Obostrana atrezija hoana u novorođenčeta

Aim: Bilateral nasal obstruction in neonates is a potentially fatal condition since neonates are obligatory nasal breathers. Congenital choanal atresia is a result of the persistence of the embryological bucconasal membrane, which separates the nasal cavity and the nasopharynx in the early embryological developement. The aim of this article is to present this rare anomaly which can be lethal in neonatal period. Case report: A female neonate was born at General Hospital Pula and soon after birth signs of respiratory distress and intermittent cyanosis could be seen. Since clinical condition and oxygen saturation on room air improved when crying, the billateral choanal atresia was suspected. Oropharyngeal airway was inserted to make the airway patent. Insertion of a feeding tube via the nostrils was not possible. Otorinolaringologist was consulted and confirmed the diagnosis. The infant was transfered to a tertiary pediatric center where CT scan of the choanal region was performed, showing membranous billateral choanal atresia. The transnasal endoscopic operation was performed and stents were put in the nostrils. Stents were removed after 11 days. The child was released home in good condition without any signs of respiratory compromise in the follow up period of 2 years. Conclusions: Billateral choanal atresia is a neonatal emergency. The anomaly can be surgically corrected.Cilj: Novorođena djeca obligatorni su nosni disači. Stoga obostrana opstrukcija nosnih hodnika u novorođenačkoj dobi može biti po život opasno stanje. Prikazat ćemo slučaj novorođenčeta s obostranom atrezijom hoana. Cilj ovog članka je prikazati anomaliju koja je izuzetno rijetka u novorođenačkoj dobi, a koja može dovesti do letalnog ishoda. Prikaz slučaja: Terminsko žensko novorođenče rođeno je u Općoj bolnici Pula i odmah po porodu bili su prisutni znakovi respiratornog distresa. Kako su se kliničko stanje i saturacija kisikom poboljšavali kada bi novorođenče plakalo, postavljena je sumnja na obostranu atreziju hoana. Postavljen je orofaringealni „airway“ kako bi se olakšalo disanje djeteta. Nazogastričnu sondu nije bilo moguće postaviti zbog otpora u nosnim hodnicima. Konzultiran je otorinolaringolog koji je potvrdio dijagnozu. Novorođenče je premješteno u Tercijarni pedijatrijski centar (KBC Rijeka) gdje je učinjen CT hoanalne regije na kojem se vidi obostrana membranozna atrezija hoana. Učinjen je operativni zahvat transnazalnom endoskopskom tehnikom i u svaku nosnicu je postavljen stent. Stentovi su uklonjeni jedanaestog postoperativnog dana. Novorođenče je otpušteno kući urednog kliničkog statusa. U daljnje dvije godine praćenja nije bilo znakova respiratornih tegoba. Zaključak: Obostrana atrezija hoana je hitno stanje koje u novorođenačkoj dobi može imati i letalni ishod. Anomalija se liječi kirurški

An exploration of childhood obesity treatment interventions to enhance their long-term effectiveness.

Childhood obesity is a major public health concern. Recent data suggests although childhood obesity prevalence rates appear to be slowing, they are still unacceptably high (Health Survey for England, 2010). To establish a downward trend in childhood obesity rates, effective treatment options are vital. To date, multi-component treatment interventions (MCTIs) incorporating a physical activity, healthy eating and behavioural component and encouraging family involvement appear to be the most promising approach to treat childhood obesity. However, no firm conclusion can be made regarding the sustainability of treatment outcomes (i.e. behavioural & weight related outcomes) (Luutikhuis et al., 2009). This thesis contributed to the evidence base regarding the sustainability of treatment outcomes from MCTIs; considered stakeholder views in the intervention design process and provided an insight into treatment recipient's reasons for attrition from MCTIs.To critically examine the evidence base, Study 1 provided a systematic review of childhood obesity treatment interventions. Results revealed gaps in the evidence in terms of how best to maintain treatment outcomes. Furthermore the study highlighted a need to better consider stakeholder views in intervention design and to fully report treatment fidelity (TF). In Study 2, a qualitative inquiry explored stakeholder perspectives towards childhood obesity treatment and the maintenance of treatment outcomes. Results revealed incongruence between treatment recipients (i.e. parents & children) and treatment deliverers (i.e. health professionals). Treatment recipients suggested they required ongoing support to maintain treatment outcomes. Conversely, treatment deliverers suggested ongoing support is unrealistic and MCTIs should create autonomous individuals who feel confident in their ability to maintain treatment outcomes. Implications included the need to consider maintenance strategies that promote autonomous motivations and perceived competence for behavioural changes in participants with the aim of improving weight maintenance following MCTIs.In light of stakeholder views in Study 2, Study 3A detailed a pilot study to test the efficacy of a maintenance intervention underpinned by Self Determination Theory (Deci & Ryan, 1985; 2000) and that integrated Motivational Interviewing (Miller & Rollnick, 1991; 2002) and cognitive behavioural strategies to improve the sustainability of behavioural and weight related outcomes following a MCTI. A secondary aim of Study 3A was to evaluate TF. Findings supported the potential importance of autonomous motivation and perceived competence in enhancing the maintenance of behavioural and weight related changes. Furthermore this study highlighted a need to explore participants' reasons for attrition from MCTIs. Study 3B provided a qualitative exploration of parents and children's reasons for attrition from MCTIs. Findings underlined the complexity of attrition with several psychological and motivational reasons appearing as the driving source for attrition. Study implications included the need to consider individual families' needs within MCTIs, targeting parents and children's motivations for maintaining a healthy lifestyle and weight differently. The collective implications of the four studies included the need for stakeholders to be involved at all levels of design, implementation and evaluation of MCTIs, the need to assess and report all aspects of TF and the need for MCTIs to develop families' perceived competence and autonomous motivations for health behaviour changes in order to improve the sustainability of weight related outcomes

