Tehran University Medical Journal

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Background: The use of synchronized intermittent mandatory ventilation (SIMV) and pressure support ventilation (PSV) have been used for older children and adults. The purpose of this study was to compare PSV and SIMV modes in weaning from mechanical ventilation in neonate with respiratory failure.

Methods: A randomized clinical trial study carried out in NICU ward of Valiasr hospital Imam Khomeini Hospital complex, Tehran, Iran. Thirty neonates enrolled in two groups of 15. At the weaning time they randomly assigned to SIMV or PSV. They compared for tidal volume (V_T), peak inspiratory pressure (PIP), incidence of pneumothorax, weaning failure and duration of weaning. For two groups to be homogeneous, maternal disease during pregnancy were also considered.

Results: In this study, V_T, PIP, incidence of pneumothorax and weaning failure did not differ between groups duration of ventilation of the two methods (hours) and duration of hospitalization (days) were separately calculated. The only meaningful difference in two groups were due to weaning duration. The neonates weaned by PSV mode experienced shorter weaning time. (6.05 hours). The weaning time in SIMV mode was longer (45 hours) (P=0.006). There were no other meaningful differences between the two groups

Conclusions: According to the results of this study there were no advantage using PSV over SIMV except that the weaning time were shorter in PSV. This decrease in weaning time causes less dependence of the neonate to the ventilator and as a result secure them from complications.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Low-birth-weight (LBW) children are at higher risk for failure to thrive. The aim of the study was to establish the trend of physical growth in Until now their growth was evaluated with normal birth weight baby's chart.
Methods: In this cohort study we investigated demographic characteristics and growth trend during the first of life 406 newborn divided into three groups: LBW (Low Birth Weight) n=103, VlBW (Very Low Birth Weight) n=20 and NBW (Normal Birth Weight) n=303. Body weight, length and head circumference were measured at the time of birth and several follow ups until 12 months of chronological age.
Results: NBW growth trend adopts the standard chart. Significant differences in terms of physical growth (weight- height- head circumference) were seen between the two groups of preterm (LBW & VLBW) and NBW children. Although it was demonstrated that growth velocity of preterm & NBW children were the same. Significant differences for weight was seen between VLBW and LBW group only until 6 months after birth. This difference was seen for height and Head circumference until the end of the first year of life.
Conclusions: VLBW and LBW babies need special growth charts. But the adjustment method of anthropometric traits to gestational age may be useful to evaluate LBW baby's growth.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: American pediatric Association proposes to screen all neonates with Oto-Acoustic Emission (OAE). In developing countries, because of several limitations, health policy makers recommend to screen only in high risk patients. This study is performed with the aim to screen hearing loss in 950 high risk newborns hospitalized in hospitals affiliated to Tehran University using the OAE test.
Methods: A total of 950 neonates hospitalized in the Neonatal and NICU wards of Vali-e-Asr, Shariati, Medical Center and Bahrami Hospitals during the years 2004-2006 who showed at least one risk factor using TEOAE hearing test were enrolled into this cross-sectional descriptive analytical study and were diagnosed with mild deafness and total deafness. Blood exchange due to hyperbillirubinemia, septicemia, congenital heart disease, the fifth minute apgar scores below six, PROM more than six hours, epilepsia, need to NICU more than five hours, pneumonia and Oto-Toxic drugs were considered as risk factors. Data was past medical history, current disease, admission cause, sign & symptoms and complications of disease.
Results: Multivariate logistic regression and paired t-test showed that blood exchange, low birth weight and low first minute Apgar scores had the highest independent risk for hearing loss among newborn.
Conclusion: Despite of the low prevalence of neonatal hearing loss, screening of hearing loss at early stages is important.

