The Quarterly Newsletter for the UNC Center for Maternal & Infant Health Winter 2005
Welcome to the Winter 2005 edition of CenterNews. We appreciate the opportunity to share medical news and information with you. Assuch, we are pleased to announce that our website has received a new look for the New Year. The site has been reorgan-ized to make it easier for patients and providers to navigate, and new information and resources have been added. This site will continue toexpand over the next several months. We hope that you will take a few minutes to check out the site and bookmark it as a favorite. As always,we appreciate your feedback on our content along with requests for more information on maternal – infant topics. We are here to serve you! UNC ECMO PROGRAM HYPEREMESIS GRAVIDARUM:
taneously and it is anticipated that 8 to12 patients will be treated during the first year.
state of the art life support for critically ill Bypass requires full anticoagulation and the neonates and pediatric patients. ECMO (extracor- most common serious complications are related to bleeding. Neonates less than 35 weeks’ gestation quoting up to a 70% incidence in the first hemodynamic and respiratory support in children and 2-2.5 kg in weight are not candidates for with reversible cardiac or lung disease. ECMO, ECMO because of the risk of intraventricular hem- also known as extracorporeal life support (ECLS), is orrhage and technical difficulties with placing the similar to the cardiopulmonary bypass used in the cannulas. The typical ECMO course can range operating room but has been adapted to allow for from several days to more than two weeks, although the longer the course, the less likely a successful outcome. Similarly, the longer a patient is ventilated prior to starting ECMO, the greater the underlying lung damage and less likely the patient will survive. In general, once a patient has been Thomas Trevett,
ventilated for more than 7 to 10 days, they are no MD, Fellow,
Improved survival in neonates has been demon- strated in a number of well-designed studies Daniel von
although survival figures vary based on the indica- al. There is evidence of a genetic predis- Allmen, MD, Chief
tion for bypass. Patients with meconium aspiration position with increased frequency in sib- have the highest survival rates (95%) while those with congenital diaphragmatic hernia and post-op twins. Some research suggests a primarily high frequency ventilation have decreased the cardiac patients have survival rates that are signifi- gastrointestinal disorder with erratic or need for ECMO over the past decade, there remains a significant group of patients for whom The reinstitution of the ECMO program at UNC ECMO can make the difference between life and adds an important tool for the support of infants with respiratory insufficiency or congenital cardiac The new program at UNC combines the exten- lesions. Mothers carrying fetuses likely to suffer data point to a reset of the “emetic center” sive ECMO experience of a broad group of physi- one of these problems can now be offered poten- cians from pediatric surgery, critical care medicine tial access to every available method of life support and neonatology with new state- of- the- art bypass equipment. The most common indications gravidarium is associated with significant reversible lung disease and following cardiac sur- gery in infants with congenital heart disease.
Division Chief of Pediatric Surgery Continued on page 3
Initially it will be possible to treat 2 patients simul- Surgeon in Chief of the NC Children’s Hospital SIDS happens in our communities
Adecline in Sudden
ing SIDS. This model suggests an infant is ent education about SIDS during pregnancy most vulnerable to SIDS when there is a con- persists after the baby’s arrival and prior to References
vergence of developmental and neuro-physio- hospital discharge. Spanish language educa- 1. American Academy of Pediatrics – Task logical, genetic and environmental factors. tion about SIDS is insufficient and the “back Force on Infant Sleep Position and Sudden to sleep” transition of NICU graduates ready Infant Death Syndrome. Task Force Members: providers caring for infants 12 months of age J. Katwinkel, Chairperson, J.G. Brooks, M.E.
infants on their backs to sleep (a waiver may North Carolina childcare licensing require- Changing concepts of sudden infant death apply), develop and communicate a written ments stipulate a signed medical waiver by an syndrome: implications for infant sleeping Safe Sleep Policy, take Infant/Toddler Safe infant’s primary care physician when a med- environment and sleep position. Pediatrics.
