Objective: The aim of this study was to establish normal SVC flow values in healthy term infants the first three days of life and to evaluate the feasibility and reliability of the off-line analyses.
Design: Doppler echocardiography of SVC flow was performed in 48 healthy term infants the first three days of life. Off-line analyses were thereafter performed by one cardiologist to investigate the changes in SVC flow from day one to three and to establish normal values. Intra- and interobserver variability was analysed in a subset of 20 infants by three paediatric cardiologists.
Results: We found a decrease in mean SVC flow from 99 ml/kg/min at day one to 77 ml/kg/min at day three. Reliable diameter images were obtained in 85%, and velocity recordings in 81%. The mean variability of SVC flow was 17% in the intraobserver analysis and 29% in the interobserver analysis.
Conclusion: The main challenge of the method is the measurement of SVC diameter.
The same observer should ideally perform sequential analyses. Special caution should be taken when making clinical implications from non-optimal pictures.
]]>Design: Prospective cohort study
Setting: Level III neonatal unit in a developing country
Patients: Consecutive mother-infant dyads (gestation ≤34 weeks) with no major neonatal malformations.
Interventions: Ten putative maternal and neonatal risk factors and use of IAP were assessed. Neonates were followed until 72 hrs for signs of EONS. Blood cultures were drawn on clinical suspicion of EONS and/or prior to starting prophylactic antibiotics for high risk asymptomatic neonates.
Main outcome: Culture-proven EONS (onset <72 hours).
Results: 601 mother-infant dyads were enrolled [mean (SD) gestation= 31.8 (2) weeks; mean (SD) birth weight 1559.4 (452) grams]. The best fitted multivariate logistic regression model had 6 independent risk factors [adjusted OR (95% CI)]: vaginal examinations ≥3 [9.5 (3, 31)], clinical chorioamnionitis [8.8 (2, 43)], birth weight <1500 gms [2.8 (2, 5)], male sex [2.7 (2, 5)], gestation <30 weeks [2 (1, 4)] and no IAP [2 (1.04, 4)]. Regression coefficients were converted into scores: 6, 6, 3, 3, 2 and 2 respectively. Internal prediction accuracy was 86.5% and c-statistic 0.75 (95% CI 0.70, 0.81, p<0.001).
Conclusions: Vaginal examinations ≥3, clinical chorioamnionitis, birth weight <1500 gms, male sex, gestation <30 weeks and no intra-partum antibiotics were independent risk factors of EONS among preterm infants ≤34 weeks.
]]>Design: We included eleven neonates (body weight 2-5kg, PNA 2-121 days) who received sildenafil and ECMO-treatment for pulmonary hypertension. Sildenafil capsules were given via a nasogastric tube. Blood samples were collected via a pre-existing arterial line to quantify sildenafil and metabolite plasma levels (219 samples). Nonlinear mixed effects modelling was used to describe sildenafil (SIL) and desmethylsildenafil (DMS) pharmacokinetics.
Results: A one-compartment model was suitable for both SIL and DMS. Inter- and intrapatient variability for clearance at 100% bioavailability were 87% and 27% (SIL) and 62% and 26% (DMS). Patient weight, postnatal age and post-ECMO time did not explain variability. Concomitant fluconazole use was associated with a 47% reduction in sildenafil clearance. The exposure expressed as AUC24 (SIL+DMS) ranged from 625 to 13579 ng*h/mL. An oral dose of 4.2 mg/kg/24h would lead to a median AUC24 (SIL+DMS) of 2650 ng*h/mL equivalent to 20 mg t.i.d. in adults. Interpatient variability was large, with a simulated AUC24 (SIL+DMS) range (10th and 90th percentiles ) of 1000 - 8000 ng*h/mL.
Conclusions: Sildenafil pharmacokinetics are highly variable in post-ECMO neonates and infants. In a median patient, the current dose regimen of 0.5 – 2.0 mg/kg q.i.d. leads to an exposure comparable to the recommended adult dose of 20 mg t.i.d. Careful dose titration, based on efficacy and the occurrence of hypotension, remains necessary. Follow-up research should include appropriate pharmacodynamic endpoints, with a population PK/PD analysis to assign a suitable exposure window or target concentration.
]]>Design: Prospective cohort study in a geographically defined population.
