Journal of Neonatal-Perinatal Medicine - Volume 4, issue 4

Authors: McAbee, G.N. | Donn, S.M. | McDonnell, W.M.

Article Type: Research Article

Abstract: The doctrine of informed consent is becoming an increasingly important ethical and medico legal issue and has significantly evolved over the past few decades. This doctrine is especially challenging in neonatal care because of the complexities of the physician-parent relationship and the uncertainty of therapeutic intervention and outcome. This commentary discusses two very important legal decisions about informed consent, which have received widespread attention in legal and insurance company publications. It discusses the impact of these decisions for neonatal care.

Keywords: Informed consent, neonatology

DOI: 10.3233/NPM-2011-52811

Citation: Journal of Neonatal-Perinatal Medicine, vol. 4, no. 4, pp. 303-307, 2011

Authors: Limrungsikul, A. | Erenberg, F. | Martin, R. | Walsh, M.

Article Type: Research Article

Abstract: Background: Some neonatologists question whether patent ductus arteriosus (PDA) closure in premature infants is necessary because interventions to promote ductal closure have not been shown to improve long term outcomes. To date, no study has investigated how neonatologists and pediatric cardiologists manage PDA in the era of antenatal steroids and surfactant use. Objectives: To determine the degree of practice variation among neonatologists and pediatric cardiologists in the diagnosis and therapeutic interventions for PDA in premature infants. Methods: Surveys were sent by standard postal mail service to neonatologists (n = 1280) and pediatric cardiologists (n = 758) listed in the directories …of neonatal-perinatal medicine and pediatric cardiology training programs in the United States. Result: The overall response rate was 46% (946 of 2038). There was agreement between neonatologists and pediatric cardiologists for clinical signs and symptoms used to diagnose hemodynamically significant patat ductus arteriosus (HsPDA). In contrast, echocardiographic parameters used to identify HsPDA differed between subspecialists. With regard to intervention, both neonatologists and pediatric cardiologists recommended treating HsPDA. Almost half of neonatologists employed a practice of prophylactic treatment of PDA, although primary reasons for using prophylactic strategies were significantly different between subspecialist groups. Conclusion: There is considerable practice variation in diagnostic echocardiographic criteria and treatment of PDA in preterm infants among neonatologists and pediatric cardiologists. Further investigations are needed to determine whether specific echocardiographic parameters are associated with successful treatment, and the relation to outcomes in this population. Show more

Keywords: Premature infants, patent ductus arteriosus, survey, drug treatment, ligation

DOI: 10.3233/NPM-2011-2768

Citation: Journal of Neonatal-Perinatal Medicine, vol. 4, no. 4, pp. 309-317, 2011

Authors: Mathew, O.P. | Ahmed, N. | Abushaala, J.

Article Type: Research Article

Abstract: Objective: The primary aim of this study was to determine whether the incidence of bradyarrhythmias in preterm infants decreases with maturation. Study design: Cardiorespiratory waveforms in preterm infants with gestational age ≤ 32 weeks were acquired on a networked computer after they were weaned to room air or to supplemental oxygen through a nasal cannula. Waveforms for 24 hours were screened for bradycardia utilizing Neoscan® software. Bradyarrhythmias were classified as non-sinus atrial, junctional, ventricular, and other. Results: Sixteen preterm infants were evaluated longitudinally. Their mean birth weight and gestational age were 1030 ± 232g and 28.2 ± 2.2 weeks, respectively. …These infants were evaluated initially at a mean postmenstrual age (PMA) of 31 ± 1.2 weeks. Mean number of bradycardia episodes was 1.25 ± 0.95 per hour; of these 0.73 ± 0.78 had bradyarrhythmias. These infants were subsequently evaluated at a mean PMA of 34.4 ± 2.0 weeks. Mean number of bradycardia episodes had decreased to 0.85 ± 0.79 per hour (P < 0.05). Furthermore, the number of bradyarrhythmias decreased significantly to 0.33 ± 0.37 per hour (P < 0.05). This decrease was also significant when expressed as a ratio of arrhythmia episodes to total bradycardia episodes (P < 0.05). The vast majority of bradyarrhythmias were non-sinus atrial rhythm; junctional rhythm accounted for the remaining. Nine infants exhibited more than one type of arrhythmia. Conclusion: Non-sinus bradyarrhythmias occur frequently in preterm infants and its incidence decreases with postnatal maturation. Show more

Keywords: Arrhythmia, bradycardia, maturation, prematurity, desaturation

DOI: 10.3233/NPM-2011-50211

Citation: Journal of Neonatal-Perinatal Medicine, vol. 4, no. 4, pp. 319-322, 2011

Authors: Carey, A.J. | Verdugo, D. | Palacios, G. | Lipkin, W.I. | Polin, R.A.

