bluuebunny/crossref_metadata_2025 huggingface dataset:
Are we considering neonatal stroke early enough in our differential diagnosis?
Authors: Paddock M. , Demetriou A. , Nicholl R.
Published: December 2019

BACKGROUND: Neonatal stroke is an important cause of neurodisability in childhood and in later life. Delay in diagnosis is often inevitable due to the non-specific presentation, the lack of clinical signs, and not considering stroke early enough in the differential diagnosis. CASE: We report the case of a baby who initially presented with apparent newborn “jitteriness” and abnormal movements. On the background of an unremarkable birth history and negative initial investigations, the baby subsequently developed focal seizures. The diagnosis was suspected to be neonatal stroke which was later confirmed on magnetic resonance imaging. CONCLUSION: General Movements assessment is an established useful tool used in the assessment of such babies and proves helpful in evaluating whether movements are normal or pathological, in addition to prognosticating outcome. Cranial ultrasound is a commonly employed first-line investigation, however, initial normal intracranial appearances do not exclude stroke. Magnetic resonance imaging is the gold standard but may not be immediately available to all practitioners.
Transport of very preterm infants with respiratory distress syndrome using nasal continuous positive airway pressure
Authors: Jani P. , Luig M. , Wall M. , Berry A.
Published: December 2019

AIM: To audit clinical practice during transport of very preterm infants (<32 weeks) with acute respiratory distress syndrome (RDS) receiving nasal continuous positive airway pressure (NCPAP). METHODS: Retrospective cohort study. RESULTS: Twenty-seven infants were receiving NCPAP before transport team's arrival, and 23 were commenced on NCPAP after team's arrival. Six infants (12%) failed NCPAP before transfer, 2 infants (4.5%) failed NCPAP less than 24 hours, and 5 infants (11.3%) failed more than 24 hours – 7 days following admission. None died or developed pneumothorax during, or 7 days after admission. We did not observe NCPAP failure during transfer. There was a statistically significant difference between the NCPAP success and NCPAP failure groups for FiO2 at admission (p < 0.05), and the duration of NCPAP (p < 0.05). CONCLUSION: NCPAP is a potentially safe and effective mode of respiratory support for very preterm infants during ground, and air transports.
A delicate subject: The impact of cultural factors on neonatal and perinatal decision making
Authors: Van McCrary S. , Green H.C. , Combs A. , Mintzer J.P. , Quirk J.G.
Published: December 2019

The neonatal intensive care unit (NICU) is a high-stress environment for both families and health care providers that can sometimes make appropriate medical decisions challenging. We present a review article of non-medical barriers to effective decision making in the NICU, including: miscommunication, mixed messages, denial, comparative social and cultural influences, and the possible influence of perceived legal issues and family reliance on information from the Internet. As examples of these barriers, we describe and discuss two cases that occurred simultaneously in the same NICU where decisions were influenced by social and cultural differences that were misunderstood by both medical staff and patients' families. The resulting stress and emotional discomfort created an environment with sub-optimal relationships between patients' families and health care providers. We provide background on the sources of conflict in these particular cases. We also offer suggestions for possible amelioration of similar conflicts with the twin goals of facilitating compassionate decision making in NICU settings and promoting enhanced well-being of both families and providers.
Intestinal fatty-acid binding protein and metronidazole response in premature infants
Authors: Sampson M.R. , Bloom B.T. , Arrieta A. , Capparelli E. , Benjamin Jr. D.K. , Smith P.B. , Kearns G.L. , van den Anker J. , Cohen-Wolkowiez M. ,   Best Pharmaceuticals for Children Act – Pediatric Trials Network Administrative Core Committee
Published: December 2019

OBJECTIVES: In premature infants with suspected intra-abdominal infection, biomarkers for treatment response to antimicrobial therapy are lacking. Intestinal fatty acid-binding protein (I-FABP) is specific to the enterocyte and is released in response to intestinal mucosal injury. I-FABP has not been evaluated as a surrogate marker of disease response to antimicrobial therapy. We examined the relationship between metronidazole exposure and urinary I-FABP concentrations in premature infants with suspected intra-abdominal infection. STUDY DESIGN: We conducted an intravenous metronidazole pharmacokinetic study, collecting ≤3 urine samples per infant for I-FABP concentration measurements. We analyzed the relationship between I-FABP concentrations and measures of metronidazole exposure and pharmacokinetics, maturational factors, and other covariates. RESULTS: Twenty-six samples from 19 premature infants were obtained during metronidazole treatment. When analyzed without regard to presence of necrotic gastrointestinal disease, there were no significant associations between predictor variables and I-FABP concentrations. However, when the sample was limited to premature infants with necrotic gastrointestinal disease, an association was found between average predicted metronidazole concentration and I-FABP concentration (p = 0.006). CONCLUSION: While a predictive association between urinary I-FABP and metronidazole systemic exposure was not observed, the data suggest the potential of this endogenous biomarker to serve as a pharmacodynamic surrogate for antimicrobial treatment of serious abdominal infections in neonates and infants.
Favorable neurodevelopmental outcome in a hypothyroid neonate following intracordal amiodarone for cardioversion of refractory supraventricular tachycardia in a fetus
Authors: Capone C.A. , Gebb J. , Dar P. , Shenoy R.U.
Published: December 2019