Setting: Trent Region, UK.
Patients: Infants admitted for neonatal care, of 23 to 32 weeks gestation, born to Trent resident mothers during a 15 year period.
Intervention: Antenatal corticosteroid treatment to pregnant women at risk of preterm birth.
Primary outcome was survival until discharge from neonatal unit. Secondary outcomes included length of stay on the neonatal unit, duration of artificial respiratory support (mechanical ventilation and CPAP), and chronic lung disease (CLD).
Results: The overall mortality amongst babies born between 24 to 29 weeks with maternal steroid was lower ( n=850 /4370; 19.4%) as compared to their counterparts whose mothers did not receive steroids (n=323/920;35.1%) The gestation specific mortality (percent) in the steroid treated group between 24 to 29 was significantly lower than the group without steroid treatment. There was a 9.9% reduction in mortality amongst babies born at 23 weeks gestation in the steroid treated group [n= 81/102;79.4%] compared to non-steroid group [ n=75/84; 89.3 %] (p=0.068). There was no significant effect of antenatal steroid treatment on length of stay, duration of respiratory support and CLD among infants who survived till discharge.
Conclusion: Antenatal corticosteroid treatment is associated with improved survival in babies born between 24 to 29 weeks gestation. This, however, does not lead to any significant improvements in length of stay, duration of respiratory support and CLD amongst survivors.
]]>Study design: 40 infants of 28-34 weeks GA (<35 wks GA), affected by moderate RDS, were considered eligible and were randomized to NCPAP (CPAP level=6 cmH2O, Group A n=20) or to Bi-level NCPAP (lower CPAP level=4.5 cmH2O; higher CPAP level=8 cmH2O, Group B n=20), provided with the variable flow devices (Infant Flow CPAP vs Infant Flow SiPAPTM, Viasys Healthcare, Yorba Linda, CA).
Main outcome measures: Inflammatory response was the primary outcome; serum cytokines were measured on days 1 and 7 of life. Length of ventilation, oxygen dependency, need for intubation and occurrence of air leaks were considered as secondary outcomes.
Results: Infants showed similar characteristics at birth (GrA vs GrB: GA 30.3 2 versus 30.2 2wks, BW 1429 545 versus 1411 560g) and showed similar serum cytokine levels at all times. GrA underwent longer respiratory support (6,2 2 days versus 3,8 1 days, p=0.025), longer O2 dependency (13,8 8 days versus 6,5 4 days, p=0.027) and was discharged later (GA at discharge 36,7 2,5 weeks versus 35,6 1,2 weeks, p=0.02). All infants survived. No BPD or neurological disorders occurred.
Conclusions: Bi-level NCPAP was associated with better respiratory outcomes versus NCPAP, and allowed earlier discharge, inducing the same changes in the cytokine levels. In our population it was well tolerated and safe.
]]>Design: Observational study.
Setting: Neonatal intensive care unit of a university-affiliated children’s hospital.
Patients: Cerebral and renal tissue oxygenation (rSO2C and rSO2R) and hemodynamic parameters were recorded for 2-3 hours (1-2 times) in clinically stable preterm neonates (n=10) using near-infrared spectroscopy (NIRS), GE DASH 4000 and Bedmaster Software.
Main outcome measures: rSO2C and rSO2R and fractional oxygen extraction (FOE-C and FOE-R) in association with the duration of pulse oximetry desaturation (SaO2 <84%), bradycardia (heart rate <90 beats per minute) and hypotension (mean blood pressure, MBP <30 mm Hg).
Results: Among the 14 sets of recorded measurements, 128 hypoxic episodes with 5-10 (n=41), 15-20 (n=26), 25-30 (n=78), 35-40 (n=14), 45-50 (n=25), and >55 seconds (n=16) duration were identified. Prolongation of hypoxic episodes for more than 30 seconds was associated with major reductions in SaO2, rSO2C, and rSO2R without significant changes in the regional FOE. Bradycardia occurred during 43.8% of hypoxemic episodes of >55 seconds duration (P<0.01) and impacted the severity of the tissue deoxygenation. Decreased renal tissue oxygenation and increased FOE-R were observed in association with mild hypotension irrespective of the systemic oxygenation status.
