Cholestatic jaundice in early infancy is a complex diagnostic problem. Misdiagnosis of cholestasis as physiologic jaundice delays the identification of severe liver diseases. In the majority of infants, prolonged physiologic jaundice represent benign cases of breast milk jaundice, but few among them are masked and caused by neonatal cholestasis (NC) that requires a prompt diagnosis and treatment. Therefore, a prolonged neonatal jaundice, longer than 2 weeks after birth, must always be investigated because an early diagnosis is essential for appropriate management. To rapidly identify the cases with cholestatic jaundice, the conjugated bilirubin needs to be determined in any infant presenting with prolonged jaundice at 14 days of age with or without depigmented stool. Once NC is confirmed, a systematic approach is the key to reliably achieve the diagnosis in order to promptly initiate the specific, and in many cases, life-saving therapy. This strategy is most important to promptly identify and treat infants with biliary atresia, the most common cause of NC, as this requires a hepatoportoenterostomy as soon as possible. Here, we provide a detailed work-up approach including initial treatment recommendations and a clinically oriented overview of possible differential diagnoses in order to facilitate the early recognition and a timely diagnosis of cholestasis. This approach warrants a broad spectrum of diagnostic procedures and investigations including new methods that are described in this review.

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BackgroundPeripherally inserted central catheters (PICCs) provide secure intravenous access for the delivery of life-sustaining medications and nutrition. They are commonly used in pediatrics. Confirmation of correct central catheter tip position is crucial. Verification is usually done by a radiograph. The aim of this study is to evaluate the ability of Fractional Multiscale image Processing (FMP) to detect PICC tips on the digital chest radiographs of neonates.MethodsA total of 94 radiographs of 47 patients were included in the study. 29 patients were male, 18 were female. The mean age of all examined children was 9.2 days (range 0–99 days). In total, six readers (two radiologists, two residents in radiology, one last year medical student, one neonatologist) evaluated 94 unprocessed and catheter-enhanced radiographs using a 5-point Likert scale (1 = poor catheter tip visualization, 5 = excellent catheter tip visualization). Additionally, the two radiologists evaluated the diagnostic confidence for chest pathologies using a 5-point Likert scale (1 = poor diagnostic confidence, 5 = excellent diagnostic confidence). Radiographs were evaluated on a dedicated workstation.ResultsIn all cases, the catheter-enhanced radiograph rated higher than (n = 471), or equal (n = 93) to, the unprocessed radiograph when visualizing catheter tips. 87% of the catheter-enhanced radiographs obtained a rating of 4 or higher, while only 42% of unprocessed radiographs received 4 or more points. Regarding diagnostic confidence for chest pathologies one radiologist rated two catheter-enhanced radiographs higher than the unprocessed radiographs, while all other 186 evaluations rated the catheter-enhanced radiographs equal to (n = 78) or lower than (n = 108) the unprocessed radiographs. Only 60% of the catheter-enhanced radiographs yielded a diagnostic confidence of 4 or higher, while 90% of the unprocessed images received 4 or more points.ConclusionCatheter-enhanced digital chest radiographs demonstrate improved visualization of low contrast PICC tips in neonates compared to unprocessed radiographs. Furthermore, they enable detection of accompanying chest pathologies. However, definitive diagnosis of chest pathologies should be made on unprocessed radiographs.

Intrauterine growth restriction (IUGR) is a risk factor for the development of hypertension in later life. Insulin-like growth factor I and growth hormone (GH) have the potential to improve metabolic syndrome after IUGR in adult animals. The objective of the present study was to examine whether transient GH treatment of pups after weaning can prevent the development of arterial hypertension in adult rats. IUGR was induced in Wistar rats by isocaloric protein restriction in pregnant dams and litter size was reduced to six male neonates after birth. Recombinant human GH was applied by daily subcutaneous injections at a dose of 3 microg/g body weight between days 24 and 60 of life. Control animals received vehicle treatment (VEH) only. Birth weight was significantly lower in low protein (LP) animals than in normal protein (NP) animals (5.1 +/- 0.3 g vs. 5.9 +/- 0.7 g, p < 0.05). Until weaning at day 23, LP animals reached similar body length, but had reduced body weight compared to NP animals. Intraarterially measured mean arterial blood pressure at day 120 was elevated in LP-VEH compared to NP-VEH animals (113 +/- 6 mmHg vs. 101 +/- 6 mmHg, p < 0.01). However, transient GH-treatment did not prevent arterial hypertension in LP animals (112 +/- 5 mmHg). Our data suggest that GH treatment between days 24 and 60 of life does not or at least not permanently reprogram blood pressure elevation after IUGR.