Change over time in internal cerebral vein pulsation in premature infants at risk of intraventricular hemorrhage.

BACKGROUND: Prolonged continuation of augmented internal cerebral vein (ICV) pulsation may be related to the development of premature intraventricular hemorrhage (IVH). However, the characteristics of ICV flow patterns in premature infants are unclear. AIM: To investigate the changes over time in ICV pulsation in premature infants at risk of IVH. STUDY DESIGN: A 5-year retrospective observational study of a single-center trial. SUBJECTS: In total, 112 very-low-birth-weight infants with gestational age of ≤32 weeks. OUTCOME MEASURES: ICV flow was measured every 12 h until 96 h after birth and thereafter on days 7, 14, and 28. The ICV pulsation index (ICVPI), which is a ratio of the minimum/maximum speed of ICV flow, was calculated. We recorded longitudinal ICVPI change and compared ICVPI among three groups classified according to gestational age. RESULTS: ICVPI started declining after day 1 and reached the minimum median value in 49-60 h after birth (1.0 during 0-36 h, 0.9 during 37-72 h, and 1.0 after 73-84 h). ICVPI was significantly lower during 25-96 h than during 0-24 h and on days 7, 14, and 28. ICVPI in the 23-25-week group was significantly lower between 13-24 h and day 14 than that in the 29-32-week group, and the same was observed for the 26-28-week group between 13-24 h and 49-60 h. CONCLUSIONS: ICV pulsation was affected by time after birth and gestational age, and this ICVPI fluctuation may reflect a postnatal circulatory adaptation.

Changes in Internal Cerebral Vein Pulsation and Intraventricular Hemorrhage in Extremely Preterm Infants.

OBJECTIVES: This study aimed to investigate the relationship between internal cerebral vein (ICV) pulsation and intraventricular hemorrhage (IVH) and to identify the cut-off values that predict IVH. We hypothesized that the severity of ICV flow pulsations was related to IVH severity. STUDY DESIGN: In this prospective observational study, ICV flow was measured in 61 extremely preterm infants using ultrasonography at every 12 hours until 96 hours after birth and on days 7, 14, and 28. The ICV pulsation index (ICVPI = minimum/maximum ICV speed) was calculated and compared among the groups determined by Papile's IVH classification. The ICVPI cut-off values for IVH were determined by receiver operating characteristic curve analysis. RESULTS: Compared with those in the no IVH (NIVH) group (n = 51), the ICVPI median values in the severe IVH (SIVH; grades 3 and 4) group (n = 5) were lower at 25 to 96 hours and on day 7, whereas those in the mild IVH (MIVH; grades 1 and 2) group (n = 5) were lower at 37 to 60 hours. All SIVH events were initially detected within 60 hours after birth. The ICVPI cut-off values for SIVH were 0.92 at 13 to 24 hours, 0.42 at 25 to 36 hours, 0.58 at 37 to 48 hours, and 0.55 at 49 to 60 hours. Infants whose ICVPI values were below the cut-off value ≥3 times between 13 and 60 hours had a significantly higher SIVH incidence than those whose ICVPI values were below the cut-off value ≤2 times (57.1 vs. 1.9%, p < 0.001). CONCLUSION: Our results indicate that SIVH had sustained pronounced internal cerebral vein pulsations and that the ICVPI values may help predict SIVH. Further research on strategies to decrease venous pressure for IVH prevention is needed. KEY POINTS: · IVH preterm infants had sustained ICV pulsations.. · ICV flow in SIVH pulsated stronger.. · ICVPI fluctuation implies postnatal adaptation.. · We newly defined ICVPI to predict SIVH..

Procalcitonin is associated with postnatal respiratory condition severity in preterm neonate.

INTRODUCTION: Postnatal respiratory failure is common in preterm neonates and is difficult to distinguish from early-onset neonatal bacterial infection by clinical symptoms. Similar to C-reactive protein (CRP), procalcitonin (PCT) is used as a marker of bacterial infection. Recently, it has been reported that the serum PCT levels increase because of respiratory failure immediately after birth. However, there is insufficient information concerning the relationship between biological inflammation markers, such as PCT and CRP, and postnatal respiratory condition severity. METHODS: Preterm neonates were classified according to the received respiratory management as follows: nonrespiratory support (NRS), respiratory support (RS), surfactant administration therapy (STA), and STA with nitric oxide inhalation therapy (NO). The median serum PCT and CRP levels at 12-36 h postnatally were compared among the four groups. Additionally, the median serum PCT and CRP levels in the STA group were compared by STA timing and STA number. RESULTS: The PCT levels for the NRS, RS, STA, and NO groups were 1.04, 6.46, 12.93, and 86.79 µg/L, respectively; the CRP levels were 0.40, 0.80, 1.10, and 16.40 mg/L, respectively. The PCT levels were significantly lower among neonates receiving STA in the birth subgroup (4.82 µg/L) than among those receiving STA in the admission subgroup (14.71 µg/L). The PCT levels were significantly higher among the STA multiple-dose subgroup (24.87 µg/L) than among the STA single-dose subgroup (12.47 µg/L). No significant differences in the CRP levels were observed. CONCLUSION: The serum PCT levels in preterm neonates were associated with postnatal respiratory condition severity.