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Background: Hypothermia is an important determinant of survival in newborns, especially among low-birth-weight ones. Prolonged hypothermia leads to edema, generalized hemorrhage, jaundice and ultimately death. This study was undertaken to examine the factors affecting transition from hypothermic state in neonates.
Methods:  The study consisted of 439 neonates hospitalized in NICU of Valiasr in Tehran, Iran in 2005. The neonates' rectal temperature was measured immediately after birth and every 30 minutes afterwards, until neonates passed hypothermia stages. In order to estimate the rate of transition from neonatal hypothermic state, we used multi-state Markov models with two covariates, birth weight and environmental temperature. We also used R package to fit the model.
Results:  Estimated transition rates from severe hypothermia and mild hypothermia were 0.1192 and 0.0549 per minute, respectively. Weight had a significant effect on transition from hypothermia to normal condition (95% CI: 0.1364-0.4165, P<0.001). Environmental temperature significantly affected the transition from hypothermia to normal stage (95% CI: 0.0439-0.4963, P<0.001).
Conclusion:  The results of this study showed that neonates with normal weight and neonates in an environmental temperature greater than 28 °C had a higher transition rate from hypothermia stages. Since birth weight at the time of delivery is not under the control of medical staff, keeping the environmental temperature in an optimum level could help neonates to pass through the hypothermiastages faster.

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Background: Patent ductus arteriosus (PDA) is a common finding among premature or low-birth-weight infants and it often does not close. Nowadays, drugs used for its treatment include indomethacin and more commonly ibuprofen. Oral ibuprofen was recently shown to be as effective and have several important advantages in preterm infants. Studies performed to find the best dose of ibuprofen for PDA treatment are limited hence, we compared the effects of two different doses of ibuprofen in this interventional study.
Methods: In this randomized controlled clinical trial, we randomly divided 60 patients with echocardiographically confirmed PDA into two groups of 30. This study was done in NICU of Valiasr hospital in 1387-89 years. In the first group, we administered a loading dose of 10 mg/kg ibuprofen on the first day, followed by two doses of 5 mg/kg in the next two days. In the second group, we administered a loading dose of 15 mg/kg ibuprofen on the first day followed by two doses of 7.5 mg/kg in next two days. Eventually, we compared PDA closure rates and complications of therapy between the two groups.
Results: Thirty (100%) patients in 15-mg/kg group and 23 (76.7%) patients in 10 mg/kg group had successful PDA closure with no need for surgery. The two groups had a statistically significant difference (P=0.011) and the highest response to treatment was seen within the first 24 hours of treatment.
Conclusion: We may conclude that higher doses of ibuprofen (15 and 2×7.5 mg/kg) would offer better outcomes for PDA closure without gastrointestinal or renal complications and less need for surgery.

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Background: Ventilator Associated Pneumonia (VAP), developing in mechanically ventilated patients after 48 hours of mechanical ventilation, is the second most common nosocomial infection. Therefore, there is a vital need to study the etiology and risk factors associated with VAP in neonates.
Methods: Neonates admitted to neonatal intensive care unit (NICU), over a period of one year and who required mechanical ventilation for more than 48 hours were enrolled consecutively into the study. Semi-quantitative assay of endotracheal aspirate was used for microbiological diagnoses of VAP. 105CFU/ml was taken as the cut off between evidence of pathological infection and colonization. The primary outcome measure was the development of VAP. Secondary outcome measures were length of mechanical ventilation, NICU length of stay, hospital cost, and death.
Results: Thirty eight patients were enrolled (58% were boys and 42% were girls). 42% of neonates developed VAP. The most common VAP organisms identified were Acinetobacter baumanni (43%). On multiple regression analysis, duration of mechanical ventilation was associated with VAP (P=0.00). Patients with VAP had greater need for mechanical ventilation (18.7 vs 6 median days), longer NICU length of stay (39 vs 21.5 median days) and higher total median hospital costs (79.5 vs 52 million rials) than those without VAP. The mortality rate was not different between two groups.
Conclusion: In mechanically ventilated neonates, those with VAP had a prolonged need for mechanical ventilation, a longer NICU stay, and a higher hospital costs. Longer mechanical ventilation was associated with an increased risk of developing VAP in these patients. Developing of VAP didn’t increase mortality in patients.