Article Type: Research Article

Abstract: Background: In infants with suspected neonatal sepsis, standard culture methods may fail to detect bacteremia due to a lower concentration of pathogens in the bloodstream. We sought to determine if MassTag PCR could accurately and reliably detect pathogens in neonates with a high suspicion of sepsis. Methods: Infants in a Level III Neonatal Intensive Care Unit (NICU) were identified by the primary medical team as having clinical signs consistent with a high likelihood of infection. Samples of sterile bodily fluid (i.e.: blood and CSF) were obtained and evaluated both by standard culture methods and the study method. The study samples …were analyzed by MassTag-PCR, using primers that targeted twelve common neonatal bacterial pathogens. Results: Samples were collected from a total of 32 infants (gestational age 24–40 weeks) with clinical sepsis. There were 8 infants with a positive result on MassTag PCR. One infant had Staphylococcus aureus identified in the blood by MassTag PCR, in whom the culture was also positive. In addition, there was one infant with a positive MassTag assay for S. aureus in the CSF. This infant had a positive blood culture for S. aureus and negative CSF culture, with normal cell counts and chemistry values. There were five infants with negative blood cultures, but a positive result on MassTag PCR for Pseudomonas three, Enterococcus one, and Propionibacterium acnes one. There was one PCR assay considered to be a contaminant with Staphylococcus species. Conclusions: MassTag PCR could potentially serve as an important method of pathogen detection in the NICU, in particular for gram-negative and anaerobic pathogens. Further studies should investigate whether infants with positive MassTag PCR and negative culture truly represent infections that could not be detected by routine blood culture. Show more

Keywords: Neonate, NICU, pathogen detection, PCR

DOI: 10.3233/NPM-2011-52611

Citation: Journal of Neonatal-Perinatal Medicine, vol. 4, no. 4, pp. 323-327, 2011

Authors: Adu-Amankwa, N.A. | Rais-Bahrami, K.

Article Type: Research Article

Abstract: Objective: Each year thousands of preterm and sick infants are admitted to neonatal intensive care units (NICU) requiring continuous cardio respiratory monitoring. A new and innovative wireless monitor was evaluated which incorporates two unique non invasive electrodeless sensors for the detection of respiration and cardiac waveforms. The objective of the study was to determine if the sensors used by the wireless Monitor (PGS Medical Research and Electronic Design, LLC, Fairfield, CT) provide equal performance for data acquisition compared to reference monitors. A further objective was to evaluate the potential ease of application and lack of wires offered by this technology …in the NICU. Methods: After approval from the Institutional Review Board (IRB) and obtaining parental consent, 25 patients were enrolled in the study. The wireless sensor belt was then placed around the abdomen. Breathing and heart rate waveform were recorded from the wireless research monitor and from the existing NICU equipment (reference monitor) for a total of 90 minutes. Results: Waveform data was recorded on a 4 channel analog Windaq system. Each file was then reviewed and 5 selections of at least 3 minutes duration wherein both monitors were displaying stable waveforms were compared for parity of peaks representing a beat. Manually counting the peaks showed a 96% correspondence with standard deviation of ± 2 beats discrepancy between the two monitors. Conclusion: The data from the study supports the wireless/electrodeless monitor as an effective method to collect cardio respiratory data in the NICU patient population. Show more

Keywords: Neonates, intensive care, wireless monitor

DOI: 10.3233/NPM-2011-51311

Citation: Journal of Neonatal-Perinatal Medicine, vol. 4, no. 4, pp. 329-332, 2011

Authors: Lemus-Varela, M.L. | López-Salazar, H. | Gómez-Meda, B.C. | Zamora-Perez, A.L. | Sola, A. | Perea-Díaz, J. | Zúñiga-González, G.M.

