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THE JOURNAL OF THE JAPAN PEDIATRIC SOCIETY
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Vol.119, No.5, May 2015
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Original Article
Title
Additional Iron Supplementation for Preterm Infants to Prevent Iron Deficiency Anemia after Discharge from Neonatal Intensive Care Units
Author
Yuya Nakano Manabu Suzuki Takeshi Shimizu Motohiro Taki Tokuo Miyazawa Motoichiro Sakurai Fumihiro Miura Katsumi Mizuno and Kazuo Itahashi
Department of Pediatrics, Showa University School of Medicine
Abstract
Although preterm infants often experience iron deficiency anemia (IDA) during infancy, it is controversial in Japan whether they should routinely receive additional iron supplementation to prevent IDA after discharge from the neonatal intensive care units (NICUs). We retrospectively evaluated laboratory data obtained at term- and 6-month-equivalent age in 52 preterm infants (born at 35 weeks' gestation or less, with a mean birth weight of 1,568 g) who participated in other cohorts, to assess the risk of IDA after discharge from the NICU. None of the infants developed IDA at term-equivalent age; however, 12 of the 52 subjects developed IDA by 6-month-equivalent age. None of the 31 preterm infants who received prophylactic iron supplementation developed IDA, whereas 12 (57.1%) of the 21 preterm infants who did not receive prophylactic iron supplementation developed IDA after discharge from the NICU by 6-month-equivalent age. A Fisher exact test revealed a significant association between prophylactic iron supplementation and prevention of IDA (p< 0.001). In addition, logistic regression analysis revealed that the odds of iron deficiency doubled with each additional month of exclusive breastfeeding in preterm infants after discharge from the NICU (odds ratio, 1.999; p=0.037). We should pay attention to the occurrence of IDA during infancy among preterm infants after discharge from the NICU, if exclusively breast-fed preterm infants do not receive iron supplementation.
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Original Article
Title
Clinical Analysis of 191 Cases Revealed NT-proBNP is a Useful Biomarker for Kawasaki Disease
Author
Keisuke Fukudome Maki Shimizu Tetsuro Furumoto Yuko Ichihara Tomoko Ichihara Emiko Fujii Zenichi Sakaguchi Hiroko Kozan and Katsuaki Ohara
Department of pediatrics, Takamatsu Red Cross Hospital
Abstract
We analyzed 191 case of Kawasaki disease (KD) and investigated whether the serum N-terminal pro brain natriuretic peptide (NT-proBNP) can be a useful diagnostic biomarker of KD or a predictive indicator of resistance for initial intravenous immunoglobulin (IVIG) and developing coronary artery lesions (CAL). More than half of the cases were infants under 1 year old (52.8%), particularly the rate of cases with incomplete diagnostic criteria was significantly more in infants under 6 months. CAL were observed in 10 cases (5.2%). NT-pro BNP levels were significantly higher in KD patients than in non-KD febrile controls (1,469.9± 214.5 pg/ml vs 310.1± 67.8 pg/ml, p< 0.001). In non-responders for initial IVIG, NT-pro BNP were significantly higher than in responders (3,140.7± 1,259.7 pg/ml vs 1,185.0± 128.5 pg/ml, p=0.003). Furthermore, the level of NT-pro BNP was significantly higher in cases with CAL than without CAL (6,620.1± 2,372.5 pg/ml vs 1,034.1± 88.3 pg/ml, p< 0.0001). The NT-pro BNP cut-off value of 281.5 pg/ml yielded a sensitivity of 83.2% and a specificity of 80.7% for diagnosis of KD, 1,354 pg/ml produced a sensitivity of 71.4% and a specificity of 59.2% to predict the response to initial IVIG, and 1,496 pg/ml gave a sensitivity of 90.0% and a specificity of 77.2% to predict CAL. In conclusion, NT-pro BNP is an exceedingly useful biomarker for diagnosis of KD and prediction of developing CAL.
