Impact of perinatal COVID on fetal and neonatal brain and neurodevelopmental outcomes.

After three years of the COVID-19 pandemic, we have learned many aspects of the disease and the virus: its molecular structure, how it infects human cells, the clinical picture at different ages, potential therapies, and the effectiveness of prophylaxis. Research is currently focused on the short- and long-term consequences of COVID-19. We review the available information on the neurodevelopmental outcome of infants born during the pandemic from infected and non-infected mothers, as well as the neurological impact of neonatal SARS-CoV-2 infection. We also discuss the mechanisms that could potentially affect the fetal or neonatal brain including direct impact after vertical transmission, maternal immune activation with a proinflammatory cytokine storm, and finally the consequences of complications of pregnancy secondary to maternal infection that could affect the fetus. Several follow-up studies have noted a variety of neurodevelopmental sequelae among infants born during the pandemic. There is controversy as to the exact etiopathogenesis of these neurodevelopmental effects: from the infection itself or as a result of parental emotional stress during that period. We summarize case reports of acute neonatal SARS-CoV-2 infections associated with neurological signs and neuroimaging changes. Many infants born during previous pandemics caused by other respiratory viruses demonstrated serious neurodevelopmental and psychological sequelae that were only recognized after several years of follow-up. It is essential to warn health authorities about the need for very long-term continuous follow up of infants born during the SARS-CoV-2 pandemic for early detection and treatment that could help mitigate the neurodevelopmental consequences of perinatal COVID-19.

Can Intubation Be Improved with Endotracheal Tubes Marked with a Color Scale? Randomized Controlled Study.

OBJECTIVE: This study aimed to assess if a color scale in the endotracheal tube (ETT) can help operators to correctly select the size and depth of placement of the ETT and decrease the time required to complete the procedure and compared with the usual numeric ETT scale in a mannequin model. STUDY DESIGN: The study was conducted in eight centers. Each size of the ETT was identified with a different color. The experimental ETTs had two different colored areas, one for the mouthpiece and another to identify where the ETT should be taped above the lip (an area of 1 cm. The operators were trained as part of the protocol using an instructional video. Four clinical scenarios requiring endotracheal intubation were designed and randomly assigned. Each operator had to select the size and depth of ETT based on the birth weight (BW), and then had to perform four intubations. RESULTS: A total of 108 operators performed 432 intubations. No differences were found in the correct placement and selection of the ETT. Median time (in seconds) required for intubation using numeric versus experimental tube was: for ETT Ø NRP (Neonatal Resuscitation Program) 2.5, 11.5 versus 8 (p < 0.001), ETT Ø 3, 12 versus 10 (p < 0.001), ETT Ø 3.5, 15.5 versus12 (p = 0.003), ETT Ø 4, 12 versus11 (p = 0.019). CONCLUSION: No significant difference was observed in the selection and correct placement of the ETT. However, the intubation time was significantly shorter using the experimental ETT. This device could improve the effectiveness of intubation by reducing the time needed to properly place the ETT at mid trachea. KEY POINTS: · It is an innovative intervention to try to solve a great inconvenience of daily practice.. · The study also raises the difficulty in maintaining the ability of endotracheal intubation.. · It proposes a scale that ensures the correct location with a safe fixation zone..

Infección tardía por Streptococcus agalactiae asociada a la leche humana: reporte de 3 casos clínicos / Streptococcus agalactiae late onset infection associated with human milk: three cases report

La infección por estreptococo ß-hemolítico del grupo B o Streptococcus agalactiae puede causar morbilidad grave y mortalidad en los recién nacidos, especialmente en prematuros. Las estrategias de prevención actuales han sido eficaces en reducir la frecuencia de sepsis neonatal temprana ocasionada por transmisión vertical. La incidencia de sepsis tardía por dicho microrganismo no se ha modificado y la vía de infección es menos clara. En niños amamantados, la transmisión a través de la leche materna es posible. Se presentan tres casos de infección tardía por estreptococo ß-hemolítico del grupo B en recién nacidos prematuros alimentados con leche materna cuyas madres tenían mastitis. En todos los casos, tanto en el cultivo de la leche materna como en los hemocultivos de los neonatos se desarrolló el mismo microrganismo.