Fetal supraventricular tachycardia (SVT), characterized by a fetal ventricular heart rate faster than 200 beats per minute (bpm), is often diagnosed during routine fetal heart monitoring or prenatal ultrasound examinations. Clinical guidelines for management of fetal SVT have not been determined in standardized trials, nor do we have a clear sense regarding the long-term developmental outcomes and side effects of in utero antiarrhythmic therapy. We describe our approach to the treatment of refractory SVT in a fetus with hydrops using direct umbilical vein treatment with amiodarone coupled with effusion evacuation. We successfully achieved in utero resolution of SVT. There was transient amiodarone-induced hypothyroidism, which we screened for early and treated with Synthroid. Ultimately our patient had normal long-term growth and development as measured by modified Denver office checklists and Ages and Stages questionnaires. Our experience advocates for vigilant screening and management of hypothyroidism in fetuses exposed to in utero amiodarone and suggests that it is possible to achieve good outcomes in high-acuity refractory cases of SVT.
Unplanned ultrasound-guided puncture of a tracheal balloon in a premature infant with congenital diaphragmatic hernia
Authors: Rugolotto S. , Giacomello L. , El-Dalati G. , Sacchetto L. , Antonello L. , De Luca G. , Raffaelli R.
Published: December 2019

Temporary tracheal balloons have been shown to improve lung growth in fetuses with severe congenital diaphragmatic hernia. Fetoscopic Endoluminal Tracheal Occlusion (FETO) is performed at 26–28 weeks gestation, and then is removed in utero at 34 weeks gestation at highly specialized centers. In case of preterm labor at a hospital without a specialized team, a number of techniques have been used to remove the balloon, sometimes with death of the newborn. We have successfully performed an ultrasound-guided approach to puncture and remove the tracheal balloon in a premature infant in an emergency setting at birth. After that she was treated for congenital diaphragmatic hernia at our Newborn Intensive Care Unit.
Placental transfusion strategies in extremely preterm infants: The next piece of the puzzle
Authors: Backes C.H. , Rivera B. , Haque U. , Copeland K. , Hutchon D. , Smith C.V.
Published: December 2019

Evidence is growing on the potential value of enhancing placental-fetal transfusion at birth, with recent endorsement of the practice by the World Health Organization and American College of Gynecologists. However, these recommendations provide clinicians with little guidance on the optimal practice among infants born extremely premature (<28 weeks gestation) and those requiring immediate resuscitation. The goals of this review are to: 1) provide rationale for better outcomes among extremely preterm infants following delayed cord clamping or umbilical cord “milking” than with immediate cord clamping; 2) describe clinical situations that warrant immediate cord clamping following delivery and explore the controversy regarding optimal cord clamping practice among extremely premature infants, including those requiring immediate resuscitation; 3) discuss the quality of evidence in this subgroup of infants; 4) consider areas for future research, with a focus on characterizing if placental-fetal transfusion affects the magnitude or timing of variables associated with physiological transition. The review provided herein suggests that delayed cord clamping or umbilical cord milking can be applied safely to infants born prior to 28 weeks gestation, but the lack of evidence on the best practice among infants born severely depressed and requiring immediate resuscitation, who comprise a greater proportion of infant deliveries at the lowest gestational ages, is recognized. Future studies using well-defined physiologic outcome measures are needed to understand the role of placental transfusion in premature infants' adaptations to extrauterine life.
Non-invasive measurement of brain temperature using radiometric thermometry: Experimental validation and clinical observations in asphyxiated newborns
Authors: Bass W. Thomas , Lattanzio F.A. , Brayman G. , Kootsey B. , Aiello F. , Perkins A.M. , Carr K.L. , Allison R.C. , Shaeffer J. , Kelley R.
Published: December 2019

BACKGROUND: Therapeutic hypothermia (HT) has been shown to decrease death and severe disability in infants with hypoxic-ischemic encephalopathy (HIE). Rectal temperature (RT) is used to determine the temperature set-points for treatment with HT, however experimental studies have shown significant differences between RT and brain temperature during HT. Knowledge of actual brain temperature during HT might allow better determination of optimal degree of cooling and improve outcomes. OBJECTIVES: To compare measurements of brain temperature obtained by non-invasive radiometric thermometry (RadT) to direct tissue measurements in an experimental model of HT, and to use RadT in newborn infants with HIE undergoing HT. STUDY DESIGN: RadT measurements of brain temperature were compared to fiber optic (Luxtron) thermometry measurements placed at a depth of 1.5 centimeters into the brain of cooled miniswine. Following validation studies, brain RadT and RT measurements were continuously recorded in thirty infants with HIE during HT and rewarming. RESULTS: RadT and Luxtron probe temperatures were comparable in miniswine throughout a temperature range similar to therapeutic HT. RadT measurements of brain temperature were higher than RT in 60% of infants with HIE undergoing HT. Higher RadT measurements compared to RT were associated with cerebral white matter abnormalities (p = 0.01). CONCLUSIONS: RadT provides a safe, passive and non-invasive way to measure brain temperature that can be used in the clinical setting. RadT may be helpful in determining the optimal degree of cooling and identifying infants at highest risk of brain injury.
Systemic inflammation and CD11b expression by neutrophils in	preterm newborns with respiratory distress syndrome not treated by	surfactant
Authors: Gad Ghada I. , Awwaad Khaled S. , Abdallah Khaled O. , ELawady Mohamed H.
Published: December 2019

