Can neutrophil to lymphocyte ratio predict late-onset sepsis in preterm infants?

BACKGROUND: The neutrophil to lymphocyte ratio (NLR) is an easily accessible biomarker that has been reported to represent disease severity in adult trials. The aim of this study was to evaluate the relationship between culture positiveness and NLR in cases where the reason of sepsis was considered, and to foresight an idea about the active agents. METHODS: Preterm infants with birth weights ≤1500 g and/or ≤32 gestational weeks were eligible for this study. The postnatal age of all included infants was more than 3 days with clinical and laboratory signs of sepsis. According to the results of blood cultures, all enrolled infants were classified into 2 groups: the culture-proven septic infants and suspected septic infants. The NLR was calculated as the ratio of neutrophil count to lymphocyte count. Initial laboratory investigations included WBC count, platelet count (PLT), C-reactive protein (CRP), and blood cultures. RESULTS: A total of 127 infants were involved: 57 culture-proven sepsis and 75 suspected sepsis. There were no significant differences between groups regarding gestational age, gender, birth weight, delivery mode, and postnatal age. Receiver operating curve analysis for NLR and CRP was calculated. The area under the curve corresponded to 0.78 ± 0.04 (NLR) vs 0.55 ± 0.05 (CRP). Using a cutoff point of 1.77 for NLR, the sensitivity was 0.73, the specificity was 0.78, and accuracy rate was 0.76. DISCUSSION: The prediction of NLR, an easy, inexpensive, and rapid method, along with CRP in the neonatal period for diagnosis of sepsis, will be more effective in detecting culture-proven sepsis and in decreasing unnecessary antibiotherapy.

Comparison of neonatal transport scoring systems and transport-related mortality score for predicting neonatal mortality risk.

OBJECTIVES: To predict the risk of mortality of neonates, birth weight and gestational age were previously used. However, these criteria were considered inadequate; therefore, various scoring systems have been developed in the recent years. The aim of the study was to evaluate the performance of predicting mortality by Mortality Index for Neonatal Transportation (MINT), Score for Neonatal Acute Physiology-Perinatal Extension II (SNAP-PE-II), and Transport Related Mortality Score (TREMS). METHODS: All infants transferred to the neonatal intensive care unit between January 1 and December 31, 2011, were included. The scores of SNAP-PE-II, MINT, and TREMS of the all cases were calculated. TREMS is our proposed scoring system and it consists of 5 variables (hypoglycemia, hypoxia, hypercarbia, hypotension, and hypothermia). The scoring systems, SNAP-PE-II, MINT, and TREMS, were compared in terms of mortality risk. RESULTS: A total of 306 newborn infants constituted the study population. The mean gestational age was 33.1 ± 5 weeks and the mean birth weight was 2031.2 ± 1018 g, and 183 (59%) babies were male. The sensitivity of MINT score for predicting mortality was higher than SNAP-PE-II and TREMS. However, specificity was higher in TREMS score. The negative predictive value was highest in MINT score, whereas TREMS has the highest positive predictive value. CONCLUSIONS: The TREMS scoring system is a simple scoring system with a high specificity for predicting mortality. Further studies with larger sample size including more centers and newborn infants with diverse clinical problems are needed to assess the validity and reliability of the TREMS scoring system.

Effects of synchronized intermittent mandatory ventilation versus pressure support plus volume guarantee ventilation in the weaning phase of preterm infants*.

OBJECTIVE: To compare the effects and short-term outcomes of pressure support ventilation with volume guarantee versus synchronized intermittent mandatory ventilation in the weaning phase of very low-birth weight infants with respiratory distress syndrome. DESIGN: Randomized controlled prospective study. SETTING: Tertiary care neonatal unit. PATIENTS: A total of 60 premature infants who were less than 33 weeks' gestation and/or less than 1,500 g birth weight and received mechanical ventilation because of respiratory distress syndrome were studied. INTERVENTIONS: All infants were ventilated from the time of admission with synchronized intermittent positive pressure ventilation mode after surfactant treatment for respiratory distress syndrome and then switched to pressure support ventilation with volume guarantee or synchronized intermittent mandatory ventilation mode in the weaning phase. The ventilatory variables and neonatal outcomes were recorded in each group. MEASUREMENTS AND MAIN RESULTS: The mean peak inflation pressure was higher in synchronized intermittent mandatory ventilation group (p < 0.001) and the mean airway pressure was higher in pressure support ventilation with volume guarantee group (p = 0.03), whereas mean tidal volume and respiratory rates were similar in both groups. The prevalence of postextubation atelectasis was higher in synchronized intermittent mandatory ventilation group, but the difference was not statistically significant (p = 0.08). No differences were found in the prevalence of reintubation, patent ductus arteriosus, intraventricular hemorrhage, retinopathy of prematurity, bronchopulmonary dysplasia, and pneumothorax between the groups. CONCLUSIONS: Pressure support ventilation with volume guarantee mode may be a safe and feasible mode during the weaning phase of very low-birth weight infants on mechanical ventilation support for respiratory distress syndrome with respect to reducing the frequency of postextubation atelectasis and using less peak inflation pressure.