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Original Article
Title
Causes of Acute Kidney Injury Accompanied by Nephrotic Syndrome
Author
Shinsuke Matsumoto Ryugo Hiramoto Norio Omori and Hironobu Eguchi
Department of Pediatrics, Matsudo City Hospital Children's Medical Center
Abstract
Causes of acute kidney injury (AKI) accompanied by childhood-onset nephrotic syndrome (NS) (NSAKI) are unclear. The subjects of this study were 85 cases (49 boys, 36 girls) with steroid sensitive NS, which were divided into 2 groups: the AKI group (18 cases), in which creatinine was more than 1.5 times than the regular value and the non-AKI group (67 cases). Considerable risk factors were compared between the 2 groups. The median age was 8.8 years old. The statistically significant risk factors were first episode, hyponatremia, BUN/creatinine ratio, weight gain and hypoalbuminemia while male gender, age, increases in fractional sodium excretion, rising urinary β2-microglobulin, increases in the concentration of hemoglobin, heavy proteinuria, use of cyclosporine A (CsA) and rising concentrations of CsA were not significant. The causes of NSAKI were evaluated based on these risk factors. Acute tubular necrosis is not likely because of little damage to proximal tubules. Considering the increased rate of hemoglobin and systolic blood pressure, renal ischemia due to decrease in circulating plasma volume is not unlikely. On the other hand, renal interstitial edema can be the main cause of NSAKI because not only some other reports but also our many AKI cases recover from the AKI state with administration of albumin. In addition, urine protein casts can also be another cause of NSAKI. NSAKI caused by renal interstitial edema and urine protein cast can recover from the AKI state by albumin administration. Because the condition of developing NSAKI is rather a flooding state and administering albumin involves the risk of pulmonary edema, administration of albumin should be carefully performed after proper evaluation of circulating plasma volume.
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Original Article
Title
A Retrospective Study of Predictive Factors of Refractory Mycoplasma pneumoniae Pneumonia
Author
Tsubasa Okano1) Yuichi Abe1) Masato Arao1) Taro Yamazaki1) Ryuichiro Araki2) Hideo Yamanouchi1) Kenichi Tokuyama1) Akira Ohtake1) and Shin Amemiya1)
1)Department of Pediatrics, Faculty of Medicine, Saitama Medical University
2)Community Health Science Center, Saitama Medical University
Abstract
Objective: We aimed to clarify the predictive factors of refractory Mycoplasma pneumoniae pneumonia to facilitate early recognition and appropriate treatment.
Methods: We evaluated 73 pediatric Mycoplasma pneumoniae pneumonia cases. These patients were divided into 2 groups, refractory and non-refractory, depending on the effectiveness of antibiotic treatment, which included either tosufloxacin or minocycline. Laboratory data, including the white blood cell count and C-reactive protein, procalcitonin, aspartate aminotransferase (AST), lactate dehydrogenase (LDH), ferritin, and urinary β 2-microglobulin levels, were compared between the 2 groups.
Results: The LDH, AST, ferritin, and procalcitonin levels were significantly higher in the refractory group, and LDH was most strongly associated with refractoriness in a receiver operating characteristic curve analysis. The cut-off values for predicting treatment refractoriness were LDH >477 IU/L, AST >54 IU/L, ferritin >207 ng/mL, and procalcitonin >0.39 ng/mL(specificity=90%).
Conclusion: These cut-off values might predict Mycoplasma pneumoniae pneumonia treatment refractoriness and indicate further treatment such as steroid therapy.
