Etiology and Outcome of Severe Apparent Life-Threatening Events in Infants.

INTRODUCTION: An apparent life-threatening event (ALTE) is defined as "an episode that is frightening to the observer and is characterized by some combination of apnea, color change, marked change of muscle tone, choking, or gagging." OBJECTIVE: The aims of this study were to determine etiology and outcome of severe ALTE (requiring resuscitation measures) and to review diagnostic approaches in infants hospitalized after such an episode of ALTE. METHODS: Retrospective analysis included patients hospitalized at the Intensive Care Unit, Institute of Child and Youth Healthcare of Vojvodina, after an episode of severe ALTE over a 4-year period. RESULTS: The study included 23 infants, 18 male (78.3%), and 5 female (21.7%). The average age at presentation was 78 days (1 day to 11 months). In 8 infants (34.7%), ALTE resulted in death. The most frequent conditions after diagnostic evaluation were lower respiratory tract infections (39.1%), intracranial and extracranial hemorrhages (13.0%), and central nervous system infections (8.6%). The cause remained unknown in 8.7% of cases. Initial investigations included complete blood cell count, C-reactive protein or procalcitonin, blood gasses, lactate, electrolytes, glucose, blood culture, urinalysis, and chest x-ray. CONCLUSIONS: Apparent life-threatening event represents a diverse disorder. Lower respiratory tract infections and neurological disorders were the most common established etiology. Prematurity and congenital heart diseases stood out as important risk factors. Diagnostic evaluation varied according to suspected cause and trigger factors.

The influence of EPO and hypothermia on the kidneys of rats after perinatal asphyxia.

The aim of this study was to determine the effects of erythropoietin (EPO), moderate hypothermia, and a combination thereof on the kidneys of newborn rats damaged during perinatal asphyxia. An animal model of perinatal asphyxia (Wistar rats) was used in which after birth, newborn rats were divided into four groups of 15 animals each: G1, rats exposed only to asphyxia; G2, rats exposed to asphyxia and hypothermia (rectal temperature 32°C) and which received EPO (darbepoetin alpha) intraperitoneally; G3, rats exposed to asphyxia and hypothermia; G4, rats exposed to asphyxia and which received EPO. The rats were sacrificed on the 7th day of life and histopathological evaluation of kidneys was performed. Damage to the proximal tubules was significantly higher in group G1 rats than in groups G2, G3, and G4 rats (p < 0.01). Damage to the distal tubules was found only in group G1 rats. Histological changes in the proximal tubules were more prominent than in the distal tubules (p < 0.01). The immature glomeruli zone was less expressed in group G4 rats than in groups G1, G2, and G3 rats (p < 0.01). Based on these results, we conclude that EPO and hypothermia, as well as the combination thereof, have a protective effect on rats' kidneys damaged during perinatal asphyxia.

Risk factors associated with failure of extubation in very-low-birth-weight newborns.

AIM: To identify risk factors associated with the failure of extubation of mechanically ventilated very-low-birth-weight newborns. STUDY DESIGN: Prospective observational study. Assessment of the occurrence of extubation failure in relation to demographic and ventilation parameters, the SpO2/FiO2 ratio, the spontaneous breathing test (SBT) and values of the Silverman-Andersen score (SAS). Extubation failure was defined as the need for reintubation for any reason within 72 h after extubation. RESULTS: Extubation failed in 14/50 (28%) patients. Tidal volume applied at the moment of extubation (p = 0.030), the values of the SpO2/FiO2 ratio (p = 0.006), SBT (p = 0.034) and SAS measured for 60 min after extubation and later (p = 0.010, p = 0.000001, p∼0.000, respectively) showed a significant association with reintubation. CONCLUSIONS: Measured TV, SpO2/FiO2 ratio, SBT at the moment of extubation and values of SAS starting 1 h after extubation might be valuable parameters in identifying those VLBW newborns in the risk to fail extubation.

Severe neonatal subgaleal hemorrhage as the first presentation of hemophilia A.

INTRODUCTION: Subgaleal hemorrhage is a rare but potentially fatal birth trauma. It is caused by rupture of the emissary veins (connections between the dural sinuses and scalp veins), followed by the accumulation of blood between the epicranial aponeurosis and the periosteum. Usually, it is associated with instrumental delivery (vacuum extraction, forceps delivery), but it may also occur spontaneously, suggesting the possibility of congenital bleeding disorder. CASE OUTLINE: A full term male neonate was born at 40 weeks gestation by spontaneous vaginal delivery, with birth weight of 3,700 g. The Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. At the age of 23 hours, the baby became pale and lethargic. Large fluctuant swelling on his head was noted. He developed severe anemia and hypovolemia as a result of massive subgaleal hemorrhage. After successful treatment, the baby fully recovered. Follow-up and further evaluation revealed hemophilia A as a result of a de novo mutation. CONCLUSION: This case illustrates that subgaleal hemorrhage may be the first presentation of hemophilia A. Infants without obvious risk factors for developing subgaleal hemorrhage should be evaluated for congenital bleeding disorder. Successful outcome in affected infants requires early diagnosis, careful monitoring and prompt treatment.