Article Type: Research Article

Abstract: Objective: To determine genotoxicity, cytotoxicity and methemoglobinemia of a mixture of lidocaine (LD) and prilocaine (PL) (EMLA® ) in an experimental model. Study design: Newborn hairless rats were studied in a prospective random and masked design. Groups I–III received topically LD-PL mixtures at 5, 10 or 20% respectively, group IV: petrolatum (negative control); group V: 5-fluorouracil 5% (genotoxicity and cytotoxicity positive control); and group VI: aniline (methemoglobinemia positive control). Blood samples were collected every 24 h from 0–144 hours. Genotoxicity and cytotoxicity were assessed by the micronucleus assay. Changes in micronucleated erythrocytes and micronucleated polychromatic erythrocytes evaluated genotoxicity, and polychromatic …erythrocytes in 1,000 total erythrocytes were used to determine cytotoxicity. Methemoglobin values were quantified by spectrophotometry. Results: The micronucleated erythrocytes number increased proportionally to the LD-PL mixture dose (p = 0.04), from 60% in group II until 90% in group III in relation to their basal value; however, no cytotoxicity effect was observed. Methemoglobin values increased in groups II, III, V and VI from the second day (p < 0.05). Conclusion: Topical administration of LD-PL mixture (10% and 20%) to neonatal rats show genotoxic effects and produces methemoglobinemia. Clinical implications of these findings require urgent further investigation before continuing to use LD-PL mixture routinely. Show more

Keywords: Local anesthetics, neonatal, genotoxicity, pain

DOI: 10.3233/NPM-2011-51011

Citation: Journal of Neonatal-Perinatal Medicine, vol. 4, no. 4, pp. 333-339, 2011

Authors: Chan, J.T. | Gill, G. | Chan, G.M.

Article Type: Research Article

Abstract: Objective: To compare the effects of four thawing methods on the fat concentration, free fatty acid concentration, total antioxidant capacity, and epidermal growth factor concentration of frozen human milk. Study design: Milk samples were obtained from 16 lactating mothers who delivered prematurely. Milk samples were divided into aliquots and frozen at −20°C. Aliquots were thawed at 4°C (refrigerator), 20°C (room temperature), 50°C (hot water) or microwaved. After thawing, the aliquots were analyzed for fat, free fatty acid concentration, total antioxidant capacity, and epidermal growth factor concentration. Results: The mean fat concentration ( ± SD) was 6.0 ± 1.8 (4°C), 5.9 …± 2.3 (20°C), 4.9 ± 1.8 (50°C), and 4.1 ± 1.8% (microwave), P < 0.001. The free fatty acid concentration was 4.0 ± 1.1 (4°C), 3.6 ± 1.4 (20°C), 2.9 ± 1.5 (50°C), and 2.4 ± 1.4 nmol/μl (microwave), P < 0.001. The total antioxidant capacity was 8.8 ± 1.2 (4°C), 8.2 ± 1.2 (20°C), 7.9 ± 1.5 (50°C), and 7.1 ± 1.1 nmol/μl (microwave), P < 0.001. No statistically significant change in epidermal growth factor concentration was noted. Conclusions: Thawing at 4°C and 20°C had the least effects with microwaving having the most effects on human milk's fat concentration, free fatty acid concentration, and total antioxidant capacity. Epidermal growth factor concentration was not affected by the thawing methods. Show more

Keywords: Antioxidants, child nutritional sciences, epidermal growth factor, fatty acids, feedings, freezing, hot temperature, humans, infant, lactation, lipids, newborn, premature, microwaves, milk, refrigeration, temperature

DOI: 10.3233/NPM-2011-51211

Citation: Journal of Neonatal-Perinatal Medicine, vol. 4, no. 4, pp. 341-346, 2011

Authors: Tantawy, A.E.El | Zekri, H.K. | Ezzeldin, Z.M. | Amin, A.I.

Article Type: Research Article

Abstract: Objectives: To determine the safety, efficacy, and cost of a second course of oral ibuprofen (OI) in closure of patent ductus arteriosus (PDA) in preterm infants. Material and methods: Preterm infants ≤34 weeks gestational age (GA) who had clinically significant PDA at a postnatal age from 48–120 hours were subjected to initial oral ibuprofen course and evaluated by echocardiography. Failure of PDA closure was followed by a second course of three doses of OI. Results of echocardiography and laboratory investigations were compared before and after each ibuprofen course. The cost of ibuprofen was calculated for each patient. Results: One-hundred patients …were enrolled; their mean gestational age was 31.3 ± 1.3 weeks and mean birth weight was 1350 ± 271 g. A total of 76 infants (76%) had PDA closed after the first course and an additional 9/19 patients (47.5%) had PDA closure after the second course. Respiratory improvement and significant decrease in the fraction of inspired oxygen were observed (P < 0.001 and P = 0.02 respectively). Non significant changes regarding urine output, renal function and platelet count were encountered after the second course. Among the 19 infants who received two courses of ibuprofen, only one (5%) had intraventricular hemorrhage. The cost of oral ibuprofen dosage was trivial ($0.2). Conclusion: Oral ibuprofen is a non-expensive drug that can be used effectively for PDA closure in premature infants. A second course of ibuprofen further improves the efficacy of the drug without clear short-term complications. Large scale trials are needed to examine side effects and long term sequelae. Show more

