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ABO incompatibility has emerged as the premier reason for hemolytic disease of the fetus and newborn (HDFN). It always occurs in the offspring of blood group O mother. We present a rare case that the fetus of group A got HDFN caused by the anti-group A immunoglobulin G from a group B mother. The direct Coombs test of the fetus blood was negative, but the indirect Coombs test on A1 standard blood cells was strong positive (4+). The acid release test of antibody on the membrane of red blood cells to A1 standard blood cells was also strong positive (4+). Bilirubin of the fetus reached the threshold of exchange transfusion, but she just received 4 days' phototherapy and 2.2 g albumin intravenous injection, with no packed blood cells transfusion, because her family refused, and came to a favorable outcome. This case reminds us not to ignore the possibility of HDFN in offspring of mothers with non-O blood group.

In newborns, both term and preterm, cochlear hearing loss is common due to different pathologies. Currently accepted methods for hearing screening in newborns are otoacoustic emission (OAE) and auditory brainstem responses. Among these two, OAE is quicker, economical and more accessible. In the present study we assessed OAEs in sick newborns, both term and preterm, having different pathological conditions. This descriptive study was conducted over 3 months in sick newborn care unit (SNCU) in a tertiary care hospital. All sick newborns admitted to SNCU in the study period were tested for otoacoustic emission. The results were subjected to the Chi square test (test of independence). Among 640 sick newborns, 184 were preterm; the rest being term newborns. Among the term sick newborns, 4.8% of those with birth asphyxia, 8.6% of those having septicaemia, 25% of those with hyperbilirubinemia needing exchange transfusion, 22.9% of those having meningitis and 33.3% of those with major congenital anomalies, had “refer” on OAE. Among preterm sick newborns, 30.8% of those with birth asphyxia, 32.5% of those having septicaemia, 75% of those with hyperbilirubinemia needing exchange transfusion, 41.7% of those having meningitis, 40% of those with major congenital anomalies and 8.7% of those with no co-morbidity had “refer” on OAE. Upon computing the p value of Chi square test performed on the results, the results were not significant (p = 0.85). Hence we didn’t find any statistically significant difference between term and preterm sick newborns on OAE. The incidence of “refer” result in OAE increases with co-morbidities in both term and preterm sick newborns, somewhat more in preterm newborns. But preterm sick newborns do not seem to have an increased incidence of hearing impairment.

Background and Aim: Neonatal Hyperbilirubinemia (NH) is the most common cause for readmission during the early neonatal period. There are reports of bilirubin induced brain damage occurred in healthy term infants even without haemolysis and the sequalae could be serious. Aim of the study was to predict the development of Neonatal Hyperbilirubinemia at birth using Cord Serum Albumin as a risk indicator.Material and Methods: Observation study was performed on 348 healthy term new-borns. Cord blood was collected from the healthy term new-borns delivered either vaginally or caesarean section for cord serum albumin level measurements. Total serum bilirubin and direct serum bilirubin were measured during 72-96 hours of life with serum sampling of peripheral venous blood. Newburn was assessed clinically daily for Neonatal Hyperbilirubinemia or for any other complication during the study period. Results: Study cohort is grouped into Group1, Group2 and Group 3 based on Cord Serum Albumin level 2.8g/dl, 2.9-3.3g/dl and 3.4g/dl, respectively. In these groups, new-borns with total serum bilirubin level 17mg/dl after 72 hours are taken as Neonatal Hyperbilirubinemia, requiring interventions like phototherapy or exchange transfusion. Conclusion: There is a correlation between Cord serum albumin level and neonatal hyperbilirubinemia in healthy term new-borns. Cord serum albumin level of 2.8 g/dl can predict the development of neonatal hyperbilirubinemia.

Acute liver failure (ALF) and acute on chronic liver failure (ACLF) are associated with significant mortality and morbidity. Extracorporeal liver support (ECLS) devices have been used as a bridge to liver transplant; however, the efficacy and safety of ECLS are unclear. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the efficacy and safety of ECLS in liver failure. We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from inception through March 13, 2019. RCTs comparing ECLS to usual care in ALF or ACLF were included. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence. We identified 25 RCTs (1796 patients). ECLS use was associated with reduction in mortality (RR 0.84; 95% CI 0.74, 0.96, moderate certainty) and improvement in hepatic encephalopathy (HE) (RR 0.71; 95% CI 0.60, 0.84, low certainty) in patients with ALF or ACLF. The effect of ECLS on hypotension (RR 1.46; 95% CI 0.98, 2.2, low certainty), bleeding (RR 1.21; 95% CI 0.88, 1.66, moderate certainty), thrombocytopenia (RR 1.62; 95% CI 1.0, 2.64, very low certainty) and line infection (RR 1.92; 95% CI 0.11, 33.44, low certainty) was uncertain. ECLS may reduce mortality and improve HE in patients with ALF and ACLF. The effect on other outcomes is uncertain. However, the evidence is limited by risk of bias and imprecision, and larger trials are needed to better determine the effect of ECLS on patient-important outcomes.

Patient: Male, newborn Final Diagnosis: Hyperkalemia Symptoms: Respiratory distress • ventricular tachycardia Medication: — Clinical Procedure: Exchange transfusion Specialty: Pediatrics and Neonatology Objective: Unknown ethiology Background: Hyperkalemia is an important cause of arrhythmias and a medical emergency that requires urgent treatment. The etiology is usually multifactorial. It is most frequently caused by impaired potassium secretion, followed by transcellular potassium shifts and an increased potassium load. Case Report: A male newborn developed monomorphic ventricular tachycardia 2 hours after birth. He was born in the 35th week of gestation by urgent C-section following placental abruption. Laboratory results showed hemolytic anemia (Hb 99 g/L, Hct 0.31) with increased bilirubin levels and reticulocytosis, thrombocytopenia (39×109/L), hypoglycemia (0.8 mmol/L), and severe hyperkalemia (9.8 mmol/L). Umbilical artery blood gas analysis showed hypoxemia with acidosis (pO2 3.8 kPa, pH 7.21, pCO2 7.84 kPa, HCO3 23.3 mmol/L, BE –5 mmol/L). Creatinine (102 µmol/L) and urea (9.8 mmol/L) were mildly elevated. Inflammatory markers were also increased (CRP 26 mg/L, blood leukocyte count 24×109/L). Early-onset sepsis, caused by Candida albicans, was confirmed approximately 24 hours after birth. Non-invasive ventilation with 35–40% O2 was necessary due to transient tachypnea. The neonate received a transfusion of packed red blood cells, a 10% glucose infusion, and empirical antibiotic therapy. Hyperkalemia accompanied by arrhythmias was treated with calcium gluconate, insulin, Sorbisterit enema, and, finally, by exchange transfusion. Conclusions: We report a case of severe hyperkalemia in a newborn immediately after birth. Making a decision as early as possible regarding exchange transfusion is essential in patients with hyperkalemia with electrocardiogram changes and hemodynamic instability.

