Point-of-care abdominal ultrasound in pediatric and neonatal intensive care units.

A spectrum of critical abdominal pathological conditions that might occur in neonates and children warrants real-time point-of-care abdominal ultrasound (abdominal POCUS) assessment. Abdominal radiographs have limited value with low sensitivity and specificity in many cases and have no value in assessing abdominal organ perfusion and microcirculation (Rehan et al. in Clin Pediatr (Phila) 38(11):637-643, 1999). The advantages of abdominal POCUS include that it is non-invasive, easily available, can provide information in real-time, and can guide therapeutic intervention (such as paracentesis and urinary bladder catheterization), making it a crucial tool for use in pediatric and neonatal abdominal emergencies (Martínez Biarge et al. in J Perinat Med 32(2):190-194, 2004) and (Alexander et al. in Arch Dis Child Fetal Neonatal Ed 106(1):F96-103, 2021).  Conclusion: Abdominal POCUS is a dynamic assessment with many ultrasound markers of gut injury by two dimensions (2-D) and color Doppler (CD) compared to the abdominal X-ray; the current evidence supports the superiority of abdominal POCUS over an abdominal X-ray in emergency situations. However, it should still be considered an adjunct rather than replacing abdominal X-rays due to its limitations and operator constraints (Alexander et al. in Arch Dis Child Fetal Neonatal Ed 106(1):F96-103, 2021). What is Known: • Ultrasound is an important modality for the assessment of abdominal pathologies. What is New: • The evidence supports the superiority of abdominal POCUS over an abdominal X-ray in emergency abdominal situations in the neonatal and pediatric intensive care units.

The Effect of Lullabies and Classical Music on Preterm Neonates' Cerebral Oxygenation, Vital Signs, and Comfort During Orogastric Tube Feeding: A Randomized Controlled Trial.

OBJECTIVE: This study investigated the effect of lullabies and classical music on preterm neonates' cerebral oxygenation, vital signs, and comfort during orogastric (OG) tube feeding. METHODS: This was a parallel-group pretest-posttest randomized controlled study. The research was conducted between December 2020 and May 2022. The sample consisted of 51 preterm neonates hospitalized in the neonatal intensive care unit (NICU) of Selçuk University Faculty of Medicine Hospital in Konya, Türkiye. Participants were randomized into three groups (17 preterm infants in each group). The first group listened to lullabies sung by their mothers and the second group listened to classical music during OG tube feeding. The control group received routine care with no music. Data were collected using a Neonatal Identification Information Form, Physiological Parameters and rSO2 Monitoring Form, and the Newborn Comfort Behavior Scale (Comfort-Neo). The study was registered on the ClinicalTrials database (NCT05333575). RESULTS: The lullaby group had stable peak heart rates and oxygen saturation levels (p = .002). Both lullaby and classical music groups had significantly higher cerebral oxygenation levels than the control group. The classical music group had the highest cerebral oxygenation level (p = .001). Both lullaby and classical music groups had significantly higher mean Comfort-Neo scores than the control group. The classical music group had the highest mean Comfort-Neo score (p = .040). CONCLUSION: Preterm neonates who listen to lullabies and classical music are likely to have higher cerebral oxygen and comfort levels. Listening to lullabies helps stabilize vital signs. These results suggest that healthcare professionals should encourage parents to get their preterm neonates to listen to lullabies and classical music.

The Effect of Breast Milk Odor on Feeding Cues, Transition Time to Oral Feeding, and Abdominal Perfusion in Premature Newborns: A Randomised Controlled Trial.

PURPOSE: The present study was conducted to determine the effect of odor stimulation with breast milk (BM) applied to premature newborns before and during enteral feeding on feeding cues, transition time to oral feeding and abdominal perfusion. DESIGN: This study was a parallel group pretest-post test randomised controlled trial (RCT). METHODS: The study was conducted in the neonatal intensive care unit (NICU) in Türkiye. Study data were collected from 32 premature newborns between October 2020 and December 2021. Newborns were randomly assigned to either intervention (n = 16) or control (n = 16) groups. Odor stimulation with BM was applied to newborns in the intervention group (IG) before and during enteral feeding for 3 days. Data were collected with the Newborn Information Form, Abdominal Perfusion Follow-up Form, and Feeding Cues Follow-up Form. Yates corrected and Fisher chi-squared test, Mann-Whitney U test, Cohen Kappa statistics, Permanova analysis, and Wilcoxon test were used in the analysis. The study was registered in ClinicalTrials.gov (NCT04843293). RESULTS: The frequency of feeding cues in newborns who were exposed to the odor of BM, was higher than in the control group (CG) (p < .05). The transition times to oral feeding were similar in newborns in the IG and CG (p > .05). Abdominal perfusion level of newborns in the IG was higher than the CG (p < .05), and the level of abdominal perfusion showed a significant difference in terms of group*time interaction (p < .05). CONCLUSION: Our findings suggest that odor stimulation with BM will be beneficial in improving the digestive functions of premature newborns.

Effect of SINC Feeding Protocol on Weight Gain, Transition to Oral Feeding, and the Length of Hospitalization in Preterm Infants: A Randomized Controlled Trial.

