Postnatal surgery for myelomeningocele in neonates: neurodevelopmental outcomes.

BACKGROUND: The study aims to evaluate the neurodevelopmental outcomes of neonates with myelomeningocele (MMC) operated in the postnatal period. METHODS: This is a prospective follow-up study in a tertiary neonatal intensive care unit. Neurodevelopmental outcomes of term neonates operated for MMC and healthy term newborns were compared with the Bayley Scales of Infant and Toddler Development -Third Edition (BSID III) at 12-18 months. RESULTS: A total of 57 cases were included in the study (patient group = 27; control group = 30). Demographic data between the groups were similar. Cognitive, linguistic, and motor composite scores of the patient group were lower than those of the control group (p < 0.001). In the patient group, those who underwent ventriculoperitoneal shunt had lower cognitive, language and motor scores than those without shunt (p < 0.05). The cognitive, linguistic, and motor composite scores in the patient group who underwent surgery before 72 h were better than those who underwent surgery after 72 h. DISCUSSION: In our study, it was found that the neurodevelopmental prognosis of MMC cases requiring ventriculoperitoneal shunt in the postnatal period was significantly worse than those without shunt. It is the first study in which the neurodevelopment of patients with MMC who were operated in the postnatal period was evaluated with BSID III evaluated and delays in all areas were shown in cases with MMC compared to normal cases. Better neurodevelopmental outcomes in patients operated in the first 72 h suggest that early surgery will improve neurodevelopmental outcomes in patients with MMC.

Is Nasal Septum-Tragus Length Measurement Appropriate for Endotracheal Tube Intubation Depth in Neonates? A Randomized Controlled Study.

OBJECTIVE: Endotracheal intubation is a frequent procedure performed in neonates with respiratory distress. Clinicians use different methods to estimate the intubation insertion depth, but, unfortunately, the improper insertion results are very high. In this study, we aimed to compare the two different methods (Tochen's formula = weight in kilograms + 6 cm; and nasal septum-tragus length [NTL] + 1 cm) used to determine the endotracheal tube (ETT) insertion depth. STUDY DESIGN: Infants who had intubation indications were enrolled in this study. The intubation tube was fixed using the Tochen formula (Tochen group) or the NTL + 1 cm formula (NTL group). After intubation, the chest radiograph was evaluated (above T1, proper place, and below T2). RESULTS: A total of 167 infants (22-42 weeks of gestational age) were included in the study. The proper tube placement rate in both groups was similar (32.4 vs. 30.4% for infants < 34 weeks of gestational age and 56.8 vs. 45.0% in infants > 34 weeks of gestational age). The ETT was frequently placed below T2 at a higher rate in infants with a gestational age of <34 weeks, especially in the NTL group (46% in the Tochen group and 60.7% in the NTL group). CONCLUSION: The NTL + 1 cm formula led to a higher rate of ETT placement below T2, especially in infants with a birth weight of <1,500 g. Therefore, more studies are needed to determine the optimal ETT insertion depth.

Can urinary biomarkers predict acute kidney injury in newborns with critical congenital heart disease?

BACKGROUND: Congenital heart disease (CHD) is the most common congenital malformation group and is the leading cause of newborn mortality in developed countries. Most of the infants with CHD develop preoperative or postoperative acute kidney injury (AKI). Acute kidney injury may develop before the serum creatinine rise and oliguria. Urinary biomarkers such as kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), interleukin (IL)-18, and cystatin C may predict AKI in patients with critical CHD (CCHD) before the serum creatinine rise. In this study, we aimed to determine the AKI incidence among newborn patients with CCHD and investigate the predictivity of urinary biomarkers for AKI. METHODS: Newborns with a gestational age >34 weeks and birth weight >1500 g with a diagnosis of CCHD were enrolled in the study. Blood and urine samples were collected at birth, during the first 24-48 h, and in the preoperative and postoperative periods. RESULTS: A total of 53 CCHD patients requiring surgery during the neonatal period were enrolled in the study. The 24-48 h KIM-1 levels of the cases with exitus were higher (P = 0.007). The 24-48 h cystatin C and preoperative NGAL levels were higher in patients with postoperative AKI (P = 0.02). DISCUSSION: In newborns with CCHD, high KIM-1 levels may predict mortality, whereas high cystatin C and preoperative NGAL levels may be indicative of AKI. These biomarkers deserve further investigation in larger study populations.