Reference ranges for sonographic renal dimensions in preterm infants.

BACKGROUND: Ultrasonographic measurement of kidney dimensions is important in evaluation of renal disease in preterm infants who have multiple comorbidities that affect renal function. OBJECTIVE: The purpose of this study was to determine the reference ranges of kidney dimensions in preterm newborns and to provide a chart to use easily in daily practice. MATERIALS AND METHODS: We evaluated renal dimensions in 498 preterm infants with a gestational age of <37 weeks using sonography within the first week of life. We statistically analyzed the relationships between all dimensions and gender, gestational age (based on the last menstrual period), height and weight. Minimum and maximum values of dimensions were defined. RESULTS: All dimensions of the kidneys were statistically different in boys and girls (P < 0.05). Both longitudinal and anteroposterior dimensions of the right and left kidneys showed high correlation with gestational age, weight and height in girls and boys. Weight correlated best with dimensions. CONCLUSION: Nomograms from these data can be used to determine an abnormality in kidneys of preterm newborns.

Reference ranges for sonographic dimensions of the liver and spleen in preterm infants.

BACKGROUND: Preterm infants usually have multiple comorbidities that affect spleen and liver. Ultrasonographic measurement of organ sizes is an important and reliable parameter in evaluation of spleen and liver pathology in preterm newborns. OBJECTIVE: The purpose of this study was to determine reference values of ultrasonographic measurements of the liver and spleen in preterm newborns. MATERIALS AND METHODS: We prospectively performed sonography on 498 preterm newborns in the first week of life. We measured spleen and liver dimensions and statistically analyzed relationships between the dimensions and gender, gestational age (based on mother's last menstrual period), height and weight. Reference ranges of dimensions were defined. RESULTS: Longitudinal and anteroposterior dimensions of the liver and spleen were statistically significantly different between the boys and girls (P < 0.05) and showed high correlation with the gestational age, weight and height. Weight was the parameter best correlated with the dimensions. CONCLUSION: Nomograms from these data are useful for sonographic evaluation of the liver and spleen in preterm newborns.

Escherichia coli brain abscess in a twin pair associated with TLR4 gene mutation.

Brain abscesses are uncommon complications of bacterial meningitis or sepsis in neonates and infants. The causative pathogens of brain abscess in newborns are various. Of those, Escherichia coli is rarely seen as a pathogen in brain abscess at this age. Herein we reported brain abscesses in twin infants caused by E. coli sepsis. Interestingly, genetic analysis identified heterozygous Toll-like receptor 4 (TLR4) gene mutation in the twins. Because TLR plays an important role in the natural response to bacterial products and initiates specific immune response against these pathogens, this may explain the development of brain abscess in the present case.

An unusual case of trisomy 18 associated with paucity of bile ducts.

A case of neonatal cholestasis associated with Trisomy 18 (Edward's syndrome) is presented. A 3-day-old boy was referred to our clinic due to respiratory distress, elevated serum direct bilirubin levels, a systolic heart murmur, growth restriction and micrognathia. Liver biopsy and chromosomal analysis revealed paucity of intrahepatic bile ducts and Trisomy 18. Extrahepatic biliary atresia was reported in only a few patients with Trisomy 18. To our knowledge, we described for the first time a patient with Trisomy 18 and neonatal cholestasis associated with paucity of interlobular bile ducts.

Central nervous system involvement of epstein barr virus associated lymphoproliferative disorder in a child with acute lymphoblastic leukemia: successful treatment with rituximab and interferon-alpha.

UNLABELLED: Central nervous system (CNS) involvement of Epstein-Barr virus (EBV)-associated lymphoproliferative disease is a rare and serious complication in children with leukemia. Although rituximab therapy seems to be promising in these cases, persistent hypogammaglobulinemia may appear after treatment due to complete depletion of normal B lymphocytes in the peripheral blood. Here we report isolated CNS involvement of EBV-associated lymphoproliferative disorder in a 4-year-old boy with acute leukemia. The patient was treated with rituximab and interferon alpha; however, persistent hypogammaglobulinemia developed as a complication. Given the rarity of the complication in children receiving these agents, our experience with such a case may be helpful to others. CONFLICT OF INTEREST: None declared.

