Journal of Neonatal-Perinatal Medicine - Volume 3, issue 4
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The aim of the
Journal of Neonatal-Perinatal Medicine is to strengthen research and education of the neonatal community on the optimal physical, mental and social health and well-being of infants through high quality publications on neonatal-perinatal medicine and to provide examples of best practices in order to improve the quality, safety and effectiveness of infants’ healthcare worldwide.
The vision for the journal is to be ‘The Reference Journal’ in the field of neonatology.
Abstract: Late preterm births have been on the increase. Though the reasons for the increase in late preterm births are unclear, non-medically indicated inductions and cesarean sections seem to be the significant preventable contributors. Late preterm infants are typically healthier than very preterm infants, but compared to term infants they are at significantly increased risk of both short and long term morbidity and mortality. In the short term they have increased rates of feeding difficulties, hypoglycemia, jaundice,…temperature instability, apnea, respiratory distress and sepsis evaluation compared to term infants. Emerging data also suggest a higher rate of long-term neurodevelopmental, social, and medical morbidity. Therefore, if elective induction of labor or cesarean section at late preterm gestation (34–36 weeks of gestational age) is considered for either maternal or fetal indications, the risk and benefits should be carefully examined. The family and physician should discuss that elective delivery of late preterm infants is not recommended unless absolutely indicated. Due to a considerably higher risk of morbidity and mortality, developing and testing new paradigms of obstetric and fetal management for pregnancies with potential for late preterm delivery are a logical objective. For example, strategies to enhance fetal physiologic maturation when late preterm delivery is unavoidable need to be explored.
Keywords: Late preterm infant, respiratory distress, thermoregulation, apnea, hyperbilirubinemia
Abstract: Objective: To describe common etiologies and diagnostic evaluations performed on term and late preterm neonates with neonatal apnea and to compare these etiologies and evaluations with those infants with infantile acute life threatening event (ALTE). Methods: Infants %isn't in document < 3 months of age and gestational age > 35 weeks, with diagnosis of apnea or ALTE were identified at Boston Children's Hospital from June 2000 to June 2009. Medical records were reviewed for…diagnostic evaluations and discharge diagnoses. For analysis, neonates who presented with neonatal apnea within the first week of life and prior to discharge from the birth hospitalization were classified as the Inpatient Group and infants who presented with apnea post discharge were identified as the Outpatient Group. Infants with clear presenting etiologies were excluded from the study. Results: One hundred otherwise healthy subjects with diagnosis of apnea or ALTE in the study period were identified. Approximately one third were classified as the Inpatient Group. Diagnostic evaluations were highly variable, but testing for bacterial or viral sepsis was most commonly performed. In most cases, an etiology was not determined, and the diagnosis of "apnea of immaturity" was assigned. Other defined etiologic diagnoses included viral infection or pertussis, reflux/aspiration, laryngomalacia, and seizures. Conclusions: Diagnostic evaluation for apnea, in otherwise well-appearing full-term and late preterm infants, remains highly variable. Testing for infection, seizure, laryngomalacia and reflux may determine the majority of treatable etiologies. Guidelines for diagnostic evaluations and treatment strategies are clearly needed.