Reference values of anthropometric measurements in healthy late preterm and term infants

Background/aim: Geographical distribution, ethnicity, and other socioeconomic factors may affect anthropometric measurements, and for that reason each society should determine their own measurements accounting for those factors. In this study, we aimed to determine the anthropometric measurements of healthy late preterm and term infants to compare the results with other national and international studies. Materials and methods: This sectional study was carried out among 1197 infants born with a gestational age of ≥35 weeks. Chest circumference, ear length, foot length, palmar length, middle finger length, philtrum distance, inner and outer canthal distances, and palpebral fissure length were measured in the first 24 h of life. Results: All measurements of late preterm infants were smaller than those of term infants (P ˂ 0.05). Compared with male infants, the chest circumference, ear length, foot length, palmar length, philtrum distance, and inner canthal distances of the female infants were lower (P ˂ 0.05). No significant differences were found between male and female infants' middle finger length, outer canthal distance, and palpebral fissure length measurements. Percentile values for all measurements of 35­42-week male and female infants were described. Conclusion: These measurements of male and female infants born between 35 and 42 weeks may be useful for early detection of syndromes by detecting anatomical abnormalities in our population.

The effect of inhaled nitric oxide therapy on thromboelastogram in newborns with persistent pulmonary hypertension.

UNLABELLED: Studies about the effects of inhaled nitric oxide (iNO) on bleeding time and platelet aggregation in newborns are limited in number and have inconclusive results. Thromboelastogram (TEG) shows the combined effects of coagulation factors and platelet functions. In this preliminary study, we aimed to evaluate the effects of iNO on coagulation using TEG in newborns with persistent pulmonary hypertension (PPH). TEG assays were performed in 10 term infants receiving iNO treatment for PPH and 32 healthy term infants. Samples of the iNO group were collected before and during iNO. Clot reaction time (R), clot kinetics (K), maximum amplitude (MA), and alpha angle were obtained from the TEG tracing. TEG-R values were statistically higher during iNO treatment (7.75 ± 3.34) when compared to the values before iNO (4.83 ± 1.38) and the healthy controls (3.75 ± 0.98). The alpha angle was lower in iNO treated infants at both periods (before iNO, 55.33 ± 8.58; during iNO, 42.90 ± 18.34) compared to the control group (64.95 ± 6.88). MA values before iNO treatment were the lowest (44.43 ± 14.09) and improved with the iNO treatment (48.40 ± 9.49) despite still being lower compared to the controls (53.67 ± 5.56). CONCLUSION: Both PPH and iNO may negatively effect in vitro coagulation tests. Therefore, newborns with PPH requiring iNO treatment should be closely monitored for coagulation problems.

Effect of partially hydrolyzed synbiotic formula milk on weight gain of late preterm and term infants-a multicenter study.

Introduction: Data on the effectiveness of hydrolyzed infant formula containing both pre- and probiotics (synbiotic formula) on the growth of infants is still scarce. This retrospective study was designed to evaluate the effect of a partially hydrolyzed synbiotic formula on growth parameters and the possible occurrence of major gastrointestinal adverse events or morbidities in infants born via cesarean section (C-section) delivery. Methods: C-section-delivered term and late preterm infants who received either partially hydrolyzed synbiotic formula, standard formula, or maternal milk and followed at seven different hospitals from five different regions of Turkey, during a 1-year period with a minimum follow-up duration of 3 months were evaluated retrospectively. All the included infants were evaluated for their growth patterns and any kind of morbidity such as diarrhea, constipation, vomiting, infection, or history of hospitalization. Results: A total of 198 infants (73 in the human milk group, 61 in the standard formula group, and 64 in the partially hydrolyzed synbiotic formula group) reached the final analysis. The groups were similar regarding their demographic and perinatal characteristics. No difference was observed between the three groups regarding gastrointestinal major side effects. Growth velocities of the infants in the human milk and partially hydrolyzed synbiotic formula groups during the first month of life were similar whereas the weight gain of infants in the standard formula group was significantly less than these two groups (p < 0.001). Growth velocities were similar among the three groups between 1st and 3rd months of age. Discussion: A partially hydrolyzed synbiotic formula provided better weight gain in late-preterm and term infants who were delivered via C-section delivery compared to the standard formula during the first month of life. This weight gain was similar to the infants receiving exclusively human milk. This difference was not observed in length and head circumference gain. No difference was observed in any of the parameters during the 1st-3rd months of age. Specially formulated partially hydrolyzed synbiotic formulas may reverse at least some of the negative impacts of C-section delivery on the infant and help to provide better growth, especially during the early periods of life.