Background: Blood exchange transfusion (ET) involves replacement of affected neonate’s blood with compatible donor blood. Although the use of ET has decreased over years, it still remains a popular emergency rescue procedure for newborns with severe jaundice. Objective: The study was done to describe the indications and complications associated with ET in a 20 bedded neonatal unit of a tertiary care center in North India. Materials and Methods: This was a retrospective observational cohort study of neonates who underwent ET from July 2014 to May 2019. Demographic profile, indications and etiology, details of ET procedure, and related adverse events were noted from medical records and chart review. Results: Of 2310 admitted neonates, 77 (3.3%) underwent 103 ETs during the study period with an average rate of 23.3 ETs per year. Hyperbilirubinemia was the most common indication for ET in 53 (68.8%) neonates. Rhesus (Rh) hemolytic disease was the single most frequent etiology for hyperbilirubinemia seen in 43 (55.8%) neonates. A total of 77 adverse events related to ET were seen in 53 (68.8%) neonates whereas 17 (22%) had more than one adverse event. The most common complication was thrombocytopenia in 40 (51.9%) neonates. Overall, mortality was 7 (9.1%); none were attributable to ET. Conclusion: The study identifies Rh hemolytic disease of newborn as the most common etiology leading to ET in newborns. Although ET is a relatively safe procedure, the high incidence of adverse events suggests vigilant monitoring and in-depth expertise for performing and managing complications of the procedure.

Objective To study the contribution of blood transfusion management in the improvement of maternal and perinatal outcomes in pregnant women with sickle cell disease in Ouagadougou. Methods A cross-sectional retrospective study with data collected from February 2012 to January 2014 was used. Patients were differentiated into three groups: patients with at least one exchange transfusion, patients who received blood transfusion, and patients who did not receive any transfusion. Data were collected from patients' patient care documents. Results One hundred and sixty-four patients were included, of whom 53 were in the first group, 32 in the second group, and 79 in the third group. Maternal complications in the last trimester of pregnancy were significantly less important (P=0.000) in the first group (58.5%) than in the second (78.5%) and third group (91.1%). The same trend was observed for postpartum maternal mortality (5.7%; 12.5%; 12.6%; P=0.009). Fetal complications such as preterm birth and early neonatal death were lower in the first group (15.1%; 1.8%) than in the second (40.6%; 23.1%) and third group (32.9%; 7.6%). Conclusion Prophylactic blood transfusion is an important part of the management of pregnant patients with sickle cell disease.

Objective This study aimed to investigate the effect of delayed cord clamping (DCC) in infants of diabetic mothers.Study Design Women who had diabetes throughout their pregnancy and gave birth at 37 weeks of gestation or later were included in the study along with their babies. Early cord clamping was performed as soon as possible after birth, while DCC was performed by clamping 60 second after birth. The two groups were compared in terms of venous hematocrit (htc) levels and rates of hypoglycemia, jaundice requiring phototherapy, and respiratory distress.Results Venous htc levels at postnatal 6 and 24 hours were significantly higher in the DCC group (p = 0.0001). Polycythemia rates were higher in the DCC group at both 6 and 24 hours, but partial exchange transfusion (PET) was not needed in either group. There were no differences between the groups with regard to the rates of hypoglycemia or jaundice requiring phototherapy. Rate of admission to the neonatal intensive care unit (NICU) was lower in the DCC group.Conclusion Although DCC increased the rate of polycythemia, it did not result in PET requirement. Moreover, DCC reduced the severity of respiratory distress and the rate of admission to NICU due to respiratory distress.

The rare blood phenotype D-- is characterized by the absence of RhCcEe antigens. Women with this blood type who have experienced previous pregnancies may produce anti-Rh17 antibodies, which may cause severe fetal hemolytic anemia or fetal death in subsequent pregnancies. We report successful management of a pregnancy associated with fetal hemolytic disease owing to high titers of anti-Rh17 (1:4096) in a woman with a history of a pregnancy with fetal hydrops and intrauterine fetal death. During her second pregnancy, she received two sets of plasma exchange (PE) per week from weeks 12 till 20. Intrauterine transfusions (IUTs) were performed at 26, 27, 29, and 31 weeks. A male infant was born at 32 weeks and 4 days by normal vaginal delivery, with a birth weight of 1916 g (+ 0.16 SD). He received an exchange transfusion on day 0, immunoglobulin (intravenous immunoglobulin: 1 g/kg) on days 0 and 1, and photo therapy from days 0 to 6. He showed normal development without neurological abnormality and was discharged from the hospital on day 36. We successfully prevented complications caused by the presence of anti-Rh17 antibodies in the mother during pregnancy. The IUT and maternal PE may have promoted this favorable outcome.

Background Mta (MNS14) is a low-prevalence antigen of the MNS system. A few cases of hemolytic disease of the fetus and newborn caused by anti-Mta have been reported in the literature, but up to now this antibody has never been associated with a hemolytic transfusion reaction (HTR). Case report A 38-year-old male with sickle cell disease undergoing exchange transfusion presented with shivering, nausea, dyspnea, and pain in the lower limbs. Biologic parameters showed increased hemolysis. The administered red blood cell (RBC) units had been issued by electronic crossmatch due to a negative antibody screening test. In the posttransfusion investigations, crossmatch of the transfused RBC units with the patient's serum showed incompatibility of one unit. The presence of an antibody against a low-prevalence antigen was suspected and further serologic testing was performed for identification. Results Anti-Mta was identified in the patient's serum. The RBCs of the incompatible unit implicated in the HTR were Mt(a+). An eluate of a posttransfusion blood sample of the patient was nonreactive with the incompatible RBCs, and the direct antiglobulin test was negative. Conclusion To our knowledge, this is the first case report of an HTR associated with anti-Mta .

Background: Advances in prenatal and postnatal care of neonates with rhesus hemolytic disease of the newborn (RHDN) have led to improved outcomes. Studies evaluating the postnatal outcomes in rhesus (Rh) isoimmunized infants from developing countries are limited. Objective: The objective of this study was to evaluate the postnatal outcomes of neonates ?32 weeks gestation with RHDN. Methods: A prospective observational study was conducted from July 2014 to June 2016 in a tertiary care neonatal unit in North India. Neonates affected by RHDN were managed as per the standard protocol and were followed up for the first 6 months of life. Primary outcomes were the duration of phototherapy (PT), need for exchange transfusion (ET), occurrence of late-onset anemia, and need for top-up transfusions. Results: A total of 33 newborns with RHDN were included in the study. Median duration of PT was 138 h (interquartile range 64–188) and was inversely correlated with intrauterine transfusion number (Spearman correlation coefficient ?0.46; p=0.02). Of 33 neonates with RHDN, 14 (42.4%) neonates required ET. Late-onset anemia was seen in 25 (75.7%) neonates and 17 (51.5%) required at least one top-up transfusion. Cholestasis was seen in 5 (15.1%) neonates. Conclusions: Despite advances in care, short-term morbidities in neonates affected by RHDN are common and require intensive management.