Keywords: Apnea, acute life threatening event, ALTE
Abstract: Objective: To determine both the incidence of perinatal hypoxic ischemic encephalopathy (HIE) in a group of preterm infants 32–36 weeks gestational age at a single center and the outcomes of these patients. Study design: The number of infants 32–36 weeks gestational age without major congenital anomalies born at Vanderbilt University Hospital between January 1, 2002 and June 30, 2008 was determined and a retrospective chart review was performed on those infants with a 5-minute…Apgar score of less than 6. Infants were considered to have experienced perinatal HIE if they met all of the following criteria: 5-minute Apgar score less than 6 Cord or initial patient blood pH less than 7.00 or base deficit greater than 15 (mmol/L) Evidence of encephalopathy at or shortly after birth (seizures, hypotonia) History of a sentinel event at the time of delivery No other cause of encephalopathy (sepsis, hypermagnesemia, hemorrhage, hyponatremia, drug induced) Preterm infants with 5-minute Apgar score less than 6 not meeting all of the criteria were considered not to have had perinatal HIE. A poor outcome was defined as death, or cerebral palsy, or neurodevelopmental impairment, or bilateral deafness, or bilateral blindness. If no follow-up data was available, the patient was recorded as being alive at discharge and considered to be normal. Results: Between January 1, 2002 and June 30, 2008 there were 1,325 infants 32–36 weeks gestational age born at Vanderbilt University Medical Center. The incidence of perinatal HIE in these patients was 12/1325 (0.9%). 58.33% of these patients suffered poor outcomes. Conclusion: With a similar incidence and experience of adverse sequelae as the term infant, preterm infants 32–36 weeks in gestation with perinatal HIE should be considered for future randomized controlled studies for treatment of this potentially devastating injury.
Abstract: Objective: The plastic used in many medical devices is composed primarily of the plastic polyvinyl chloride (PVC). PVC is made flexible by treating it with chemical compounds called plasticizers. The most commonly used plasticizer is di(2-ethylhexyl) phthalate (DEHP). The general population is exposed daily to DEHP and one of its many metabolites, mono(2-ethylhexyl) phthalate (MEHP), primarily through food and aerosolization of environmental exposure. Exposure rises dramatically in premature or ill neonates, who are…exposed to medical devices including enteral, blood and infusion bags, tubes and infusion devices. The rate of leaching of DEHP depends on many factors, including contact with lipophilic solutions and the amount of DEHP found in the product. Highly lipophilic substances readily extract plasticizers from PVC bags and tubes. Our objective was to determine the concentration of DEHP and MEHP in the urine of infants undergoing extracorporeal membrane oxygenation (ECMO) and near-miss ECMO to determine if ECMO results in increased concentrations of DEHP and MEHP in the urine. Study design: Using an in vivo prospective comparative study design, we evaluated 12 term or near-term neonates requiring ECMO. Our control population included 17 neonates with similar underlying diagnoses, referred to our NICU for ECMO but who ultimately responded to maximal medical therapy without ECMO. Two baseline urine samples were collected on admission to the NICU for DEHP and MEHP analysis on both the ECMO and near-miss populations. Daily urine samples were collected sequentially for five days in both populations. Urine samples were collected prior to discharge/transfer for both populations. Urinary DEHP and MEHP analysis was performed using tandem mass spectroscopy. Demographic data was collected for each patient. Results: We enrolled a total of twenty-nine patients in the study. All patients were transported to our NICU from outside birthing centers. Twelve neonates required ECMO support. The other seventeen patients responded to maximal medical therapy without ECMO. The mean DEHP for the ECMO group was 38.0 (95% CI=29.6, 47.5) compared to 33.0 (95% CI = 26.6, 40.1) in the near-miss group. The mean MEHP for the ECMO group was 29.8 (95% CI=22.4, 38.2) compared to 26.1 (95% CI=20.6, 32.3) for the near-miss group. Conclusion: Even though urinary levels of DEHP and MEHP were slightly higher in the ECMO group compared to the near-miss group, these differences were not statistically significant.