Early Immunomodulatory Effects of Different Natural Surfactant Preparations in Preterms With Respiratory Distress.

Background: Respiratory distress syndrome (RDS) is the most common respiratory disease in premature infants. Exogenous natural surfactant preparations are used in the treatment of RDS. In recent years, it has become increasingly evident that surfactant plays an immunoregulatory role. Objectives: The aim of this study was to evaluate cytokine and chemokine response following three different regimens of natural surfactant treatment in preterm newborns with RDS. Methods: Premature newborns below 32 weeks of gestation who were intubated for RDS and given early surfactant rescue therapy were included in the study. Newborns were randomly divided into three groups and Beractant 100 mg/kg (B-100), Poractant alfa 100 mg/kg (Pα-100) and Poractant alfa 200 mg/kg (Pα-200) were administered intratracheally. Blood samples and transtracheal aspirates (TA) were collected just before and 4-6 h after the surfactant treatment. Total eosinophil count, inducible T Cell alpha chemoattractant (ITaC), macrophage inflammatory protein 3 beta (MIP3b), interleukins (IL) 5, 8, 9, 10, 13, immunoglobulin E (IgE), interferon gamma (IFN-γ), eotaxin and tumor necrosis factor beta-1 (TGF-ß1) were measured from blood and tracheal aspirate samples. Results: A total of 45 infants, 15 in each group, were included in the study. Mean gestational age, birth weight, antenatal, demographic and clinical characteristics of the study groups were similar. IFNγ concentration and eosinophil counts in TA decreased after surfactant replacement in all groups, especially in the infants treated with Pα-100 and Pα-200. Eotaxin, TGF beta and IL-8 concentrations in TA increased significantly in the infants treated with Pα-100 and Pα-200. IL-9 levels in TA decreased in the B-100 group but increased in the Pα-100 and Pα-200 groups. Blood levels of cytokines and chemokines showed significantly decreased levels of ITaC and MIP3b only in the B-100 group, but no significant change was observed in the Pα-100 and Pα-200 groups. Conclusion: In our study, the different immunomodulatory effects of natural surfactant preparations on newborn lung is proven. We found that Poractant α, one of the natural surfactant preparations, shifted the lung immune system toward TH2.

Evaluation of macronutrient content of fresh and frozen human milk over 6 months.

AIM: In this study; we aimed to see the time-dependent changes in the macronutrient content of early frozen breast milk and also to compare it with fresh breast milk in the first 6 months. MATERIALS AND METHOD: We evaluated the milk samples of 43 mothers who delivered at term. Milk samples after the first 15 days following delivery were expressed and collected dividing into seven aliquots to be stored frozen at -20 °C. Every month freshly collected new milk samples were analyzed together with one aliquot of the stored samples, up to 6 months. The energy, protein, lipid, and carbohydrate contents of samples were analyzed by Miris Human Milk Analyzer. RESULTS: In the first 3 months, fresh milk had higher caloric and lipid content when compared to frozen samples. The protein content of fresh milk decreased after 2 months and became lower than frozen samples. The energy and lipid content of frozen milk decreased over time but protein and carbohydrate contents stayed stable. Carbohydrate content of fresh and frozen samples did not show major changes. CONCLUSION: It may be more suitable to consume the frozen milk that was collected in the early weeks of delivery within first 2 months.