Group B ß-hemolytic Streptococcus or Streptococcus agalactiae is a major cause of morbidity and mortality in neonates, especially in premature infants. Current prevention strategies have been effective in reducing the frequency of early onset neonatal sepsis caused by vertical transmission. The incidence of late onset sepsis due to this microorganism has not changed and the route of infection is less clear. In breastfed infants, transmission through breast milk is possible. We report three cases of late group B ß-hemolytic streptococcal infection in breastfed preterm infants whose mothers had mastitis. In all cases, both the breast milk culture and the blood cultures of the neonates developed the same microorganism.

[Streptococcus agalactiae late onset infection associated with human milk: three cases report]. / Infección tardía por Streptococcus agalactiae asociada a la leche humana: reporte de 3 casos clínicos.

Group B ß-hemolytic Streptococcus or Streptococcus agalactiae is a major cause of morbidity and mortality in neonates, especially in premature infants. Current prevention strategies have been effective in reducing the frequency of early onset neonatal sepsis caused by vertical transmission. The incidence of late onset sepsis due to this microorganism has not changed and the route of infection is less clear. In breastfed infants, transmission through breast milk is possible. We report three cases of late group B ß-hemolytic streptococcal infection in breastfed preterm infants whose mothers had mastitis. In all cases, both the breast milk culture and the blood cultures of the neonates developed the same microorganism.

La infección por estreptococo ß-hemolítico del grupo B o Streptococcus agalactiae puede causar morbilidad grave y mortalidad en los recién nacidos, especialmente en prematuros. Las estrategias de prevención actuales han sido eficaces en reducir la frecuencia de sepsis neonatal temprana ocasionada por transmisión vertical. La incidencia de sepsis tardía por dicho microrganismo no se ha modificado y la vía de infección es menos clara. En niños amamantados, la transmisión a través de la leche materna es posible. Se presentan tres casos de infección tardía por estreptococo ß-hemolítico del grupo B en recién nacidos prematuros alimentados con leche materna cuyas madres tenían mastitis. En todos los casos, tanto en el cultivo de la leche materna como en los hemocultivos de los neonatos se desarrolló el mismo microrganismo.

Association between Intermittent Hypoxemia and Severe Bronchopulmonary Dysplasia in Preterm Infants.

Rationale: Bronchopulmonary dysplasia increases the risk of disability in extremely preterm infants. Although the pathophysiology remains uncertain, prior exposure to intermittent hypoxemia may play a role in this relationship. Objectives: To determine the association between prolonged episodes of intermittent hypoxemia and severe bronchopulmonary dysplasia. Methods: A post hoc analysis of extremely preterm infants in the Canadian Oxygen Trial who survived to 36 weeks' postmenstrual age was performed. Oxygen saturations <80% for ⩾1 minute and the proportion of time per day with hypoxemia were quantified using continuous pulse oximetry data that had been sampled every 10 seconds from within 24 hours of birth until 36 weeks' postmenstrual age. The study outcome was severe bronchopulmonary dysplasia as defined in the 2001 NIH Workshop Summary. Measurements and Main Results: Of 1,018 infants, 332 (32.6%) developed severe bronchopulmonary dysplasia. The median number of hypoxemic episodes ranged from 0.8/day (interquartile range, 0.2-1.1) to 60.2/day (interquartile range, 51.4-70.3) among the least and most affected 10% of infants. Compared with the lowest decile of exposure to hypoxemic episodes, the adjusted relative risk of severe bronchopulmonary dysplasia increased progressively from 1.72 (95% confidence interval, 1.55-1.90) at the 2nd decile to 20.40 (95% confidence interval, 12.88-32.32) at the 10th decile. Similar risk gradients were observed for time in hypoxemia. Significant differences in the rates of hypoxemia between infants with and without severe bronchopulmonary dysplasia emerged within the first week after birth. Conclusions: Prolonged intermittent hypoxemia beginning in the first week after birth was associated with an increased risk of developing severe bronchopulmonary dysplasia among extremely preterm infants. Clinical trial registered with www.isrctn.com (ISRCTN62491227) and www.clinicaltrials.gov (NCT00637169).

Ischemic Lesions in the Brain of a Neonate With SARS-CoV-2 Infection.