Background Red blood cell exchange (RCE) transfusions are a mainstay in the treatment of sickle cell anemia (SCA), and allow a temporary restoration of physiological parameters with respect to erythrocyte oxygen carrying capacity and systems metabolism. Recently, we noted that 1) RCE significantly impacts recipients' metabolism in SCA; 2) fresh and end-of-storage red blood cell (RBC) units differently impact systems of metabolism in healthy autologous recipients; and 3) phosphate/inosine/pyruvate/adenine (PIPA) solution reverses the metabolic age of stored RBCs. Therefore, we hypothesized that RCE with PIPA-treated RBC units could further increase the metabolic benefits of RCE in SCA patients. Study design and methods Circulating plasma and erythrocytes were collected from patients with SCA before and after RCE, with either conventional or PIPA-treated RBC units, prior to metabolomics analyses. Results Consistent with prior work, RCE significantly decreased circulating levels of markers of systemic hypoxemia (lactate, succinate) and decreased plasma levels of acyl-carnitines and amino acids. However, PIPA-treated exchanges were superior to untreated RCEs, with a higher energy state and an increased capacity to activate the pentose phosphate pathway and glutamine metabolism. In addition, RBCs and plasma from recipients of PIPA-treated RBC units resulted in significantly decreased levels of post-transfusion plasticizers, though at the expense of higher circulating levels of oxidized purines (hypoxanthine, xanthine, and the antioxidant urate). Conclusion Transfusion of PIPA-treated RBCs further increases the metabolic benefits of RCE to patients with SCA, significantly reducing the levels of post-transfusion plasticizers.

To explore the effects of exchange transfusion on auditory neuropathy spectrum disorder (ANSD) in neonates with severe hyperbilirubinemia (SH).The clinical data of 2216 SH neonates who met the standard of exchange transfusion and 732 non severe-hyperbilirubinemia (NSH) neonates in the same period who did not require exchange transfusion in the neonatology department of Childrens' Hospital of Chongqing Medical University between January 2010 and December 2015 were retrospectively analyzed. In addition, the SH neonates were further divided into the exchange transfusion group and photography group. Hearing screening was conducted on all neonates using transiently evoked otoacoustic emission (TEOAE) and auto auditory brainstem response (AABR), and neonates who failed the above screening were performed diagnostic hearing test. And then neonates diagnosed with hearing disorder were followed up for 2-5 years.The pass rates of hearing screening were 80.58%, 79.71% and 87.84% in the phototherapy group, exchange transfusion group and NSH group respectively, with a significant difference(P 0.05). Hearing loss was diagnosed in 10.15%, 12.39% and 8.54% of neonates in the phototherapy group, exchange transfusion group and NSH group. After follow-up, ultimate incidence rates of ANSD were 11.96%, 11.57% and 2.4% respectively in the 3 groups, with a significant difference (P 0.05).SH is one of risk factors for ANSD. SH neonates have a lower incidence of ANSD in the exchange transfusion group than in the phototherapy group. Neonates who meet the standards of exchange transfusion adopt this therapy in early stage, which can quickly decrease bilirubin level and ultimately reduce incidence of ANSD.

BACKGROUND Nitrous oxide (N O) is an inhalational medication that has anxiolytic, amnestic, potent venodilatory and mild-to-moderate analgesic properties commonly used in the emergency department (ED) setting. N2 O has a rapid onset of action (

Aims: We investigated the relationship between total serum bilirubin (TSB) and carboxyhemoglobin (COHb) in term neonates with detected and treated hemolysis within a particular time frame with the aim of augmenting the case for early diagnosis and prevention of morbidity in hemolysis. Materials and Methods: The study group comprised term newborns who were above the 95th percentile for TSB, underwent intravenous immunoglobulin (IVIG) or applied total exchange transfusion due to hemolysis. Newborns without hemolysis who were above the 95th TSB percentile and required phototherapy comprised the control group. Results: At a cutoff COHb value of 2.2%, 80.8% sensitivity, 95.5% specificity, 18.1 likelihood ratio, positive predictive value of 94.7%, and negative predictive value of 83.2% were identified. Conclusion: We found that COHb is a sensitive and specific method for detecting hemolysis, and it can be used in the early diagnosis of hemolytic diseases causing early and severe hyperbilirubinemia.

Introduction A blood exchange transfusion (BET) is most commonly performed to treat severe neonatal haemolytic disease. A distinct form of blood transfusion adverse reaction is transfusion-related immunomodulation. The purpose of our retrospective single-centre case-control cohort study was to investigate whether a blood exchange transfusion in the neonatal period provokes immunomodulation and affects humoral immune response to vaccination, morbidity and occurrence of autoantibodies. Methods Study subjects were 74 apparently healthy children, who were born at term as appropriate for gestational age and received four doses of diphtheria and tetanus toxoid vaccine. Forty-one received BET due to neonatal hemolytic disease and no other blood product afterwards, while 33 did not receive any blood products. Analysis of diphtheria, tetanus and autoimmune antibodies was performed and their medical records were analyzed for infectious, allergic, cancerous and autoimmune diseases. Results A clearly exaggerated immune response to diphtheria (1.016 IU/mL, 95% confidence interval (CI) 0.662–1.369 IU/mL vs. 0.515 IU/mL, 95% CI 0.363 to 0.626 IU/mL, P = 0.011) and slightly exaggerated immune response to tetanus vaccine (1.798 IU/mL, 95% CI 1.180–2.416 IU/mL vs. 1.036 IU/mL, 95% CI 0.398–1.673 IU/mL, P = non-specific) were observed in BET subjects. A propensity towards autoimmunity (25.8% vs. 12.5%, P = non-specific) was observed in BET subjects. However, BET in the neonatal period did not influence the occurrence of bacterial, childhood viral diseases with exception of varicella (43.9% vs. 21.2%, P = 0.040), autoimmune and cancer diseases. Conclusion BET impacted humoral immune response to diphtheria and tetanus vaccine and occurrence of autoimmune antibodies, but did not affect morbidity and the occurrence of autoimmune diseases. These effects could be related to massive antigenic load of BET and an accelerated priming of immune cells and consequent immunomodulation.

BACKGROUND We report a case of a premature newborn girl with a hospital course complicated by suspected respiratory syncytial virus pneumonitis for which she was placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Despite phototherapy, her total bilirubin steadily increased to a peak of 50.4 mg/dL with concern for bilirubin-induced neurologic dysfunction, kernicterus. STUDY DESIGN AND METHODS Therapeutic plasma exchange (TPE) was achieved via connection with the VA-ECMO circuit. Our institution's standard apheresis procedural parameters were adjusted to account for the small body weight and thus the low blood volume of the neonate while on ECMO. These included calculating the total blood volume to include the patient as well as the ECMO circuit, priming of the apheresis instrument with packed red blood cells to limit the extracorporeal volume, using a lower inlet flow rate, the connection setup of the inlet and return line, and monitoring of ionized calcium and anticoagulation throughout the procedure. RESULTS A total of three TPE procedures were performed over three consecutive days. This resulted in improvement and stabilization of the patient's bilirubin. CONCLUSION This case emphasizes that TPE is feasible on a neonate with a suboptimal body weight and thus a low blood volume due to the increased blood volume provided while on ECMO. In the absence of ECMO, whole blood manual exchange transfusion is recommended as TPE would be unsafe due to significant extracorporeal volume that would occur during TPE in a pediatric patient with low body weight.