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Case Report
Title
A Case of Infectious Endocarditis with a Ventricular Septal Defect that Caused Cardiopulmonary Arrest on Arrival
Author
Kousuke Yonehara1) Tadanori Nakatsu2) Tsutomu Watanabe2) Akiyoshi Takahashi2) Takako Taniguchi2) Kouichi Shichijo2) Rieko Kondo2) Ayumi Tomimoto2) and Mari Kubota2)
1)Division of Pediatrics, Nagano Red Cross Hospital
2)Division of Pediatrics, Tokushima Red Cross Hospital
Abstract
A 12-year-old boy was given a diagnosis of a small ventricular septal defect (VSD), and owing to the small size of defect, follow-up was stopped before he began elementary school. The child experienced prolonged fever for 3 weeks, which did not improve even after the administration of oral antibiotics. Subsequently, his mother found him unconscious, and he was transported to the hospital by ambulance. However, the patient experienced cardiopulmonary arrest on arrival and could not be resuscitated. Autopsy revealed infectious endocarditis and rupture of the Valsalva sinus due to on the infundibular VSD. Patients with infundibular VSD require careful follow-up, even when the size of defect is small, since this lesion can cause aortic regurgitation or an aneurysm of the Valsalva sinus. Additionally, infectious endocarditis should be suspected in a child with VSD and prolonged fever.
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Case Report
Title
A Severely Developmentally Disabled Child Suffering Tracheoinnominate Artery Fistula during Therapy for Malignant Lymphoma
Author
Masamitsu Mikami Mitsutaka Shiota Kuniaki Tanaka Tatsuya Morishima Atsuko Hata Ken Watanabe and Daisuke Hata
Department of Pediatrics, Tazuke Kofukai Foundation, Medical Research Institute, Kitano Hospital
Abstract
One complication of tracheotomy that must be considered is tracheoinnominate artery fistula (TIF). Severely handicapped children increasingly suffer from malignant tumors, largely because of their longer life expectancy attributable to medical advances. Their treatment tumors has increasingly involved the application of chemotherapy. A 17-year-old boy developed cervical lymphadenopathy and received a diagnosis of ALK-negative anaplastic large cell lymphoma (stage II). At age 5 days, he suffered from hypoxic encephalopathy. Thereafter, developmental delay, epilepsy, and chest scoliosis developed. He was hospitalized more than 20 times because of respiratory infections, despite having received mechanical ventilation after tracheotomy at six months of age. After extensive discussion with his family members, who desired curative treatment, he received chemotherapy with reduced intensity of the ALCL99 protocol because of his severe scoliosis, reduced left ventricular diastolic capacity, and infection by both multidrug-resistant Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. Sixty-seven days after beginning chemotherapy, he suffered from hemorrhagic shock by tracheoinnominate artery fistula (TIF) and died in 1 hour. The incidence of TIF in severely developmentally disabled children is more frequent than that among all children. It should be reaffirmed that TIF can occur even if the chemotherapy intensity is attenuated in cases of severely developmentally disabled children.
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Case Report
Title
A Case of Antineutrophil Cytoplasmic Antibodies-Associated Glomerulonephritis Diagnosed by 3-year Old Urinary Screening
Author
Masako Ikemiyagi1)2) Shunsuke Shinozuka1)3) Hiroshi Hataya3)4) and Isamu Kamimaki1)
1)Department of Pediatrics, National Hospital Organization Saitama National Hospital
2)Department of Urology, Tokyo Women's Medical University Hospital
3)Department of Nephrology, Tokyo Metropolitan Children's Medical Center
4)Division of General Pediatrics, Tokyo Metropolitan Children's Medical Center
Abstract
A 3-year old boy was referred to our hospital for having hematuria and proteinuria which was found by urinary screening. His urinalysis one month prior to screening was normal. At his first visit to our hospital, his serum creatinine was 0.19 mg/dl and he had microhematuria with 10-19 red blood cells/HPF and mild proteinuria (urinary protein/Cr ratio 0.47). Two months later, his renal function deteriorated with serum creatinine level elevating to 0.28 mg/dl and proteinuria increasing to 0.67 at the urinary protein/Cr ratio. We then checked antineutrophil cytoplasmic antibodies (ANCA). The titer of MPO-ANCA was amazingly high (1,950.0 IU/ml) and renal biopsy was performed. Renal biopsy specimens showed necrotizing lesions, one crescentic glomerulus and some sclerotic glomeruli which are compatible with ANCA-associated nephritis. The diagnosis of ANCA-associated nephritis was made definite.