Neuroprotective effects of hypothermia and erythropoietin after perinatal asphyxia in newborn rats.

OBJECTIVE: Evaluation of neuroprotective effects of hypothermia, erythropoietin and their simultaneous use after perinatal asphyxia in newborn rats. METHOD: Hysterectomy was performed to Wistar female rats on the last day of gestation. Perinatal asphyxia was induced by submersion of uterus containing pups in saline for 15 min. After resuscitation, pups were randomized into 4 groups, 15 animals in each: G1 - asphyxia; G2 - asphyxia + hypothermia (rectal temperature 33 °C for 1 h); G3 - asphyxia + erythropoietin (Darbepoetin-α 2.5 µg, intraperitoneally) and G4 - asphyxia + erythropoietin + hypothermia. Pups were sacrificed on 7th day of life and histopathological analysis of hippocampus was performed. RESULTS: Measure of damage to dorsal, ventral and entire hippocampus was significantly lower in groups G2, G3 and G4 than in group G1 (p ~ 0.00; respectively). Measure of damage to hippocampus in group G4 was significantly lower than in group G2 (p = 0.029). CONCLUSIONS: This study demonstrates that simultaneous use of hypothermia and erythropoietin has more expressed neuroprotective effects than sole use of hypothermia after perinatal asphyxia in newborn rats.

A simultaneous comparison of four neonatal pain scales in clinical settings.

OBJECTIVE: To evaluate the usefulness of four neonatal pain scales (DAN, NIPS, PIPP, and NPAS) in describing newborn's response to a painful event in clinical settings. METHODS: Prospective observational study at university-affiliated neonatal unit. Three hundred-sixty newborns were observed during venepuncture and heel lancing as a part of routine blood workout. Values of pain scales were determined in three time frames (start of procedure - T0, maximal response - T1, end of procedure - T2). RESULTS: In T0 versus T1 time frame, a sharp increase of percentage was observed in all pain scales independently of procedure with high statistical significance (P ∼ 0.00). NIPS showed the highest (venepuncture 742%; heel lancing 1472%) and PIPP the lowest increase (venepuncture 303%; heel lancing 510%). In T1 versus T2 time frame, for venepuncture NIPS showed the highest (49%) and PIPP the lowest (38%) percentage of decrease, whereas for heel lancing PIPP had the highest (28%) and NIPS the lowest (20%) one. All pain scales showed significant individual and overall variability (CV > 30%). PIPP had the lowest (42.7 + 14.3) and NIPS the highest (103.8 + 91.3) overall coefficient of variation. DAN's confidence parameters were the most uniform ones (se 1.0, sp 0.93, ppv 0.93, npv 1.0), whereas PIPP's confidence parameters were the highest while measuring high intensity pain (se 0.94, sp 1.0, ppv 1.0, npv 0.94). CONCLUSION: DAN is a pain scale convenient for the use in clinical settings, especially if a fine distinction of magnitude of the present pain is not needed, whereas PIPP can be used if adequate equipment is available.

[Morbidity and mortality of premature neonates after introduction of national in vitro fertilisation programme--our experience].