Nutritional B12 deficiency in infants of vitamin B12-deficient mothers.

AIM: Nutritional vitamin B12 deficiency in infants may occur because the maternal diet contains inadequate animal products. Clinical presentations of the infants who had nutritional vitamin B12 deficiency were analyzed in this study. SUBJECTS AND METHODS: Patients with nutritional vitamin B12 deficiency were enrolled in the study between 2003 and 2010. The diagnosis was based on a nutritional history of mothers and infants, clinical findings, hematological evaluation, and low level of serum vitamin B12. RESULTS: Thirty children aged 1 - 21 months constituted the study group. Poverty was the main cause of inadequate consumption of animal products of the mothers. All infants had predominantly breastfed. The most common symptoms were developmental delay, paleness, apathy, lethargy, anorexia, and failure to thrive. Hematological findings were megaloblastic anemia (83.3 %), thrombocytopenia (30 %), and severe anemia (13.3 %). All of the mothers had low serum B12 levels; eight of them had megaloblastic anemia. CONCLUSION: The unusual clinical manifestations of vitamin B12 deficiency may also be seen apart from neurological and hematological findings. Nutritional vitamin B12 deficiency due to maternal deficiency might be a serious health problem in infants. Therefore, screening and supplementation of pregnant and lactating women to prevent infantile vitamin B12 deficiency should be considered.

Acute hemorrhagic edema of infancy: a case report.

Acute hemorrhagic edema of infancy is a rare vasculitic syndrome affecting young children. Although presentation is dramatic and striking, it is a benign disorder. A 9-month-old boy with fever, rhinorrhea, edema, and purpuric lesions involving the face, oral mucosa, ears, and extremities was presented.

Reticular dysgenesis in a preterm infant: a case report.

Reticular dysgenesis (RD) is a rare congenital immunodeficiency classified within the severe combined immunodeficiencies (SCIDs) and characterized by impairment of both lymphoid and myeloid cell development. Neutropenia unresponsive to recombinant human granulocyte colony-stimulating factor (rGCSF) is the hallmark of RD and the clinical course is rapidly fatal due to overwhelming infections. The authors report a female newborn at 32 weeks of gestation presenting with severe leukopenia at birth. The bone marrow showed a maturation arrest in the myeloid and lymphoid lineage. She had no response to granulocyte colony stimulating factor (rGCSF) treatment and died with sepsis at age of 2 months.

Value of urinary kidney injury molecule-1 levels in predicting acute kidney injury in very low birth weight preterm infants.

OBJECTIVE: This study aimed to evaluate the significance of urinary kidney injury molecule-1 (uKIM-1) levels in predicting acute kidney injury (AKI) and mortality in very low birth weight (VLBW) preterm infants. METHODS: This prospective, observational cohort study was conducted on 39 VLBW preterm infants. Serum creatinine (SCr) and uKIM-1 levels were measured in the first 24 and 48 to 72 hours of life. The estimated glomerular filtration rate (eGFR) was calculated. Levels of uKIM-1 were measured with an enzyme-linked immunosorbent assay. RESULTS: Among 39 VLBW infants, 9 (23%) developed AKI. The mortality rate was 17.9% (n = 7 neonates). There was no significant difference in SCr levels, uKIM-1 levels, or the eGFR obtained in the first 24 hours in the AKI group compared with controls. However, significant differences were found in SCr and uKIM-1 levels, and the eGFR rate at 48 to 72 hours between the groups. Levels of uKIM-1 were significantly higher in non-survivors than in survivors in the first 24 and 48 to 72 hours of life. CONCLUSION: The level of uKIM-1 can be used as a simple noninvasive diagnostic method for predicting AKI and mortality, especially within 48 to 72 hours of life.Clinical trial registration: We do not have a clinical trial registration ID. In Turkey, clinical trial registration is not required for non-drug, noninvasive, clinical studies.

Diagnostic value of urine soluble triggering receptor expressed on myeloid cells (sTREM-1) for late-onset neonatal sepsis in infected preterm neonates.

