Neurodevelopmental evaluation of newborns who underwent hypothermia with a diagnosis of hypoxic ischemic encephalopathy based on the Bayley-III scale.

Background/aim: Hypoxic ischemic encephalopathy (HIE) is one of the common causes of mortality and morbidity in newborns. Despite therapeutic hypothermia, an important treatment with proven efficacy, the morbidity and mortality rates remain high. The aim of this study was to neurodevelopmentally evaluate patients who underwent therapeutic hypothermia. Material and method: Included herein were patients who underwent hypothermia between 2018 and 2020. Their medical files were reviewed retrospectively, and their demographic and clinical information was recorded. Patients whose contact information was available were called to the developmental pediatrics outpatient clinic for a neurodevelopmental evaluation. The Bayley Scales of Infant and Toddler Development 3rd Edition (Bayley-III) was used as the evaluation tool. Laboratory values and clinical parameters of the patients were further analyzed. Results: It was found that 42 patients underwent hypothermia in 3 years, of whom 14 (33.3%) had died. Of the 28 patients who were discharged, 20 children could be reached, and a neurodevelopmental evaluation was performed. Developmental delay in the cognitive area was detected in 11 (55%) patients, delay in the language area was found in 9 (45%) patients, and delay in the motor area was found in 11 (55%) patients. The correlation and regression analysis results determined that the time to start cooling was the most effective common factor in all 3 fields of scoring. Conclusion: The time to start cooling is related to the neurodevelopmental outcomes of patients with HIE. The earlier cooling is started, the better the neurodevelopmental results. Despite therapeutic hypothermia, the neurodevelopmental development of infants may be adversely affected. These patients should be followed-up neurodevelopmentally for a long time.

Mortality related factors on hypoxic ischemic encephalopathic patients treated with therapeutic hypothermia: an 11-year single-center experience.

BACKGROUND: Hypoxic-ischemic encephalopathy (HIE) is a condition that may cause multiple organ dysfunction and has a high rate of mortality and morbidity. Therapeutic hypothermia is the only proven treatment that decreases the sequel and mortality rate of neonates that are born after 36 weeks of pregnancy and have moderate-severe HIE. METHODS: Our study was a single-center, retrospective study that includes newborns (gestational age ≥ 36 weeks) who underwent therapeutic hypothermia due to hypoxic-ischemic encephalopathy between 2010 and 2020. We evaluated 125 patients who were diagnosed with moderate to severe HIE and received therapeutic hypothermia. Demographic and clinical data were obtained from electronic medical records and patient files. The patients were separated into two groups as exitus group (n = 39) and discharged group (n = 86). We aimed to evaluate factors affecting mortality. RESULTS: We determined that the median resuscitation times were longer in the delivery room [retrospectively, 10th minutes (0-30) vs. 1 min (0-20), p < 0.05], the tenth min APGAR scores were lower [respectively, 4 (0-7) vs. 6 (3-10), p < 0.05], and the median pH value in the first blood gas taken was lower [respectively, 6.87 (6.4-7.14) vs. 6.90 (6.58-7.12), p < 0.05] in the exitus group. We also determined that multiple organ dysfunction is seen more often in the exitus group. DISCUSSION: This study demonstrated that the depth of acidosis in the blood gas, multiple organ dysfunction, and the existence of early-onset seizures are the signs of poor prognosis. Therefore, physicians need to be aware of such prognostic factors to follow these patients more closely in terms of possible complications and to inform their parents.

Global gene expression profiling in congenital diaphragmatic hernia (CDH) patients.

Congenital diaphragmatic hernia (CDH) is an anomaly characterized by a defect in the diaphragm, leading to the passage of intra-abdominal organs into the thoracic cavity. Herein, the presented work analyzes the global gene expression profiles in nine CDH and one healthy newborn. All of the patients had left posterolateral (Bochdalek) diaphragmatic hernia, operated via an abdominal approach, and stomach and bowels in the thorax cavity. Some patients also had additional anomalies. A total of 560 differentially regulated genes were measured. Among them, 11 genes showed significant changes in expression associated with lung tissue, vascular structure development, and vitamin A metabolism, which are typical ontologies related to CDH etiology. Among them, SLC25A24 and RAB3IL1 are involved in angiogenesis, HIF1A and FOXC2-AS1 are related with the alveolus, MAGI2-AS3 is associated with the diaphragm, LHX4 and DHH are linked with the lung, and BRINP1, FZD9, WNT4, and BLOC1S1-RDH5 are involved in retinol. Besides, the expression levels of some previously claimed genes with CDH etiology also showed diverse expression patterns in different patients. All these indicated that CDH is a complex, multigenic anomaly, requiring holistic approaches for its elucidation.

