Intravenous Immunoglobulin Use in Hemolytic Disease Due to ABO Incompatibility to Prevent Exchange Transfusion.

Introduction: Intravenous immunoglobulin (IVIG) has been widely used to treat the hemolytic disease of the newborn (HDN). Although it has been shown that IVIG treatment reduces the duration of phototherapy and hospitalization, the use of IVIG in hemolytic disease due to ABO incompatibility has been controversial in recent years. This study aimed to investigate the role of IVIG in the prevention of exchange transfusion in infants with ABO HDN who presented with bilirubin levels at or above the level of exchange transfusion. Materials and Methods: This study evaluated the data of infants with ABO HDN in the Turkish Neonatal Jaundice Online Registry. The infants with ABO HDN who met the total serum bilirubin level inclusion criteria (within 2-3 mg/dL of exchange transfusion or even above exchange transfusion level) were included in the study according to the guidelines from the American Academy of Pediatrics and the Turkish Neonatal Society. All patients were managed according to the unit protocols recommended by these guidelines and received light-emitting diode (LED) phototherapy. Infants who only received LED phototherapy, and who received one dose of IVIG with LED phototherapy were compared. Results: During the study period, 531 term infants were included in the study according to inclusion criteria. There were 408 cases in the phototherapy-only group, and 123 cases in the IVIG group. The demographic findings and the mean bilirubin and reticulocyte levels at admission were similar between the groups (p > 0.05), whereas the mean hemoglobin level was slightly lower in the IVIG group (p = 0.037). The mean age at admission was earlier, the need for exchange transfusion was higher, and the duration of phototherapy was longer in the IVIG group (p < 0.001, p = 0.001, and p < 0.001, respectively). The rate of re-hospitalization and acute bilirubin encephalopathy (ABE) was higher in the IVIG group (p < 0.001 and p = 0.01, respectively). Conclusion: In this study, we determined that one dose of IVIG did not prevent an exchange transfusion nor decrease the duration of phototherapy in infants, who had bilirubin levels near or at exchange transfusion level, with hemolytic disease due to ABO incompatibility.

Impact of antenatal corticosteroid exposure on thymus size in premature infants.

BACKGROUND: This study examined the effect of corticosteroids on the thymic index (TI) and the thymus/weight index (TWI) in infants exposed to antenatal corticosteroids (ACS). METHODS: This prospective study was conducted between August 2014 and October 2018. A thymus ultrasound was performed to assess thymus size on the second day of life. Thymus size was assessed as TI and TWI. RESULTS: In total, 167 neonates (≤34 weeks gestation)  constituted the study population, including 94 ACS-exposed infants and 73 untreated infants. The treatment group exhibited significantly lower birth weight and significantly shorter birth length than the ACS (-) group. Therefore, TI was smaller in the treatment group than in the untreated group (6.96 ± 4.05 cm3 vs. 5.64 ± 3.39 cm3). The TWI was 3.69 ± 1.8 cm3/kg in the ACS (-) group versus 3.32 ± 1.56 cm3/kg in the ACS (+) group. The median anteroposterior diameter of the right lobe was 1.33 cm (range, 0.45-2.40) in the ACS (-) group compared to 1.15 cm (range, 0.47-2.40) in the ACS (+) group. The median anteroposterior diameter of the left lobe was 1.40 cm (range, 0.43-2.20) in the ACS (-) group and 1.19 cm (range, 0.32-2.36) in the ACS (+) group. The median largest sagittal area was 2.64 cm2 (range, 0.5-5.46) in the ACS (-) group versus 2.20 cm2 (range, 0.55-5.90) in the ACS (+) group. CONCLUSION: We found that TWI was not significantly changed by ACS exposure in premature infants.

Vitamin D Deficiency Prevalence in Late Neonatal Hypocalcemia: A Multicenter Study