Epidemiological characteristics of neonates transferred from General Hospital Pula to a tertiary pediatric center in a ten-year-period (2006-2015)

The goal of our study is to present epidemiological characteristics of neonates transferred from General Hospital Pula (GH Pula) to tertiary pediatric center in a ten-year-period. In our retrospective research we analized medical histories of neonates hospitalized at our Department from January 1st 2006 to December 31st 2015 and transferred to a tertiary pediatric center. There are about 1300-1500 live births in our hospital every year. In the ten-year-period 14266 neonates were born and 158 (1,1%) of them were transferred to a tertiary pediatric center. Hundred and fifty of them were transferred to University Hospital Center (UHC) Rijeka and 8 of them to UHC Zagreb. In forty-seven neonates (29,7%) had to be used mechanical ventilation during the transport. Thirty-two (20,3%) premature infants born before the 32nd gestational week were transferred to UHC. The reasons for transportation to a tertiary pediatric center were: congenital heart defects and rhytm abnormalities (N=41), respiratory problems (respiratory distress syndrome, pneumonia, neonatal meconium aspiration sindrome) (N=25), gastrointestinal disorders (N=21), disorders of central nervous system (N=15), disorders of hematological system (N=6), sepsis (N=7), perinatal asphyxia (N=3), disorders on extremities (N=1), metabolic disorders (N=2), chromosomopathies (N=), disorders of genital tract (N=2). Pregnancy complications were present in 53 cases. There were 146 singelton pregnancies and 6 twin pregnancies. One hundred neonates had vaginal delivery (63,3%), and fifty-eight neonates (36,7%) were delivered by cesarean section. Forty-one neonates were resuscitated after birth (25,9%). All premature infants born before the 32nd gestational week and all other premature neonates and term neonates that require long-term mechanical ventilation, specific diagnostic and therapeutic approach or surgical treatment are transferred to a tertiary pediatric center, using vehicles for ground transport with all the necessary equipment and with escort of our medical team. The majority of neonates were transported to UHC Rijeka, and only few neonates were transported to UHC Zagreb

SINDROM USTEZANJA OD OPIJATA U NOVOROĐENAČKOJ DOBI – ISKUSTVA DJELATNOSTI ZA PEDIJATRIJU OPĆE BOLNICE PULA (2001-2010)

Opiate abuse during pregnancy is a serious problem for both the mother and her newborn. The pregnancies of opiate abusing mothers are by definition high risk; the prenatal care is usually inadequate, abuse of alcohol, nicotine and other drugs is often present and there is a high incidence of hepatitis and HIV infections. Shortly after birth, neonates develop acute withdrawal symptoms. In Istria, in the period of 1996 to 2009 there were 2073 registered drug abusers, 355 of them were females. In our study, we present 29 newborns of opiate addicted mothers. The neonates were mostly born on term with spontaneous labor, were eutrophic and with normal Apgar scores. The withdrawal symptoms developed mainly (93%) in the first 48 hours; the most common symptoms were hyperphagia (100%), hyperirritability (79%), tremor (55%) and high-pitched cry (52%). All newborns were treated with Phenobarbital. The initial dose was 5-10 mg/kg/day in 3 to 4 divided doses and the maximal dose was 15 mg/kg/day. The duration of Phenobarbital therapy was 16,6±8,7 days and the hospital stay was 21,6±12,2 days respectively. The cost of the treatment was 13158,8±5563,3 kn. Two neonates were transported to the Pediatric Tertiary Care Center (Clinical Hospital Center Rijeka); one because of convulsions that couldn’t be managed with diazepam and Phenobarbital, and one because of apnoea after birth necessitating mechanical ventilation in an Intensive Care Unit. One newborn was referred to the Orthopedics’ ward because of major anomalies of extremities