Animal models and human neonatal case reports suggest a direct relationship between ANCA and nephritis. Since elevation of ANCA value occur prior to development of nephritis, ANCA measurement is very important for early diagnosis. In 12 cases of ANCA-associated nephritis detected by school urinary screening since 2001, cases with low serum creatinine level had more favorable outcomes than others. Four of 5 cases that had more than 1.0 mg/dl of serum creatinine had diffuse crescentic glomerulonephtitis. Measuring ANCA in cases with hematuria and protinuria found at 3-year-old urinary screening is necessary for early diagnosis and early treatment.
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Case Report
Title
A Fatal Case of Acute Encephalopathy Associated with Hypercytokinemia at the Onset of Rotavirus Infection
Author
Hideyuki Matsunaga1)2) Kaori Kumazaki1)3) Shigekazu Maeda1) Yasuhiro Wakano1) Naoyuki Iwata1) Kazuyuki Yamamoto1) Hiroshi Naruse1) and Yoshishige Miyake1)
1)Department of Pediatrics, Ichinomiya Municipal Hospital
2)Department of Intensive Care Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health
3)Department of Emergency and General Pediatrics, Shizuoka Children's Hospital
Abstract
Recent reports have indicated that rotavirus infection can cause several types of acute encephalopathy, in which digestive symptoms commonly occur ahead of other symptoms. In the present report, we describe an infant who developed fulminant encephalopathy shortly after the onset of rotavirus infection, when gastroenteritis was not yet apparent.
During a seasonal rotavirus outbreak in our region, a previously healthy 15-month-old girl was admitted to our hospital due to seizures and loss of consciousness a few hours after the onset of fever. She exhibited diarrhea immediately after her arrival. Although prompt intensive care was administered, she developed multiple organ failure and severe brain edema. Her electroencephalogram became flat 16 hours after her hospitalization. Her serum obtained on admission tested positive for rotavirus antigen, and rotavirus RNA was detected in a stool sample obtained on the second day of illness. These findings suggest that she developed acute encephalopathy at the early stages of rotavirus infection. Further analyses revealed that the serum levels of cytokines and neuroinjury biomarkers in the cerebrospinal fluid were markedly elevated soon after her hospitalization. Consequently, we considered that it was impossible to save her without any sequelae despite all possible prompt interventions.
The present report suggests that rotavirus can very rapidly cause acute encephalopathy associated with systemic hypercytokinemia, a condition that is known to result in poor prognosis. Without an established treatment for this type of encephalopathy, it would be important to minimize rotavirus outbreaks by introducing universal vaccination in order to prevent the occurrence of rotavirus-related encephalopathy.
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Brief Report
Title
Monitoring Serum Infliximab Levels before BCG Vaccination in an Infant Born to a Mother Receiving Infliximab
Author
Yu Kawasaki Kousaku Matsubara Yoshiko Uchida Aya Iwata Kazuo Yura Hiroyuki Nigami and Takashi Fukaya
Department of Pediatrics, Nishi-Kobe Medical Center
Abstract
We describe a case of an infant born to a mother with refractory Crohn's disease, who was treated with infliximab (IFX) throughout her pregnancy. We planned the safe administration of the BCG vaccination to this infant by monitoring serum infliximab levels. The infant was born without complications after 38 weeks of gestation via a spontaneous vaginal delivery. The last infusion of infliximab to the mother was administered 32 days before delivery. Serum IFX levels at 0, 30, 87, and 178 days of age were 39.4, 10.41, 2.12, and 0.21 μg/ml, respectively. The infant received a BCG vaccination at 7 months of age without any complications after the serum concentration of IFX decreased below that required for biological activity. No adverse effects were observed following the BCG vaccination. The administration of the BCG vaccination to infants exposed to anti-TNF-α agents in utero, especially in the late term, can cause severe and potentially fatal infections due to a disseminated BCG infection. Further studies are needed to determine the safety of the BCG vaccination for infants born to mothers receiving immunomodulating biological products.
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