Abstract: Background: Recently, we observed an increase in the number of late preterm neonates with pneumatosis coli (Pcoli) an infrequently reported benign form of necrotizing enterocolitis (NEC). Objective: To review our experience (2000–09) with infants who presented with visible blood in the stools (VBS) and pneumatosis intestinalis (PI). Methods: Retrospective cohort study. There were 65~infants who had VBS and PI. Thirty-two who constituted the pneumatosis coli (Pcoli) group were compared with 33 infants with…VBS and PI who were designated as classic NEC. Results: 75% of Pcoli cases occurred during 2008–09. Demographics and obstetrical risk factors (except for preterm labor and antepartum steroid use) for the mothers of both groups were similar. Ninety-one percent of Pcoli were $\geq $ 34w while 82% of classic NEC cases were ⩽ 33w GA. At the time of diagnosis 70% of infants in the Pcoli group and 30% of those in the classic NEC group were < 7d old. In the Pcoli group prior to VBS, 78% of these infants were taking formula and 22% formula and breast milk. VBS was the only clinical sign which prompted radiographic evaluation. Thirty of these 32 infants had blood cultures (all negative), 20% received antibiotics, 50% continued with feedings, no patients had surgery and all survived. In the classic NEC group prior to VBS 47% were taking formula, 47% formula and breast milk and 6% breast milk. Seventy-four percent of these infants had abdominal distention, emesis or apnea, 48% had abnormal WBC-diff, and 6 infants had positive blood cultures. Ten infants had surgery and 3 of them expired. Among Pcoli infants, PI was limited to the colon in 94% of the cases. In the classic NEC group 35% of infants had difuse PI, 65% had focal PI and 27% had portal venous gas. Conclusion: Pcoli is a benign form of NEC that affects mainly late preterm or term infants, who once diagnosed, in contrast to classic NEC patients, require less intensive care. Further studies are needed to elucidate etiology (including the role of feeding practices) and to explore preventive or therapeutic measures.
Keywords: Pneumatosis coli, benign necrotizing enterocolitis, late preterm infant
Abstract: Objective: To define the range of intra-abdominal pressure (IAP) in sick neonates using surrogate measurements of bladder pressure. Methods: Neonatal intensive care unit (NICU) patients requiring an indwelling urinary catheter were enrolled in the study. A bladder pressure monitoring system was attached to the catheter and measurements recorded every 2–4 h. Results: Data were collected on 30~neonates. Median birth weight, gestational age, and duration of study were 2580 g, 37 wk, and 5.5 d, respectively. 1219 measurements…were obtained with median (interquartile range)= 8 (3–10) mmHg and 90th percentile =13 mmHg. 18 neonates (60%) required abdominal surgery and 85% of IAP values > 90th percentile occurred post operatively (p< 0.001). 72% (13/18) of post operative patients had IAP > 90th percentile compared to 18% (2/12) of non surgical patients (p=0.008). Conclusions: Measuring IAP in sick neonates can be done as part of neonatal intensive care. The time of highest risk for elevated IAP appears to be in the post-operative period.
Abstract: Objective: Underdeveloped thermoregulatory capability predisposes the preterm infant to metabolic instability. An ideal incubator environment should reduce thermal challenges of routine care. We compared the thermal responses of the newborn pig to clinical manipulations in 2 incubators and the impact of a heating blanket on these responses. Design: Anesthetized, paralyzed, and ventilated newborn pigs were randomized to pre-warmed Caleo® or Giraffe® Omnibed®, with or without a…heating blanket, and subjected to warmup and a series of open door perturbations. The temperature variation, time constant, and change in skin temperature were calculated and analyzed by 2-factor analysis of variance. Results: There were no differences between the incubators during warm-up; incubator plus heating blanket decreased the time constant, independent of device. With the side access door open, the change in skin temperature was less in the Caleo®; the heating blanket attenuated the change in skin temperature in both devices. Conclusion: These data demonstrate device and clinical manipulation-dependent differences in the thermal responses of the newborn pig.
Abstract: Objective: To establish a score to predict late-onset sepsis in very low birth weight infants. Study Design: Two successive prospective multi center studies in very low birth weight infants were used: infants in the first served as calculation cohort, those in the second as validation cohort. Infants were divided into a sepsis group, a non-sepsis group, and an undetermined group by predefined criteria partially based on the sepsis definition by the Robert Koch institute.…In the first study 39 parameters recorded daily were compared in the sepsis and the non-sepsis group between Day -3 and Day 0 of sepsis. The score was created combining those parameters with the highest area under the ROC curve. Results: A score was generated consisting of five clinical and laboratory categories: peripheral circulation, respiration, gastrointestinal tract, general laboratory findings and infection-specific laboratory findings. Sepsis was defined as pathological findings in at least 2 out of these 5 categories. This scoring system reached a sensitivity of 84.0% and a specificity of 91.7% (PPV 87.5% and NPV 89.2%) in discriminating the sepsis group from the non-sepsis group in the validation cohort. Conclusion: We created a score for early diagnosis of late-onset sepsis in very low birth weight infants. The score may be of value when comparing infants with sepsis in multi center studies.
