UDCA for TPN-AC in VLBW infants

Screening examinations for retinopathy of prematurity (ROP)—Safety first Hered reports the results of a questionnaire sent to 735 neonatal intensive care units (NICUs) across the United States, querying whether sterile instruments (eyelid speculum and scleral depressor) were used for each infant’s examination for ROP. Hered devised criteria for ‘‘best practice,’’ which included use of separate sterile instruments for each examination, constancy of availability of adequate sterile supplies, disallowing ophthalmologists from bringing their own instruments, and disallowing instrument reuse without sterilization. Surprisingly, only 36% of respondents reported ‘‘best practice’’ management of instruments. Although only 41% of those surveyed returned the questionnaire, it is unlikely that nonrespondents would be more likely to have ‘‘best practice’’ policies. In those responding, recollection of infection(s) occurrence in their NICU related to examination for ROP was highly associated with lack of ‘‘best practice.’’ Although a different study design would be required to validate these findings, simple tenets of infection control are as applicable here as elsewhere. Direct conjunctival inoculation of any microorganism—from the ophthalmologist, another patient, or the environment—is not acceptable. —Sarah S. Long, MD Page 308

UDCA for TPN-AC in VLBW infants The lexicon of the newborn intensive care unit (NICU) includes a bewildering set of abbreviations. Equally bewildering is the nutritional management of the very-low-birth-weight (VLBW) infant. In the presence of immaturity and/or injury to the gastrointestinal tract, sepsis, and hypoxia, oral feedings are often poorly tolerated and total parenteral nutrition (TPN) is required. With prolonged TPN administration, cholestasis (conjugated hyperbilirubinemia) may develop. The incidence of TPN-associated cholestasis (TPN-AC) is high, affecting as many as 50% of recipients. There is no effective therapy other than discontinuation of TPN and initiation of oral feedings. In this issue of The Journal, Chen et al report a retrospective study of VLBW infants who received ursodeoxycholic acid (UDCA) within 14 days of the initiation of TPN. Compared with a similar group of VLBW infants who did not receive UDCA, the former group had a shorter duration of cholestasis and the degree of bilirubin elevation was less intense. A placebo-controlled trial in this group of infants, who are highly susceptible to TPN-AC, is warranted.

—William F. Balistreri, MD Page 317

Regulatory T cells and Kawasaki disease The pathophysiology of Kawasaki disease remains unknown. CD25+ CD4+ T cells, which constitute 5% to 10% of peripheral CD4+ T cells, maintain immunologic self-tolerance. These cells appear to play a critical role in controlling immune reactions to infection and preventing autoimmunity. In this issue, Furuno et al report on the results of a study of CD25+ CD4+ T cells in Kawasaki disease. They found that this population of T cells is decreased in the acute phase of Kawasaki disease compared with normal controls and controls with active infections. The decrease in these regulatory T cells may represent an unusual responsiveness to infection and could play a role in the development of Kawasaki disease by promoting an inflammatory state.

—Stephen R. Daniels, MD, PhD Page 385

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September 2004

The Journal of Pediatrics