Ethnopharmacological relevance Cotoneaster nummularioides Pojark manna (Shir-e-Khesht) is popular in Persian medicine. Different effects of some Cotoneaster species manna include antibacterial, antioxidant, anticancer, and hepatoprotective effects, as well as bilirubin serum levels reduction. Cotoneaster species manna is used in many parts of Iran as a laxative and accelerates the passage of meconium. Neonatal jaundice has relatively costly and sometimes invasive therapeutic interventions, which its prevention from becoming severe cases can be a priority in neonatal medicine. Aim of the study The aim of this study was to evaluate the effectiveness of an herbal product (Purgative Manna, native to Iran and Asian countries) in preventing severe cases of jaundice and reducing total bilirubin levels in neonates. Materials and methods This randomized double-blind controlled clinical trial included full-term babies. Four hundred and forty-five (445) eligible neonates were assigned to two groups using the block balanced randomization method; 222 neonates received the Purgative Manna product as drops, and 223 neonates received placebo drops. The neonates received a dose of 5 drops per kilogram of neonatal weight (divided into three doses per day) for three days. The treatment period was three days, and a 24-h (three times) examination was performed to measure the initial outcome of the trial (i.e., the total serum bilirubin level). The secondary outcomes of this trial were the need for hospitalization due to jaundice and/or phototherapy from 4 to 14 days after birth, the frequency of defecation within 24 h, and the triple complications of diarrhoea, dehydration symptoms, and abdominal colic. Results In this study, 220 neonates in the Purgative Manna product group and 222 neonates in the placebo group completed their interventions within the predicted period of the study. At the end of study, the total bilirubin level in the Purgative Manna treated group was significantly lower than that of the placebo group. The difference between the mean total bilirubin levels of the two groups was approximately 2.1 mg/dl on the third day after treatment, with an effect size of 0.79 (95% CI: 0.06–0.98). The relative risk for reducing the need for hospitalization or phototherapy in the group treated with Purgative Manna drops was 0.26, compared with the placebo group. The risk of occurrence of severe jaundice or phototherapy in the Purgative Manna group was 75% lower than that of the placebo group. The median frequency of defecation in the intervention group at three time intervals in the first, second and third days after treatment was 1–2 times more than that of the comparison group (p Conclusions Meanwhile, considering the fact that one in every eight neonates who used the product avoided having a severe and high-risk case of jaundice or the need for phototherapy intervention (even through an exchange transfusion), the use of Purgative Manna drops can be recommended; however, further study is necessary.

Background Children who develop malaria after returning to a setting in which the disease is not endemic are at high risk for critical delays in diagnosis and initiation of antimalarial therapy. We assessed the clinical impact of the implementation of malaria rapid diagnostic testing (RDT) on the management of children with malaria at an urban US children’s hospital that serves a large immigrant population. Methods This was a retrospective cohort study of all children diagnosed with laboratory-confirmed malaria at the Children’s Hospital of Philadelphia (CHOP) between 2000 and 2014. RDT using a US Food and Drug Administration–approved immunochromatographic assay was introduced at CHOP on August 1, 2007. We compared clinical management and outcomes of patients with malaria diagnosed before and after RDT introduction. Results We analyzed 82 pediatric malaria cases (32 before and 50 after RDT implementation). The majority of these patients had traveled to West Africa (91.5%) and were infected with Plasmodium falciparum (80.5%). The mean time to a positive result decreased from 10.4 to 0.9 hours (P < .001) after the introduction of RDT for patients with P falciparum. The mean time to antimalarial therapy decreased from 13.1 to 6.9 hours (P =; .023) in hospitalized patients. We found no significant reduction in the mean number of clinical signs of severe malaria between 0 and 48 hours of hospitalization and no difference in the need for exchange transfusion, time to resolution of parasitemia, or length of hospital stay. Conclusions Implementation of RDT for malaria was associated with shorter times to malaria diagnosis and initiation of antimalarial therapy. The results of this study support RDT in the optimal management of patients with malaria who present in settings in which the disease is not endemic.

Most cases of transient abnormal myelopoiesis (TAM) in neonates with Down syndrome (DS) resolve spontaneously; however, DS-TAM neonates with hydrops fetalis (HF) show poor clinical outcomes. We report three infants with DS-TAM and HF who were treated with exchange transfusion (ET) followed by low-dose cytarabine (LD-CA). All of them survived without developing liver failure, acute leukemia, or other serious adverse events. Our results suggest that this combination treatment with ET and LD-CA would be safe, tolerable and effective as an novel approach for DS-TAM patients with HF.

OBJECTIVES: Newborns hospitalized with unconjugated hyperbilirubinemia without critical comorbidities may receive intensive phototherapy (IP) in non-ICU levels of care, such as a mother-newborn unit, or ICU levels of care. Our aim was to compare outcomes between each level. METHODS: Using hospital discharge data from 2005 to 2011 in New York’s State Inpatient Database, we performed multivariate analyses to compare outcomes that included total cost of hospitalization, length of stay, 30-day readmission rate after IP, and the number of cases of death, exchange transfusion, and γ globulin infusion. We included term newborns treated with IP in their first 30 days of life and without diagnosis codes for other critical illnesses. Explanatory variables included level of care, sex, race, insurance type, presence or absence of hemolysis, hospital, volume of IP performed at each hospital, and year of hospitalization. RESULTS: Ninety-nine percent of IP was delivered in non-ICU levels of care. Incidence of major complications was rare (≤0.1%). After adjusting for confounders, ICU level of care was not associated with difference in length of stay (relative risk: 1.2; 95% confidence interval [CI]: 0.91 to 1.15) or 30-day readmission rate (odds ratio: 0.74; 95% CI: 0.50 to 1.09) but was associated with 1.51 (95% CI: 1.47 to 1.56) times higher costs. CONCLUSIONS: For otherwise healthy term newborns with jaundice requiring IP, most received treatment in a non-ICU level of care, and those in intensive care had no difference in outcomes but incurred higher costs. IP guideline authors may want to be more prescriptive about IP level of care to improve value.

Background: Isoimmune hemolytic disease is a major cause of neonatal severe indirect hyperbilirubinemia that requires phototherapy or exchange transfusion which is an invasive procedure to avoid brain injury. Administration of intravenous immunoglobulin (IVIG) is used as an adjunct treatment to phototherapy in order to decrease the rate of exchange transfusion. Methods: This retrospective case-control study aimed to describe the safety and efficacy of IVIG therapy in newborns with isoimmune hemolytic disease and to compare their clinical outcomes to those of a control group who were treated only with phototherapy. Criteria for IVIG treatment were variable; when phototherapy threshold was reached or when exchange transfusion level was approached, using either indication is based on the attending discretion. Results: Ninety-four infants were included in the IVIG group, compared to 108 infants in the control group. Most of the included infants were term infants and most common cause was ABO incompatibility. There were no side effects documented in all the included infants. The IVIG group had more severe hemolysis with average highest bilirubin of 14.6 ± 3.7 mg/dL in the IVIG group versus 12.6 ± 3 in the control group (P = 0.0001). Complication of hemolysis was seen more in the IVIG group with higher rate of rebound hyperbilirubinemia, blood transfusion and exchange transfusion. Conclusions: IVIG use as an adjunct treatment to phototherapy in isoimmune hemolytic disease of the newborns is safe. The favorable results of the phototherapy only group were supportive of using selective criteria for administration of IVIG in neonates with isoimmune hemolytic disease. J Clin Med Res. 2019;11(11):760-763 doi: https://doi.org/10.14740/jocmr4003