The Predictive Value of Procalcitonin and High-Sensitivity C-Reactive Protein for Early Bacterial Infections in Preterm Neonates.

INTRODUCTION: Evidence on the reliability of using procalcitonin (PCT) and high-sensitivity C-reactive protein (hs-CRP) as diagnostic markers for early-onset neonatal bacterial infections is still insufficient because of their physiological elevation during the early neonatal period. This study aimed to assess the respiratory influence of serum PCT and hs-CRP levels and evaluate their predictive value for bacterial infections during the first 72 h of life in preterm neonates. METHODS: The preterm neonates enrolled in this single-center retrospective cohort study were categorized into 3 groups: reference, infection-unlikely respiratory failure, and probable bacterial infection; their serum PCT and hs-CRP levels were assessed. Subsequently, age-specific 95th percentile curves were plotted and the median and cutoff PCT and hs-CRP levels for predicting bacterial infections at birth and 7-18, 19-36, and 37-72 h after birth were determined. Moreover, the analysis of PCT and hs-CRP with a neonatal sequential organ failure assessment (nSOFA) score was performed in very low birth weight neonates. RESULTS: Serum PCT levels were influenced by respiratory failure. A significant difference was found in the median PCT and hs-CRP levels among the 3 groups at each time point. PCT sensitivities for predicting bacterial infection were slightly higher than those of hs-CRP in each time frame during the first 72 h of life. In both PCT and hs-CRP, there was no significant difference between infants with nSOFA scores of >4 and those with nSOFA scores of ≤4. DISCUSSION/CONCLUSION: Age-specific evaluation showed that PCT has better predictive value than hs-CRP for early-onset bacterial infections in preterm neonates.

Reversal of blood flow in deep cerebral vein in preterm intraventricular hemorrhage: two case reports.

BACKGROUND: Intraventricular hemorrhage during the early stage is a major complication in very low birth weight infants. Elevation of venous pressure is one of the contributing factors. The internal cerebral vein receives most of the venous flow from the subependymal germinal matrix, the most common site of origin of intraventricular hemorrhage. Recently, it has been reported that pulsatile or partially interrupted internal cerebral vein waveforms might also be risk factors for intraventricular hemorrhage in extremely low birth weight infants. Here, we report two cases of partially reversed internal cerebral vein flow with intraventricular hemorrhage. There are no published reports documenting this unique flow pattern. CASE PRESENTATION: Between 2013 and 2020, we had in our neonatal intensive care unit two cases of very low birth weight infants (27 and 25 weeks of gestational age) who showed a partially reversed internal cerebral vein waveform pattern, which was recognized as a new blood flow pattern. Their internal cerebral vein flow patterns were continuously flat early after birth. They showed an intraventricular hemorrhage on the unilateral side with partially interrupted internal cerebral vein flow at 31 and 41 hours after birth (27- and 25-week-old neonates, respectively). Consecutively, their internal cerebral vein flow changed to a partially reversed pattern with intraventricular hemorrhage on the contralateral side at 43 and 87 hours after birth (27- and 25-week-old neonates, respectively). Their flow patterns improved by day 7. These partially reversed patterns were equivalent to triphasic venous flow, and the reverse flow corresponded to A- and V-waves. CONCLUSION: In the two cases, the internal cerebral vein flow patterns were normal and flat before intraventricular hemorrhage and changed to a severe flow pattern (partially interrupted or reversed flow) at the same time as the detection of intraventricular hemorrhage. After the development of intraventricular hemorrhage, they improved. These cases indicate that a partially reversed or interrupted internal cerebral vein flow pattern may be derived from central venous pressure elevation and related to intraventricular hemorrhage in very low birth weight infants, however, it is difficult to determine when this flow pattern occurs in relation to intraventricular hemorrhage.