Keywords: Late onset neonatal sepsis, NICU, sepsis score, very low birth weight
Abstract: Objective: This study was undertaken to study physiological and behavioral pain responses of neonates and to assess the analgesic effect of orally administered sucrose as assessed by the behavioral pain rating scale [DAN (Douleur Aiguë du Nouveau-né) score] during venepuncture in neonates. Method: In 50 healthy neonates requiring bilirubin estimation, blood sugar was randomly assigned to receive 2ml of 30% sucrose two minutes before the venepuncture (intervention) in comparison to a group not receiving…sucrose (control). During the procedure, pain was assessed by behavioral pain rating scale [Douleur Aiguë Nouveau-né (DAN) scale]. The heart rate, oxygen saturation before, during and after procedure as well as crying time was noted. Results: There was significantly lower pain (DAN) score in the intervention group compared to control group. Median (inter-quartile) DAN score in the group receiving sucrose was 3 (1.5–5.5) compared to 7 (5–9.5) in control group. The difference in median DAN score between two groups was statistically significant (p=0.0001). There was a significant increase in heart rate in the control group whereas in group receiving sucrose, no significant change in heart rate was observed. Similarly, oxygen saturation was also significantly reduced in control group when compared to intervention group. Conclusion: The analgesic effect of 30% sucrose was large enough to be clinically significant and can thus be detected by behavioral rating scale for acute pain (DAN). Sucrose reduces the physiological alteration occurring during venipuncture.
Abstract: Anterior myelocystocele has not been reported previously. Our case showed anterior herniation of myelocystocele sac. This challenges the established hypothesis of Steinbock and Cochrane which holds partial neural-epidermal adhesion responsible for drawing the neural tissue outwards towards the skin. This cannot explain occurrence of anterior myelocystocele as there is no neural-epidermal adhesion anteriorly at any stage of embryogenesis. Myelocystoceles need to be differentiated from meningoceles as early as possible (preferably prenatally) due…to different surgical treatments and possibility of fetal intervention.
Abstract: Presence of systemic venous anomalies including a persistent left superior vena cava to a dilated coronary and interrupted inferior vena cava with azygous continuation are extremely rare in absence of heterotaxia or cardiosplenic syndrome. For this reason, the diagnosis of extracardiac venous anomalies can often be missed in absence of a heterotaxia as was the case in our patient whose prior fetal echocardiogram and the first postnatal echocardiogram read by other pediatric cardiologists failed to detect…these anomalies. We report these systemic venous anomalies in a fetus in the absence of heterotaxia and further describe the echocardiographic findings helpful in their detection in-utero.
Keywords: Fetus, echocardiogram, interrupted inferior vena cava, persistent left superior vena cava, azygous vein, congenital cardiac malformation, cardiosplenic syndrome, left atrial isomerism, heterotaxia, systemic venous anomalies
Abstract: We report the case of a newborn infant who developed persistent pulmonary hypertension of the newborn and was successfully treated with a combination of inhaled nitric oxide (iNO), nasal continous positive airway pressure (nCPAP) and seldinafil. This approach may decrease the need for intubation and mechanical ventilation and subsequently lung injury in similar cases.
Abstract: We studied the case of a newborn infant with severe congenital malformations following carbimazole exposure during the early weeks of pregnancy. The pattern of these malformations – choanal atresia, tetralogy of Fallot, duodenal atresia, dysmorphic features, and hypothelia – is unusual and is consistent with methimazole embryopathy.
Keywords: Carbimazole, choanal atresia, duodenal atresia, tetralogy of Fallot, embryopathy