Background: neonatal hyperbilirubinemia is a leading cause of morbidity and mortality in developing countries. Adverse consequences include neonatal mortality, classic manifestations of choreoathetoid cerebral palsy, isolated auditory impairment, and a diverse manifestation of subtle processing disorders because of BIND. Aim of the Work: the aim of the current study was to evaluate the effectiveness of intensive phototherapy on BIND score in neonates with severe hyperbilirubinemia. Patients and Methods: the current study is a prospective study conducted on 100 neonates with severe hyperbilirubinemia admitted to NICU at university Hospital, Faculty of Medicine, Al-Azhar University, Assuit, Egypt in the period between November 2017 and May 2018. The study group was divided into 2 groups, hemolytic and non-hemolytic hyperbilirubinemia groups. Results: regarding TSB and direct bilirubin at admission no significant difference was detected between both groups (p=0.543 and 0.632). Regarding TSB and direct bilirubin at discharge no significant difference was detected between both groups (p=0.712 and 0.213). Results show no significant change between hemolytic and nonhemolytic jaundice regarding rate of decline per hour of total bilirubin and direct bilirubin after 8 hs. No significant difference between study groups regarding BIND score at admission. At discharge, 95 (95%) neonates had BIND score 0 and 4 (4%) had BIND score 1-3. One neonate (1%) died before scoring. Conclusion: care must be taken not to delay the decision of exchange transfusion to the degree that endangers baby's life. BIND score can be used to assess the efficacy of intensive phototherapy in newborn with hyperbilirubinemia.

Background: hemolytic disease of the newborn is an autoimmune haemolytic disease and caused by antibodies produced due to Rh and ABO incompatibilities. Neonatal jaundice is a common clinical problem encountered during the neonatal period. To avoid the associated neurological complications; exchange transfusion and phototherapy have been traditionally used. Aim of the work: was to assess the efficacy of intravenous immunoglobulins in neonates with Rh and/or ABO incompatibility in reducing the duration of phototherapy and the need for exchange transfusion and hospital stay. Subjects and Methods: in this clinical intervention study 40 patients diagnosed with hemolytic disease of newborn were grouped into group A and B. All neonates were treated with standard protocol for phototherapy and exchange transfusion. Group A patients received only phototherapy. Group B patients received intravenous immunoglobulins in a dose of 0.5 gm/kg of body weight single dose and phototherapy. Exchange transfusion was given to the patients of both groups if the bilirubin rose by 0.5 mg/dl per hour. Results: there was a significant decrease of bilirubin level in group B [that received phototherapy plus Intravenous Immunoglobulin (IVIG)] than group A [that received phototherapy only]. Hospital stay and duration of phototherapy decreased in group B than group A. Number of cases exchanged blood in group A was higher than cases of group B. Conclusion: addition of intravenous immunoglobulins for treatment of hemolytic disease of newborn significantly reduces bilirubin levels, duration of phototherapy, need for exchange transfusion and hospital stay.

Sclerema neonatorum (SN) is a rare clinical condition usually seen during the 1st week of life. It presents as hardening of the skin and has a high mortality rate. It is usually associated with congenital anomalies, hypothermia, respiratory illnesses, and sepsis. Defective lipolytic enzymes, a high melting point, and resultant low solidification point of saturated fatty acids of subcutaneous fat, edema of connective tissue septae, and signs of underlying systemic diseases are the various theories proposed for the development of SN. The skin biopsy shows the thickening of trabeculae, sparse inflammatory infiltrates of lymphocytes, histiocytes and multinucleate giant cells, and X-ray diffraction of a biopsy sample of SN shows crystals in affected sites. The systemic corticosteroids have been used by various authors with variable response. Use of exchange transfusion has recently shown good results in improving the outcome of SN.

Neonatal hyperbilirubinemia or jaundice is associated with kernicterus, resulting in permanent neurological damage or even death. Conventional phototherapy does not prevent hyperbilirubinemia or eliminate the need for exchange transfusion. Here we investigated the potential of therapeutic bile acids ursodeoxycholic acid (UDCA) and obeticholic acid (OCA, 6-α-ethyl-CDCA), a farnesoid-X-receptor (FXR) agonist, as preventive treatment options for neonatal hyperbilirubinemia using the hUGT1*1 humanized mice and Ugt1a-deficient Gunn rats. Treatment of hUGT1*1 mice with UDCA or OCA at postnatal days 10–14 effectively decreased bilirubin in plasma (by 82% and 62%) and brain (by 72% and 69%), respectively. Mechanistically, our findings indicate that these effects are mediated through induction of protein levels of hUGT1A1 in the intestine, but not in liver. We further demonstrate that in Ugt1a-deficient Gunn rats, UDCA but not OCA significantly decreases plasma bilirubin, indicating that at least some of the hypobilirubinemic effects of UDCA are independent of UGT1A1. Finally, using the synthetic, non-bile acid, FXR-agonist GW4064, we show that some of these effects are mediated through direct or indirect activation of FXR. Together, our study shows that therapeutic bile acids UDCA and OCA effectively reduce both plasma and brain bilirubin, highlighting their potential in the treatment of neonatal hyperbilirubinemia.

Objectives We aimed to evaluate total serum calcium (TSC) and ionized serum calcium (ISC) levels and their effects on clinical outcomes in neonates underwent exchange transfusion (ET). Method In this study, the data of newborn infants who underwent ET due to hyperbilirubinemia in a third level neonatal intensive care unit (NICU) were retrospectively analyzed. The patients were monitored by electrocardiogram during ET. Cardiac and respiratory rates, peripheral oxygen saturation, blood pressure values ​​and clinical findings as convulsion, tremor, hypertonia, laryngospasm, cyanosis and apnea were recorded in ET observation forms. The infants with no symptoms of hypocalcemia during the procedure were not routinely given IV calcium gluconate. TSC and ISC measured at the beginning, at the end and 24 h after the end of ET were evaluated retrospectively. Results Data of 36 newborn patients were evaluated. Median gestational age was 39 (35−40) weeks, mean birthweight was 2840 ± 841 (mean ± SD) grams. During the ET, desaturation was observed in five patients(13.9 %), sinus bradycardia in six(16.7 %), tachypnea in two(5.5 %), sinus tachycardia in one(2.8 %), and rare ventricular extrasystoles in one(2.8 %). Hypocalcaemia was not detected in any of the patients at the beginning of ET. Hypocalcemia was observed in two cases (5.5 %) at the end of ET. There was no statistically significant difference between the TSC and ISC levels at the beginning of ET, at the end and at the end of 24 h. Conclusion As a result, routine intravenous (IV) calcium administration seems to be unnecessary provided that vital signs and neurological status are closely monitored during ET.

