A REVIEW OF ANTIBIOTIC USED IN SUSPECTED EARLY-ONSET NEONATAL SEPSIS FROM MALAYSIAN PERSPECTIVE: WHICH ONES TO CHOOSE AND HOW LONG TO GIVE?

Objective: Suspected early-onset sepsis is a common diagnosis among neonates which warrants admission to the neonatal intensive care unit. Prolonged empiric antibiotic is the biggest concern and treatment duration is still controversial. Antimicrobial stewardship (AMS) program promotes early antibiotic de-escalation to reduce unnecessary antibiotic exposure and its implementation in the intensive care setting seems to be feasible. The primary objective of this review was to compare the existing guidelines and review the literature regarding choice and duration of empiric antibiotic in managing suspected early-onset neonatal sepsis.Methods: Two Malaysian Ministry of Health guidelines were compared with guidelines from America (n=1), Australia (n=1), and United Kingdom (n=2). The literature search was conducted from January to June 2017 through open access journal and databases available at the author's institution library (EBSCOHost, Ovid and Science Direct).Results: All guidelines recommended similar antibiotics range and suggested to review treatment at 36– 72 h post antibiotic exposure. A total of 113 abstracts and full articles were identified, and only 11 full-text articles published in English were related to the subject of interest. All studies show differences either in study design, choice of antibiotics, treatment duration or outcome measures; thus, a meta-analysis was not possible to be conducted.Conclusion: From this review, we found the potential to performed early empiric antibiotic de-escalation especially in clinically well-appearance neonates, and it is best to customize our guidelines based on local evidence which justify the need for more local research in this area

Identification of sensitive raw materials at a milk preparation room of a neonatal intensive care unit in the Canselor Tuanku Muhriz Hospital

The implementation of a Hazard Analysis and Critical Control Point (HACCP) system in infant milk preparation can prevent and reduce the risk of bacterial contamination in infant feedings. Therefore, it is very important to determine the sensitive raw materials (SRM) in a milk room of a neonatal intensive care unit (NICU) to prevent contamination that can affect the safety of milk feeding. This study was conducted to identify the SRM at the milk preparation room of a NICU in the Canselor Tuanku Muhriz Hospital, Cheras, Kuala Lumpur, Malaysia. SRM were identified via HACCP system decision tree by the Malaysian Standard (MS1480:2007). The results showed that donor expressed breast milk (DEBM), expressed breast milk at home (EBMH), freshly expressed breast milk (FEBM) and powdered infant formula (PIF) were identified as SRM. Expressed breast milk (DEBM, EBMH, FEBM) were known as non-sterile milk which were able to transmit pathogenic microorganisms such as Klebsiella pneumoniae and Pseudomonas aeruginosa derived from the mother or donor. PIF is also not sterile that are associated with Cronobacter sakazakii and Salmonella infections causing serious illnesses among premature and infants. Ready to feed milk (RTF) is classified as non-sensitive material as it is sterile, free from bacterial contamination and safe for high-risk infant’s feeding compare to PIF. Preventive measures were applied to control the significant hazards in all identified SRM to ensure the final product (milk) is safe for consumption

Expressed breast milk feeding: knowledge and attitude of employed mothers

Appropriate knowledge on expressing, storing and use of breast milk are essential for mothers to continue breastfeeding when they return to work. The objective of this study was to assess the knowledge and attitude of employed mothers towards breast milk expression, storage and usage. This cross-sectional study was conducted among 300 full-time employed mothers who delivered at a tertiary hospital in Kuala Lumpur, Malaysia. A content-validated questionnaire consisting of 28 questions testing knowledge and nine questions assessing attitude was used. The highest possible scores for knowledge and attitude were 28 and 45, respectively. The mean score for knowledge was 20.47 (SD 4.06). Mothers who scored ≥ 21 (≥75% of maximum score) were categorized as having “good knowledge” while those who scored <21 were considered to have “poor knowledge”. One hundred and seventy (57%) mothers had good knowledge. Good knowledge was significantly associated with Malay ethnicity, tertiary education, multiparity status and prior breastfeeding experience. Two hundred and nineteen (73%) mothers had a positive attitude (scored ≥34). Malay ethnicity, tertiary education, multiparity status, prior experience in giving expressed milk and feasibility of expressing breast milk at the workplace were significantly associated with a positive attitude. More than half of the mothers had good knowledge, and a higher proportion had a positive attitude towards breast milk expression, storage and usage. Additional support and education should be given to mothers who are: non-Malay, non-tertiary educated and having their first child as these factors were associated with poor knowledge and negative attitude

Breast milk expression for premature infant in the neonatal intensive care unit: A review of mothers’ perceptions

Objective: To identify the existing literature on mothers’ perception towards the impact of expressing breast milk for their premature infant in the neonatal intensive care unit. Method: Guided by the PRISMA Statement review checklist, a systematic review of the Scopus and Web of Science database has identified 10 related studies. The articles were assessed and analysed after evaluated using The Joanna Briggs Institute Critical Appraisal tools (JBI). Thematic analysis was obtained after using Nvivo software as a tool for data analysis by author. Result: Further review of these articles resulted in four main themes— maternal changes during expressing breast milk, pumping challenges and impact of motivation factors to initiating lactation. Conclusion: Expressing breast milk should be recognized as an important way to restructure motherhood with a preterm infant in NICU. However, maintaining expressed breast milk during preterm infants’ treatment period in NICU may increase stress and difficulties for some mothers. Some recommendations are emphasized in relation to the need for more qualitative studies in this issue, which is to have a specific and standard systematic review method for guide research synthesis in context of climate change adaptation

Retropharyngeal Abscess in a Neonate After Extravasation Injury: To Drain or not to Drain?