Objectives: To evaluate CD11b expression by neutrophils in the first 12 hours of life in preterm newborns with respiratory distress syndrome (RDS) as a marker of systemic inflammation and an indicator for severity of illness.

Subjects and methods: In this prospective case-control study, we obtained peripheral blood samples from subjects during the first 12 hours of life. We measured CD11b expression by neutrophils using flow cytometry. Surfactant was not used for treatment of RDS due to economic reasons. The clinical severity of RDS was graded into 4 sub-categories based on the initial radiographic findings. Expression of CD11b was compared between groups. Correlation analyses between CD11b, RDS severity, and clinical outcomes were done using spearman correlation coefficient.

Results: We studied 60 preterms with RDS (Cases) and 30 Controls. CD11b expression was significantly increased in Cases compared to Controls and differed significantly among the 4 radiological sub-categories within Cases; the highest being in RDS grade 4 and lowest in RDS grade 1. CD11b expression was significantly higher among RDS neonates who received mechanical ventilation compared to those who did not, and in neonates who developed bronchopulmonary dysplasia (BPD) or died compared to those who did not. CD11b expression in Cases was negatively correlated with gestational age and positively correlated with the severity of RDS.

Conclusion: CD11b expression as a marker of systemic neutrophil activation is markedly increased in preterm newborns with RDS who did not receive surfactant. It can serve as an indicator for the severity of illness and adverse outcomes of RDS. The response of CD11b expression to surfactant treatment and its impact on outcomes in infants with RDS needs to be explored.
Evaluation of serum iron and iron storage in neonates undergoing	extracorporeal membrane oxygenation
Authors: Gaitatzes Chrysanthe G. , Rais-Bahrami K.
Published: December 2019

Objective: To evaluate iron storage indices in neonates undergoing extracorporeal membrane oxygenation (ECMO) support.

Study design: Thirty neonatal ECMO patients were evaluated by measuring pre- and post- ECMO iron, ferritin, transferrin, and total iron binding capacity (TIBC). Each patient's post-ECMO values were compared to his/her pre-ECMO measurements. Multivariate regression analysis was used to evaluate factors affecting serum iron and iron storage indices.

Results: All measured iron storage indices were increased during ECMO in the majority of our patients. The increase in serum iron and TIBC was dependent on the amount of blood transfused during ECMO (p = 0.038 for iron; p = 0.026 for TIBC). Change in ferritin level was dependent on both the duration of ECMO (p = 0.012) and the amount of blood transfused (p = 0.01).

Conclusion: We observed increases in iron indices measured in neonates on ECMO. We recommend individualized attention to the iron storage indices in neonatal ECMO patients.
Obstetricians' attitudes and practices of life support for	extremely premature low birth weight infants in El Salvador
Authors: Martinez Alma M. , Mathes Erin D. , Foster-Rosales Anne F. , Partridge John Colin
Published: December 2019

Background: The increasing availability of costly life-support technologies in developing countries raises questions about the utility of resuscitation and intensive care for extremely premature infants.

Objective: To characterize obstetricians' attitudes and resuscitation practices for preterm infants in El Salvador.

Design/Methods: Surveys (n = 214) were mailed to Salvadoran perinatal providers in 2000, and 100 more were distributed at a Latin American obstetrics and gynecology conference in December 2000. Survey questions covered counseling practices, resuscitation thresholds for prematurity, attitudes on life support, and demographics.

Results: Of 111 Salvadoran respondents, more providers counsel parents antenatally (41% at 25 wks to 58% at 29 wks) as gestational age increased. Median thresholds for resuscitation were 26 weeks for intubation and ventilation and 27 weeks for cardiac massage or pharmacologic resuscitation, and 1000 grams for each of these interventions. Seventy-two percent of respondents would use all interventions to save life regardless of anticipated outcome, a stance correlated with religious activity (p = 0.03). Decisions to limit resuscitation were influenced by congenital anomalies (62%) more than parental wishes (28%), infant pain (21%) and moral or religious considerations (27%). Older obstetricians were more likely to withdraw support from an extremely premature infant with perinatal HIV exposure (p = 0.006), but not with severe intraventricular hemorrhage or a major congenital anomaly. Fifty-five percent felt their institution was "not aggressive enough" in caring for infants < 26 wks gestation. Less religious obstetricians were more likely to perceive their unit as "too aggressive." Over 80% believed that physicians (44%), rather than parents (15%), should make final resuscitation decisions when consensus cannot be reached.