Objective: Late neonatal hypocalcemia (LNH) is a common metabolic problem associated with hypoparathyroidism, high phosphate intake and vitamin D deficiency, often presenting with seizures. In this cross-sectional study, we aimed to evaluate the role of vitamin D deficiency in LNH in Turkey and to describe the characteristics of affected newborns. Methods: Conducted with a cross-sectional design and with the participation of 61 neonatal centers from December 2015 to December 2016, the study included term neonates with LNH (n=96) and their mothers (n=93). Data were registered on the FAVOR Web Registry System. Serum samples of newborns and mothers were analyzed for calcium, phosphate, magnesium, albumin, alkaline phosphatase, intact parathyroid hormone (iPTH) and 25 hydroxyvitamin D [25(OH)D] levels. Results: The median (range) onset time of hypocalcemia was 5.0 (4.0-8.0) days of age, with a male preponderance (60.4%). The median (range) serum 25(OH)D levels of the neonates and their mothers were 6.3 (4.1-9.05) and 5.2 (4.7-8.8) ng/mL, respectively. The prevalence of vitamin D deficiency (<12 ng/mL) was high in both the neonates (86.5%) and mothers (93%). Serum 25(OH)D levels of the infants and mothers showed a strong correlation (p<0.001). While the majority (93.7%) of the neonates had normal/high phosphorus levels, iPTH levels were low or inappropriately normal in 54.2% of the patients. Conclusion: Vitamin D deficiency prevalence was found to be high in LNH. Efforts to provide vitamin D supplementation during pregnancy should be encouraged. Evaluation of vitamin D status should be included in the workup of LNH.

Determination of tissue hypoxia by physicochemical approach in premature anemia.

BACKGROUND: Anemia is a common problem in premature infants and its most rapid and effective therapy is erythrocyte transfusion. However, owing to inherent risks of transfusion in this population, transfusions should be administered only when adequate oxygen delivery to tissues is impaired. The aim of this study was to determine tissue acid levels using Stewart method in an attempt to evaluate the tissue oxygenation level and thereby the accuracy of transfusion timing. METHODS: This study included 47 infants delivered at gestational age below 34 weeks who required erythrocyte transfusion for premature anemia. Strong ion gap (SIG), unmeasurable anions (UMA), tissue acid levels (TA), and Cl/Na ratios were calculated before and after transfusion. RESULTS: The mean birth weight and gestational age of the study population were 1210 ± 365 g and 29.2 ± 2.7 weeks, respectively. Tissue acid levels were increased (TA ≥ 4) and tissue hypoxia developed in 10 (16.6%) of 60 erythrocyte transfusions administered according to the restrictive transfusion approach. The patients were divided into two groups according to tissue acid levels as low (<4) and high (≥4) tissue acid groups. The group with tissue hypoxia (TA ≥ 4) had significantly higher UMA levels but a significantly lower Cl/Na ratio; and UMA levels decreased and Cl/Na ratio increased after transfusion in this group. Tissue hypoxia secondary to anemia was shown to be improved by erythrocyte transfusion. CONCLUSION: The results of the present study suggest that the determination of the level of tissue hypoxia by the Stewart approach may be an alternative to restrictive transfusion guidelines for timing of transfusion in premature anemia. It also showed that a low Cl/Na ratio can be used as a simple marker of tissue hypoxia.

Association of Serum Albumin Level and Mortality in Premature Infants.

BACKGROUND: Hypoalbuminemia has been proven to be a powerful predictor of mortality in adult patients. However, prognostic value of serum albumin in neonates is not clear. OBJECTIVE: To assess the relationship between serum albumin level within the first day of life and outcome in preterm infants born before 32 weeks of gestation. METHODS: The study was conducted prospectively in Baskent University Hospital between October 2008 and November 2009. Patients were divided by gestational age into two groups as below or of 28 weeks and above 28 weeks. Then serum albumin percentile groups were established within each gestational age group and were defined as <25, 25-75, and >75 percentile groups by combining percentile groups between the two gestational age groups. Three serum albumin percentile groups were compared regarding neonatal outcomes. RESULTS: A total of 199 infants with mean birth weight of 1,272 ± 390 g and mean gestational age of 29.2 ± 2.2 weeks were admitted to the study. The mean serum albumin level was 30.6 ± 4.7 g/l for all patients. The mean serum albumin levels were 25.5 ± 3.8, 30.1 ± 2.7, and 35.3 ± 3.7 g/l for <25, 25-75, and >75 percentile groups, respectively. Prevalence of infants with respiratory distress syndrome and prevalence of infants with sepsis and mortality were significantly higher in <25 percentile group. Logistic regression analysis showed that serum albumin <25 percentile and birth weight were independent predictive variables of mortality. Albumin concentrations lower than 27.2 g/l was associated with mortality, with a sensitivity of 71% and a specificity of 86%. CONCLUSION: Low serum albumin level within the first day of life is an independent predictor of mortality in preterm infants.

Is umbilical cord milking always an advantage?