Conclusions: Prolongation of hypoxemia contributes to the severity of the deoxygenation (systemic and regional) and development of bradycardia. In stable preterm neonates, mild decreases in mean blood pressure can independently from the hypoxemia affect the renal but not cerebral tissue oxygenation and oxygen utilization.
]]>Design: Prospective, observational study. Cox proportional hazards and nonparametric rank sum tests to assess the relationship between NNS and feeding outcome measures.
Setting: Neonatal intensive Care Units – rural/academic, urban/tertiary center
Patients: 51 premature infants born between 25 and 34 weeks’ PMA, birthweight 1512.3 ± 499.4 grams.
Interventions: Measurement of non-nutritive sucking; standardized feeding advance schedule; performance of NOMAS; standardized, permissive, oral feeding advance schedule.
Main outcome measures: Transition time from first to full oral feeding, gestational age at full oral feeding.
Results: Higher NNS organization score predicted shorter transition to full oral feeding (p<0.05): infants with a more organized suck pattern reached independent oral feeding 3 days earlier (16 vs. 13 day transition) than infants with more chaotic patterns of suck bursts. Consistency of the suck waves also corresponded with feeding milestones: infants with more regular suck wave pressure deflections became competent oral feeders approximately 3 days earlier than those with irregular suck pressure waves. PMA at birth was inversely associated with PMA at full oral feeding. NOMAS measures were not associated with outcome measures.
Conclusions: Measures of NNS organization and suck consistency constitute useful candidate predictors of feeding performance by premature infants. Results accord with previous findings linking PMA at birth with age at independent feeding.
]]>Design: Retrospective observational study on ROP screening and treatment. It involved a cross-sectional review of all eligible infants over a seven year period. Statistical tests used were the Kruskal-Wallis test and Mann-Whitney U test. Logistic Regression was used to control for any differences in birth weight and gestational age.
Setting: City Hospital and Birmingham Women's Hospital, Birmingham, United Kingdom.
Results: 1690 preterm infants underwent ROP screening. Birth-weight was lower in black (1142.5g) and Asian infants (1180 g) when compared to white infants (1196.5g). Gestational age was lower in black infants (28.5 weeks) compared to Asian and white infants (both 29 weeks). Compared to white infants, the odds of severe ROP requiring treatment was higher in Asian infants [odds ratio (OR): 2.52; 95% confidence interval (CI): 1.41-4.50] and black infants [OR: 2.51; 95% CI: 1.30-4.86]. The additional risk from ethnicity was present even after adjusting for birth-weight and gestational age [adjusted OR for Asian vs. white infants: 2.45; 95% CI: 1.334 - 4.497]; [adjusted OR for black vs. white infants: 2.0; 95% CI: 1.004 - 4.014].
Conclusions: Ethnicity is a risk factor for severe ROP. Asian and black infants have a higher risk of developing threshold ROP compared to white infants.
]]>The survival rate for children born with gestational ages 22-27 weeks is increasing, and this may be associated with higher rates of disability. The aims of this study were to determine the outcomes at age 8 for a regional cohort of children born at 22-27 weeks during 1997, and to compare their rates of disability with a cohort of the same gestational age born in 1991-92.
Consecutive children with gestational ages 22-27 weeks born in the state of Victoria, Australia, in 1997 and matched term controls were assessed at 8 years. Outcomes included blindness, deafness, cerebral palsy and intellectual impairment, and disabilities caused by these impairments. These outcomes were compared with a cohort of 22-27 week and term children born in 1991-92 in the same region.
Follow-up rates for the 1997 cohort at 8 years of age were 95% (144/151) for 22-27 week survivors, and 89% (173/195) for controls. Rates of disability were substantially higher in the preterm cohort than the controls. The 1997 and 1991-92 preterm cohorts had similar rates of moderate or severe disability (19%), however the rate of mild impairment was greater in 1997 (40% vs 24%). Rates of disability were almost identical in control groups. Intellectual impairment and cerebral palsy were the major reasons for the higher rates of disability.
The high prevalence of adverse neurodevelopmental outcome in children born at 22-27 weeks compared with term controls at school age persists, and may even be increasing over time.
Vitamin K deficiency bleeding (VKDB) in infants is a rare but serious worldwide problem, particularly in Southeast Asia. Apart from exclusive breast-feeding, little is known of materno-fetal risk factors that predispose to VKDB.