AIM: To describe a term newborn with acquired severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and multisystem involvement including seizures associated to ischemic lesions in the brain. BACKGROUND: Coronavirus disease 2019 (COVID-19) is predominantly a respiratory infection, but it may affect many other systems. Most pediatric COVID-19 cases range from asymptomatic to mild-moderate disease. There are no specific clinical signs described for neonatal COVID-19 infections. In children, severe central nervous system compromise has been rarely reported. CASE DESCRIPTION: We describe a 17-day-old newborn who acquired a SARS-CoV-2 infection in a family meeting that was admitted for fever, seizures and lethargy and in whom consumption coagulopathy, ischemic lesions in the brain and cardiac involvement were documented. CONCLUSIONS: SARS-CoV-2 neonatal infection can be associated with multi-organic involvement. In our patient, significant central nervous system compromise associated to ischemic lesions and laboratory findings of consumption coagulopathy were found. CLINICAL SIGNIFICANCE: Although neonatal SARS-CoV-2 infections are infrequent, they can be associated with multi-organic involvement. Neonatologists and pediatricians should be aware of this unusual way of presentation of COVID-19 in newborn infants.

Estrategias de preparación en unidades de neonatología durante la pandemia de COVID-19: Encuesta en maternidades de la Argentina / Preparedness strategies in neonatology units during the COVID-19 pandemic: A survey conducted at maternity centers in Argentina

Introducción. El objetivo de este estudio fue analizar recursos disponibles, guías utilizadas y preparación para la atención de neonatos en maternidades de Argentina durante la pandemia de COVID-19.Método. Estudio transversal mediante una encuesta enviada a equipos médicos y de enfermería. En mayo de 2020, se contactaron instituciones de más de 500 nacimientos anuales en la Argentina, el 58 % del sector público.Resultados. Respondieron 104/147 instituciones (el 71 %). Todas contaban con guías para la atención durante la pandemia, y un 93 % refirió haber recibido capacitación para su uso. No autorizaban la presencia de acompañante en el parto el 26 % de instituciones privadas y el 60 % de las públicas (p < 0,01). El 87 % recomendaba ligadura oportuna del cordón, el 62 % promovía internación conjunta en neonatos asintomáticos, un 70 % recomendaba la puesta al pecho con medidas de protección, y el 23 %, leche materna mediante biberón. El 94 % restringía el ingreso de familiares a Neonatología.Las dificultades incluyeron imposibilidad de contar con habitaciones individuales para neonatos sintomáticos y potencial limitación del personal de salud y equipos de protección personal.Conclusiones. Todas las instituciones conocen las guías nacionales para enfrentar la pandemia. La mayoría cuenta con recursos para respetar las medidas de protección recomendadas. Existe incertidumbre sobre si, ante un aumento significativo en el número de casos, serán suficientes los elementos de protección personal, el personal y el espacio físico disponible en los distintos centros

Introduction. The objective of this study was to analyze available resources, guidelines in use, and preparedness to care for newborn infants at maternity centers in Argentina during the COVID-19 pandemic.Method. Cross-sectional study based on a survey administered to medical and nursing staff. In May 2020, Argentine facilities with more than 500 annual births were contacted; 58 % of these were from the public sector.Results. In total, 104/147 facilities answered (71 %). All had guidelines for care during the pandemic, and 93 % indicated they had been trained on how to use them. A companion was not allowed during childbirth in 26 % of private facilities and in 60 % of public ones (p < 0.01). Deferred cord clamping was recommended in 87 %; rooming-in with asymptomatic newborns was promoted in 62 %; breastfeeding using protective measures was recommended in 70 %; and breast milk using a bottle, in 23 %. In 94 %, family visiting in the Neonatology Unit was restricted.Difficulties included the unavailability of individual rooms for symptomatic newborn infants and a potential shortage of health care staff and personal protective equipment.Conclusions. All facilities are aware of the national guidelines to fight the pandemic. Most have the resources to comply with the recommended protective measures. There is uncertainty as to whether personal protective equipment, staff, and physical space available at the different facilities would be enough if cases increased significantly

Neonatal Hypoglycaemia: A Never-Ending Story?