A randomized trial comparing the short binasal prong to the RAM cannula for noninvasive ventilation support of preterm infants with respiratory distress syndrome.

PURPOSE: In this study, we compared the efficacy of the RAM cannula and the short binasal prong (SBP) as noninvasive ventilation (NIV) interfaces in preterm infants with respiratory distress syndrome (RDS). MATERIALS AND METHODS: Premature infants with RDS who required NIV were randomized in the RAM cannula and SBP groups within the first half hour. The groups were compared in terms of their need for invasive ventilation, their surfactant use, and their morbidities. RESULTS: We assessed 126 patients (62 SBPs and 64 RAM cannulas). Clinical and demographic features of the groups were similar. Within the first 72 hours, the RAM cannula group showed a higher need for invasive ventilation (32.8 and 9.6%, p = .002, respectively), surfactant (42.1 and 19.3%, p = .007, respectively), and rate of pulmonary hemorrhage was also higher. There were no differences between the groups in terms of other morbidities. CONCLUSIONS: In preterm infants with RDS, RAM cannula use as an interface for NIV results in increased invasive ventilation and surfactant use.

An Observational, Prospective, Multicenter, Registry-Based Cohort Study Comparing Conservative and Medical Management for Patent Ductus Arteriosus.

No consensus has been reached on which patent ductus arteriosus (PDAs) in preterm infants require treatment and if so, how, and when they should be treated. A prospective, multicenter, cohort study was conducted to compare the effects of conservative approaches and medical treatment options on ductal closure at discharge, surgical ligation, prematurity-related morbidities, and mortality. Infants between 240/7 and 286/7 weeks of gestation from 24 neonatal intensive care units were enrolled. Data on PDA management and patients' clinical characteristics were recorded prospectively. Patients with moderate-to-large PDA were compared. Among the 1,193 enrolled infants (26.7 ± 1.4 weeks and 926 ± 243 g), 649 (54%) had no or small PDA, whereas 544 (46%) had moderate-to-large PDA. One hundred thirty (24%) infants with moderate-to-large PDA were managed conservatively, in contrast to 414 (76%) who received medical treatment. Eighty (62%) of 130 infants who were managed conservatively did not receive any rescue treatment and the PDA closure rate was 53% at discharge. There were no differences in the rates of late-onset sepsis, necrotizing enterocolitis (NEC), retinopathy of prematurity, intraventricular hemorrhage (≥Grade 3), surgical ligation, and presence of PDA at discharge between conservatively-managed and medically-treated infants (p > 0.05). Multivariate analysis including perinatal factors showed that medical treatment was associated with increased risk for mortality (OR 1.68, 95% Cl 1.01-2.80, p = 0.046), but decreased risk for BPD or death (BPD/death) (OR 0.59, 95%Cl 0.37-0.92, p = 0.022). The preferred treatment options were ibuprofen (intravenous 36%, oral 31%), and paracetamol (intravenous 26%, oral 7%). Infants who were treated with oral paracetamol had higher rates of NEC and mortality in comparison to other treatment options. Infants treated before postnatal day 7 had higher rates of mortality and BPD/death than infants who were conservatively managed or treated beyond day 7 (p = 0.009 and 0.007, respectively). In preterm infants born at <29 weeks of gestation with moderate-to-large PDA, medical treatment did not show any reduction in the rates of open PDA at discharge, surgical or prematurity-related secondary outcomes. In addition to the high incidence of spontaneous closure of PDA in the first week of life, early treatment (<7 days) was associated with higher rates of mortality and BPD/death.