To assess (a) the relationships between functional vitamin K insufficiency in a large cohort of Thai mothers to that of their newborn infants and (b) the importance of delivery risk factors and maternal intakes of vitamin K as determinants of neonatal vitamin K status.
Vitamin K status was assessed by measuring undercarboxylated prothrombin (PIVKA-II) in 683 mothers and in the cord blood of their babies by sensitive immunoassay. Dietary phylloquinone (vitamin K1; K1) intakes were assessed in 106 of these mothers by food frequency questionnaire.
Babies were categorized as ‘normal’ (n=590) or ‘high-risk’ (n=93) according to birth weight and delivery type. PIVKA-II was detectable (>0.15 Arbitrary Units (AU)/ml) in 85 mothers (12.4%) and 109 babies (16.0%) with median levels of 0.78 and 1.04 AU/ml in mothers and babies, respectively. ‘High-risk’ babies had both a higher median detectable PIVKA-II concentration than ‘normal-risk’ babies (3.1 vs. 1.0 AU/ml, p=0.02) and a higher prevalence of clinically relevant (>5.0 AU/ml) concentrations (p=006). Mothers with K1 intakes below the U.S. recommended ‘Adequate Intake’ for pregnancy (<90 µg/d) had a higher prevalence of detectable PIVKA-II (18.8%) than those with adequate intakes (3.3%) (p=0.01).
Functional, clinically relevant, vitamin K insufficiency was more common in ‘high-risk’ than ‘normal-risk’ newborns. Vitamin K insufficiency in mothers was linked to lower dietary K1 intakes during pregnancy.
Conventional magnetic resonance imaging (MRI) at term age has been reported to be superior to cranial ultrasound (cUS) in detecting white matter (WM) abnormalities and predicting outcome in preterm infants.[1] However, in that study cUS was performed during the first 6 weeks only and not in parallel to MRI at term age. Therefore, we aimed to study brain injuries in preterm infants performing concomitant cUS and MRI at full-term age.
In a population based cohort of 72 extremely low gestational age infants paired cUS and conventional MRI were performed at term age. Abnormalities on MRI were graded according to a previously published scoring system.[1,7,8] On cUS images the lateral ventricles, the corpus callosum, the interhemispheric fissure and the subarachnoidal spaces were measured and the presence of cysts, grey matter abnormalities and gyral folding were scored.
Moderate or severe WM abnormalities were detected on MRI in 17% and abnormalities of the grey matter in 11% of infants. Amongst infants with normal ultrasound (n=28, 39%) none had moderate or severe WM abnormalities or abnormal grey matter on MRI. All infants with severe abnormalities (n=3, 4%) were identified as severe on both MRI and cUS.
All severe white matter abnormalities identified on MRI at term age were also detected by cUS at term, providing the examinations were performed on the same day. Infants with normal cUS at term age were found to have a normal MRI or only mild WM abnormalities on MRI at term age.
Guidelines recommend avoidance of excessive oxygen administration during neonatal resuscitation. Blenders are used in some but not all hospitals. It has been suggested that self-inflating bags without a reservoir deliver around 40% oxygen and could be used to provide an inexpensive and effective technique of avoiding oxygen toxicity.
To explore how much oxygen is delivered when using two different brands of neonatal self-inflating resuscitation bags without a reservoir.
In a benchtop setting, the smallest non-disposable self-inflating bags from the Laerdal® and Ambu® ranges were tested. Oxygen concentration delivered by these devices under a variety of conditions was measured. 108 combinations of oxygen flow rates (10, 5 to 1 L/min), ventilation rates (30, 60, 100 inflations/min) and peak inspiratory pressure ranges (20-25 cmH2O, 35-40 cmH2O or pop-off valve range, 55-60 cmH2O) were tested.
Delivered oxygen concentration varied depending on 3 parameters: gas flow rate, ventilatory rate and pressure. At a pressure of 20-25 cmH2O, mean oxygen concentration delivered by both bags exceeded 70% at any gas flow rate except for 1 L/min (where delivered oxygen concentration was 60-70%). When the pop-off valve was opened at 35-40 cmH20, oxygen concentrations fell to 30%-45% at gas flow rates ≤2 L/min. The Ambu bag delivered a lower oxygen concentration than the Laerdal bag but this difference was not clinically important.