Conclusions: In El Salvador, the obstetric management of extreme prematurity is influenced by providers' level of religious activity. The majority of obstetricians regard care in their unit as not aggressive enough, despite using higher resuscitation thresholds than in other developing countries. Local economic constraints influence resuscitation options available to obstetricians and parents of extremely premature infants.
A case of Meconium Periorchitis presenting as a scrotal mass
Authors: Ali Yasir A. , Lutfi Samawal A.
Published: December 2019

We report a case of antenatal intestinal perforation and meconium periorchitis in an infant born to a mother who was maintained on NSAIDS due to a history of rheumatoid arthritis. The intestinal perforation had not completely healed prior to birth, which resulted in a pneumoperitoneum after the introduction of feeds. We caution against early or aggressive feeding regimes in infants presenting with any signs of antenatal intestinal perforation.
Live births of infants less than 23 weeks gestation	disproportionately affect infant mortality rates in the United States
Authors: Paul David A. , Thompson John M.D. , Gibson Eric
Published: December 2019

Objective: The aim of the study was to determine if states with high infant mortality rates (IMR) have more live births of infants < 23 weeks gestation than states with low IMR, and to determine if there are racial differences in births < 23 weeks in low and high IMR states.

Study Design: Data were assessed using United States linked birth and death certificate data from 1997–2000. Ten states with the highest IMR over the 4-year study period were compared to 10 states with the lowest IMR. Statistical analysis was carried out by logistic regression.

Results: After controlling for potential confounders, the odds of death from a birth < 23 weeks gestation were significantly higher in the states with the highest overall IMR. IMR was adjusted by removing live births < 23 weeks. African American infants < 23 weeks in high IMR states contributed to a greater percentage of IMR (25%) compared to African American infants in low IMR states (20%), or Caucasian infants in high IMR (15%), or low IMR (13%) states.

Conclusions: States with high IMR are more likely to have live births of infants < 23 weeks gestation, compared to those states with low IMR. The contribution to the IMR from births < 23 weeks in high IMR states is disproportionately from African American infants.
Unilateral disruptive lung malformation: Genetics, embryology,	management and follow-up
Authors: Dembinski Jörg
Published: December 2019

Unilateral pulmonary malformation presenting as agenesis, aplasia or dysplasia is rare with variable outcome. Neonatal presentation does not allow for a reliable prognosis, ranging from mild repiratory distress to severe pulmonary failure requiring mechanical ventilation. Unilateral lung malformation frequently indicates other, singular or complex defects (e.g.: renal, vascular). Disrupted regulation of factors involved in early lung morphogenesis (e.g. T-box-genes, Pitx2, FGgf 10 and cell signaling pathways such as sonic hedgehog and Wnt) may be involved in the etiology of pulmonary malformation. Suspected lung agenesis, aplasia and dysplasia on fetal ultrasound should direct perinatal management and complete diagnostic work-up. Consideration of associated anomalies frequently observed improves identification and management of these potentially vital conditions.

Presence of additional defects, predominantly vascular and/or genitourinary anomalies, contribute significantly to prognosis. Pulmonary hypertension may result from reduced lung vascular capacity. Development of thoracic deformity significantly impacts quality of life in these patients. Interdisciplinary management is required in presence of additional defects.

This article reviews the current experience on neonatal management and long-term-follow-up including discussion of prenatal diagnosis, the embryo-genetic basics of lung development and suggestions for diagnostic work-up.
Male gender is related to the development of parenteral	nutrition-associated cholestasis in neonates
Authors: Takemoto Koji , Nakayama Atsushi , Ito Masatoki , Sato Yoshiaki , Saito Akiko , Torii Yuka , Kaneko Ken-ichiro , Ando Hisami , Hayakawa Masahiro
Published: December 2019

Objective: The development of cholestatic jaundice is a well-recognized complication of parenteral nutrition (PN). The etiology of PN-associated cholestasis (PNAC) has not been fully established. The aim of this study was to identify the risk factors for PNAC in newborn infants.

Methods: Patients who received PN containing amino acids for more than a week were enrolled. The roles of gestational age, small for gestational age, sex, surgery, sepsis, days of starting enteral feeding (EF), days until EF more than 100 mL/kg per day was attained, and composition of PN in the development of PNAC were evaluated by multiple logistic regression analysis.

Results: Fifty-eight infants were exposed to PN for more than a week during the study period. Cholestasis developed in 12 of 58 subjects after the start of PN. Male gender was associated significantly with a higher incidence of cholestasis compared with female gender (83.3% vs 45.7%, respectively). Other confounding factors did not correlate significantly with the development of cholestasis. Multiple logistic regression analysis revealed that male gender was the only independent factor (odds ratio, 8.2; 95% CI, 1.4–47.0) associated with cholestasis.