SINDROM USTEZANJA OD OPIJATA U NOVOROĐENAČKOJ DOBI – ISKUSTVA DJELATNOSTI ZA PEDIJATRIJU OPĆE BOLNICE PULA (2001-2010)

Opiate abuse during pregnancy is a serious problem for both the mother and her newborn. The pregnancies of opiate abusing mothers are by definition high risk; the prenatal care is usually inadequate, abuse of alcohol, nicotine and other drugs is often present and there is a high incidence of hepatitis and HIV infections. Shortly after birth, neonates develop acute withdrawal symptoms. In Istria, in the period of 1996 to 2009 there were 2073 registered drug abusers, 355 of them were females. In our study, we present 29 newborns of opiate addicted mothers. The neonates were mostly born on term with spontaneous labor, were eutrophic and with normal Apgar scores. The withdrawal symptoms developed mainly (93%) in the first 48 hours; the most common symptoms were hyperphagia (100%), hyperirritability (79%), tremor (55%) and high-pitched cry (52%). All newborns were treated with Phenobarbital. The initial dose was 5-10 mg/kg/day in 3 to 4 divided doses and the maximal dose was 15 mg/kg/day. The duration of Phenobarbital therapy was 16,6±8,7 days and the hospital stay was 21,6±12,2 days respectively. The cost of the treatment was 13158,8±5563,3 kn. Two neonates were transported to the Pediatric Tertiary Care Center (Clinical Hospital Center Rijeka); one because of convulsions that couldn’t be managed with diazepam and Phenobarbital, and one because of apnoea after birth necessitating mechanical ventilation in an Intensive Care Unit. One newborn was referred to the Orthopedics’ ward because of major anomalies of extremities

Neonatal hearing screening program in General hospital Pula (2011.-2015.)

Neonatal hearing screening program (NHSP) started in Croatia at the beginning of year 2002 (University hospital „Sv Duh“, Zagreb), and by the end of year 2002 it was implemented in almost all maternity units in Croatia. From the year 2006 the NHSP is mandatory and there is a specific health legislation. In General hospital Pula, the NHSP is performed before the time of discharge home, using A-OAE method. Those who are positive on hearing impairment (HI), are checked again using the same method 3-4 weeks after the discharge. Those who are positive again are checked using A-ABR method and if they are positive twice, they are sent to the University hospital for a specific audiologic evaluation. The aim of this study is describe the outcome of NHSP in General hospital Pula (Pula, Croatia) in a five-year period (2011.-2015.). In the above mentioned period, there were 6799 live births and NHSP was performed in 6535 neonates (96,12%). Thirty-two children were positive on HI (Two A-OAE checkings plus two A-ABR checkings) and were sent to the University hospital for audiologic evaluation. HI was diagnosed in 12 children; four of them had unilateral HI and eight of them had billateral HI. The incidence of HI in our population is 0,18%

Epidemiological Characteristics of Neonates with Cleft Lip and/or Palate Born at General Hospital Pula in a Ten-Year Period (2003-2012)

Cleft lip and palate are common craniofacial anomalies, requiring complex multidisciplinary treatment and having lifelong implications on affected individuals. The etiology is multifactorial. In our study, we are present 18 neonates with cleft lip and/or palate born at General Hospital Pula in the ten-year period (January 2003 - December 2012). The overall incidence of cleft lip and/or palate was 1,25/1000. The diagnosis was made after birth in all cases. Ultrasound exams of heart, brain, urinary tract and abdominal structures were performed in all neonates. We found five atrial septal defects, one ventricular septal defect, one case of Tetralogy of Fallot and one unilateral renal agenesis. All neonates were fed with special nipples at our Department and after the appropriate growth was achieved the children were discharged home. Craniofacial surgeon was consulted in all cases during the hospital stay and recommended/arranged further diagnostic and therapeutic management at the Tertiary Craniofacial Center (Clinical Hospital Dubrava, Zagreb)

Epidemiological Characteristics of Neonates with Cleft Lip and/or Palate Born at General Hospital Pula in a Ten-Year Period (2003-2012)

