiring thiopentone coma were found to be significant predictors of mortality. Focal seizures were however associated with better survival [OR 0.12; 95% CI:0.03-0.47; p-0.002]. Age, site or etiology of bleed did not affect outcome. On multivariable analysis, progression to AKI [OR 5.86; 95% CI:1.53-22.4; p-0.01] predicted poor outcome. Conclusions: Etiology of SICH varies with age. Age or site of bleed did not predict outcome. Refractory status requiring thiopentone and development of MODS (shock, AKI) were associated with poor outcome.

Pediatric strokes: A hospital based observation

Childhood strokes are not so rare as once thought and its incidence is equal to pediatric brain tumors. The recent advent of more accurate diagnostic techniques has lead to a surge of interest, which may lead in the near future to strategies for treatment and prevention. We retrospectively analyzed the prevalence of first episode of arterial stroke in children. This study was conducted in a private tertiary care hospital for children from June 2002 to May 2004 involving 12 children with first episode of arterial stroke out of 23,125 admissions. Majority (42%) of the children was between 1 month and 5 years and hemiplegia/hemiparesis was the common clinical presentation. Ten children had infarct and two had hemorrhage. The causes identified after detailed investigations were tetralogy of Fallot (2), protein C deficiency (1), homocystinuria (1), nonspecific vasculitis (1), hypercholesterolemia (1), factor XIII deficiency (1), late hemorrhagic disease of the newborn (1) and idiopathic (4). All the children recovered though some had neurological deficit and there was no mortality. Ischemic stroke was more common than hemorrhagic stroke. Prognosis of pediatric stroke is good and the treatment is largely supportive.

G258(P) A twelve month review of paediatric intensive care in myanmar to guide service development

Aims Reliable healthcare statistics are limited in Myanmar. This study aims to describe the typical patient journey through a Paediatric Intensive Care Unit (PICU) and provide vital information to guide future development. Methods A retrospective review of the PICU admission records and patient medical notes was undertaken for all patients admitted to the PICU from 1st November 2011 until 31st October 2012. Patient information was anonymised and key data was extracted including basic demographics, history of presenting complaint, investigations, management and outcome on the PICU. Results The PICU had 10 beds, 7 ventilators and 1 haemodialysis machine. There was a shortage of staff with only 1 doctor and 2 nurses at night. Routine investigations were available although microbiology culture was rarely performed. 407 patients were admitted with the majority being infants (range 0–16 years). The furthest distance travelled was 907Km for a child with lead poisoning. Most patients were admitted for less than 5 days. The peak admission period was during the rainy season which corresponds to the peak incidence of dengue. 64 patients (17.5%) presented with dengue shock syndrome or dengue haemorrhagic fever. The principle reasons for admission included status epilepticus (26.5%); pneumonia (20%); dengue (17.5%); multi-organ failure (14.2%); septicaemic shock (11.7%); and encephalitis (9.5%). Other important reasons for admission were meningitis; gastroenteritis; post-measles complications; diphtheria; snake bite; Beriberi (including Wernicke’s encephalopathy); tetanus; rabies; malaria; late haemorrhagic disease of the newborn; malnutrition; tuberculosis; HIV; and poisoning (organophosphates; traditional medicine). All patients with a viper bite died of complications including shock, acute renal failure and pulmonary haemorrhage. The majority of patients with diphtheria were managed with a tracheostomy. Overall mortality on the PICU was 34%. Conclusions This study provides a unique insight into the local disease burden, resources available and challenges faced in providing paediatric intensive care. The relatively high incidence of vaccine preventable diseases is of particular concern. Key priorities include support for the development of nurse and doctor training; staff retention; evidence-based guidelines; data management including follow-up; referral pathways; access to routine investigations; and a reliable supply of essential medications and equipment.

G385(P) A twelve month review of paediatric intensive care in myanmar to guide service development

Aims Reliable healthcare statistics are limited in Myanmar. This study aims to describe the typical patient journey through a Paediatric Intensive Care Unit (PICU) and provide vital information to guide future development. Methods A retrospective review of the PICU admission records and patient medical notes was undertaken for all patients admitted to the PICU from 1st November 2011 until 31st October 2012. Patient information was anonymised and key data was extracted including basic demographics, history of presenting complaint, investigations, management and outcome on the PICU. Results The PICU had 10 beds, 7 ventilators and 1 haemodialysis machine. There was a shortage of staff with only 1 doctor and 2 nurses at night. Routine investigations were available although microbiology culture was rarely performed. 407 patients were admitted with the majority being infants (range 0–16 years). The furthest distance travelled was 907 Km for a child with lead poisoning. Most patients were admitted for less than 5 days. The peak admission period was during the rainy season which corresponds to the peak incidence of dengue. 64 patients (17.5%) presented with dengue shock syndrome or dengue haemorrhagic fever. The principle reasons for admission included status epilepticus (26.5%); pneumonia (20%); dengue (17.5%); multi-organ failure (14.2%); septicaemic shock (11.7%); and encephalitis (9.5%). Other important reasons for admission were meningitis; gastroenteritis; post-measles complications; diphtheria; snake bite; Beriberi (including Wernicke´s encephalopathy); tetanus; rabies; malaria; late haemorrhagic disease of the newborn; malnutrition; tuberculosis; HIV; and poisoning (organophosphates; traditional medicine). All patients with a viper bite died of complications including shock, acute renal failure and pulmonary haemorrhage. The majority of patients with diphtheria were managed with a tracheostomy. Overall mortality on the PICU was 34%. Conclusions This study provides a unique insight into the local disease burden, resources available and challenges faced in providing paediatric intensive care. The relatively high incidence of vaccine preventable diseases is of particular concern. Key priorities include support for the development of nurse and doctor training; staff retention; evidence-based guidelines; data management including follow-up; referral pathways; access to routine investigations; and a reliable supply of essential medications and equipment.