Objective Sepsis is a complex clinical condition caused by a dysregulated immune response to an infection resulting in a fatal outcome. This study aimed to investigate the value of urine soluble triggering receptor expressed on myeloid cells (sTREM-1) for diagnosing culture-proven sepsis in preterm infants. Methods Preterm neonates were evaluated for late-onset sepsis (LOS). Laboratory investigations were performed. Urine sTREM-1 samples and blood cultures were synchronously collected. Using blood culture results, preterm neonates were divided into the culture-proven group and suspected sepsis group. Results A total of preterm 62 infants were included in the study; 31 had culture-proven sepsis and 31 were suspected as having sepsis. There were no significant differences in gestational age, sex, birth weight, and delivery mode between the groups. Neonates in the culture-proven group had significantly higher urine sTREM-1 levels than did those in the suspected sepsis group. Using a cut-off point for a urine sTREM-1 level of 78.5 pg/mL, the sensitivity was 0.90, specificity was 0.78, positive predictive value was 0.68, and negative predictive value was 0.94. Conclusions The present study highlights the role of urine sTREM-1 levels in LOS. Urine sTREM-1 may be a reliable and sensitive marker in detecting sepsis in preterm infants.

Impact of targeted-volume ventilation on pulmonary dynamics in preterm infants with respiratory distress syndrome.

BACKGROUND: Mechanical ventilation is an essential therapy in the treatment of respiratory failure in preterm infants. However, optimal ventilation strategy continues to be difficult to define. OBJECTIVE: To compare the effects of volume guarantee (VG) combined with intermittent mandatory ventilation (SIMV) and VG combined with pressure support ventilation (PSV) on the pulmonary mechanics and short term prognosis in preterm infants with respiratory distress syndrome. METHODS: Infants of <32 weeks gestational age ventilated for respiratory distress syndrome were randomized to receive either SIMV + VG or PSV + VG. The patient characteristics, ventilator variables including PIP, PEEP, MAP, VT, dynamic compliance, resistance, C20/C, and neonatal outcomes (IVH, ROP, oxygen dependency at 28th postnatal day and 36 weeks of PMA), mortality and extubation failure were recorded in each groups. RESULTS: Thirty-four infants were enrolled in to the study: 19 patients were randomized to the SIMV + VG group, and 15 patients to the PSV + VG group. No significant differences were observed between the two groups in terms of the birth weight, gestational age, gender, multiple pregnancy, delivery mode, and antenatal steroid treatment. The respiratory and ventilatory parameters were similar in the groups. The need for reintubation were common in SIMV + VG group (P < 0.01). CONCLUSIONS: Volume guaranteed ventilation combined with PSV may be a convenient method for preterm infants with RDS in terms of reducing postextubation atelectasis and the need for reintubation. Pediatr Pulmonol. 2017;52:213-216. © 2016 Wiley Periodicals, Inc.

Congenital Complete Tracheal Ring in a Neonate: A Case Report.

Abnormalities of the upper airway tract lead to congenital high airway obstruction and may complicate neonatal airway management in the delivery room. Congenital complete tracheal rings are a rare and unusual tracheal anomaly, usually presenting in the neonate or infant as respiratory distress. The clinical presentation can vary from almost asymptomatic patients to near-fatal airway obstruction. It may exist as an isolated entity, or in association with other congenital malformations, in particular, cardiac anomalies along with vascular rings and pulmonary slings. Other associated anomalies have also been reported, for example, chromosomal anomalies, malformation of other parts of the respiratory tract, esophagus and skeletal systems. Here, we report an extreme case of VACTERL/TACRD association presented with congenital complete tracheal ring, encephalocele, bilateral radial agenesis with absent thumbs, equinovalgus deformity on right foot, low-set ears and micrognathia.

Reference values of serum IgG and IgM levels in preterm and term newborns.

AIM: Although, variations of normal immunoglobulin (Ig) levels in different gestational age and birth weight groups have been studied so far, data are still limited in newborns, especially in preterm infants. The aim of this study was to determine serum IgG and IgM levels in newborns in order to generate a reference standard for neonatal intensive care unit (NICU) and address the variations in preterm babies. METHODS: This study was conducted from June 2012 to June 2013 in a level III NICU. A total of 300 newborn infants hospitalized within first 72 h were included in the study. The quantification of serum IgG and IgM was performed by nephelometric method. RESULTS: Both serum IgG and IgM levels were increased in correlation with increased gestational age and birth weight. CONCLUSION: The reference values of serum IgG and IgM levels should be further evaluated in larger series with the presented data in this article. In addition, preterm babies appear to have lower Ig levels thus carry the risk of relevant morbidity.

Congenital cutis marmorata telangiectatica and syndactyly in a preterm: case report.

Cutis marmorata telangiectatica congenita (CMTC) is a rare, commonly benign, congenital, localized or generalized vascular anomaly of unknown aetiology. It is characterized by persistent cutis marmorata, telangiectasia and phlebectasia. Extracutaneous findings may be associated with CMTC in 18.8-70% of the cases. Diagnosis of the disorder is based on the clinical findings. The prognosis is good and improvement is observed within 2 years after birth. Herein, we report a case of a male neonate with CMTC presented on the skin of all his limbs, trunk and face, and an associated anomaly including syndactyly. We present this case because of its rarity.