Conclusions: Male infants had a significantly higher risk of development of PN-associated cholestasis compared with female infants.
Cord blood lymphocytes show higher ATP production compared to	peripheral blood lymphocytes from children and adults
Authors: Jayaram Archana , Zeevi Adrianna , Goyal Rakesh K. , Bentlejewski Carol , Lin Yan , Michaels Marian G.
Published: December 2019

Background: Data on the developmental maturation of the neonatal immune system remains sparse. This study compared the immune response of cord blood (CB) to that of healthy children and adults in response to mitogens, Phytohemagglutinin (PHA) and Concanavalin-A (Con-A).

Methods: De-identified CB samples were obtained from healthy women > 36 weeks gestation. Blood was obtained from children attending routine healthcare visits and healthy adults. The Cylex® assay was used to measure ATP production by CD4+ and CD3+ cells in response to PHA and Con-A, respectively.

Results: Samples from 17 CB, 16 children and 14 adults were evaluated. After PHA stimulation, ATP production by CB was significantly higher (median 863 ng/mL, 95% CI 735.3–978.6) than children (median 370 ng/mL, 95% CI 225.1–603.1; p< 0.001) and adults (median 522 ng/mL, 95% CI 431.3–609.8; p< 0.001). Similarly, CB showed increased ATP production following Con-A stimulation (median 662 ng/mL, 95% CI 506.4–944.1) compared to children (median 93.4 ng/mL, 95% CI 31.8–163.9; p< 0.001) and adults (median 290 ng/mL, 95% CI 231.8–406.6; p < 0.001).

Conclusions: This pilot study shows that CB lymphocytes have a robust in vitro response to mitogen stimulation. Further studies to validate these findings and elucidate their significance in neonatal immune function are warranted.
Improved perinatal and very low birth weight infant outcomes	following neonatal and perinatal regionalization in a rural setting
Authors: Hadeed Anthony J. , Neufeld Michael D. , Jackson J. Craig
Published: December 2019

Objective: To evaluate the changes in outcome that occurred during implementation of a comprehensive outreach program to five level I newborn care facilities, by one level III neonatal intensive care unit in rural WA State.

Study design: Standardized outreach educational programs were provided. Outcome measures were assessed by collecting monthly perinatal and postnatal data on 61,551 births. Three six-year periods were defined. Period I (1988–1994) was compared with period II (1994–2000) and period III (2000–2006).

Results: Comparing the averages for the three periods, there was a statistically significant increase in maternal transports from level I hospitals, and significant decreases in early-onset sepsis, meconium aspiration syndrome, low Apgar scores, major congenital malformations, neonatal and perinatal mortality rates, very low birth weight (VLBW) infant mortality, chronic lung disease and duration of hospital stay (all p< 0.001).

Conclusion: A successful regionalization of perinatal service in rural areas can be accomplished by establishing extensive outreach programs. This model can be utilized to improve perinatal, neonatal and VLBW infant outcomes.
Newborn care practices in urban slums: Evidence from central	India
Authors: Agarwal Siddharth , Sethi Vani , Srivastava Karishma , Jha Prabhat K. , Baqui Abdullah H.
Published: December 2019

One-third of India's urban population resides in slums and squatters, in extreme poverty conditions. Newborn care is sub-optimal among India's urban poor, yet scarcely documented. We assessed newborn care practices in 11 urban slums of Indore in Central India. Practices such as clean cord care, thermal care, timely initiation of breastfeeding and exclusive breastfeeding upto neonatal period were enquired from 312 mothers of infants aged 2–4 months. Correlates of these practices were identified using multiple logistic regression. 72.1% births were home births (slum-home: 56.4%, native-village home: 15.7%). Slum-based traditional birth attendants (sTBAs) conducted 77.3% slum-home births. Skilled assistance during slum-home births was low (7.4%). Clean cord care (22.2%) and thermal care (10.2%) practices were also low. Trained or skilled assistance during slum-home births was positively associated with clean cord care (OR 4.8 CI 1.7–13.6) and thermal care (OR 2.0 CI: 1.1–4.1). Timely initiation of breastfeeding was sub-optimal (50.6%) even in facility births. Exclusive breastfeeding upto neonatal period was higher for mothers counselled on exclusive breastfeeding by a health volunteer during neonatal period (OR 2.3, CI 1.4–3.8). Following emerge imperative for improving newborn care in urban slums- i) antenatal and postnatal counselling by trained health volunteers, ii) enhancing competence of sTBAs and linking them to affordable facilities and iii) sensitizing and training public health facility staff.
Management of pregnancies complicated by reduced fetal metabolic	reserve
Authors: Ventolini Gary , Dektas Beth , Neiger Ran
Published: December 2019

During labor, the obstetrician's role is to prevent maternal and fetal morbidity and mortality. High on the list of potential complications is intrapartum fetal acidemia leading to asphyxia. Factors that increase the risk of acidemia and poor fetal outcome include conditions that had affected the fetus prior to labor such as: intrauterine growth restriction, oligohydramnios and placental abruption. Recent advances in the antepartum assessment of fetal and placental reserve provide us with a better ability to predict the fetal tolerance of labor and delivery. Using this information helps to decrease the risk of intrapartum fetal injury and death.
Do beractant dosing intervals make a difference?
Authors: Attar Mohammad A. , Hieber Susan M. , Lieberman Kathleen E. , Donn Steven M.
Published: December 2019

Introduction: Surfactant dosing in extremely premature infants is not based on rigorous human pharmacokinetic data. Beractant (Survanta®) is an animal-derived surfactant. The manufacturer's package insert suggests a dosing interval of "no sooner than 6 hours" after a preceding dose. Other animal-derived surfactant preparations are commonly dosed at 12 hour intervals. We evaluated Survanta use following a change in the re-treatment dosing interval from no less than 6 (Q6 h) to no less than 12 hours (Q12 h) in June 2007.