BACKGROUND: The present study aims to test the effect of the Safe Individualized Nipple-Feeding Competence (SINC) protocol on the preterm infants' weight gain, transition to oral feeding, and duration of hospitalization. METHODS: The procedure was designed as a single-blind, parallel-group randomized controlled trial. The trial was conducted in a neonatal intensive care unit (NICU) in Konya, Turkey. Data were collected from 80 preterm infants between February 2018 and March 2019. Infants (gestational weeks 28-33) were randomly assigned to the intervention (n = 39) and control groups (n = 41). The intervention group received the SINC feeding protocol, whereas the control group received the standard feeding. Data were collected using the Family Information Form, the Preterm Infant Follow-Up Form, and the SINC Protocol Evaluation Checklist. Infants were followed from hospitalization to discharge. The outcomes were weight gain, transition to oral feeding, and the length of hospitalization from birth to discharge. Pearson χ2 test, Fisher exact test, independent t-test, Mann-Whitney U test, and general linear model test were used in analyzing the data. RESULTS: The main effects of groups on weight measurements were found to be statistically significant (P < .001). There were no significant differences in terms of the transition from gavage to full oral feeding and the length of hospitalization (P > .05). CONCLUSIONS: SINC protocol positively influences weight gain in preterm infants. It is important to evaluate different evidence-based feeding methods both as they apply to the NICU stay and how they may affect long-term outcomes of preterm infant.

Central Diabetes Insipidus in a Preterm Neonate Unresponsive to Intranasal Desmopressin.

Central or neurogenic diabetes insipidus (DI) is uncommon in the pediatric age group and rarely occurs in neonates. It should be suspected in any neonate presenting with excessive urine output and hypernatremia that persists despite increased fluid administration. Diabetes insipidus may be secondary to asphyxia, intraventricular hemorrhage, infection, and structural abnormalities or may be idiopathic or genetic. Diagnosis includes a careful history, laboratory testing, and magnetic resonance imaging. Management of neonatal DI involves a careful balance between fluid intake and pharmacologic treatment. In this article we report a case of an extremely low birth weight infant presenting with central DI possibly caused by abnormality of the pituitary gland. Persistent hypernatremia was the initial presentation. Increased fluids were given initially but were only partially helpful. Eventually subcutaneous desmopressin (DDAVP) was required. The infant was unresponsive to intranasal DDAVP and required subcutaneous DDAVP upon discharge.

Neonatal hemodynamics and management of hypotension in newborns.

Hemodynamic instability is frequent in high-risk infants admitted to neonatal intensive care units. However, monitoring and treatment strategies of those conditions might show variations among the units. Different factors can compromise hemodynamic status in preterm/ term infants. Treatment options mostly include volume replacement, inotropes and/or vasopressors (dopamine, dobutamine, epinephrine and milrinone) and hydrocortisone. In general, these treatments are driven by predetermined protocols, which are not patient-based. According to the current knowledge, a physiology-driven approach that takes the individual characteristics of the newborn into consideration is accepted to be more suitable. In neonatal hemodynamics, important determinants are cardiac output, systemic vascular resistance, blood pressure, regional tissue perfusion and oxygenation. The novel technological methods, "targeted neonatal echocardiography" and "near-infrared spectroscopy" can help to delineate the underlying pathophysiology better, when added to the clinical assessment. In this review, strategies for the assessment of neonatal hemodynamics, as well as etiology, monitoring, and treatment of hemodynamic instability in preterm and term infants are presented.

Radiographic confirmation of feeding tube placement: a diagnostic tool identifying gastrointestinal anomalies.

Feeding tubes are commonly used in neonatal intensive care units, and their abnormal position seen on radiographs may indicate underlying serious problems. We recently cared for two infants who presented with clinical deterioration. An abnormally placed feeding tube seen on the chest radiograph revealed underlying serious conditions. The first case was an infant 29 weeks of age who presented with right-sided pneumothorax after birth. By history and a right-side-displaced orogastric (OG) tube, iatrogenic esophageal perforation was diagnosed. The second case was a 16-day-old infant who presented with recurrent vomiting. An OG tube extending into a cystic mass at the right cardiophrenic angle resulted in diagnosis of a herniated stomach with organoaxial-type volvulus, which required surgical repair. Both cases recovered uneventfully. As illustrated in these two rare cases, feeding tube position is not only important for feeding practice, but it also has diagnostic implications in newborn infants.

Regulation of adenosine levels during cerebral ischemia.

Adenosine is a neuromodulator with its level increasing up to 100-fold during ischemic events, and attenuates the excitotoxic neuronal injury. Adenosine is produced both intracellularly and extracellularly, and nucleoside transport proteins transfer adenosine across plasma membranes. Adenosine levels and receptor-mediated effects of adenosine are regulated by intracellular ATP consumption, cellular release of ATP, metabolism of extracellular ATP (and other adenine nucleotides), adenosine influx, adenosine efflux and adenosine metabolism. Recent studies have used genetically modified mice to investigate the relative contributions of intra- and extracellular pathways for adenosine formation. The importance of cortical or hippocampal neurons as a source or a sink of adenosine under basal and hypoxic/ischemic conditions was addressed through the use of transgenic mice expressing human equilibrative nucleoside transporter 1 (hENT1) under the control of a promoter for neuron-specific enolase. From these studies, we conclude that ATP consumption within neurons is the primary source of adenosine in neuronal cultures, but not in hippocampal slices or in vivo mice exposed to ischemic conditions.