Background Red blood cell alloimmunisation during the pregnancy is a significant cause for neonatal mortality and morbidity. This study was planned to determine the prevalence and specificity of irregular erythrocyte antibodies in antenatal mothers and their neonatal outcome. Methods In this observational study, blood grouping and red cell antibody screening of mothers were performed at first visit and after 28 weeks of gestation and positive cases were identified and followed up monthly till delivery by repeating antibody titre and middle cerebral artery—peak systolic velocity. After delivery of alloimmunised mothers, cord blood haemoglobin, bilirubin and direct antiglobulin tests (DAT) were analysed and further outcome of neonate was recorded. Results Among 652 registered antenatal cases, 18 multigravida women were found to be alloimmunised, accounting to prevalence of 2.8%. Most common alloantibody identified was anti D (>70%) followed by anti-Lea, anti-C, anti-Leb, anti-E and anti-Jka. Only 47.7% Rh D negative women received anti-D prophylaxis during previous pregnancies or whenever indicated. DAT was positive in 56.2% of neonates. Among nine DAT positive neonates, two early neonatal deaths due to severe anaemia were observed following birth resuscitation. Four antenatal mothers required intrauterine transfusion in view of fetal anaemia while three neonates received double volume exchange transfusion and top up transfusions after birth. Conclusions This study emphasises importance of red cell antibody screening for all multigravida antenatal women at registration of pregnancy and additionally at 28 weeks or later in high-risk cases irrespective of RhD status.

Rh incompatibility is a not common pediatric problem, that cause morbidity and mortality in children, and it is an important cause of hemolysis, anemia and jaundice in newborn. To study Rhesus hemolytic disease, its severity, its complications; to evaluate if ABO incompatibility is protective or not, so to find out the efficacy of anti-D globulin ; to evaluate the efficacy of phototherapy and exchange transfusion as a treatment. This study was done on neonates with jaundice, seventy five patients (1-10 days old) who had Rh incompatibility were studied during period from the first of January 2008 to the 30th of June 2008. History was taken about age, gender and gestational age of the patients, determination of gestational age and hepatosplenomegally as a cause of extramedullary hematopoiesis. Investigations done for patients were hemoglobin, total serum bilirubin, reticulocyte count, blood group and Rh, and direct coombs test. From 75 patients studied, 55 patients (73%) required treatment for jaundice;25 of them (46%) required only phototherapy due to mild degree of hemolysis, and 30 of them (54%) required exchange transfusion with phototherapy due to severe degree of hemolytic. The remaining 20 patients (27%) required observation alone. Family history of previous hemolysis was positive in 44 patients and it was a risk factor for having hemolysis in present pregnancy. Early evaluation of patients for jaundice was useful in early recovery. ABO incompatibility in association with Rh incompatibility was not necessarily protective against hemolysis. The administration of anti-D globulin to the mother within first 72 hours after delivery was protective against sensitization. Early and proper management of of Rh incompatibility may reduce need for exchange transfusion. ABO incompatibility was not necessarily protective against hemolysis. Anti-D globulin administered to mothers within 3 days after delivery was protective against sensitization, History of hemolytic in previous siblings is considered as a risk factor for present hemolytic in neonates with Rh incompatibility.

Background Although it is known that unbound bilirubin can enter the brain, there is little evidence of its association with the development of acute bilirubin encephalopathy. Here, we investigated this potential relationship in neonates who had undergone exchange transfusion. Methods Data from 46 newborns who underwent exchange transfusion between 2016 and 1-1 to 2018-12-31 at the First People’s Hospital of Changde City in China were analyzed. The unbound bilirubin level was taken as the independent variable and the development of the acute bilirubin encephalopathy as the dependent variable. The covariates were age, birth weight, sex, red blood cell count, blood glucose, hemolytic disease, and whether the infant had received phototherapy. Results The mean age and gestational age of the neonates were 146.5 ± 86.9 h and 38.6 ± 1.3 weeks [38.7(34.6–41.1) weeks] old, respectively; 52.17% were male. Binary logistic regression analysis after adjustment for covariates showed a positive association between the levels of unbound bilirubin and the development of acute bilirubin encephalopathy (odds ratio = 1.41, 95% confidence intervals 1.05–1.91, P = Conclusion There is a significant association between unbound bilirubin levels and the development of acute bilirubin encephalopathy in neonates. Further investigations are required to explore the mechanisms.

Sickle cell disease (SCD) is a qualitative hemoglobinopathy that can cause widespread sickling and vaso-occlusive events in all organ systems. Sickle cell hepatopathy is an umbrella term for various acute and chronic pathologies of the liver as a result of sickling in SCD patients. We present below the case of a 49-year-old woman who had an acute liver failure in the setting of a hepatic crisis with recovery after exchange transfusion. Hepatic involvement in SCD may be life-threatening. Understanding the etiology and severity of hepatic involvement by sickling is necessary for appropriate treatment.

Streptococcus agalactiae or group B streptococcus (GBS) is a pathogen that causes severe neonatal infections, resulting in sepsis, pneumonia, and meningitis. Neonatal GBS meningitis has a poor neurological prognosis and a high mortality rate. GBS disease is classified as early- and late-onset if the onset age is 0-6 and 7-89 days after birth, respectively. There is currently no effective preventive strategy against late-onset GBS (LOGBS) disease. Here, we report a case of female infant with LOGBS meningitis who recovered from the septic shock by two exchange transfusions (ExTs) but still experienced severe neurological sequela. She was born at a gestational age of 39 weeks via caesarian section due to oligohydramnios and had fever 11 days after birth. GBS was detected in her cerebrospinal fluid (CSF) and blood but not in the vaginal or breast-milk cultures of the mother. The patient was treated with intravenous antibiotic administration; however, she suddenly developed pulseless ventricular tachycardia and asystole the next day. Her heart rate was normalized via cardiopulmonary resuscitation. We also performed two ExTs, and she recovered from the septic shock. Cytokine-profile analysis revealed that the serum and CSF levels of various pro-inflammatory and anti-inflammatory cytokines were elevated before the ExTs, after which the serum levels of several of these cytokines decreased. Two ExTs were effective in saving the life of the patient but did not improve the neurological prognosis. Given that neonatal GBS meningitis has high fatality and sequela rates; thus, it is necessary to establish a preventive strategy.

INTRODUCTION Priapism is a urologic emergency that may require surgical intervention in cases refractory to supportive care. Exchange transfusion (ET) has been previously used to manage sickle cell disease (SCD), including in priapism; however, its utilization in the context of surgical intervention has not been well-established. Aim To explore the utilization of ET, as well as other patient and hospital-level factors, associated with surgical intervention for SCD-induced priapism Methods Using the National Inpatient Sample (2010–2015), males diagnosed with SCD and priapism were stratified by need for surgical intervention. Survey-weighted regression models were used to analyze the association of ET to surgical intervention. Furthermore, negative binomial regression and generalized linear models with logarithmic transformation were used to compare ET vs surgery to length of hospital stay (LOS) and total hospital charges, respectively. Main Outcome Measures : Predictors of surgical intervention among patients with SCD-related priapism RESULTS A weighted total of 8,087 hospitalizations were identified, with 1,782 (22%) receiving surgical intervention for priapism, 484 undergoing ET (6.0%), and 149 (1.8%) receiving combined therapy of both ET and surgery. On multivariable regression, pre-existing Elixhauser comorbidities (e.g. ≥2 Elixhauser: OR: 2.20; P < 0.001), other forms of insurance (OR: 2.12; P < 0.001), and ET (OR: 1.99; P = 0.009) had increased odds of undergoing surgical intervention. In contrast, Black race (OR: 0.45; P < 0.001) and other co-existing SCD complications (e.g. infectious complications OR: 0.52; P < 0.001) reduced such odds. Compared to supportive care alone, patients undergoing ET (adjusted IRR: 1.42; 95% CI: 1.10–1.83; P = 0.007) or combined therapy (adjusted IRR: 1.42; 95% CI: 111–1.82; P < 0.001) had a longer LOS vs. surgery alone (adjusted IRR: 0.85; 95% CI: 0.74–0.97; P = 0.017). Patients receiving ET (adjusted Ratio: 2.39; 95% CI: 1.52–3.76; P < 0.001) or combined therapy (adjusted Ratio: 4.42; 95% CI: 1.67–11.71; P = 0.003) had higher ratio of mean hospital charges compared with surgery alone (adjusted Ratio: 1.09; 95% CI: 0.69–1.72; P = 0.710). CONCLUSIONS Numerous factors were associated with the need for surgical intervention, including the use of ET. Those receiving ET, as well as those with combined therapy, had a longer LOS and increased total hospital charges.