Method: We used a retrospective comparison of two cohorts, Q6 h and Q12 h, born at <31 weeks' gestation or with birth weights < 1100 grams treated with Survanta for respiratory distress syndrome (RDS). Infants could receive up to 4 doses, if clinically indicated.

Results: Infants in the Q12 group (n=77) and the Q6 group (n=140) had similar birth weight (mean ± SD; 1079 ± 351 vs. 1117 ± 326 g, p=0.44), birth in a tertiary center (inborn) (84% vs. 84%, p=1.0), prenatal treatment with steroids (88% vs 81%, p=0.17), Cesarean section delivery (78% vs. 73%, p=0.51), and singleton birth (64% vs. 62%, p=0.93). However, infants in the Q12 group had a slightly lower gestational age (mean ± SD; 27 ± 2 vs 28 ± 2 wk, p=0.014) and had a higher proportion of male infants (62% vs 48%, p=0.047.The Q12 group also had a higher but not statistically significant proportion of white infants (82% vs. 69%, p=0.053) than the Q6 group. Infants in the Q12 group received fewer surfactant doses per patient (mean ± SD; 1.91 ± 0.54 vs. 2.11 ± 0.63, p=0.018) and less frequently received more than two doses of surfactant (8% vs. 21%, p=0.012) compared to the Q6 group. The Q12 and the Q6 groups had similar rates of chronic lung disease (CLD) (23% vs. 18%, p=0.25), death (18% vs. 14%, p=0.44), duration of mechanical ventilation (mean ± SD; 21 ± 21 vs. 18 ± 25 days, p=0.477), and total hospital length of stay (mean ± SD; 58 ± 39 vs. 59 ± 33 days, p=0.94).

Conclusions: Administering Survanta to premature infants at 12 hour intervals was associated with using less surfactant to treat RDS compared to dosing at 6 hour intervals and similar measured respiratory parameters, including duration of hospitalization and mechanical ventilation and rates of death and CLD. We speculate that using a longer Survanta dosing interval would also result in significant cost savings.
Amikacin-heparin lock for prevention of catheter-related	bloodstream infection in neonates with extended umbilical venous catheters use:	A randomized controlled trial
Authors: Seliem Wael , Abdel-Hady Hesham , El-Nady Ghada
Published: December 2019

Objective: To ascertain the safety and the efficacy of amikacin-heparin lock technique in the prevention of catheter-related-bloodstream infection (CRBSI) in neonates with extended umbilical venous catheters (UVCs) use and to determine the applicability of keeping UVCs in situ for 14 days.

Methods: A randomized controlled – blind trial was conducted on neonates who were expected to require UVC for at least 48 hours. Babies were randomized to have the catheter locked twice daily for 20 minutes either with heparinized normal saline (n=42) or heparinized saline containing amikacin 1.5 mg/mL (n=41). The blood glucose level was measured at the end of indwelling time and any episode of hypoglycemia was recorded. Doppler ultrasound was performed for the umbilical, portal and inferior vena cava veins. Surveillance cultures were taken from enrolled patients' skin to detect colonization by amikacin-resistant organisms. The UVCs were removed whenever their use was deemed unnecessary or at the 14th day after insertion.

Results: There were 4 CRBSI episodes (definite, probable) in amikacin-heparin lock group and 12 episodes in the saline-heparin lock group [RR: 0.34; 95% CI: (0.02–0.65); p=0.01]. Density incidence of CRBSIs was 3.6 per 1000 catheter days in amikacin-heparin lock group and 18.4 per 1000 catheter days in saline-heparin lock group [RR: 0.19 CI: (0.08–0.67), p= 0.02]. No amikacin-resistant organisms were recovered from any of the cultures. Transient asymptomatic hypoglycemia occurred in 13 (15.6%) neonates at the end of catheter-lock period. No portal or inferior vena cava thrombosis was detected in any of our babies.