La piel marmórea telangiectásica congenita (cutis marmorata telangiectatica congenita, CMTC) es una anomalía vascular congenita rara, a menudo benigna, localizada o generalizada, de etiología desconocida. Se caracteriza por piel marmórea persistente, telangiectasia y flebectasia. Podrían presentarse manifestaciones extracutáneas asociadas con la CMTC en el 18,8-70% de los casos. El diagnóstico de este trastorno se basa en los hallazgos clínicos. El pronóstico es bueno y suele mejorar dentro de los dos años de vida. En este artículo presentamos el caso de un varón recien nacido con CMTC en la piel de todas las extremidades, el tronco y el rostro, y una anomalía asociada, que incluía sindactilia. Presentamos este caso debido a su rareza.

Surfactant treatment for neonatal respiratory disorders other than respiratory distress syndrome.

BACKGROUND: It is suggested that there may be expanded use of surfactant replacement for the neonatal diseases such as meconium aspiration syndrome (MAS), pneumonia and possibly bronchopulmonary dysplasia (BPD). OBJECTIVE: To evaluate the characteristics and short-term outcome of the neonates given exogenous surfactant because of the diseases other than respiratory disease syndrome (RDS). METHODS: This retrospective study included 35 neonates admitted to the neonatal intensive care unit from January 2012 to December 2012 for an expanded use of surfactant. Data related to gestational age, birth weight, gender and perinatal risk factors were obtained from the patients' records. The short-term prognosis was also noted. RESULTS: The diagnosis was sepsis in 16 patients, eight MAS, seven transient tachypnea of the newborns (TTN) and four BPD. Mean gestational age was 35.6 ± 4.5 weeks and mean birth weight was 2661 ± 981 g. Of overall cases, 65% were boys and 35% girls. The mortality rate was 17%. Of six fatal cases, three was with BPD, two with sepsis and one with MAS. CONCLUSION: We think that surfactant replacement may be life saver in the neonatal diseases other than RDS such as BPD, MAS and sepsis by rapidly improving oxygenation. Further investigation is necessary to validate the significance of expanded use of surfactant.

Is radiological appearance of lower respiratory tract infection due to respiratory syncytial virus a predictor of clinical outcome?

OBJECTIVE: Respiratory syncytial virus (RSV) lower respiratory tract infection is the most common viral infection in childhood. RSV-infected infants demonstrate various radiographic findings. The aim of the study is to evaluate whether assessment of radiological characteristics of lower tract infection due to RSV may be a predictor of clinical outcome in newborns. METHODS: The study included 36 newborn infants hospitalized for lower tract infection. In order to detect RSV, RSV Respi-Strip (Coris Bioconcept Organization) test kits were used on admission. Chest X-rays and clinical characteristics of the study group were reviewed. RESULTS: Of 36 patients hospitalized for lower tract infection from October 2012 to April 2013, 18 (50%) newborns were infected with RSV. The study included 36 neonates. Patients with RSV-positive infants at admission had greater need for respiratory support, supplemental oxygen and prolonged stay in the NICU. Newborns with an atelectasis pattern on admission chest radiograph had greater at RSV-positive infants. CONCLUSION: Chest radiological patterns with lower respiratory tract infection in newborn infants due to RSV are a predictor of clinical outcome.

The effect of topical ointment on neonatal sepsis in preterm infants.

OBJECTIVE: To investigate the effects of topical ointment therapy on neonatal sepsis in premature infants. METHODS: A total of 197 premature infants≤34 weeks gestation were randomized to receive topical ointment (Aquaphor Original Emollient) or routine skin care group. Skin cultures were obtained on 3th, 7th and 14th day and blood cultures were obtained if sepsis was suspected clinically. Data included the maternal and neonatal characteristics, factors affecting the risk of sepsis and neonatal outcomes of both groups were collected. RESULTS: There were no significant differences in terms of gestational age, birth weight, gender, mode of delivery, multiple pregnancy and receiving antenatal corticosteroids between the study and control group. No statistically significant difference was found in the prevalence of sepsis, in the positive skin culture rates at any follow-up and in terms of the neonatal morbidities including patent ductus arteriosus and necrotizing enterocolitis between the groups. Although the rate of death was higher in the topical ointment group, no statistically significant difference was found between the groups. CONCLUSIONS: Our data suggests that applying topical ointment during the first 2 postnatal weeks did not affect the risk of neonatal sepsis in preterm infants, although it changed the bacterial flora on the skin compare to the routine care group.