Background Retinopathy of prematurity (ROP) is a potentially vision threatening disease affecting preterm babies. Progress in neonatal intensive care in recent years has led to an increased survival of preterm & sick babies and subsequently, to an increasing incidence of ROP. Objectives To analyze the incidence, risk factors and outcome of ROP. Methods STUDY POPULATION 50 Babies ≤32 weeks gestational age and 50 preterm babies >32 weeks gestational age. INCLUSION CRITERIA Babies with birth weight ≤1500 g. Babies born at ≤32 weeks of gestation. Selected preterm babies with a birth weight between 1500 grams and 2000 grams or gestational age of more than 32 weeks with additional risk factors (eg. oxygen therapy, sepsis, apnea, birth asphyxia, RDS, NEC, use of surfactant, exchange transfusion, IVH, PRBC transfusion). Group1: Babies with gestation ≤32 weeks and/or babies with birth weight ≤1500 g. Group2: Selected preterm babies with a birth weight between 1500 grams and 2000 grams or gestational age of more than 32 weeks with additional risk factors as mentioned above EXCLUSION CRITERIA Outborn babies treated in our NICU STUDY PERIOD: 2017- 2018 When to screen: First screening examination should be carried out at 31 weeks of gestation or 4 weeks of age, whichever is later. All the babies found to have ROP were regularly followed up in both our high risk clinic and in Ophthalmology outpatient department for one year. Results Incidence of ROP was 23% in our study. Incidence was 38% in the 1 st group & 8% in the 2 nd group. Most common findings were stage III ROP (39%) and zone II ROP (70%). 3 (13%) had APROP (Aggressive posterior ROP) and 2 (8.7%) had retinal detachment. The incidence of ROP increased as the birth weight and period of gestation decreased- no ROP was found in gestation ≥35 weeks and birth weight >1.828 kg. In our study, oxygen administration through mechanical ventilator or CPAP, sepsis, therapy with surfactant, apnea, PRBC transfusion, NEC and birth asphyxia were found to be significant risk factors. The risk of ROP is more in RDS, IVH and only head box oxygenation but the risk is not significant. We have not found any ROP in the babies who have undergone exchange transfusion. 13 (57%) babies had spontaneous regression of ROP and rest 10 (43%) required some intervention. To summarize the intervention (n=10), 5 (50%) responded to LASER only, 3 (30%) required intravitreal injection with Bevacizumab (anti-VEGF) following LASER, 1 (10%) required TPPV (Trans Pars Plana Vitrectomy) in left eye for ROP stage IVb along with LASER and 1 (10%) baby required all the three- LASER, intravitreal Bevacizumab and left sided TPPV. Conclusions Thus the need for a routine screening program for the detection of ROP in preterm and sick neonates with risk factors is very essential in our clinical settings. Prevention of blindness from ROP can be very effective through early detection and urgent treatment. This needs awareness among neonatologists and pediatricians for referral to the ophthalmologists at appropriate age of the baby.

Background Medication errors can cause significant harm, but are a preventable cause of morbidity and mortality in the presence of effective intervention strategies. The complexity of intravenous medication administration in neonates involves an increased risk of medication errors. Also, neonates have a less capacity to buffer the unintended consequences of the medication error due to physiological immaturity. Lipids are considered as high alert medication and overdose can cause significant complications including hypertriglyceridemia, respiratory failure, metabolic acidosis, hemolysis, liver dysfunction and pancreatitis. Long-term complications include pulmonary hypertension, chronic lung disease and neurodevelopmental delay. Objectives Aim: To highlight intervention strategies and learning involved in a medication error due to lipid overdose. Case History: A baby boy born at 29 weeks was commenced on Parenteral Nutrition (PN) including lipid for suspected Necrotising enterocolitis. The infusions were ‘checked’ by two trained nurses at the start and at two handovers; with hourly pump readings. After 16 hrs, the infusion pump delivering lipid alarmed noting the bag as empty. This prompted a review of fluid balance chart only to note that the infusion rate of lipids was set incorrectly; 120 mls of lipid was infused; instead of expected 17.1 mls (7 times higher). The baby developed mild respiratory distress, observations were stable. The lipid infusion was stopped immediately. The triglyceride level of the baby was 83.8 mmol/l (40 times higher) (Normal 0.34 – 2.0 mmol/l). The baby was transferred to tertiary NICU, required respiratory support and received ‘ Double volume exchange transfusion’. Parents were updated and supported throughout. Methods INTERVENTIONS: National Patient Safety Agency (NPSA) alert was raised. A serious incident root-cause analysis was carried out to identify the opportunities to minimise the recurrence of error. This case illustrated a lack of robust checking system and no clearly identifiable process to differentiate between multiple infusions. This emphasised on independent checks by two trained nurses, and cot side checklist during handover (to be signed by two qualified nurses) to allow checking of pumps and rates to overcome involuntary automaticity. The process of administration of PN in neonatal unit was reviewed to include a detailed workflow diagram to identify specific problem areas. The bags were colour coded, clear labels were used and infusions were set to run for a maximum of 4 hours. A competency based workbook was developed to improve uniformity in practice with regards to administrations of medication including PN. Debrief session and shared learning was organised for all staff, reinforcing the lessons learnt and incorporating into neonatal mandatory training. Results Our investigation led to a major change in manufacturing nationwide. Based on recommendations, the volume in lipid bags was reduced from 120 mls to 60 mls and changed to red coloured bags. Conclusions Exchange transfusion remains the mainstay of treatment for lipid overdose to prevent acute and delayed complications. Human factors play a crucial role. Identifying human errors and developing robust intervention strategies is challenging but very important. Medication safety in neonatal care involves education and training of the staff; debriefs and shared learning from errors, and timely review of the practices.