Conclusions: Amikacin-heparin lock reduced the incidence of CRBSI in neonates with extended UVCs use, without promoting amikacin resistance.
Pulmonary embolism presenting with sudden respiratory failure in	two previously stable neonates
Authors: Werthammer Joseph , Pritt Audra , Reechi Laura , Brown Linda , Heydarian Mahmood
Published: December 2019

Pulmonary artery embolism (PE) is a rare and life-threatening complication in the neonate. We describe two previously stable infants who incurred respiratory failure from PE. The first case is a late preterm infant with gastroschisis with autopsy confirmation of PE presumably as a result of a central venous line (CVL) with thromboembolism. The second case is an extreme low birth weight infant with sudden onset of respiratory failure, abnormal chest x-ray, disseminated intravascular coagulation (DIC), and echocardiographic confirmation of a thrombus at the junction of the superior vena cava and right atrium at the site of a previous CVL. This infant was successfully managed with thrombolytic therapy and anticoagulation. We suggest that PE be considered in an infant with a history of a CVL who presents with otherwise unexplained respiratory failure.
Beckwith-Wiedemann Syndrome: Influence of the genetic pattern on	the clinical picture
Authors: Kalyanasundaram S. , Ibhanesebhor S.E. , Manjunatha C.M. , Mathews A.Z.
Published: December 2019

Beckwith-Wiedemann Syndrome (BWS) is a condition associated with macroglossia, omphalocele, macrosomia and hypoglycemia, in addition to increased susceptibility to malignancies, especially Wilm's tumor and hepatoblastoma. Over the past few years, a clear pattern is emerging revealing a close link between the genetic pattern, clinical presentation and risk of developing malignancies. We report two cases of BWS seen recently in our neonatal unit to illustrate this aspect of the condition.

Beckwith-Wiedemann Syndrome (BWS) is a condition associated with macroglossia, omphalocele, macrosomia and hypoglycemia, in addition to increased susceptibility to malignancies, especially Wilm's tumor and hepatoblastoma. This overgrowth-malformation syndrome has been linked to chromosome 11 p15, a region with many imprinted genes [1]. There has been a great deal of interest in the underlying genetic pattern in BWS especially since it has been shown to influence the clinical presentation as well as the risk of developing tumors (Wilm's tumor and Hepatoblastoma).

We report two cases of BWS seen recently in our neonatal unit to illustrate the varied clinical presentation and underlying genetics of the condition. This is followed by a discussion focused on the various genetic patterns underlying the problem, and its possible influence on the clinical presentation.
Clinical profile of early postnatal body weight changes in	extremely low birth weight infants
Authors: Verma Rita Prasad , Shibli Syed , Fang Hai
Published: December 2019

Background: Early postnatal weight changes are widely variable and unpredictable in the extremely low birth weight infants (ELBW, birth weight < 1000 g). As the fluid volume therapy is calculated based on the body weight these changes could potentially have implications in the hydration related morbidities in them. Early postnatal weight changes have not been systematically investigated in this population.

Objectives: To determine the pattern and magnitude of weight changes early in life and its relationship with maturation and birth weight (BW) in ELBW infants.

Methods: We studied the maximum weight loss (MWL), and the daily body weight changes from birth weight (DΔ bw) during the first 15 days of life. Prospectively entered infants' and maternal demographic and relevant clinical data were retrospectively extracted via computerized reports and chart reviews during a three-year study period. MWL and DΔ bw (calculated as % of birth weight and expressed as mean ± SD) were determined and correlated with gestational age (GA) and BW. Data were analyzed via Pearson's correlation co-efficient and the ordinary least square regression tests.

Results: The mean ± standard deviation of GA and BW in 102 enrolled ELBW infants were 26.1 ± 2 weeks and 779.9 ± 157 g respectively. MWL in the entire cohort was 14.2 ± 5.4%. After initial loss the BW was regained on 14.5 ± 4.2 postnatal days of life. MWL varied widely within unit GA groups and was highest in infants born at 23 weeks. MWL correlated inversely with GA (r= − 0.3, p=0.007) but not with BW (r=0.17, p=0.09). DΔ bw varied widely and was highest on postnatal day 4. DΔ bw correlated negatively and significantly with GA during days 1–8 of life (p 0.05 to < 0.01) except for day 2 (p= 0.06). The slopes of regression coefficients for the two variables were also negative and highly significant during postnatal days 1–8 (p < 0.01) except for day 2 (p= 0.06). DΔ bw did not correlate with GA during 9–15 postnatal days and displayed a positive slope on day 15.

Conclusions: MWL is related inversely to GA and has no relationship with BW in ELBW infant. DΔ bw is predictable by GA during the first but not the second postnatal week. The BW is regained on an average of 14 days of postnatal life.
The effect of listening to lullaby music on physiologic response	and weight gain of premature infants
Authors: Farhat Ahmadshah , Amiri Rana , Karbandi Sohaila , Esmaily Habibollah , Mohammadzadeh Ashraf
Published: December 2019

Objectives: The environment plays a key role in survival and brain development for premature infants. Recent interest lends consideration to non pharmacological interventions as a beneficial alternative. This study seeks to investigate the effect of lullaby music on the physiological response and weight gain of premature infants in Mashhad, Iran.

Method: In this study, 44 very low birth weight infants ⩽ 34 weeks of gestational age that were admitted to the Neonatal Intensive Care Unit (NICU) of Imamreza Hospital in Mashhad, Iran were enrolled. Infants were randomly assigned to one of two groups: the Music group and the Control group. Lullaby music was played through earphones for the Music group. This continued for 8 days at 20 minutes per day. The Control group received routine auditory stimulation. Neonates in the two groups were in stable condition and kept in their isolettes. Infants were monitored for 40 minutes; 10 minutes baseline, 20 minutes into the intervention and 10 minutes post intervention. Data measures were heart rate, respiration rate, oxygen saturation and body weight.