Nodular Purpura and Intracranial Bleeding due to Late Onset Hemorrhagic Disease of Infancy: A case report

UHQ, a four -month-old female child, was rushed to the Emergency Medicine Department (EMD) due to severe spontaneous bleeding. This exclusively breast fed child had a history of diarrhea, vomiting and taking broad-spectrum antibiotics over the last two weeks. She developed nodular purpuric spots for about three days prior to the intracranial bleeding. She was unconscious and responding only to pain, and was severely pale. She was transfused with two units of whole blood and underwent a craniotomy for draining the hemorrhage. She was treated with Vitamin K supplements. Her OFC was 44cm on admission. She was discharged after one week, with OFC 41cm. On follow-up, she is developing normally.

Late hemorrhagic disease of the newborn - Need for a second dose of Vitamin K ?

Late hemorrhagic disease of the newborn - Need for a second dose of Vitamin K ?

ABSTRACT 310

Background and aims: Late Vitamin K Deficiency Bleeding (VKDB) continues to be a cause of infant mortality with increased promotion of exclusive breast feeding and controversies over the administration of vitamin K. Aims: To describe the clinical profile of infants with late VKDB and determine the neurodevelopmental outcome of the survivors. Methods: Data of infants admitted with a diagnosis of VKDB or Late Hemorrhagic Disease of the Newborn between the years 2008–2011 was retrieved from the hospital’s computerized database. Surviving infants were followed up at a single visit. Results: Twenty four infants, 22 (91.7%) of them boys were identified. While 66% were between 31–60 days, 20% were between 7–30 days of life at presentation. The mean duration of illness was 1.9(range: 0.5–7) days. 58.3% had received vitamin K intramuscularly/ orally surely. 70.8% were exclusively breast fed. Cholestasis was present in 33%. 91.6% of infants had intracranial bleed, subdural in 41.7%, followed by parenchymal in 29.8%. 20.8% underwent decompressive craniectomy. 15 (62.5%) survived to hospital discharge. Of the 14 surviving infants who were followed up, 9 (64%) had developmental sequelae, of whom 2 (14.2%) had severe neurological sequelae. Conclusions: Intracranial hemorrhage caused by VKDB occurring despite vitamin K administration in the neonatal period continues to be seen among our ICU patients. Mortality and morbidity are significant. Role of a second dose of vitamin K, its time of administration and maternal supplementation of vitamin K to prevent late VKDB need to be evaluated.

Late onset hemorrhagic disease of newborn due to CMV hepatitis presenting as scalp hematoma

Vitamin K deficiency bleeding (VKDB) according to recent studies is the preferred term for hemorrhagic disease of the newborn (HDN). This is due to deficiency of clotting factors as a result of vitamin K deficiency. VKDB was first described over a hundred years ago but its relationship to vitamin K was not released until 40 years later. Vitamin K is required for the production of clotting factors II, VII, IX and X. It is involved in the normal clotting of blood, is present in some plants and is also synthesized by some E. coli in the gut. Due to low levels of vitamin K all newborn infants are at risk of developing hemorrhagic disease of the newborn. The body has very limited ability to store the vitamin. We present an unusual case of Neonatal Hepatitis due to CMV as a rare cause of late onset vitamin kdeficiency bleeding.

Prevalence of Retinal Hemorrhages in Critically Ill Children

Retinal hemorrhages (RHs) with encephalopathy and subdural bleeding are considered suggestive of abusive head trauma (AHT). Existing studies describing RH focus on AHT and have potential selection bias. We undertook a prospective observational study to define the prevalence, distribution, and extent of RH in critically ill children. From February 2008 to December 2009, emergency intensive care admissions ≥ 6 weeks of age underwent dilated retinal examination by either a pediatric ophthalmologist or RetCam (retinal photograph) imaging after written informed consent. Patients with suspected or proven AHT, penetrating eye trauma, and elective admissions were excluded. The prevalence of RH was 15.1% (24/159; 95% confidence interval [CI]: 9.5%-21%); 16/24 (66%) mild, and 2/24 (8%) moderate. Severe multilayered RH were seen in only 6 patients (3.7%), 3 with myeloid leukemia and sepsis, 2 with severe accidental head injury, and 1 with severe coagulopathy secondary to late onset hemorrhagic disease of newborn. There was no detectable impact of age, gender, seizures, coagulopathy or cardiopulmonary resuscitation on prevalence of severe multilayered RH; however, sepsis (odds ratio: 3.2; 95% CI: 1.3-8.0, P = .018) and coagulopathy (odds ratio: 2.8; 95% CI: 1.2-7.0, P = .025) were significantly associated with any RH. Only admission diagnosis was independently associated with severe multilayered RH on logistic regression. RHs were seen in critically ill children with a prevalence of 15.1% (24/159); however, most were mild. Severe multilayered RH resembling those described in AHT were rare (6/24) and were only seen in patients with fatal accidental trauma, severe coagulopathy, sepsis with myeloid leukemia, or a combination of these factors.