When using the Laerdal and Ambu infant resuscitation self-inflating bags without a reservoir, delivered oxygen concentration is greater than 70% for currently recommended flow and pressure settings.
The validity and applicability of before-after studies compared to randomised controlled trials of fluconazole prophylaxis for very low birthweight infants is uncertain.
We aimed to examine whether the study design (before-after studies compared to randomised controlled trials) affected the estimate of effect size yielded in meta-analyses and to explore possible causes for any differences detected.
We undertook a systematic review and meta-analysis of before-after studies that assessed the effect of fluconazole prophylaxis on the incidence of invasive fungal infection in very low birthweight infants. Data were compared with estimates generated from meta-analyses of randomised controlled trials. Funnel plots were examined for evidence of publication bias.
Meta-analysis of eleven before-after studies found a reduced risk of invasive fungal infection following introduction of fluconazole prophylaxis: relative risk 0.19 (95% confidence interval 0.13 to 0.27). This estimate is significantly lower than the estimate from meta-analysis of randomised controlled trials: relative risk 0.48 (95% confidence interval 0.31 to 0.73). Funnel plot inspection of before-after studies revealed that smaller studies with large effects sizes contributed an excess of data points suggesting that publication bias contributes to the inflation of the effect size estimate.
Data from before-after studies should be interpreted and applied cautiously. Evidence to guide policy and practice for antifungal prophylaxis for very low birthweight infants should be derived from well-designed randomised controlled trials.
To compare the pain experienced by premature infants undergoing screening for retinopathy of prematurity (ROP) by wide-field digital retinal imaging (WFDRI) and binocular indirect ophthalmoscopy (BIO).
Infants were recruited at Edinburgh Royal Infirmary Neonatal Unit. Eyes were examined by both WFDRI and BIO with eyelid speculum by two experienced paediatric ophthalmologists in random order. We measured pain using the Premature Infant Pain Profile (PIPP).
We recruited 76 infants. The mean PIPP score was 15.0 for WFDRI and 15.2 for BIO (difference not statistically significant). We observed that infants started crying with corresponding physiological changes as soon as the eyelid speculum was inserted and crying stopped on speculum removal.
WFDRI and BIO with eyelid speculum are similarly painful for infants. We suggest that the eyelid speculum rather than the examination method may contribute most to the pain experienced.
aEEG is a valuable tool for evaluating neonatal encephalopathy and identification of electrographic seizures.
To compare seizure activity and background pattern (BGP) between 1- and 2-channel aEEG recordings in full-term neonates.
The 2-channel aEEG recordings (F3-P3; F4-P4) of 34 neonates with seizures were compared with single-channel recordings (P3-P4).
All 34 infants, with either unilateral (n=14), diffuse (n=18) or without (n=2) brain injury had seizure patterns on 1- and 2-channel recordings, with 18% more seizure patterns detected with 2-channel recording. In 79% of infants with unilateral injury more seizures were noted on the ipsilateral side compared to the contralateral side. In 39% of the infants with diffuse brain damage more seizures were found with 2-channel recordings. A sensitivity of 65% was found when using the automatic seizure detection algorithm.
In 4/14 (29%) infants with unilateral injury a more severely affected BGP was seen on the ipsilateral side compared to the BGP on 1-channel recording. In infants with diffuse injury differences in BGP pattern were seen in 6-17% of the infants depending on the system used for scoring.
Although there were no major differences found between seizure detection with 1- or 2- channel aEEG, in a subgroup of infants with a predominantly unilateral brain lesion, 2-channel recording did provide additional information with identification of more seizure patterns on the affected side, sometimes also associated with a difference in BGP. To improve early diagnosis of unilateral lesions and improve seizure detection in these infants, routine use of 2-channel recordings is recommended.
We describe video observations and recordings of respiratory signals from mannequin studies and delivery room resuscitations. This article discusses the uses of a respiratory function monitor during training and resuscitations along with potential pitfalls and limitations. It adds objectivity to the clinical assessment. A respiratory function monitor provides real-time, quantitative information including tidal volume and leak. It may be used to teach correct mask-hold and positioning techniques during simulation-based mannequin. We provide examples demonstrating its potential usefulness during resuscitations. However, further studies are needed to investigate whether it can help improve short- and long-term outcomes.