Cleft lip and palate are common craniofacial anomalies, requiring complex multidisciplinary treatment and having lifelong implications on affected individuals. The etiology is multifactorial. In our study, we are present 18 neonates with cleft lip and/or palate born at General Hospital Pula in the ten-year period (January 2003 - December 2012). The overall incidence of cleft lip and/or palate was 1,25/1000. The diagnosis was made after birth in all cases. Ultrasound exams of heart, brain, urinary tract and abdominal structures were performed in all neonates. We found five atrial septal defects, one ventricular septal defect, one case of Tetralogy of Fallot and one unilateral renal agenesis. All neonates were fed with special nipples at our Department and after the appropriate growth was achieved the children were discharged home. Craniofacial surgeon was consulted in all cases during the hospital stay and recommended/arranged further diagnostic and therapeutic management at the Tertiary Craniofacial Center (Clinical Hospital Dubrava, Zagreb)

An unusual clinical course of congenital subglottic stenosis – case report

Cilj: Prikazati slučaj neuobičajenog kliničkog tijeka prirođenog laringealnog stridora i razmotriti indikacije za endoskopskim pregledom u takvim slučajevima. Prikaz slučaja: Terminsko eutrofično muško novorođenče je po porodu radi akutnog skrotuma te respiratornih teškoća u vidu tahipneje i hipoksemije primljeno u Kliniku za pedijatriju. Neposredno nakon kirurškog zahvata dijete je rutinski ekstubirano. Međutim, vrlo brzo nakon odvajanja od tubusa ponovno je naglo razvilo respiratorne teškoće obilježene stridorom i hipoksemijom. Dijete je ponovno intubirano i vraćeno na strojnu ventilaciju. U daljnjem tijeku se u više navrata pokušavao provesti postupak ekstubacije. Isti nije bilo moguće učiniti jer bi se nakon odvajanja od tubusa vrlo brzo vratili znakovi respiratornih teškoća pod kliničkom slikom akutnog laringotraheobronhitisa. S obzirom na probleme otežane ekstubacije i ovisnosti o tubusu te na perzistentne atipične simptome krupa i neučinkovitost farmakoterapije, dijete je u dobi od mjesec dana podvrgnuto endoskopskom pregledu dišnih putova. Vizualizirana je koncentrična subglotična stenoza membranskog tipa. U pripremama za liječenje endoskopskom laserskom ablacijom stridor je bivao sve manje izražen. Dva tjedna nakon prvog endoskopskog pregleda učinjen je kontrolni na kojem je vizualni nalaz sugerirao značajnu regresiju subglotičnog membranskog suženja. Odustalo se stoga od planirane intervencije laserom, a stridor se u dojenčeta spontano povukao. Zaključak: Iako je laringomalacija daleko najčešća etiološka podloga prirođenog stridora, i ne predstavlja apsolutnu indikaciju za endoskopijom dišnog puta, isti može biti izazvan nizom drugih rijetkih stanja uključujući prirođenu subglotičnu stenozu. U prikazanom slučaju zabilježena je neuobičajena spontana regresija subglotične stenoze membranskog tipa.Aim: To report an unusual clinical course of an infant with congenital laryngeal stridor. Indications for endoscopic examination of airways in such cases have also been discussed. Case report: A full-term male newborn was admitted to the Department of Paediatrics because of the symptoms of acute scrotum as well as because of breathing difficulties and severe hypoxemia. Soon after surgery the child was extubated but breathing difficulties persisted. A loud inspiratory stridor together with rapid respiratory deterioration occurred. The infant was intubated and underwent mechanical ventilation again. In the following period several trials of extubation were repeatedly unsuccessful despite favourable weaning parameters. Just few hours after each trial of extubation symptoms of acute laryngotracheobronchitis were apparent. Because of extubation failure, tube dependency and persistent atypical symptoms of croup unresponsive to standard pharmacotherapy, endoscopic assessment was performed at the age of one month. Concentric central membranous subglottic stenosis was visualized. While preparing for the endoscopic laser ablation treatment, stridor was getting less pronounced. Two weeks later patient underwent endoscopy again and significant regression of subglottic membrane narrowing was documented. Planned laser intervention was canceled. At the age of four months stridor disappeared. Conclusion: Laryngomalacia is the most common cause of congenital laryngeal stridor and endoscopic evaluation is usually not indicated in such cases. However, there are other causes of congenital stridor which are not so common, including congenital subglotttic stenosis. In this case an unusual spontaneous regression of congenital membranous subglottic stenosis was reported