OBJECTIVE: The role of cord milking as an alternative to delayed cord clamping is an area that requires more research. Purpose of this clinical trial was to investigate the impact of umbilical cord milking on the absolute neutrophil counts (ANCs) and the neutropenia frequency of preterm infants. METHODS: Fifty-eight pregnant women were randomly assigned to one of the umbilical cord milking and control groups. A total of 54 preterm infants (gestational age ≤ 32 weeks) were enrolled into the study. The umbilical cords of 25 infants were clamped immediately after birth, and in 29 infants, umbilical cord milking was performed first. RESULTS: The ANCs were statistically significantly lower in the cord milking group compared with the control group on days 1, 3 and 7. The frequency of neutropenia was higher in the cord milking group compared with the control group. CONCLUSION: In our study, ANCs were lower in the cord milking group and the frequency of neutropenia was higher. Umbilical cord milking plays a role on the ANCs of preterm infants.

An aggressive parenteral nutrition protocol improves growth in preterm infants.

The objective of this study was to compare postnatal growth and clinical outcomes of preterm infants after an adjustment in amino acid and lipid administration practice. The study was conducted retrospectively in preterm infants with a birth weight < 1250 g for the periods January-June 2007 and June-November 2010. In 2007, amino acid solution was initiated at 2 g/kg/ day on the first day of life and advanced 1 g/kg/day to a maximum of 3 g/kg/day; lipid solution was initiated at 1 g/kg/day on the first day of life and advanced 0.5 g/kg/day to a maximum of 2 g/kg/day (low-dose parenteral nutrition group). In 2010, amino acid solution was initiated at 3 g/kg/day on the first day of life and advanced 1 g/kg/day to a maximum of 4 g/kg/ day; lipid solution was initiated at 1 g/kg/day on the first day of life and advanced 1 g/kg/day to a maximum of 3 g/kg/day (high-dose parenteral nutrition group). Patient characteristics were similar in the two groups. Infants in the high-dose parenteral nutrition group showed a significant reduction in the time needed to regain birth weight and a significant reduction in the maximum weight loss. Weight, length and head circumference at discharge were significantly higher in the high-dose parenteral nutrition group. The mean duration of parenteral nutrition, mean number of days to reach full enteral feeding and incidence of sepsis and necrotizing enterocolitis were significantly lower in the high-dose parenteral nutrition group. There was no significant difference in the mortality rate between the groups. In conclusion, a more aggressive parenteral nutrition protocol for preterm infants resulted in a more rapid increase in weight, length and head circumference, and decreased incidence of sepsis and necrotizing enterocolitis.

Idiopathic central diabetes insipidus presenting in a very low birth weight infant successfully managed with lyophilized sublingual desmopressin.

Neonatal central diabetes insipidus (DI) is an extremely rare disorder that can cause severe morbidity and mortality. We have reported a very low birth weight infant with idiopathic central DI presenting in the first month of life who was successfully treated with sublingual desmopressin therapy. In this report, we emphasize that central DI should be kept in mind in an infant with unexplained hypernatremia and polyuria. Timely diagnosis and treatment with lyophilized desmopressin may prevent severe morbidity and mortality.

Poor postnatal weight gain predicts stage 3+ retinopathy of prematurity in very low birth weight infants.

Multiple systemic risk factors are associated with retinopathy of prematurity (ROP). We analyzed the role of low weight gain (WG) to predict the development of stage 3+ ROP among preterm infants. This study included 126 newborns with birth weight ≤1500 g and gestational age <32 weeks. Preterm newborn infants were divided into two groups according to severity of ROP as: preterm infants without ROP or mild ROP (Group 1) and preterm infants with stage 3+ ROP (Group 2). WG and WG proportion were measured at completed 4 and 6 weeks of life. The patients under the cut-off point according to receiver operating characteristic curve were classified as low WG patients. WG and WG proportion were significantly lower in Group 2 than in Group 1 at the 4th and 6th weeks of life. We concluded that low WG and WG proportion at the 4th and 6th weeks of life were predictive for the development of stage 3+ ROP. Preterm babies with low birth weight and low WG should be followed closely for severe ROP.

Hepatic laceration as a life-threatening complication of umbilical venous catheterization.

Umbilical venous catheterization is an intravenous infusion route for maintenance fluids, medications, blood products, and parenteral nutrition in preterm neonates. However, this procedure may be associated with several complications, such as infection, thrombosis, vessel perforation, and cardiac and hepatic injuries. Hepatic laceration is a rare but life-threatening complication of umbilical venous catheterization that is a result of direct injury through the liver parenchyma. Here, we present a preterm newborn with hepatic laceration as a rare and serious complication of umbilical venous catheterization.