Keywords: Oral ibuprofen, second course, patent ductus arteriosus, premature neonates

DOI: 10.3233/NPM-2011-51411

Citation: Journal of Neonatal-Perinatal Medicine, vol. 4, no. 4, pp. 347-352, 2011

Authors: Kitsantas, P. | Gaffney, K.F. | Bunch, S. | Franklin, P.

Article Type: Research Article

Abstract: Objective: To examine racial differences in survival among small, large and appropriate for gestational age (SGA, LGA and AGA, respectively) non-Hispanic black and non-Hispanic white infants and assess the impact of selected sociodemographic and behavioral risk factors on infant survival for the three weight for gestational age (WGA) groups. Methods: Data were obtained from the North Carolina (U.S.) linked birth/infant death files from 1999 to 2007. Kaplan-Meier survival curves and Cox regression were used to assess the effect of maternal race and other factors on infant survival for all WGA groups. Results: Unadjusted analyses demonstrated that black SGA and LGA …infant survival time was greater than that of white infants in these categories. However, when our analyses were adjusted for sociodemographic, behavioral, and life factors, the significant differences in survival between black and white infants no longer remained for any of the three WGA groups. We did not find any significant racial differences in survival time among the AGA infants. Conclusion: Overall, the findings of this study indicate that infants born to black mothers do not survive longer than infants born to white mothers. Further, our results show that several socioeconomic and behavioral factors need to be addressed if the national Healthy People 2020 objective of reducing infant mortality rate is to be met. Show more

Keywords: Infant mortality, preterm birth, weight for gestational age, infant survival, race

DOI: 10.3233/NPM-2011-52111

Citation: Journal of Neonatal-Perinatal Medicine, vol. 4, no. 4, pp. 353-361, 2011

Authors: Shah, S.I. | McKenna, K. | Hudak III, J. | Cohen, J.C.

Article Type: Research Article

Abstract: Background: Exogenous surfactant is a mainstay of neonatal care, however, time-dependent changes in respiratory function during the peri-surfactant period are not well known. This critical time contributes to baro- and volu-trauma effects, heralding chronic lung disease. The purpose of the study was to determine real-time changes in respiratory function minute-by-minute during the immediate post-surfactant period and determine the effect of increased PEEP on these parameters. Methods: Thirty, time-pregnant, Sprague-Dawley rat pups received surfactant or phosphate buffered saline (PBS) control between post-natal age 10 and 12 days. Airway resistance, compliance, tissue dampening, elastance, eta (ratio of dampening to elastance), were measured …at PEEPs of 3 and 6 cm H2 O at 1, 2, 5, 8, 12 and 15-minutes. Pressure-Volume curves were generated. Student's t-test of running averages of each respiratory function parameter were used for comparison. Results: At PEEP of 6 cm H2 O, airway resistance remained elevated at 12 minutes (p < 0.01), but was significantly lower by 8 minutes in the group at PEEP of 3 cm H2 O (p < 0.05). Increased PEEP led to an earlier changes in tissue dampening (2 min vs. 8 min, p < 0.01), earlier increases in elastance (5 min vs. 8 min, p < 0.05), and an earlier alteration in eta (2 min vs. 15 min, p < 0.01). Time dependent pressure-volume loops demonstrated significant decreases in variability within 2 minutes at PEEP of 3 (p < 0.001). The PV curves were normalized at 5 minutes. Conclusions: Acute minute-by-minute changes occur in airway resistance, elastance, compliance, eta and tissue damping occur following surfactant delivery, but normalize by 15 minutes. At higher PEEPs, respiratory parameters normalized earlier and variability in PV curves was reduced. Consideration of the time-dependent nature of respiratory function changes in the peri-surfactant period may improve administration. Show more

DOI: 10.3233/NPM-2011-2751

Citation: Journal of Neonatal-Perinatal Medicine, vol. 4, no. 4, pp. 363-372, 2011