INTRODUCTION: Infertility occurs in approximately 10% of couples and in vitro fertilisation (IVF) is its most efficient treatment method. The National IVF Programme started in October 1st, 2006. OBJECTIVE: Examination of morbidity and mortality of premature neonates conceived by IVF after initiation of the National IVF Programme. METHODS: Retrospective analysis of history charts of IVF premature neonates treated at the Neonatal Intensive Care Unit (NICU) of the Institute of Child and Youth Healthcare of Vojvodina, Novi Sad, Serbia, from March 1st, 2007 to March 1st, 2008. RESULTS: Of 189 treated premature neonates, 25 (13.23%) were IVF conceived, with mean gestational age (GA) of 29.46 +/- 3.28 gestational weeks (GW), one-minute Apgar score 5.44 +/- 2.45, five-minute Apgar score 7.16 +/- 1.92 and birth weight (BW) 1299 +/- 484.35 g; from singleton 12 (48%), twin 10 (40%), and trigeminal 3 (12%) gestations. The largest number of neonates were of GA between 29 and 31.9 GW (12; 48%) and BW between 1500 and 2499 g (9; 36%). All of them were treated due to respiratory distress syndrome, complicated in 2 (8%) with air leak syndromes and in 4 (16%) with pulmonary haemorrhage. Congenital anomalies were detected in 2 (8%) and intracranial haemorrhage developed subsequently in 21 (84%) neonates. Lethal outcome occurred in 7 (28%) neonates, in all cases in lower gestation groups (<29 GW). Variable analysis showed significantly higher incidence of chorioamnionitis (p = 0.0004) and lower GA (p approximately 0.00), BW (p approximately 0.00), one-minute Apgar score (p = 0.0007) as well as significant difference in prophylactic surfactant application (p approximately 0.00) and mean arterial pressure on admission (p = 0.002). CONCLUSION: Morbidity and mortality of IVF premature neonates does not differ significantly from that of other premature neonates treated at NICU. Prematurity and low BW are important factors in pathology of these neonates and final outcome is influenced by perinatal asphyxia, risk of systemic infection, prophylactic surfactant application and arterial hypotension.

Newborns from in vitro fertilization conceived pregnancies.

Infertility, defined as 'unsuccessful conception after 1 year of unprotected intercourse', is an increasing problem in many countries. Demographic data in Serbia continue to show negative trend of depopulation. One-third of married couples in Serbia are childless and half of them cannot have offspring due to health problems. Analysis of morbidity and mortality of premature newborns IVT (in vitro fertilization) conceived and treated in two Department of Intensive Care, in Novi Sad and Belgrade, Serbia during 2 years. Significant number of IVF conceived newborns are treated at NICUs. Prematurity, low birth weight, perinatal asphyxia, systemic infection, as well as proper initial stabilization, especially prevention and early treatment of systemic hypotension are important factors contributing to morbidity of these patients.

Intracranial haemorrhage after transport of premature newborns.

Intracranial hemorrhage remains an important factor of premature newborns' morbidity. Its incidence is significantly influenced by adequate perinatal care and safe neonatal transport. Risk factors for the development of intracranial hemorrhage in premature newborns after neonatal transport were analyzed in the retrospective transversal clinical study. Out of 150 study subjects, 60% (n = 90/150) had intracranial hemorrhage with a statistically significant difference in relation to Apgar score, gestational age, birth weight, age at the moment of transport and the prophylactic use of surfactant. In this group, grades I/II intracranial hemorrhage were detected in 77% (n = 69/90), while grades III/IV intracranial hemorrhage were diagnosed in 23% (n = 21/90). A statistically significant difference was observed in relation to gestational age, birth weight, antenatal use of tocolytics and steroids, delivery mode and age in the time of transport between these groups. All patients were transferred to Intensive Care Unit, the duration of transport was less than 5 minutes in 71% 9n = 107/150), whereas longer transport was recorded in 29% (n = 43/150). In the group of longer transport, prophylactic surfactant was less frequently used with a higher incidence of grades III/IV intracranial hemorrhage. In order to prevent the development of intracranial hemorrhage in premature newborns, the most important measures are the antenatal use of steroids and postnatal prophylactic use of surfactant.

Prenatal urinary ascites due to the idiopathic bladder rupture.

The case of intrauterine idiopathic bladder rupture with consecutive urinary ascites is presented. Conservative management resulted in complete resolution of the lesion.

Chronic inflammatory demyelinating polyradiculoneuropathy, in an 8-year-old girl, complicated by deafness and kidney fibrosis.

Based on case history and clinical and electrophysiological examinations, the authors report on a case of an 8-year-old girl who was diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy. The disease was complicated by deafness and kidney fibrosis. During treatment with methylprednisolone and intravenous immunoglobulin, followed by mycophenolate mofetil, prompt improvement of neurological findings occurred. The improvement of hearing was poor. Because the pathogenesis of chronic inflammatory demyelinating polyradiculoneuropathy has still not been clear, and on the grounds of several cases of chronic inflammatory demyelinating polyradiculoneuropathy conjoined with the kidney disease described in literature (glomerulopathy, interstitial nephritis), every patient with chronic inflammatory demyelinating polyradiculoneuropathy needs to undergo the urinalyses.

[Acute renal failure in premature neonates].