]]>Along with most aspects of neonatal care how, when and what is given as enteral feeds has evolved considerably over the last 2 decades. Feeds are started earlier and advanced more rapidly and they are much more likely to be human milk. Steriod administration pre delivery and surfactant post delivery resulting in preterm babies needing less intensive respiratory support has in part allowed this more liberal approach. However increasing evidence that using the gut carefully and wherever possible with breast milk will aid adaption to extra uterine life has also helped.
]]>Although it is generally accepted that a standardised approach to the collection of perinatal and neonatal data is required, definitions of the most straightforward outcomes such as perinatal and neonatal mortality still vary across the developed world. As such the wide variations seen in neonatal outcomes may be attributable to external influences, for example: differences in definition, ascertainment levels and registration as well as hospital policies regarding delivery and neonatal unit admission, particularly around the limits of viability [1-5]. The evaluation and comparison of neonatal outcomes are used for the clinical governance and performance management of neonatal medicine at many levels: from local to national and international comparisons. Ensuring true ‘like for like’ comparison is therefore of utmost importance.
]]>Introduction: The precision of temperature control achieved in clinical practice during therapeutic hypothermia in neonates has not been described.
Methods: We examined hourly rectal temperature recordings from 17 infants treated with servo controlled and an equal number treated with manually adjusted cooling equipment. The target rectal temperature for all infants is 33.5oC rectal for 72 hours.
Results: During 6-72 hours after start of cooling the mean, (95% confidence interval) and variance of the averaged rectal temperatures was 33.6oC (33.4oC-33.8oC), 0.1oC in the manually adjusted group and 33.4oC (33.3oC-33.5oC), 0.04oC in the servo controlled group, means: P=0.08, equality of variance: P=0.03. The variance was also significantly different between infant groups during 1-5 hours after start of cooling, P=0.01, but not during rewarming.
Conclusion: The rectal temperature can be maintained close to the target temperature with either manually adjusted or servo controlled equipment, but there is less temperature variability with the servo controlled system in use in the UK.
]]>The aim of this study was to generate reference ranges for Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT) in preterm infants by describing the observed plasma concentration of these enzymes in babies born between 22 and 36 weeks’ gestation. A service evaluation was conducted in babies admitted to two large neonatal intensive care units in the United Kingdom. 7006 blood samples from 1860 infants admitted to the two units between 2004 and 2008 were included. Extremely premature infants had high plasma enzyme concentrations when compared to babies at a later corrected gestational age. This may be due to more severe illness immediately after birth.
]]>Objective: To evaluate the effect of opioid analgesics, compared to placebo, no drug, or other non-opioid analgesics or sedatives, on pain, duration of mechanical ventilation, mortality, growth and neurodevelopmental outcomes in newborn infants on mechanical ventilation.
Design: Sistematic review and meta-analysis of randomized controlled trials.
Data sources: Cochrane, Medline, Embase, and Cinhal databases, references from review articles.
Review methods: Randomised controlled trials or quasi-randomised controlled trials comparing opioids to a control, or to other analgesics or sedatives in newborn infants on mechanical ventilation.
Results: Thirteen studies on 1505 infants were included. Infants given opioids showed reduced premature infant pain profile (PIPP) scores compared to the control group (weighted mean difference -1.71; 95% confidence interval -3.18 to -0.24). Heterogeneity was significantly high in all analyses of pain. Meta-analyses of mortality, duration of mechanical ventilation, and long and short-term neurodevelopmental outcomes showed no statistically significant differences. Very preterm infants given morphine took significantly longer to reach full enteral feeding than those in control groups (weighted mean difference 2.10 days; 95% confidence interval 0.35 to 3.85). One study that compared morphine with midazolam showed similar pain scores, but fewer adverse effects with morphine.
Conclusions: There is insufficient evidence to recommend routine use of opioids in mechanically ventilated newborns. Opioids should be used selectively, when indicated by clinical judgment and evaluation of pain indicators. If sedation is required, morphine is safer than midazolam.
]]>Aim: To describe neonatal outcomes following intrauterine transfusion (IUT) for severe rhesus isoimmunisation over a twelve year period (1993-2004).