Neonatal hypoglycaemia is a common metabolic disorder presenting in the first days of life and one potentially preventable cause of brain injury. However, a universal approach to diagnosis and management is still lacking. The rapid decrease in blood glucose (BG) after birth triggers homeostatic mechanisms. Most episodes of hypoglycaemia are asymptomatic, and symptoms, when they occur, are nonspecific. Therefore, neonatologists are presented with the challenge of identifying infants at risk who might benefit from a rapid and effective therapy while sparing others unnecessary sampling and overtreatment. There is much controversy regarding the definition of hypoglycaemia, and one level does not fit all infants since postnatal age and clinical situations trigger different accepted thresholds for therapy. The concentration and duration of BG which cause neurological damage are unclear. Recognizing which newborn infants are at risk of hypoglycaemia and establishing protocols for treatment are essential to avoid possible deleterious effects on neurodevelopment. Early breastfeeding may reduce the risk of hypoglycaemia, but in some cases, the amount of breast milk available immediately after birth is insufficient or non-existent. In these situations, other therapeutic alternatives such as oral dextrose gel may lower the risk for NICU admissions. Current guidelines continue to be based on expert opinion and weak evidence. However, malpractice litigation related to neurodevelopmental disorders is frequent in children who suffered hypoglycaemia in the neonatal period even if they had other important factors contributing to the poor outcome. This review is aimed to help the practicing paediatricians and neonatologists to comprehend neonatal hypoglycaemia from physiology to therapy, hoping it will result in a rational decision-making process in an area not sufficiently supported by evidence.

Preparedness strategies in neonatology units during the COVID-19 pandemic: A survey conducted at maternity centers in Argentina. / Estrategias de preparación en unidades de neonatología durante la pandemia de COVID-19: Encuesta en maternidades de la Argentina.

INTRODUCTION: The objective of this study was to analyze available resources, guidelines in use, and preparedness to care for newborn infants at maternity centers in Argentina during the COVID-19 pandemic. METHOD: Cross-sectional study based on a survey administered to medical and nursing staff. In May 2020, Argentine facilities with more than 500 annual births were contacted; 58 % of these were from the public sector. RESULTS: In total, 104/147 facilities answered (71 %). All had guidelines for care during the pandemic, and 93 % indicated they had been trained on how to use them. A companion was not allowed during childbirth in 26 % of private facilities and in 60 % of public ones (p < 0.01). Deferred cord clamping was recommended in 87 %; rooming-in with asymptomatic newborns was promoted in 62 %; breastfeeding using protective measures was recommended in 70 %; and breast milk using a bottle, in 23 %. In 94 %, family visiting in the Neonatology Unit was restricted. Difficulties included the unavailability of individual rooms for symptomatic newborn infants and a potential shortage of health care staff and personal protective equipment. CONCLUSIONS: All facilities are aware of the national guidelines to fight the pandemic. Most have the resources to comply with the recommended protective measures. There is uncertainty as to whether personal protective equipment, staff, and physical space available at the different facilities would be enough if cases increased significantly.

Introducción. El objetivo de este estudio fue analizar recursos disponibles, guías utilizadas y preparación para la atención de neonatos en maternidades de Argentina durante la pandemia de COVID-19. Método. Estudio transversal mediante una encuesta enviada a equipos médicos y de enfermería. En mayo de 2020, se contactaron instituciones de más de 500 nacimientos anuales en la Argentina, el 58 % del sector público. Resultados. Respondieron 104/147 instituciones (el 71 %). Todas contaban con guías para la atención durante la pandemia, y un 93 % refirió haber recibido capacitación para su uso. No autorizaban la presencia de acompañante en el parto el 26 % de instituciones privadas y el 60 % de las públicas (p < 0,01). El 87 % recomendaba ligadura oportuna del cordón, el 62 % promovía internación conjunta en neonatos asintomáticos, un 70 % recomendaba la puesta al pecho con medidas de protección, y el 23 %, leche materna mediante biberón. El 94 % restringía el ingreso de familiares a Neonatología. Las dificultades incluyeron imposibilidad de contar con habitaciones individuales para neonatos sintomáticos y potencial limitación del personal de salud y equipos de protección personal. Conclusiones. Todas las instituciones conocen las guías nacionales para enfrentar la pandemia. La mayoría cuenta con recursos para respetar las medidas de protección recomendadas. Existe incertidumbre sobre si, ante un aumento significativo en el número de casos, serán suficientes los elementos de protección personal, el personal y el espacio físico disponible en los distintos centros.

Nosocomial Respiratory Viral Infection in the Neonatal Intensive Care Unit.