Late onset hyponatremia in preterm newborns: is the sodium content of human milk fortifier insufficient?

Introduction: In this study, we aimed to define the incidence and time to detection of late onset hyponatremia (LOH) as well as factors affecting its development in preterm newborns. We also aimed to determine the daily sodium requirement of these patients.Methods: We studied a total of 145 very low birth weight infants with a full or nearly full enteral diet and followed them up until discharge. We recorded demographic and clinic characteristics. We measured serum sodium (SNa) levels at least once a week after the second week. We compared infants with LOH with other infants to analyze possible risk factors.Results: Twenty-nine (20%) infants developed LOH in an average of 23.4 ± 7.8 days. The mean SNa level of these infants was 124.6 ± 5.6 mmol/L. Logistic regression analysis showed that a birth weight of less than 1000 g, preterm early membrane rupture, and nutrition with fortified human milk alone were risk factors for LOH. The mean daily amount of sodium added to the nutrition of hyponatremic preterm infants was 3.6 ± 2.1 mmol/L. Subgroup analysis showed that the incidence of LOH was two times higher (39.2%) in infants with a birth weight of less than 1000 g.Conclusion: We observed the development of LOH within three to four weeks in nearly half of preterm infants fed with fortified human milk, especially those with a birth weight of less than 1000 g. We believe that the sodium content of currently used human milk fortifiers should be increased.

Can High Average Oxygen Saturation be a Risk Factor for Necrotizing Enterocolitis in VLBW Infants?

BACKGROUND: Avoiding hyperoxia with oxygen saturation monitoring is important in the follow-up of very low birth weight (VLBW) infants. Role of oxygen-derived free radicals in the pathogenesis of necrotizing enterocolitis (NEC) has been well defined. However, a great majority of the evidence supporting the role of hyperoxia in NEC development are data from experimental studies and there are very few clinical studies. In this study, the association between NEC and average oxygen saturation (SpO2) levels in VLBW infants was researched. METHODS: Average SpO2 values of VLBW infants in the last 24 h were recorded prospectively with pulse oximeter. Average SpO2 records were continued at least for 10 days starting from the first day after birth. In the follow-up, the average SpO2 values of the patients who developed NEC and those who did not were compared. RESULTS: A total of 127 VLBW infants were followed up. Thirteen patients developed NEC (Bell's classification ≥ stage II). No differences were found between the average SpO2 levels (94.9 and 94.8%) of the patients who developed NEC and those who did not. It was found that average SpO2 value higher than 93 or 95 was not a risk for NEC development (P = 0.693 and P = 0.771). CONCLUSIONS: In this study, no association was found between average SpO2 values recorded in the first weeks of VLBW infants and NEC.

The association of early postnatal weight loss with outcome in extremely low birth weight infants.

BACKGROUND: To compare outcomes of extremely low birth weight (ELBW) infants having different weight losses in the first 3 days of life. METHODS: One hundred and twenty six ELBW infants were evaluated retrospectively for weight loss percentages on the third day of life compared to their birth weight. We examined the weight loss on the third day of life compared to the birth weight for the ELBW infants and tested its association with mortality and morbidities. The mortality was subgrouped as overall mortality and mortality in the first 7 days of life. The morbidities were patent ductus arteriosus (PDA), intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD). BPD was defined as need for supplemental oxygen at 36 weeks' postconceptional age. We grouped the infants into four quartiles according to weight loss percentage on the third day of life: Group 1 (Quartile 1), infants with weight loss of 0-3% of birth weight; Group 2 (Quartile 2); infants with weight loss of 3.1-7.5%, Group 3 (Quartile 3), infants with weight loss of 7.51-12%; and Group 4 (Quartile 4), infants with weight loss of more than 12%. The mortality and morbidities were analyzed according to these groups and other risk factors. RESULTS: Overall mortality and mortality in the first 7 days of life were significantly higher in Groups 1 (36% and 27%) and 4 (43% and 24%), compared to Groups 2 (10% and 10%) and 3 (18% and 9%), respectively. CONCLUSION: Weight loss less than 3% and more than 12% was significantly associated with an increase in mortality. There was a positive correlation between weight loss on the third day of life and IVH. CONCLUSION: Inappropriate weight loss in ELBW infants is associated with increased mortality and IVH. Appropriate weight loss can improve outcomes in this population.