Intracortical injection of endothelin-1 induces cortical infarcts in mice: effect of neuronal expression of an adenosine transporter.

BACKGROUND: Activation of adenosine A1 receptors has neuroprotective effects in animal stroke models. Adenosine levels are regulated by nucleoside transporters. In vitro studies showed that neuron-specific expression of human equilibrative nucleoside transporter 1 (hENT1) decreases extracellular adenosine levels and adenosine A1 receptor activity. In this study, we tested the effect of hENT1 expression on cortical infarct size following intracerebral injection of the vasoconstrictor endothelin-1 (ET-1) or saline. METHODS: Mice underwent stereotaxic intracortical injection of ET-1 (1 µl; 400 pmol) or saline (1 µl). Some mice received the adenosine receptor antagonist caffeine (25 mg/kg, intraperitoneal) 30 minutes prior to ET-1. Perfusion and T2-weighted magnetic resonance imaging (MRI) were used to measure cerebral blood flow (CBF) and subsequent infarct size, respectively. RESULTS: ET-1 reduced CBF at the injection site to 7.3 ± 1.3% (n = 12) in hENT1 transgenic (Tg) and 12.5 ± 2.0% (n = 13) in wild type (Wt) mice. At 48 hours following ET-1 injection, CBF was partially restored to 35.8 ± 4.5% in Tg and to 45.2 ± 6.3% in Wt mice; infarct sizes were significantly greater in Tg (9 ± 1.1 mm3) than Wt (5.4 ± 0.8 mm3) mice. Saline-treated Tg and Wt mice had modest decreases in CBF and infarcts were less than 1 mm3. For mice treated with caffeine, CBF values and infarct sizes were not significantly different between Tg and Wt mice. CONCLUSIONS: ET-1 produced greater ischemic injury in hENT1 Tg than in Wt mice. This genotype difference was not observed in mice that had received caffeine. These data indicate that hENT1 Tg mice have reduced ischemia-evoked increases in adenosine receptor activity compared to Wt mice.

Efficacy of local instillation of recombinant tissue plasminogen activator for restoring occluded central venous catheters in neonates.

OBJECTIVE: To evaluate the efficacy of local instillation of tissue plasminogen activator (tPA) for restoring function to occluded central venous catheters (CVCs) in the neonatal population. STUDY DESIGN: This was a retrospective review of patients admitted to the neonatal intensive care unit during September 2000 to April 2006 who received instillation of tPA for occluded CVCs. RESULTS: Among 18 infants who received tPA for occluded CVCs, gestational age at birth was 32.5 weeks, birth weight was 1550 g, and gestational age at tPA administration was 39 weeks, with 4 neonates < or =32 weeks' gestational age at tPA administration; age at tPA use was 39 days (medians reported). Ten of 18 (55%) of CVC occlusions were successfully opened after using tPA. No bleeding complications of tPA were noted, including increased or new-onset intraventricular hemorrhage, overt bleeding, or changes in INR or partial thromboplastin time attributed to tPA use. Three patients (16.5%) had bacteremia within 7 days of tPA administration, and no catheter ruptures occurred. CONCLUSIONS: Local instillation of tPA was successful in restoring function to occluded CVCs in a significant proportion of neonates, although success rates were lower than that reported in populations of older age. Despite the vulnerability of neonates to the potential complications of tPA, no major complications were detected even among premature infants.

Buccal midazolam for treatment of prolonged seizures in children.

Midazolam is a relatively new anticonvulsive agent in the benzodiazepine group. It has a short onset of duration and is practical for use, providing several alternatives such as intravenous, intramuscular, and intranasal routes. The buccal route could be an alternative choice for seizure control in an emergency setting. However, no sufficient reports are available on buccal midazolam administration. The present study was designated to examine the efficacy of buccal midazolam in children at different ages with seizures of more than 5 min duration. Nineteen previously unreported children, aged from 1 month to 15 years, were treated with a 0.3 mg/kg dose of buccal midazolam; 13 had prolonged seizures, and six had status epilepticus, with a duration of 5-45 min (mean 22 min). Sixteen of 19 seizures (84.2%) stopped within 10 min of buccal midazolam being given. The drug efficacy in patients with status epilepticus was 50%. However, all patients with convulsions shorter than 30 min showed a perfect response (100%). Convulsion episodes stopped within 3.89+/-2.22 min (median time 3 min). Seizure duration was correlated with cessation of seizure (r=0.76, P<0.001). No clinically important side effects were seen in any patient. On the basis of this experience, we concluded that a 0.3 mg/kg dose of buccal administration of midazolam might offer an effective treatment in all ages of children.