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Background: Respecting gestational age and medical intervention at birth, Combined Apgar score, a new method proposed by American Academy of Pediatrics (AAP) may better evaluate neonatal condition at birth compared with conventional Apgar score. The combined Apgar consists of the Specified and the Expanded Apgar describe a more detailed condition at birth. In Expanded Apgar, administered intervention and in Specified Apgar, infant`s condition regardelless of gestational age and intervention are emphesised. To evaluate combined Apgar score in perinatal asphyxia, we compared conventional versus Combined Apgar scores to anticipated neonatal asphyxial complications. Methods: In a prospective cohort study, we assessed 464 neonates admitted in, Vali-e-Asr University Hospital, during one year from September 2012 to September 2013. We assessed neonates by Conventional and Combined Apgar scoring at 1, 5 and 10 minutes after birth. Asphyxia was recognized based on newborn`s records. Diagnostic criteria for asphyxia include, occurrence of metabolic or mixed acidosis, apgar score less than three in 5th minute, occurrence of neurological complications like seizure, hypotonia, coma and multiple organ failure. Then we used SPSS V16 for data analysis and compare sensitivity between two methods of Apgar scoring. Results: From 2200 delivered neonates, we assessed 464 neonates. 9.3% of studied neonates had Asphyxia, which equals 2% of live births. The Apgar score was lower in asphyxiated neonates by both methods (6±1 vs. 9±1 according to conventional method and 9±1 vs. 16±1 scored in combined method). Combined method was more sensitive than the Conventional Apgar scoring (99% vs. 88%). Conclusion: In asphyxiated neonates sensitivity and specificity of combined apgar were more than conventional apgar. With respect to this study, better assessment could be achieved by combined apgar score method instead of conventional Apgar.

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Background: The incidence of Patent Ductus Arteriosus (PDA) in premature infants whose birth weight is less than 1500 grams is approximately 30-60%, most of them need medical or surgical interventions. The purpose of this study is to determine the efficacy of prophylactic treatment with oral paracetamol (Acetaminophen- Hakim® Oral Drops 100 mg/ml, Hakim Pharmaceutical Co., Tehran, Iran) for PDA in preterm infants. Methods: A randomized clinical trial conducted from March 2012 to March 2013. Thirty-two preterm newborns whose gestational age was under 32 weeks and birth weight was 1500 grams or less, admitted in neonatal intensive care unit (NICU) of Vali-Asr Hospital, Tehran were studied prospectively. They were randomly assigned in two groups. The prophylaxis group received oral paracetamol for a period of two days starting during first 24 hours of life. No placebo was given to the control group. Echocardiography was performed 24-36 hours after the last given dose in prophylaxis group and on the 4th and 5th day in control group. A p-value less than 0.05 are considered significant. Results: There were 16 newborns in each group (20 boys and 12 girls). In 12 newborns of prophylaxis group the ductus arteriosus was closed although in control group in 8 newborns the duct was closed. No significant difference was observed in sex, gestational age, birth weight, mode of delivery, multifetal gestation and birth order between two groups. The rate of ductal closure was 75% and 50% in prophylaxis group and control group respectively (P=0.27). Conclusion: Our study demonstrated that prophylactic paracetamol is ineffective in PDA closure, although the rate of ductal closure between two groups seems remarkable. Paracetamol as a new strategy for PDA closure because of cost effectiveness and harmlessness may be used in future. However, we presume larger sample size studies are needed to show the efficacy of paracetamol, side effects, and complications in PDA prophylaxis treatment.

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Background: Over the last two decades invasive candidiasis has become an increasing problem in neonatal intensive care units (NICUs). Colonization of skin and mucous membranes with Candida spp. is important factor in the pathogenesis of neonatal infection and several colonized sites are major risk factors evoking higher frequencies of progression to invasive candidiasis. The aim of this study was to detect Candida colonization in NICU patients.

Methods: This cross-sectional study was conducted on 93 neonates in NICUs at Imam Khomeini and Children Medical Center Hospitals in Tehran. Cutaneous and mucous membrane samples obtained at first, third, and seventh days of patients’ stay in NICUs during nine months from August 2013 to May 2014. The samples were primarily cultured on CHROMagar Candida medium. The cultured media were incubated at 35°C for 48h and evaluated based on colony color produced on CHROMagar Candida. In addition, isolated colonies were cultured on Corn Meal Agar medium supplemented with tween 80 for identification of Candida spp. based on their morphology. Finally, polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was performed for definite identification of isolated species.