A Case with Neonatal-onset Type 2 Neuronal Ceroid Lipofuscinosis: A Novel Mutation.

Neuronal ceroid lipofuscinosis (NCL) is a lysosomal storage disorder that causes progressive neurodegenerative disease as a result of storage in neurons and other cells. Late infantile type (NCL Type 2) of NCL, which is the most common neurodegenerative disease in childhood, is characterised by a homozygous mutation in the tripeptidyl peptidase-1 (TPP-1) gene. A male infant was referred to our neonatal intensive care unit (NICU) on 26th day of life with a diagnosis of metabolic disease. He was intubated. He was hypotonic and newborn reflexes were not present. Cranial magnetic resonance (MR) imaging revealed severe atrophy and delayed myelination of cerebellum and cerebral hemispheres. A novel homozygous pathological mutation was detected in exon 9 of the TPP-1 gene. With this case, it should be kept in mind that NCL may rarely start early in neonatal period and should be suspected in newborns with cerebral and cerebellar atrophy for early diagnosis. Key Words: Hypotonia, Lysosomal storage diseases, Metabolic disease, Neuronal ceroid lipofuscinosis, Newborn.

Severe central nervous and respiratory system depression after sedation with chloral hydrate: a case report.

Chloral hydrate is generally considered a safe sedative-hypnotic drug, and is commonly used for sedation of infants and young children before diagnostic procedures. Even chloral hydrate administered within the recommended maximal dose limits can cause serious morbidity and mortality. Here the authors describe a four-month-old girl with a life-threatening central nervous system and respiratory depression after administration of a therapeutic dose of chloral hydrate. The patient gradually recovered with supportive treatment including ventilation therapy.

Normal electrocardiogram values of healthy children.

AIM: Electrocardiography is an important diagnostic tool in the evaluation of cardiac diseases. Normal electrocardiograms are age-dependent and may also vary due to several factors. Many studies have been performed to establish the normal values for the childhood period. The aim of this study was to determine the normal electrocardiograms values for healthy Turkish children in Aydin. MATERIAL AND METHODS: All children underwent physical examination by a pediatrician and the electrocardiograms were analyzed by the same pediatrician. In the event of improper or insufficient data, the analyses were repeated. Children with a suspicious electrocardiograms or physical examination were recalled and examined by same pediatric cardiologist in outpatient clinic. RESULTS: In this study, electrocardiogram records were collected randomly from 1163 children with a sampling rate of 500 Hz. Of the children, 562 were female (47.4%) and 601 were male (52.6%). The total population was divided into ten age groups. Significant differences in normal limits were determined compared with previously published studies. CONCLUSION: The observed differences in various electrocardiograms parameters could be related to biologic variability and to some technical details such as precordial electrode placement and visual checking of the records in addition to race.

AMAÇ: Elektrokardiyografi kardiyak hastaliklarin degerlendirilmesinde önemli bir tani aracidir. Normal elektrokardiyogram yasa bagimlidir ve çesitli etmenlerle degismektedir. Çocukluk dönemi normal degerlerini belirlemek için bir çok çalisma yapilmistir. Bu çalismanin amaci Aydin ilinde saglikli Türk çocuklarinda normal elektrokardiyogram degerlerini belirlemektir. GEREÇ VE YÖNTEMLER: Çalismada tüm çocuklarin fizik bakisi çocuk doktoru tarafindan yapildiktan sonra ayni kisi tarafindan elektrokardiyogramlari çekilerek degerlendirilmistir. Uygun olmayan verilerin olmasi durumunda analiz tekrar edilmistir. Fizik bakida ya da elektrokardiyogramda süphe olmasi durumunda hastaneye çagrilarak çocuk kardiyologu tarafindan ayrintili inceleme yapilmistir. BULGULAR: Çalismada 500 Hz örneklem hiziyla toplam 1 163 olgudan elektrokardiyogram örnekleri alinmistir. Olgularin 562'si kiz (%47,4%) iken 601'i erkekti (%-52,6). Tüm çalisma popülasyonu toplam 10 yas grubuna ayrildi. Tüm gruplardan elde edilen normal degerlerde daha önce yayinlanmis normal degerlere göre anlamli farkliliklar görüldü. ÇIKARIMLAR: Elektrokardiyogram degiskenlerinde gözlenen farkliliklar biyolojik degiskenlik ve irksal özelliklere ek olarak prekordiyal elektrot yerlestirme, kayitlarin görsel kontrolü gibi bazi teknik detaylarla iliskili olabilir.