Results: 116 neonates were identified who had undergone 457 IUTs (median 4; range 1-9). There were 3 neonatal deaths, all prior to 1995; 2 due to hypoxic ischaemic multi organ failure and 1 due to overwhelming E coli sepsis. 13 neonates (11%) were delivered by emergency Caesarean section following either an IUT complication or the spontaneous onset of preterm labour. They were more likely to require intubation (p<0.0001), on-going respiratory support (p=0.0007) and an exchange transfusion (p=0.007). Overall 23 babies (20%) required an exchange transfusion and 63 (54%) at least one top-up transfusion.
Conclusions: Contemporary management of severe rhesus disease is associated with encouraging neonatal outcomes and the majority of infants can be managed with phototherapy and a limited number of top up transfusions. IUT complications are rare but inevitably significantly increase neonatal mortality and morbidity. Antenatal counselling should address the likely postnatal course for these infants and this review provides recent data from the UK to assist in this.
]]>Objective: To assess evolutions in the care and health of very preterm babies between 1998 and 2003 after implementation of a regionalisation policy in France.
Design: Comparison of two population-based cohorts.
Setting: The Parisian region.
Patients: All live births 24 to 31 weeks of gestation in 1997 (EPIPAGE study, N=488) and 2003 (MOSAIC study, N=580).
Interventions: Implementation of regionalised perinatal networks.
Main outcome measures: In-hospital mortality and morbidity, including intraventricular haemorrhage (IVH) grade III and IV, cystic periventricular leukomalacia (PVL) and bronchopulmonary dysplasia (BPD).
Results: Over this period, babies born in level III units rose from 67 to 77% and use of antenatal corticosteroids, indicated deliveries and surfactant increased. In-hospital mortality and intraventricular haemorrhage grades III/IV declined, ORs of 0.66 (95% CI: 0.46-0.95) and 0.27 (95% CI: 0.15-0.47) respectively, while periventricular leukomalacia and bronchopulmonary dysplasia stayed constant. The rate of very preterm babies discharged alive per 1000 total births increased by 18%, but declined for babies with severe brain lesions.
Conclusions: We found improvements in mortality and morbidity for very preterm babies and changes in their care over a 6 year period following reinforcement of regionalisation policies.
]]>The interactions between the postnatal development of the circulation and the presence of congenital cardiovascular malformations have been recognized for many years [1]. The changes in the pulmonary circulation after birth are crucial in altering the circulatory dynamics, resulting in clinical features of congenital cardiovascular anomalies, such as cardiac failure.. Because clinical disturbances were common in the early neonatal period, congenital cardiovascular anomalies were thought to have little adverse effect on the fetus. It was believed that the patterns of blood flow and the foramen ovale and ductus arteriosus shunts normally present in the fetus allowed the circulation to adapt adequately to the presence of cardiovascular malformations. However, in recent years, ultrasound studies of human fetuses and experimental studies of fetal lambs with simulated lesions have demonstrated that congenital cardiac anomalies may drastically affect the fetal circulation and fetal development and even survival. Furthermore, they may induce circulatory changes that profoundly alter normal adaptation after birth.
]]>Background: Neonatal pain assessment generally requires access to facial expression. Improved neonatology practices, such as greater protection against bright lights and non-invasive mask ventilation, have made facial observation more difficult.
Objective: To validate a "faceless" acute neonatal pain scale (FANS), which does not depend on facial expression.
Methods: Prospective, multicentric study, we videotaped 24- to 40-week-old neonates during a painful procedure (heel prick). Three investigators then scored the pain using FANS and a validated scale: DAN (Douleur aiguë du Nouveau-né). FANS is based on assessment of limb movement, cry and autonomic reaction. Reliability was assessed by interrater agreement and internal consistency (Cronbach’s alpha). Validity was evaluated by agreement between scales [intraclass correlation coefficient (ICC)]. The Wilcoxon test evaluated the FANS score differences between conditions. Results are expressed as medians [25th and 75th percentiles]. Ranges are presented for outcome parameters.
Results: From April 2006 to September 2007, we observed 53 preterms of 32 [30-35] gestational weeks and 1500 [1000-2200] g. Cronbach’s alpha was 0.72. ICC was 0.92 [0.9-0.98] for interrater agreement and 0.88 [0.76-0.93] for agreement between scales.
