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Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Risk for post‐resuscitation complications: Are recovered term newborns all better?

Infants who had recovered by 5 minutes after resuscitation still had increased risk for complications.

Transfer to an NICU for post‐resuscitation care is recommended for all newborns who require active resuscitation in the delivery room, but some infants respond rapidly and do not require further intervention. To examine whether recovered neonates should be cared for in this type of setting, researchers at one perinatal center retrospectively compared medical charts of 33 term neonates who required active intervention but who seemingly recovered by 5 minutes of age (1‐minute Apgar score [less-than-or-eq, slant]4, positive pressure ventilation during the first minute of life, 5‐minute Apgar score [gt-or-equal, slanted]8) with those of a control group consisting of the next same‐sex term infant with an Apgar score [gt-or-equal, slanted]8 delivered at the center.

Compared with controls, infants in the study group had significantly more perinatal risk factors. Twice as many study infants were known to be at risk and therefore had a resuscitation team in the delivery room prior to delivery. Seventeen study infants were admitted to the NICU: 4 from the delivery room and 13 from the wellborn nursery after experiencing complications. Only 1 control infant (with transient tachypnea) was admitted to the NICU. Twenty study infants had complications: 8 had hypoglycemia (5 requiring intravenous glucose), 6 had transient tachypnea, 4 had meconium aspiration, and 2 had hypermagnesemia. Two infants had pneumothorax, 1 had hyperbilirubinemia, and 1 required evaluation for sepsis.

Comment

The authors conclude that these findings support caring for seemingly recovered resuscitated infants in an environment where post‐resuscitation complications can be monitored and treated. Having data to support what seems logical is good, and the message is clear: No matter how well infants might appear after responding to positive pressure ventilation, they must be monitored for complications (some of which might not be apparent unless they are investigated). Why the infant required resuscitation is important for the pediatrician to know.

William P. Kanto, Jr., MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 28, 2007

[filled triangle] Frazier MD, et al. Post‐resuscitation complications in term neonates. J Perinatol 2007;27:82–4.

Rapid recovery of consciousness after febrile seizures

When a child with an untreated, apparent febrile seizure takes longer than 1 hour to recover, consider other etiologies.

Consciousness is often impaired following epileptic seizures in children. Investigators at a neurology referral center in the U.K. assessed the duration of seizures and time to recovery of consciousness (Glasgow Coma Scale score [gt-or-equal, slanted]15) in 90 children (age range, 1–16 years).

Of 110 seizure episodes, 59 were febrile seizures with a median duration of 2.5 minutes and a median recovery time of 18 minutes (range, 3 minutes to 9 hours). Ninety percent of children with febrile seizures recovered within 1 hour. The 25 seizures in children with preexisting central nervous system (CNS) disorders (remote symptomatic) lasted a median of 8 minutes, with a median recovery time of 1.25 hours. The 19 idiopathic seizures lasted a median of 5 minutes with a median recovery time of 1.35 hours. The 7 seizures occurring after acute CNS insult (acute symptomatic) lasted 0.3 to 8 minutes, with a median recovery time of 4.57 hours. Median recovery time in children treated with antiepileptic rescue drugs was significantly longer than in children who were not (3.46 hours vs. 28 minutes). Seizure duration was not related to recovery time.

Comment

Although this referral population is not typical of a community practice, the results reaffirm the lore that febrile seizures are associated with relatively short recovery times. The authors suggest consideration of other etiologies when a child with an untreated, apparent febrile seizure takes longer than 1 hour to recover. The results also challenge the common belief that the duration of a seizure is related to the degree of postictal impairment.

F. Bruder Stapleton, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 21, 2007

[filled triangle] Allen JE, et al. Recovery of consciousness after epileptic seizures in children. Arch Dis Child 2007;92:39–42.

Hearing loss detected at newborn screening may well warrant genetic testing

When a hearing problem is identified during infant screening, most families will benefit from genetic evaluation.