Results: Colonization by Candida spp. was occurred in 20.43% of neonates. Fifteen and four patients colonized with one and two different Candida spp., respectively. Isolated Candida spp. identified as; C. parapsilosis (n: 10), C. albicans (n: 7), C. tropicalis (n: 3), C. guilliermondii (n: 2), and C. krusei (n: 1). In present study non-albicans Candia species were dominant (69.56%) and C. parapsilosis was the most frequent isolate (43.47%). Using Fisher's exact test, the correlation between fungal colonization with low birth weight, low gestational age, and duration of hospital stay was found to be statistically significant (P=0.003).

Conclusion: The results of this study imply to the candida species colonization of neonates. Neonates in NICU are at the highest risk for severe infection with Candida parapsilosis. Therefore, isolation of C. parapsilosis as the most common species (43.47%) in present study was noteworthy.

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Background: In fact, there is no doubt that medical education should be to prepare students for those clinical problems that they may encounter in their future performance. But according to the findings of previous studies in this area, one of the important priority and basic needs in education is training health workers, including physicians. Methods: In this qualitative study focuses on the content analysis of typical (conventional content analysis) was performed. The aim of this study was to determine the needs and skills required to train neonatal subspecialists in the ability to manage vulnerable neonates problems and their families specialized in the field of comprehensive health care have driven. Based on purposive sampling, the research participants, staff and alumni of the second year and above the five-year sub-specialty in neonatology, formed by the association of neonatal diseases were chosen. Saturation as a termination criterion was applied to the collected data. Method of data collection was semi-structured interviews and focus group discussions. Reliability means the adequacy and accuracy that was measured by four methodological criteria: credibility, confirmability, transferability and dependability. All phases of study were recorded elaborately and the researchers reported all findings in the same speech research participants. Results: Respondents consider themselves some week points in neonatal medicine education; they expressed their opinions in three categories with four subcategories as follow: "competent person knowledgeable", "weakness of the curriculum", "educational challenges", "need to review the curriculum", "the need to reform medical education system in the country", and "effective strategies for teaching". Conclusion: Editing curriculum to teach coherent and comprehensive clinical skills in one hand, social support and health care for vulnerable children and families in other hand will improve care for vulnerable neonates.

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Background: Human breast milk contains high levels of fat and toxins. These substances which exist in our country based on many reports. This study aimed to evaluate the concentration of polychlorinated biphenyls (PCBs) in the mother’s milk during the first postnatal week. Methods: This study was accomplished on 50 mothers who gave birth to a healthy infant at Vali-e-Asr University Hospital, Tehran University of Medical Sciences, Tehran, Iran, from 2014 through 2015. Within the first postnatal week a 20 cc sample of mother’s breast milk was obtained and was sent for laboratory analysis to measure PCB levels via GC-Mass method. Except of PCBs, triglycerides (TG), high-density cholesterol in breast milk was also measured. Also the relation between fat and polychlorinated bi phenyl was assessed. The association between PCBs and body mass index of mothers was investigated. Results: Mean age of mothers was 29.41±6.14 year. PCB180 was significantly correlated with TG values, while this correlation was not observed for other types of PCBs. There was no correlation between cholesterol and fat high-density with PCBs. Other PCB isomers 138, 153, 180 and 101, had not correlation with triglyceride, cholesterol and high density fat. There was a significant correlation between increasing weight and the concentration of PCB101, and PCB180 concentrations. It was also observed between increasing weight and the concentration of PCB101 (P=0.033, r=0.293) and concentrations of PCB180 (P=0.034, r=0.428), there was a significant correlation. In our study PCB101, (r=0.278, P=0.048) and PCb28 (r=0.328, P=0.021) were significantly correlated with body mass index (BMI).

Conclusion: The present study showed a higher than normal concentration of polychlorinated biphenyls in breast milk. And therefore these compounds will be transferred to the baby. Due to the damaging effects of these toxins, it is recommended additional studies on larger groups and other types of samples (mother blood, cord blood etc.).