Preterm Infants May Better Tolerate Feeds at Temperatures Closer to Freshly Expressed Breast Milk: A Randomized Controlled Trial.

PURPOSE: Feeding intolerance is one of the most frequent problems among preterm infants. These infants are fed with expressed breast milk or preterm formulas of which the temperature is not routinely measured. In this study, we aimed to examine the effects of feeds with warm milk versus room temperature milk in preterm infants. MATERIALS AND METHODS: Infants with a birth weight ≤1,500 g or gestational age ≤34 weeks were included in the study and assigned to two different feeding temperature groups (22-24°C and 32-34°C). Some infants in both groups were exclusively breast milk-fed, and some received breast milk and artificial milk (mixed feeding). Feeding tolerance of infants in both groups and the consequences were evaluated. RESULTS: In total, 80 preterm infants (group 1 fed with milk at 22-24°C, n = 40; group 2 fed with milk at 32-34°C, n = 40) were prospectively included in the study. There was a slight decrease in gastric residual frequency in infants fed with breast milk in group 2. Apnea was significantly more frequent in group 1 (p = 0.006), and these infants needed more anti-reflux treatment (p = 0.013). CONCLUSION: According to our results, warming enteral feeds close to body temperature are encouraging especially due to the decrease in gastric residual frequency, apnea of prematurity, and need for anti-reflux treatment. More studies may confirm the positive effect of warm enteral feeds on feeding tolerance in preterm infants.

The value of peripheral perfusion index measurements for early detection of critical cardiac defects.

BACKGROUND: Approximately 25% of congenital heart diseases (CHD) are estimated to be critical and require an intervention. In this study, we aimed to investigate the additional value of peripheral perfusion index (PPI) measurements to pulse oximetry screening for critical CHD (CCHD). METHODS: Infants born at Ege University Hospital between May 2013 and September 2015 were prospectively included in the study. In addition to physical examination, pre- and postductal oxygen saturations and PPI values were measured with a new generation pulse oximeter before discharge from the hospital. RESULTS: A total of 3175 newborns (33 with an antenatal diagnosis of CCHD) were included in the study. With the combination of physical examination, pulse oximetry screening and peripheral perfusion index (PPI) measurements, all newborns with CCHD were detected in our study including three infants without an antenatal diagnosis in whom pulse oximetry screening was negative. CONCLUSION: PPI measurements may be valuable for early detection of obstructive left heart lesions where pulse oximetry screening has limitations in diagnosis.

Early neonatal outcomes of very-low-birth-weight infants in Turkey: A prospective multicenter study of the Turkish Neonatal Society.

OBJECTIVE: To investigate the early neonatal outcomes of very-low-birth-weight (VLBW) infants discharged home from neonatal intensive care units (NICUs) in Turkey. MATERIAL AND METHODS: A prospective cohort study was performed between April 1, 2016 and April 30, 2017. The study included VLBW infants admitted to level III NICUs. Perinatal and neonatal data of all infants born with a birth weight of ≤1500 g were collected for infants who survived. RESULTS: Data from 69 NICUs were obtained. The mean birth weight and gestational age were 1137±245 g and 29±2.4 weeks, respectively. During the study period, 78% of VLBW infants survived to discharge and 48% of survived infants had no major neonatal morbidity. VLBW infants who survived were evaluated in terms of major morbidities: bronchopulmonary dysplasia was detected in 23.7% of infants, necrotizing enterocolitis in 9.1%, blood culture proven late-onset sepsis (LOS) in 21.1%, blood culture negative LOS in 21.3%, severe intraventricular hemorrhage in 5.4% and severe retinopathy of prematurity in 11.1%. Hemodynamically significant patent ductus arteriosus was diagnosed in 24.8% of infants. Antenatal steroids were administered to 42.9% of mothers. CONCLUSION: The present investigation is the first multicenter study to include epidemiological information on VLBW infants in Turkey. Morbidity rate in VLBW infants is a serious concern and higher than those in developed countries. Implementation of oxygen therapy with appropriate monitoring, better antenatal and neonatal care and control of sepsis may reduce the prevalence of neonatal morbidities. Therefore, monitoring standards of neonatal care and implementing quality improvement projects across the country are essential for improving neonatal outcomes in Turkish NICUs.