Result: The two groups differed significantly in the respiratory rate (p= 0.01) and oxygen saturation (p= 0.001). There were no significant differences in the heart rate (p= 0.24) and weight gain (p= 0.093) between the two groups.

Conclusion: Preterm infants respond to lullaby music as evidenced by the changes in their respiratory rates and oxygen saturations. Although this study did not demonstrate an improvement in weight gain, further studies are recommended to examine the effect of music on other growth and developmental aspects
The vulnerable very low birth weight infant: Late onset	bloodstream infections
Authors: Gibbs Kathleen A. , Kleinman Lawrence C. , Jenkins Stephen G. , Herold Betsy C. , Holzman Ian R.
Published: December 2019

Objective: To review the epidemiology of late-onset bloodstream infections (LOBSI), evaluate risk factors associated with LOBSI and to compare our findings with the literature in light of new National Healthcare Safety Network (NHSN) birth weight categories.

Design/methods: A retrospective case-controlled study of infants with LOBSI at ⩾ 72 hours of life admitted to the NICU between 2000 and 2005. Infection rates were determined for birth weight categories adopted by the NHSN. The exposures of cases and controls to established risk factors were compared. Antimicrobial susceptibility patterns were evaluated.

Results: A total of 4061 neonates were studied. LOBSI occurred in 150 (3.7%) of infants. Out of these 150, 196 episodes of infection occurred with 210 isolated pathogens. Most cases of LOBSI were in the infants whose birth weight was < 1000 grams (ELBW). Sepsis was associated with increased mortality (23%) in very low birth weight infants (p< 0.05). Coagulase-negative staphylococci were responsible for most cases; LOBSI due to Candidal infections were less common but associated with high mortality rates (37%) in the ELBW infant. Rates of methicillin-resistant Staphylococcus aureus remained low. Infants who developed LOBSI had prolonged exposures to a number of established risk factors. In the logistic regression analysis, bacteremia was associated with use of parenteral nutrition (OR =5.9) and umbilical catherization (OR= 32).

Conclusions: ELBW infants had the highest rates of LOBSI. There was a low overall incidence of LOBSI due to yeast. However, infections with a Candida species were more common in ELBW infants and were associated with a higher mortality.
Oxygen saturation monitoring in the Neonatal Intensive Care Unit	(NICU): Evaluation of a new alarm management
Authors: Brostowicz Heather M. , Rais-Bahrami K.
Published: December 2019

Objective: Oxygen saturation (SpO $_{2}$ ) monitoring is an integral part of patient care in intensive care units. Unfortunately, the clinical application of this technology has been adversely affected by the unacceptably high rate of false alarms, which has resulted in desensitizing the clinicians to SpO $_{2}$ alarms The SatSeconds™ alarm management feature (Nellcor™) incorporates an integral alarm. The primary hypothesis is that there will be progressive reduction in percentage saturation using the SatSeconds™ alarm feature depending on the integral settings.

Study design: 29 patients were monitored for 2 hours each with the study monitor. Upper and lower oxygen saturation alarm limits were determined individually and manually recorded and preset on the test oximeter for later analysis of alarm events. Test oximeter display values were not used for patient management. Audible alarms were silenced throughout the study.

Results: Alarm events were recorded while the SatSeconds™ alarm management feature was set at various points. With application of the SatSeconds™ alarm management feature, there was an overall decrease in alarms to 40% with a setting of 50 SatSeconds™.

Conclusion: Application of an integrated alarm system such as SatSeconds™ alarm management feature allows caregivers to respond to clinically relevant alarms.
Fungal CNS infection in a term neonate: Can a radiologist help	with diagnosis?
Authors: Rohilla Seema , Yadav Rohtas K. , Singh Jagjit , Gathwala Geeta , Dhaulakhandi Dhara B.
Published: December 2019

Brain abscesses can be bacterial or fungal. It is usually difficult to distinguish between the two clinically as well as radiologically. However, careful scrutiny of the radiological images for subtle radiological signs and proper analysis of serial images can help in narrowing down the diagnosis and preventing delay in specific treatment.

We report an infant who initially presented with a small parietal hemorrhage and subsequently evolved into multiple brain abscesses. Since fungi and not bacteria are preferentially known to invade blood vessels, the infant had a radiological diagnosis of fungal abscess in the brain. Although the cerebrespinal fluid did not grow any fungal micro-organism, the infant clinically improved after the administration of anti-fungal antibiotics. Blood and urine cultures later grew Candida albicans.
Late preterm births: Epidemiology, possible causes, and consequences
Authors: Perugu Sirisha , Rehan Virender
Published: December 2019

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.
Evaluation of healthy full-term and late preterm infants	presenting with apnea in the newborn nursery: A comparison of neonatal apnea	and infantile acute life threatening event (ALTE)
Authors: Bozzetti Valentina , Tagliabue Paolo , Rhein Lawrence
Published: December 2019

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.