Conclusion: FANS, which is reliable and valid, is the first scale to score pain in the preterm newborn when facial expression is not accessible.
]]>The role of MRI in fetal imaging is expanding. The depth of structural information provided by MRI places it as more than just a useful adjunct to ultrasound, as several structures are more clearly visualised and many of the limitations of ultrasound are avoided. Currently, MRI is most frequently utilised in the fetal central nervous system and is valuable in ventriculomegaly, agenesis of the corpus callosum and posterior fossa abnormalities. Outside this, MRI remains primarily a research tool, with increasing interest in thoracic abnormalities and scope for development in other niche areas. MRI is able to accurately determine fetal organ volumes and weight, although whether such measurements could play a role in conditions such has fetal growth restriction, has yet to be fully established. Techniques such as diffusion weighted imaging, magnetic resonance spectroscopy and functional imaging are also being remodelled for use in the fetus, improving our knowledge of in utero metabolism and development.
]]>The United Kingdom Infantile Spasms Study (UKISS) comparing hormonal treatment against vigabatrin in the management of infantile spasms showed that cessation of spasms was more likely in infants given hormonal treatment.
We believe this study has changed our practice and the advice we give colleagues across our region regarding the management of infantile spasms. We undertook this audit to see if this was confirmed.
]]>Objective: Micronutrient deficiencies during pregnancy may be linked to poor newborn health and host defenses against infection. We assessed newborn morbidity to determine the impact of four combinations of antenatal micronutrient supplements.
Design: Cluster-randomized, double-masked, controlled trial.
Setting: Rural community in Nepal.
Interventions: Women received daily supplements from early pregnancy through 3 months postpartum of vitamin A alone (control) or vitamin A with folic acid, folic acid + iron, folic acid + iron + zinc or a multiple micronutrient supplement containing these and 11 other nutrients.
Main outcome measures: Infants were visited in their home at birth (n=3927) and for each of 9 days thereafter to elicit a 24-h history of 9 infant morbidity symptoms, measure infant respiratory rate and axial temperature, and assess the infant for chest indrawing. At 6 weeks of age, infants were visited again in their homes to elicit a 30-day and 7-day history of 10 morbidity symptoms using parental recall.
Results: Maternal micronutrient supplementation had no impact on 10-d morbidity or morbidity 30-d and 7-d morbidity assessed at 6 wk of age; all relative risks were close to 1. Symptoms of birth asphyxia increased by about 60% (p<0.05) in infants of women who received the multiple micronutrient supplement compared to the control. Symptoms of combinations of sepsis, preterm, and birth asphyxia were associated with 8-14-fold increased odds of 6-mo infant mortality.
Conclusions: None of the combinations of antenatal micronutrient supplements tested improved symptoms of neonatal morbidity in the first 10 days of life or at 6 weeks of age. Further research is needed to elucidate the association and mechanism of increased risk of birth asphyxia following maternal multiple micronutrient supplementation.
]]>Objective: To determine the prevalence of vitamin D deficiency in newborn infants of mothers at risk of vitamin D deficiency because of dark skin or the wearing of concealing clothes (such as a veil), compared with a group supposed not to be at risk. A second aim was to correlate these newborns’ vitamin D concentrations to biochemical parameters of vitamin D metabolism and bone turnover at birth.
Design: A prospective study conducted between April 2004 and February 2006 including women delivering in this period, and their newborns.
Setting: Outpatient clinic of the obstetrics department, Sint Franciscus Gasthuis, Rotterdam, the Netherlands.
Patients: Eighty-seven newborns of healthy mothers either with dark skin and/or concealing clothing (risk group) or with light skin (control group).
Results: We found a significant difference in the prevalence of vitamin D deficiency (25-hydroxyvitamin D3 < 25 nmol/l) between newborns born to mothers at risk and newborns born to mothers in the control group (63.3% vs. 15.8%; p<0.0001). Mean alkaline phosphatase concentrations were significantly higher in the risk group.
Conclusions: Newborn infants of mothers with dark skin or of mothers wearing concealing clothes are at great risk of vitamin D deficiency at birth. Clinical implications are unknown. Further research is necessary to determine the long-term consequences of maternal and neonatal vitamin D deficiency in order to issue guidelines on vitamin D supplementation during pregnancy.
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