A Newborn with Gastric Hemangioma Treated Using Propranolol.

Gastric hemangiomas are rare benign vascular tumors that can cause severe gastrointestinal system bleeding. We presented the case of a neonate with fresh bleeding and melena from the orogastric tube and detected gastric hemangioma in esophagogastroduodenoscopic examination. Propranolol is widely used in treatment of cutaneous hemangiomas and non-gastric gastrointestinal system hemangiomas. However, the surgical approach is preferred for treating gastric hemangiomas, and there are few reports of gastric hemangiomas associated with non-surgical treatment. Gastric hemorrhage decreased with antacid and somatostatin treatment. Propranolol treatment was initiated before the surgery decision. After three weeks of treatment, we observed regression in the hemangioma with endoscopic evaluation. During the course of treatment, the patient's gastrointestinal system bleeding did not recur, and there were no side effects associated with propranolol.

Development of severe hyponatremia due to cerebrospinal fluid leakage following meningomyelocele surgery in a newborn.

Cerebrospinal fluid leakage following meningomyelocele surgery is a frequent complication in the wound-healing period and is associated with wound dehiscence. CSF loss can cause severe hyponatremia, especially in the newborn and early infancy periods when dietary sodium content is relatively low. Hyponatremia in the newborn period can result in adverse neurodevelopmental outcomes. In addition, hyponatremia's cerebral effects can increase complications in neurosurgery patients. The authors present the case of a newborn in whom CSF leakage from the operative site and severe hyponatremia developed following meningomyelocele surgery. To the best of their knowledge, severe hyponatremia caused by CSF leakage after meningomyelocele surgery has not been previously reported in the literature.

Successful Implementation of a Bundle Strategy to Prevent Ventilator-Associated Pneumonia in a Neonatal Intensive Care Unit.

BACKGROUND: We aimed to investigate the effectiveness of evidence-based bundle that we developed to reduce ventilator-associated pneumonia (VAP) rates and to assess the degree of compliance rates to this strategy in a tertiary neonatal intensive care unit. METHODS: This before-after prospective cohort trial divided into two periods was conducted. All neonates requiring ventilation were enrolled in the study. VAP incidence, compliance rates to bundle components and the contribution of each bundle component to VAP rates were compared between the periods. RESULTS: Throughout the study period, 13 VAP episodes were observed. Full adherence to all six components of the bundle doubled in the active-bundle period (12.8 vs. 24.3%, p < 0.01). The mean VAP rate decreased from 7.33/1000 to 2.71/1000 ventilator days following intervention (p = 0.083). CONCLUSION: This study showed that reliable implementation of a neonate-specific VAP prevention bundle can produce sustained reductions in VAP rates.

Intrapleural streptokinase for the treatment of complicated parapneumonic effusion and empyema in 2 newborns.

The management of complicated parapneumonic effusions by conventional first-line treatment with closed intercostal tube drainage and antibiotic therapy may fail because of thick viscous fluid and multiple pleural space loculations. Intrapleural fibrinolytic treatment is a non-invasive therapeutic option. In this report, we present successful use of intrapleural streptokinase for complicated parapneumonic effusion and empyema in 2 newborns. Intrapleural fibrinolytic therapy with streptokinase appears to be a safe and effective adjunctive therapy of choice and may have significant benefit even in newborns with complicated parapneumonic effusion and empyema, and thus, it can obviate surgical intervention.

Trimethoprim-sulfamethoxazole treatment for meningitis owing to multidrug-resistant Elizabethkingia meningoseptica in an extremely low-birthweight, premature infant.

Elizabethkingia meningoseptica is a recognised cause of meningitis in premature neonates and severe infections in immunocompromised adults; multi-drug resistance is a major issue. A premature infant developed sepsis, meningitis and hydrocephalus owing to E. meningoseptica and was treated successfully with trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 weeks. A ventriculoperitoneal shunt was required for hydrocephalus. This is the youngest patient with meningitis caused by E. meningoseptica to have responded to TMP-SMZ.