Neonatal retropharyngeal abscess (RPA) is a rare and life-threatening entity. Most of the cases are idiopathic in nature. We encountered a case of RPA in a newborn secondary to extravasation injury. The presence of neck swelling with clinical deterioration following extravasation of total parenteral nutrition (TPN) infused via a peripherally inserted central catheter at the right upper limb raised the suspicion of neck abscess. This was later confirmed to be RPA based on magnetic resonance imaging of the neck. She was treated with prolonged intravenous antibiotics in the Neonatal Intensive Care Unit (NICU). Her condition gradually improved, evidenced by resolution of the collection on serial imaging. Early recognition and prompt management are crucial to reduce the morbidity and mortality from RPA

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

An analysis of targeted single nucleotide polymorphisms for the risk prediction of gestational diabetes mellitus in a cohort of Malaysian patients

Recent association studies have described genetic variants among type 2 diabetes mellitus (T2DM) and their related traits. Gestational diabetes mellitus (GDM) is pathophysiologically similar to T2DM and may share genetic susceptibility.However, genetic susceptibility within GDM in our own population is still not yet explored. This study was to determine the association of GDM genetic variants in the Malaysian population.We genotyped 384 T2DM related SNPs among 174 cases of GDM and 114 controls of pregnant women using Illumina’s Golden Gate genotyping assay. In this case-control study, a custom of 384-SNP plex of 236 candidate genes was designed using the Illumina’s Assay Design Tool. The data analysis showed 12 SNPs had a significant association with GDM among Malaysians with p values 0.002 to 0.048 with their respective odd ratios. The SNPs rs7754840, rs10946398, rs9465871, rs7756992, rs6823091, rs7935082,rs237889, rs7903146, rs7961581 were significant under additive model while rs10811661, rs1016472, rs2270031 were associated with GDM under recessive model. Three SNPs namely rs7935082, rs1016472 and rs2270031 had reduced risk towards GDM while another nine SNPs which were rs7754840, rs10946398, rs9465871, rs7756992,rs10811661, rs6823091, rs237889, rs7903146 and rs7961581 had increased risk as much 1.75 to 2.62 times. Twelve genetic variants of T2DM were replicated in the SNP profiling among Malaysians GDM. Thus with a more significant result in a bigger sample, SNP screening is potentially a useful method in predicting the risk of gestational diabetes mellitus

Neonatal hypoxic encephalopathy: Correlation between post-cooling brain MRI findings and 2 years neurodevelopmental outcome

Objective: This study aims to evaluate the magnetic resonance imaging (MRI) brain patterns among hypoxic-ischemic encephalopathy (HIE) babies who underwent post-cooling MRI brain as well as to correlate the post-cooling brain scoring with patient’s neurodevelopmental outcome at 2 years. Subjects and Methods: It was a retrospective cross sectional study carried out at a tertiary university hospital. Record of patients diagnosed with neonatal HIE from 2007 until 2016 who completed 72 h of cooling therapy and had MRI brain within 2 weeks of life were included in this study. A new scoring system by Trivedi et al. that emphasizes on subcortical deep gray matter and posterior limb internal capsule injury were utilized upon MRI assessment, using TW, T2W, and diffusion-weighted imaging (DWI) sequences. Cumulative MRI brain score was obtained and graded as none, mild, moderate, and severe brain injury. The MRI brain scoring was then correlated with patient’s 2 years neurodevelopmental outcome using Fisher’s Exact Test. Results: A total of 23 patients were eligible of which 19 term neonates were included. 13% of these neonates (n = 3) had mild MRI brain injury grading with 52.2% (n = 12) moderate and 34.8% (n = 8) severe. There was no significant correlation seen between MRI brain grading and developmental outcome at 2 years old (P > 0.05). Conclusion: There was no significant correlation between neonatal MRI brain injury grading and 2 years neurodevelopmental outcome. Nevertheless, the new MRI brain scoring by Trivedi et al. is reproducible and comprehensive as it involves various important brain structures, assessed from different MRI sequences

Stress and its associated psychosocial factors among Malaysian gifted students

Introduction-The gifted students in Malaysia are housed together in a residential school which provides a competitive, yet stressful environment. The high expectations for academic achievement coupled with perpetual public expectations to be the “future elites” in the society could have made them vulnerable to stress and other psychological disturbances. Objectives-The aims of this study were to assess the prevalence and level of stress among Malaysian gifted students, to determine its correlation with depression and anxiety, and to evaluate its association with academic performance and other socio-demographic factors. Methods-A cross-sectional study was conducted on 227 Malaysian gifted students aged between 16-18 years old, based at PERMATApintar™/ASASIpintar, National University of Malaysia (UKM). Respondents were assessed through self-administered Depression Anxiety Stress Scale-21(DASS-21) questionnaires. Data on socio- demographics, family characteristics and academic performance were also obtained and analysed. Results-Stress was detected in 117 (52.9%) respondents and the mean stress score was 15.6±7.5. Out of those with stress, 43% experienced moderate level of stress, followed by mild level of stress (40%) whilst the remainder 17% experienced severe or extremely severe level of stress. Male students had significantly higher mean stress scores compared to female students (15.7±8.3 vs. 15.5±6.7, p<0.05). Stress was noted to be positively and significantly correlated with depression (r=0.682, p<0.01) and anxiety (r=0.704, p<0.01). There was no significant association between mean stress scores and academic performance, race, parental marital status and total family income. Conclusion-Stress is highly prevalent and is positively correlated with depression and anxiety among these gifted students. The sources of stress need to be explored in a positive perspective. Early screening for detection of pathological stress is highly recommended and promptly managed by a multidisciplinary team