The use of surfactant in the neonatal period- the known aspects, those still under research and those which need to be investigated further.

Respiratory distress syndrome is pulmoner insufficiency caused by the lack of surfactant and the main reason of morbidity and mortality in preterm infants. Mothers at high risk of preterm birth should be transferred to perinatal centers with experience for respiratory distress syndrome and ante-natal steroids should be given before 35 weeks' of gestational age. Surfactant treatment should be applied to babies with or at high risk for respiratory distress syndrome. Prophylaxis should be given to infants of <26 weeks of gestational age and to infants requiring entubation in the delivery room. Nasal continuous positive airway pressure should be considered in infants with complete steroid treatment and without entubation need. Early surfactant may be given if entubation is performed during follow-up. Natural forms of surfactant should be preferred when needed. If the infant is stable, early extubation and non-invasive respiratory support should be considered. In this review, the recent studies' current data about surfactant treatment will be discussed.

Endoscopic evacuation of cerebellar hematoma in a term newborn.

Intracerebellar hemorrhage is very rare in term infants and only severe cases with massive intracranial hemorrhage, posthemorrhagic hydrocephalus and clinical deterioration due to increased intracranial pressure require neurosurgical evacuation. In recent adult studies endoscopic hematoma evacuation has been shown as a rapid, effective, and safe technique. A term newborn hospitalized for meconium aspiration syndrome showed hypertonia, jitteriness and abnormal amplitude integrated electroencephalogram findings. He was diagnosed with cerebellar hematoma which caused hydrocephalus by cranial magnetic resonance imaging (MRI). The hematoma was successfully evacuated neuroendoscopically as the first case in literature to our knowledge. Neurologic, a-EEG and MRI findings resolved.

Serial intravesical pressure measurements can predict the presence and the severity of necrotizing enterocolitis.

BACKGROUND AND AIMS: Necrotizing enterocolitis (NEC) which is accompanied with gastrointestinal ulceration and necrosis is one of the most important problems of preterm infants in neonatal intensive care unit (NICU). Increased intra-abdominal pressure (IAP) is detected among most of the pediatric patients hospitalized in intensive care unit and undergoing surgery or trauma. This pathology, namely, abdominal compartment syndrome, causes ischemia and hypoperfusion of abdominal organs. Recently, the effect of increased IAP on NEC is under focus and this increase is thought to be related with the onset of NEC by leading to intestinal ischemia and necrosis. In this study, we aimed to investigate if serial intravesical pressure (IVP) measurements as an indirect indicator of IAP may help to early diagnosis in NEC and to decision for surgery besides to predict the mortality of NEC. MATERIAL AND METHOD: A total number of 61 preterm infants with a birth weight of ≤ 1,500 g hospitalized in NICU were included to the study. IVP values were measured by the same nurse twice daily during their hospitalization through urinary catheter. The IVP values of the preterm infants with and without NEC were compared. RESULTS: Totally 61 premature infants included in the study were grouped as follows: group 0, the control group without NEC (n = 38); group 1, medically treated NEC patients (n = 14); and group 2, NEC patients undergoing surgery (n = 9). The median IVP measurements of group 0 were lower than the other groups (p = 0.001). No statistically significant difference in IVP measurements was detected between group 1 and group 2 (p = 0.155). A 10% of increase in IVP measurement was significant in predicting the development of NEC with consecutive serial measurements. The mean IVP measurements were higher in infants with NEC who died during their follow-up at NICU compared with NEC patients who survived (p = 0.043). CONCLUSION: Serial IVP measurements may help for early diagnosis and surgery decision of NEC and high IVP levels also may predict mortality in cases with NEC.