Infections caused by respiratory viruses in neonates during their stay in the neonatal intensive care unit (NICU) are more frequent than generally suspected. Respiratory syncytial virus (RSV), a highly contagious pathogen, is the most common etiologic agent, and it carries a high risk of nosocomial spread. During the RSV season, overcrowding of the NICU, shortage of staff, and unrestricted visitors are factors predisposing outbreaks. Since signs and symptoms of RSV infections are no specific, a high index of suspicion is essential to prevent or limit epidemics. The etiologic agent should be confirmed and polymerase chain reaction (PCR) is the gold-standard test. Shedding of the virus by infected preterm infants is prolonged and RSV lasts for several hours on countertops and other surfaces. The first case should be isolated and strict cohorting must be instituted. Compliance with hand washing must be warranted. Wearing gowns and gloves may help. The severity of nosocomial RSV infections tends to be higher than that of those community acquired. There is no uniform recommendation to start palivizumab during hospital stay of premature and high-risk infants. The use of this monoclonal antibody to stop or limit the spread of outbreaks is controversial. It is recommended by some professional organizations and not by others but its use during large outbreaks in infants at risk who share the room with infected neonates is not uncommon. KEY POINTS: · During peak community epidemic, NICU outbreaks of RSV infections are not uncommon.. · High index of suspicion is essential as initial signs are nonspecific in preterm neonates.. · Isolation and cohorting, strict hand washing, gowns, gloves, and eventually palivizumab are main tools for management..

Postpartum use of oxytocin and volume of placental transfusion: a randomised controlled trial.

OBJECTIVE: To assess whether oxytocin administered before clamping the umbilical cord modifies the volume of placental transfusion. DESIGN: Randomised controlled trial. METHODS: Mothers of term infants born vigorous by vaginal delivery with informed consent provided in early labour were randomly assigned to oxytocin (10 IU) given intravenously within 15 s of birth (group 1) or after clamping the umbilical cord 3 min after delivery (group 2). Soon after birth, all infants were weighed using a 1 g precision scale and subsequently placed on the mother's abdomen or chest. At 3 min, in both groups, the cord was clamped and cut, and the weight was again obtained. The primary outcome (volume of placental transfusion) was estimated by the difference in weights. RESULTS: 144 patients were included. There were no differences in the primary outcome: infants in group 1 (n=70) gained a mean weight of 85.9 g (SD 48.3), and in group 2 (n=74) 86.7 g (SD 49.6) (p=0.92). No differences were found in secondary outcomes, including newborns' haematocrit and bilirubin concentrations and severe maternal postpartum haemorrhage. On the advice of the Data and Safety Monitoring Committee, the trial was stopped due to futility at 25% of the planned sample size. CONCLUSIONS: When umbilical cord clamping is delayed for 3 min, term newborn infants born vigorous receive a clinically significant placental transfusion which is not modified by the administration of intravenous oxytocin immediately after birth. TRIAL REGISTRATION NUMBER: NCT02618499.

The rising incidence and impact of non-medically indicated pre-labour cesarean section in Latin America.

In the poorest populations of the world the difficulties of performing a surgical procedure lead to extremely low cesarean section rates associated with very high perinatal mortality. Meanwhile the proportion of births by cesarean section has been increasing for several decades in many areas of the world, reaching alarmingly high rates especially in Latin America. This review aims to describe this secular trend. The causes of the increase in cesarean deliveries are analyzed with a multidimensional approach, trying to recognize the reasons behind the choice of the route of delivery. We are facing a shift in the guiding paradigm, leaving the classical biomedical one. Advantages and disadvantages of non-medically indicated cesarean section are being sought, comparing it with the results of vaginal delivery, with special emphasis on the short- and long-term morbidity of the newborn. Several variables involved in this controversial topic are considered, with the objective of stimulating critical thoughts about the medical, bioethical and social aspects of the increasing trend in the cesarean section rate.

Meconium "aspiration" (or respiratory distress associated with meconium-stained amniotic fluid?).

The designation meconium aspiration syndrome (MAS) reflects a spectrum of disorders in infants born with meconium-stained amniotic fluid, ranging from mild tachypnea to severe respiratory distress and significant mortality. The frequency of MAS is highest among infants with post-term gestation, thick meconium, and birth asphyxia. Pulmonary hypertension is an important component in severe cases. Prenatal hypopharyngeal suctioning and postnatal endotracheal intubation and suctioning of vigorous infants are not effective. Intubation and suctioning of non-breathing infants is controversial and needs more investigation. Oxygen, mechanical ventilation, and inhaled nitric oxide are the mainstays of treatment. Surfactant is often used in infants with severe parenchymal involvement. High-frequency ventilation and extracorporeal membrane oxygenation are usually considered rescue therapies.