New reference ranges of procalcitonin excluding respiratory failure in neonates.

BACKGROUND: Existing reference data on serum procalcitonin (PCT) in neonates include the effects of respiratory disorders commonly occurring during birth. We aimed to determine new 95% reference intervals in neonates after excluding the influence of respiratory failure at birth, and to investigate the effects of gestational age (GA) and respiratory condition at birth on postnatal transient serum PCT elevation. METHODS: Samples were obtained from term and preterm neonates during the first 3 days of life. Neonates were classified into reference, respiratory failure, and bacterial infection groups. In the reference group, the correlation between PCT level and GA was investigated. RESULTS: The median PCT level within the 95% range 12-36 h after birth was 1.05 ng/mL (0.14-4.39) in term neonates (143 samples) and 1.01 ng/mL (0.15-4.44) in preterm neonates (95 samples). There was no correlation between GA and serum PCT level during 1-48 h after birth. There was a significant difference in median serum PCT level during 12-36 h after birth between the respiratory failure (9.56 ng/mL) and bacterial infection (49.82 ng/mL) groups in preterm neonates but no difference between term neonates (respiratory failure 6.83 ng/mL, and bacterial infection 7.43 ng/mL). CONCLUSIONS: Respiratory failure is the main effector for the transient elevation in serum PCT levels at 3 days of life. After excluding the influence of respiratory failure, the chronological pattern and range were very similar between term and preterm neonates. Procalcitonin can be useful for clinicians in distinguishing bacterial infection from respiratory failure, aiding decisions on appropriate antibiotic use.

Fluctuation of blood glucose levels in an infant with an ileostomy on continuous glucose monitoring: A case report.

Infants with an ileostomy can be at high risk of hypoglycemia because of inadequate nutritional intake; however, there are no reports investigating blood glucose (BG) in infants with ileostomy. We experienced a case of an extremely low birth weight infant who was born at 24 wk of gestation and weighted 623 g. He received an ileostomy because of an intestinal perforation. After the ileostomy, he had recurrent hypoglycemia. Continuous glucose monitoring showed fluctuation of BG levels (postprandial BG elevations and subsequent declines) and non-fasting hypoglycemia, which were undetectable with intermittent fasting BG measurement. The fluctuation of BG levels and non-fasting hypoglycemia improved after closure of the ileostomy. Patients with ileostomy may present with hypoglycemia that is undetectable with intermittent fasting BG measurement. In this case, continuous glucose monitoring was very useful for detecting fluctuation of BG levels and hypoglycemic episodes. Therefore, we recommend that continuous glucose monitoring be performed in infants with an ileostomy to confirm whether they have hypoglycemia or a fluctuation in BG levels. Further studies on the postprandial dynamics of various hormones in infants with ileostomy are required.

Amelioration by glycine of brain damage in neonatal rat brain following hypoxia-ischemia.

BACKGROUND: Glycine protected adult brains against injury in an experimental model of stroke, but, because the ischemic response of neonatal brains differs from that of adult brains, we examined the neuroprotective efficacy of glycine and associated mechanisms in an experimental model of neonatal hypoxic-ischemic (HI) encephalopathy. METHODS: Neonatal (postnatal day 7) Wistar rats were randomly divided into an untreated group (non-HI) and two HI groups that were treated with left common carotid artery ligation and saline control or glycine. After recovery, pups that received surgery were injected i.p. with saline or glycine (800 mg/kg; optimal dose determined in pilot experiments) and were placed in a controlled 8% O2 chamber for 120 min. Brains were harvested at various times after return to normoxia (several hours-days after HI) for analysis of infarct area, glial activation, cell apoptosis, and tumor necrosis factor-α (TNF-α) expression on histology and reverse transcription-polymerase chain reaction. RESULTS: Glycine injections induced large (approx. 15-fold) but brief (approx. 2 h) increases in cerebrospinal fluid concentrations. In particular, the glycine group had a >70% decrease in infarct areas compared with controls at 7 days after HI. Glycine also significantly reduced astrocyte reactive transformation, microglia activation, and terminal deoxynucleotidyl transferase dUTP nick end labeling-positive (apoptotic) cell numbers in peri-lesional areas at 3 days after HI, and TNF-α mRNA expression in the injured hemisphere at 12 and 24 h after HI. CONCLUSION: Glycine protected neonatal rat brains against HI, in part by inhibiting TNF-α-induced inflammation and gliosis. Hence, systemic glycine infusions may have clinical utility for the treatment of HI injury in human newborns.