Sleep and SIDS Risk Reduction in Child Care ical condition contraindicates the supine sleep (ITS-SIDS) training and implement other pre- position. Inappropriate requests by parents for cautionary measures. Since February 2003, this medical waiver should not lead to the 2. Willinger, M. New directions in fetal and more than 24,800 childcare providers have inappropriate use of the medical waiver by infant mortality research. Presentation at the Although health professionals across North Medical professionals have an opportunity Programs Fifteenth Annual Conference March Carolina have been active increasing SIDS to strengthen SIDS risk reduction practices and awareness and education, infant safe sleep to inform patients that SIDS risk reduction practices in hospitals and related parent edu- begins before the baby is born. For those cation appear inconsistent. Policies governing providers working in the hospital setting, does infant sleep safety in newborn nurseries may your hospital nursery have a comprehensive be non-existent or inadequate. A deficit in par- infant safe sleep policy that is consistent with North Carolina Healthy Start Foundation Continued from page 1
tinued. If there is an improvement in symptoms, parenteral nutrition will rarely allow for appropri- include significant weight loss (defined as loss of therapy should be continued with a slow taper ate caloric intake. Central total parenteral hyper- > 5% of pre-pregnancy weight), severe dehydra- alimentation (TPN) has been the mainstay of ther- tion, electrolyte abnormalities (which can lead to apy until recent times. Complications with cen- cardiac dysrhythmias and even sudden cardiac tral access catheters led to the introduction of the death), acute renal failure and renal tubular PICC lines, however these too are associated with septicemia and thrombosis in pregnancy. Today, Initial therapy for hyperemesis can be under- enteral feeding through a gastrostomy/jejunosto- taken through outpatient managment - avoidance my feeding tube is the preferred method of nutri- of “nausea triggers,” small, frequent meals along tion in these severe cases. Line placement is usu- with the addition of pyridoxine (vitamin B6).
ally through endoscopic visualization.
Second line therapy includes the addition of a Kenneth J. Moise,
Complications such as infection, hepatotoxicity, half tablet of doxylamine (Unisom®) and other Jr., MD, Professor,
and thrombosis are virtually eliminated and the antiemetics as promethazine (Phenergan®), brush border of the GI tract is maintained through prochlorperazine (Compazine®), and metaclo- stimulation by the enteral feeding solutions.
pramide (Reglan®) (see table). Ondansetron Baseline metabolic caloric needs are increased (Zofran®) should be reserved for cases when by 100 kcal/day for each trimester to support nor- these agents fail due to its expense. Intermittent intravenous fluid and electrolyte replacement can weight loss of > 5% of pre-pregnancy weight, Today, new pharmacologic agents and meth- usually be undertaken in an outpatient setting supplemental nutrition is warranted. Peripheral ods of nutrition can allow for a successful out- MEDICATION
(generic name)
(brand name)
Algorithms) for further details of in 24 hours, a bland liquid diet isinitiated. In women who are Etiology and Recurrence Risks in Congenital Heart Disease
fter a baby is born with congenital heart the normal population is 8 out of every 1000 newborns or 0.8%. Of those 8 children, only 4 Ais what is the risk is for a subsequent to certain medications,
will require some sort of surgical intervention. If child to have heart problems. In general the one sibling has congenital heart disease the risk causes of most forms of congenital heart disease for the next baby increases to 2% – 4%. In cer- are thought to be due to some as yet undeter- tain left-sided obstructive lesions, the recurrence mined genetic-environmental interaction, how- risk may be as high as 10%. If there are two ever some causes of congenital heart disease affected children in the family the risk is even are known. These generally are fall into three higher for the next baby to be affected. If one of John Cotton, MD,
categories, chromosomal, syndromic, and envi- the parents has congenital heart disease the risk of transmission to their offspring is about 5%.
anomalies that are associated with congenital Chromosomal abnormalities may also affect the heart disease include trisomy 21 (Down syn- next pregnancy. Once a child is born with con- drome), trisomy 18, trisomy 13, and Turners lithium, retinoic acid, and warfarin. Maternal genital heart disease, genetic counseling for the syndrome (XO syndrome). Certain syndromes systemic lupus erythematosus has been shown family is recommended to define recurrence are associated with congenital heart disease, to cause cardiac rhythm abnormalities. Finally risks and address parental concerns.
and in some of these a specific chromosomal maternal rubella, cocksackie virus, and toxo- anomaly has been identified as the cause.
plasmosis have all been associated with an Examples of these include Noonan syndrome, increased risk of structural heart disease. Holt-Oram syndrome, Williams syndrome, and The incidence of congenital heart disease in CenterNews Bowes-Cefalo Young Researcher Grants Awarded
W I N T E R 2 0 0 5
Angela Gantt,
Terry Harper, MD,
The Mission of the Center for Maternal and Infant Health is to improve the health of North Carolina’s women and infants through clinical services, early identification and treatment, research, advocacy, and public and medical / allied health education.


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