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Background: The possible pathophysiology of the relationship between gastro-esophageal reflux disease and apnea of prematurity has been widely investigated. Various physiological protective reflex responses provide a plausible biological link between gastro-esophageal reflux and apnea of prematurity. It is uncertain whether or not there is a causal relationship between the two diseases. PATIENT'S FINDINGS: Twins were admitted to the neonatal intensive care unit due to feeding problems. Physical examination was normal except for reticulated, blueviolet skin changes. Short apneic attacks occurred on the first day in twin 1 and on the second day in twin 2, and these were initially treated by stimulation and increased ambient O2 concentration. Then, we conducted methylxanthine and continuous positive airway pressure treatment. Laboratory and radiological analysis were normal. As gastro-esophageal reflux disease was thought to be the causes of the treatment-refractory apnea, therapy with gaviscon and domperidon was begun for both cases. Apneic attacks did not recur after gaviscon and domperidon therapy., Conclusion: Pharmacological therapy for gastro-esophageal reflux disease has not definitively been shown to be effective in improving symptoms and hence, should be reserved especially for infants with treatment refractory apnea episodes suspected as being gastro-esophageal reflux in premature infants.

Neonatal sepsis is a significant cause of morbidity and mortality among term and preterm infants. Ampicillin and gentamicin are standard empiric therapy for early onset sepsis. Four cases of neonatal sepsis secondary to Escherichia coli (E. coli) found to be gentamicin resistant occurred within a five week period in one neonatal intensive care unit (NICU). To determine whether these cases could be tied to a single vector of transmission, and to more broadly evaluate the incidence of gentamicin resistant strains of E. coli in the neonatal population at our institution compared to other centers, we reviewed the charts of the four neonates (Infants A through D) and their mothers. The E. coli isolates were sent for Pulse Field Gel Electrophoresis (PFGE) to evaluate for genetic similarity between strains. We also reviewed all positive E. coli cultures from one NICU over a two year period. Infants A and B had genetically indistinguishable strains which matched that of urine and placental cultures of Infant B's mother. Infant C had a genetically distinct organism. Infant D, the identical twin of Infant C, did not have typing performed. Review of all cultures positive for E. coli at our institution showed a 12.9 percent incidence of gentamicin-resistance. A review of other studies showed that rates of resistance vary considerably by institution. We conclude that gentamicin-resistant E. coli is a relatively uncommon cause of neonatal sepsis, but should remain a consideration in patients who deteriorate despite initiation of empiric antibiotics.

Persistently patent ductus arteriosus (PDA), affecting approximately one-third of all very low birth weight infants, can lead to significant morbidity and mortality. Recently, ibuprofen has been recommended over indomethacin to close PDAs because of a reduction in risk of necrotizing enterocolitis. Pulmonary hypertension is a rare but potentially fatal complication of ibuprofen administration in preterm infants. We report 2 infants who developed this complication after receiving therapeutic L-lysine ibuprofen preparation for the PDA closure. The first infant, 1 of twins weighing 640 g, was born at 24 weeks' gestation. The second infant, born at 26 weeks' gestation, was small for gestational age, weighing 439 g. In both cases, ibuprofen was initiated after echocardiographic confirmation of a moderate-sized to large PDA and an otherwise normal intracardiac anatomy. Both infants had echocardiographic evidence of increased pulmonary vascular resistance but shunting across the PDA was left to right. The infants deteriorated within 48 to 72 hours, and repeat echocardiograms revealed evidence of severe pulmonary hypertension. Both infants died of refractory hypotension and hypoxemia. When considering the use of ibuprofen therapy for PDA closure, clinicians should keep in mind the potential serious complication of pulmonary hypertension, even if a shunt across the PDA is left to right.

Breast milk can occasionally transmit serious viral and bacterial infections to preterm infants. We present three cases of late-onset neonatal sepsis, including one that resulted in death, occurring in preterm infants. The likely source of the microorganisms in all three cases was expressed breast milk.

We report extremely preterm twins who developed late-onset Escherichia coli sepsis in the second postnatal week within a short time of each other. The asymptomatic twin was not treated initially, and within 2 days developed life-threatening septicemia and meningitis, followed by other serious morbidity. Occurrence of late-onset sepsis in a twin should prompt concurrent investigation and consideration of presumptive treatment of the apparently asymptomatic co-twin.

Aim: To evaluate vasopressin as a rescue therapy in catecholamine-refractory septic and cardiogenic shock in very-low-birthweight (VLBW) infants., Methods: Prospective assessment of vasopressin therapy in three VLBW infants with catecholamine-refractory septic shock (24 + 6 wk, 600 g) and cardiogenic shock (26 + 1 wk, 890 g; 26 + 1 wk, 880 g) at a university hospital., Results: Adequate systemic arterial blood pressure could only be restored after vasopressin administration as a continuous infusion over a 36-h period in the preterm suffering from septic shock; in the two neonates with cardiogenic shock, only a transient stabilization in mean arterial pressure was observed, which did not impact on the poor prognosis., Conclusion: Although vasopressin appears to be a suitable rescue therapy in catecholamine-resistant septic shock in VLBW infants, further evaluation in controlled clinical trials is warranted.

Unlabelled: Primary cutaneous aspergillosis is a rare diagnosis. Predisposing factors are immunodeficiency and macerated skin. The mortality of infections with Aspergillus species is high, especially in neonatal intensive care units (NICUs). We present a premature (24 wk of gestation) infant with primary cutaneous aspergillosis appearing on the sixth day of life. Predisposing factors in this patient were prematurity, extremely vulnerable skin, treatment with antibiotics and renovation in the radiology department nearby. The patient was treated with amphotericin B intravenously for a total of 40 d. He did not have, nor develop, disseminated aspergillosis, and suffered no side effects from the treatment. The only remaining trace of his infection was scarring in the affected area., Conclusion: After having treated this patient successfully and having gone through the available literature, we conclude that treating primary cutaneous aspergillosis with intravenous amphotericin B prevents disseminated aspergillosis and is the treatment of choice.