BACKGROUND/AIM: Hemodynamic stress is the leading cause of acute renal failure (ARF) in premature neonates. Incidence of ARF in this population is between 8 and 24%. The aim of this study was to determine the frequence of presence of ARF in premature neonates, as well as its impact on their survival. METHODS: A retrospective study of 114 premature neonates [(gestational age, GA less than 37 gestation weeks (gw)] admitted to the Intensive Care Unit (ICU) at the Pediatric Clinic, Institute of Child and Youth Healthcare of Vojvodina in 2007 was conducted. Serum creatinine, urea and bilirubine were determined on the 3rd day of life in 65 newborns who met inclusion criteria. ARF was diagnosed in 16 newborns (n = 16/65; 25%). RESULTS: The premature neonates with ARF had significantly lower GA [<28 gw - 8/16 (50%) vs. 5/49 (10%); p < 0.05], birth weight (BW) (1265 g vs. 1615 g; p < 0.05) and systolic blood pressure (43.37 mm Hg vs. 52.7 mmHg; p < 0.05) than ones without ARF. Non-olyguric ARF was diagnosed in 62% of newborns with ARF (n = 10/16), while the rest had the olyguric type (n = 6/16; 38%). Twenty-five percent of premature neonates with ARF (n = 4/16) died in contrast to 10% of premature neonates without ARF (n = 5/49). ARF was treated conservatively in all but 3 cases when peritoneal dialysis was performed. Renal function has recovered completely in all of the survivors. In order to determine their predictivity in relation to ARF, following parameters were analyzed: GA, BW < 1500 g, presence of concomitant sepsis and intracranial hemorrhage grade III/IV. BW < 1500 g demonstrated the highest sensitivity (se 0.75), while GA < 28 gw, sepsis and intracranial hemorrhage grade III/IV showed high specificity (sp = 0.90, 0.89 0.88, respectively). CONCLUSION: Acute renal failure frequently occurs in population of premature neonates and requires meticulous fluid and electrolyte balance, especially in the case of low birth weight and extreme immaturity.

[Pain indicators in newborns].

DEFINITION OF PAIN: The International Association for the Study of Pain has defined pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage." The interpretation of pain is subjective. Each person forms an internal construct of pain through encountered injury. PAIN AND NEWBORN: The issue of pain perception in newborns, its management and prevention has been neglected for decades. The inability of "self-report" of painful experience has contributed significantly to misunderstanding of the importance of this problem and inadequate treatment. The main characteristic of this 'critical window of brain development' period is rapid enlargement of brain volume and its great plasticity. Harmful short-term and long-term consequences can arise as a consequence of disturbance of the sophisticated balance between newborn and its surrounding. NEONATAL PAIN INDICATORS: As a response to a present painful stimulus, the newborn adapts to this acute stress with changes in endocrine, vegetative, immune and behavioral area. An ideal pain indicator in neonatal period does not exist. There are several different groups of them, namely contextual and developmental indicators (gestational age, contributed illness, medication, for example), physiological (heart rate, vagal tone, breathing rate, blood pressure, oxygen saturation, transcutaneous partial pressures of oxygen and carbon-dioxide, intracranial pressure, palm sweating) and behavioral ones (face expression, movements of limbs, cry), several neonatal pain scales were constructed on the basis of these indicators.

[The use of peritoneal dialysis in newborns].

INTRODUCTION: Acute renal failure is a common complication in critically ill newborn infants. The therapy of acute renal failure is conservative and etiological. Patients not responding to this kind of therapy require peritoneal dialysis. MATERIAL AND METHODS: This retrospective study included 6 newborn infants undergoing peritoneal dialysis during the period from January 2004 to June 2006, at the Nephrology Department of the Institute of Child and Youth Health Care in Novi Sad. All patients presented with complications of acute renal failure including hypercalemia and uremic encephalopathy. RESULTS: Complete restoration of kidney function was evident in four patients on peritoneal dialysis. Three patients are still alive, but in one patient acute renal failure progressed to chronic renal failure. One patient died in the third month of life due to multiple organ dysfunction, after just two days of dialysis. Several complications were reported: intra-abdominal hemorrhage, dialysate leakage, peritonitis and dialysis catheter obstruction. DISCUSSION: Periotoneal dialysis catheter placement is a great problem due to the size of the newborn. If it is estimated that it will be a long-lasting dialysis, Tenckhoff catheter is recommended. In very low birth weight newborn infants, in poor overall condition, general anesthesia is too risky, and acute peritoneal dialysis catheter should be placed (i.v. cannula, venous catheter). CONCLUSION: Peritoneal dialysis is the method of choice in newborns with acute renal failure, and it is used in the treatment of neonatal asphyxia till the restoration of kidney function is achieved.