Background Neonatal hyperbilirubinemia is a common cause for neonatal admission in term and preterm infants. These infants are primarily managed on postnatal wards; however, they require admission to neonatal unit due to jaundice above the exchange level, rapidly increasing bilirubin levels, pathological jaundice or sepsis. Failure to initiate and establish adequate breastfeeding can play an important role in development of severe jaundice. Face-to-face professional support has been shown to increase breastfeeding success. Objectives The objectives of this project included evaluation of the management of infants admitted to neonatal unit with jaundice including the feeding practices; and identifying the areas of improvement to reduce admissions. Methods This was a retrospective observational project including infants born at ≥ 35 weeks admitted to neonatal unit at District Hospital with a diagnosis of jaundice from January 1, 2017 to December 2018. Data was collected using proforma, medical records and blood results on computer system. Results A total of 519 infants ≥ 35 weeks were admitted to the neonatal unit of which 12%(60) infants were admitted due to jaundice. 42%(25) were preterm and 58%(35) were term infants. The risk factors for jaundice were identified as male infant (66%), first born (49%), gestation, prematurity, and breast fed babies. The mean birth weight was 2892.5 grams and 20%(12) were low birth weight. 35%(21) infants were admitted from home (average 3.9 days) and 65%(39) from postnatal wards. 27%(16) infants had jaundice 10% weight loss on admission. DAT was positive in 23%(14) infants of which 8 infants presented Sepsis was suspected in 72% (43) infants but was proven in none. Only 20%(12) received lactation support on the postnatal ward prior to admission whereas 43%(26) did not receive any support. 36 infants were exclusively breastfed, 13 were formula fed and 11 were mixed-fed. After admission, formula feeds were added to 32 infants while 4 infants exclusively breast fed. 10 infants were given intravenous fluids. The causes of jaundice included prematurity(25), ABO incompatibility(11), Rh incompatibility(3), poor feeding or exaggerated jaundice(25). 33 infants had bilirubin above exchange line, and required a mean of 24 hours (range 6- 144 hours) of phototherapy. None of them required immunoglobulins or exchange transfusion. The mean length of stay was 3 days (range 1–14 days) and there was a remarkable decrease in breast feeding as only 7(11.6%) infants were breast fed on discharge. Conclusions There is a scope to decrease the admissions due to jaundice by optimising the postnatal support on the postnatal wards and community in the presence of risk factors. Transitional care for late preterm infants is important to reduce admission to the neonatal unit thereby reducing the separation of mother and baby. The opportunities to support breast feeding on postnatal ward and neonatal unit are often missed. Effective measures should be taken to promote lactation support at all levels.

Background Few reports have described the application of exchange transfusion in patients with hyperleukocytosis. Methods A retrospective clinical analysis of infants with exchange transfusion in the treatment of hyperleukocytosis was performed. Results A total of 13 patients were enrolled in the study.7 patients survived and 6 died after exchange transfusion.The incidence of pulmonary hypertension, heart failure, pertussis encephalopathy, Increased C-reactive protein, and increased PCT in the survival group were lower than those in the death group,The incidence of received Gamma globulin and received steroids were higher than those in the death group.The highest WBC count in the survival group was 74.15 ± 19.68*10^9/L, and in the death group patients was 86.29 ± 23.51*10^9/L.There were not significant differences two groups(P = 0.332). Decrease rate of WBC after the first ET in the survival group was significantly higher than that of the death group (P༜0.05). In the survival group, there were 5 patients (71.42%) which decrease rate of WBC after the first ET more than 50%, and the remaining 2 patients (28.58%) all exceeded 45%.In contrast, there was 1 patient which decrease rate of WBC exceeded 45% ,no patient exceed 50%. All patients with Decrease rate of WBC after the first ET exceed 50% survived. In the death group, there were 4 patients (66.67%) which N/L exceeded 1, 3patients (50%) which N/L exceeded 2. In the survival group, only 3 patients (42.85%) which N/L exceeded 1, but there was no patient which N/L exceed 2. Conclusion Exchange transfusion is an effective method to reduce WBC count. Patient with Decrease rate of WBC after the first ET exceed 50% were easier to survive. Patients with hyperleukocytoemia which N/L exceeding 2 predict death.

Background and objectives Guidelines and indications for exchange transfusion in haemolytic disease of the foetus and newborn (HDFN) have changed drastically in the past decades, causing a decline in exchange transfusion rate. This study aims to evaluate the incidence of exchange transfusions (ETs) in neonates with Rh-mediated HDFN over the past 20 years at our centre, and report potentially ET-related complications as well as indicators for bilirubin encephalopathy.Material and methods In this observational study, 438 neonates were included with HDFN, born >= 35 weeks gestational age at the Leiden University Medical Centre between January 2000 and July 2020. The incidence of ET and procedure-related complications were assessed in three consecutive time periods determined by changes in guidelines and indications for ET.Results The incidence of ET in our centre declined from (104/156) 67% (time period 2000-2005), to (39/181) 22% (2006-2015) and to (10/101) 10% (2015-2020, p < 0 center dot 001). The maximum bilirubin levels in neonates after birth increased from 13 center dot 6 mg/dL (or 233 mu mol/L), to 15 center dot 0 mg/dL (257 mu mol/L) and to 15 center dot 3 mg/dL (263 mu mol/L). The incidence of complications associated with the use of ET (including sepsis, haematologic disorders and respiratory failure) remained stable throughout the years, and no neonates died during the study period.Conclusion Exchange transfusion incidence declined significantly over the past two decades. Decrease in ET incidence, and concomitant decrease in exposure and expertise, was not associated with an increase in procedure-related complications.

Transfusion-related lung injury (TRALI) is a condition that develops suddenly within the first six hours after a blood transfusion and it is one of the most important causes of blood transfusion-related mortality. There are few data in the literature about TRALI in the neonatal period. We present two newborn patients who developed TRALI after exchange transfusion due to high bilirubin levels. Our first case was a late preterm LGA baby and was on CPAP. The baby was intubated due to sudden deterioration after the exchange transfusion. Our second case was born at term and, an exchange transfusion was performed on the 5th day of life. He developed respiratory distress unexpectedly soon after the exchange transfusion and was intubated. Glucose-6- phosphate dehydrogenase (G6PD) deficiency was detected in both of our cases. We wanted to emphasize that TRALI should be considered in the differential diagnosis of respiratory distress that develops soon after a transfusion in the newborn period and to draw attention to that TRALI may develop more frequently in patients with G6PD deficiency.

Rationale Beta thalassemia is a congenital defect in the production of the beta globin chain. Patients with beta thalassemia major will have higher levels of hemoglobin F (HbF), which is suboptimal in releasing oxygen to tissue. Herein, we describe the use of red blood cell (RBC) exchange transfusion, a therapy typically used in sickle cell patients, in the management of a patient with beta thalassemia with extensive extramedullary hematopoiesis and elevated levels of HbF. Patient concerns: A 34-year-old male of mixed African American and Southeast Asian descent with a known history of beta thalassemia major presented with progressive dyspnea on exertion with marked fatigue. Diagnoses: The patient was transferred to our facility for management of acute hypoxemic, hypercapnic respiratory failure associated with cor pulmonale. Interventions The patient was initially managed with non-invasive positive pressure support ventilation (NIPPV) and intravenous diuresis. Hydroxyurea and epoprostenol nebulization were added to his treatment regimen; however, he progressively became more unstable, necessitating inotropic support. With extramedullary hematopoiesis leading to mass-like effect on critical organs and very high HbF (96%) thought to contribute to his presentation, red blood cell exchange transfusion was initiated once the blood pressure stabilized. Outcomes The patient clinically improved, and was discharged home within a week on supplemental oxygen by nasal cannula and long-term red blood cell exchange. Lessons We postulated that significantly elevated HbF contributed to the patient's chronic hypoxia and subsequent respiratory complications. Based on the patient's clinical improvement following the intervention, we believe that RBC exchange transfusion could be considered in the management of beta thalassemia patients with significantly elevated levels of HbF.