Of the approximately 1 in 500 newborns with hearing loss, about half the cases are thought to have a genetic basis. The large number of genes and specific syndromes associated with congenital hearing loss often require special testing to make a specific diagnosis. Most congenital hearing loss is nonsyndromic (isolated, without other anomalies), but about 30% are syndromic (associated with additional congenital anomalies).

Investigators at a specialized genetics of hearing loss clinic screened 500 children who were referred for testing for genetic forms of hearing loss (76% bilateral, 24% unilateral). GJB2 (which encodes the connexin protein) mutational analysis, clinical examination, family history, and laboratory testing (including renal and thyroid evaluations, EKG, CT scan, ophthalmologic examination, and other genetic testing) led to a specific diagnosis in 22% of the patients. Overall, 14% of infants had a syndromic etiology (28 different syndromes), and 8% had GJB2 mutations (which included 19 variants of the GJB2 gene).

Comment

When a hearing problem is identified with infant screening, families need a variety of referrals and support. Most families will benefit from genetic evaluation. Because of major advances in the diagnosis of congenital types of hearing loss, a specific diagnosis often can be made, allowing families to know the recurrence risk, to identify carriers, and to learn about the natural history of the specific disorder.

Pediatricians need to remember that cytomegalovirus (CMV) is another important cause of newborn hearing loss and should be considered early, as this pathogen is best tested during the newborn period (i.e., a urine culture for CMV during the first 3 weeks). In this study, a specific diagnosis was made in fewer than 50% of cases referred to the genetic hearing loss clinic. This probably reflects the fact that obvious genetic cases (positive family history, presence of other congenital anomalies, etc.) were referred to the general genetics clinic.

Judith G. Hall, OC, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 21, 2007

[filled triangle] Yaeger D, et al. Outcomes of clinical examination and genetic testing of 500 individuals with hearing loss evaluated through a genetics of hearing loss clinic. Am J Med Genet A 2006;140:827–36.

Treatment of Kawasaki disease

These data do not support adding IV steroids to routine treatment.

Intravenous immune globulin (IVIG) plus aspirin reduces the risk for coronary artery disease in patients with uncomplicated, acute Kawasaki disease (KD). The use of steroids in patients with complicated disease has led to speculation that steroids should become part of routine therapy. In a U.S. multisite, double‐blind, clinical trial, researchers randomized 199 patients with KD and fever for [less-than-or-eq, slant]10 days to receive a single pulsed dose of IV methylprednisolone (30 mg/kg) or placebo added to conventional therapy with IVIG (2 g/kg) and aspirin (80–100 mg/kg/day).

At week 1 and week 5, no differences were noted between groups in any measure of coronary disease, including changes in dimensions of the left anterior descending and right coronary arteries. However, compared with placebo recipients, patients who received IV steroids had shorter periods of initial hospitalization and a lower median erythrocyte sedimentation rate at week 1 (69 vs. 57 mm/hr). The total number of hospital days (including readmissions), days of fever, patients requiring retreatment with IVIG, and adverse events was similar in both groups.

Comment

As noted by the authors and an editorialist, these data do not support the addition of a single dose of IV steroids for primary treatment of uncomplicated KD. However, the duration of follow‐up was short. Steroids possibly might further prevent the long‐term development of coronary artery disease, but because IVIG reduces the rate of coronary‐artery aneurysms detectable by echocardiography to between 3% and 5%, a much larger study would be needed to detect any additional benefit from steroids. In contrast with the results of this study, a randomized study of Japanese children with KD reported improved outcomes using a different IVIG and steroid regimen.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 14, 2007

[filled triangle] Newburger JW, et al. Randomized trial of pulsed corticosteroid therapy for primary treatment of Kawasaki disease. N Engl J Med 2007;356:663–75.

[filled triangle] Burns JC. The riddle of Kawasaki disease. N Engl J Med 2007;356:659–61.


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