Skin care practices in newborn nurseries and mother-baby units in Maryland.

OBJECTIVE: Skin provides several important homeostatic functions to the developing neonate. However, no consensus guidelines exist in the United States for skin care in the healthy term newborn. STUDY DESIGN: We performed a study of skin and umbilical cord care (including bathing practices, vernix removal and antiseptic cord application) in newborn nurseries and mother-baby units throughout the state of Maryland to determine practices in a variety of clinical settings and assess if uniformity in skin care exists. These data were then assessed in the context of a review of the current literature. RESULTS: We received responses from over 90% of nurseries across the state. In our cohort, practices varied widely between institutions and specific populations, and often were not evidence-based or were contrary to best practices discussed in the scientific literature. CONCLUSION: The frequent departures from evidence that occur regarding the aforementioned practices are likely due to a lack of consensus on these issues as well as limited data on such practices, further highlighting the need for data-driven guidelines on newborn skin care.

Low-dose ouabain protects against excitotoxic apoptosis and up-regulates nuclear Bcl-2 in vivo.

Sodium-potassium ATPase (Na+,K+-ATPase) regulates the electrochemical gradient in cells, thereby providing fluid and ionic homeostasis. Additionally, interaction of the Na+,K+ pump with cardiac glycosides can activate intracellular signaling cascades (resulting in cell growth) and up-regulate transcription factors that promote cell survival. We used an in vivo excitotoxicity model to assess if Na+,K+-ATPase plays a role in neuronal apoptosis. After unilateral, intrastriatal injection of the glutamate receptor agonist kainic acid into postnatal day 7 rats, Na+,K+ pump function was increased at 12 h after excitotoxic challenge, and levels of neuron-specific enzyme subunits were preserved (up to 24 h after injection) in membrane-enriched striatal fractions. In addition, co-injection of kainic acid with a low-dose (0.01 nmol) of the cardiac glycoside ouabain significantly (P<0.05) reduced striatal apoptosis (at 24 h post-injection) without diminishing Na+,K+-ATPase activity. To evaluate the possible mechanisms for this neuroprotection, we examined the levels of nuclear factor kappa B and Bcl-2 after cardiac glycoside exposure. Low-dose ouabain increased nuclear Bcl-2 (but not nuclear factor kappa B) protein levels at 6 h post injection. Our results suggest that Na+,K+-ATPase allows for progression of apoptosis in excitotoxically-injured neurons, and that sublethal concentrations of ouabain provide neuroprotection against excitotoxicity. The mechanism for this ouabain neuroprotection could be intracellular cascades linked to the Na+,K+-ATPase-ouabain interaction that modulate subcellular Bcl-2 levels. Targeted, therapeutic inhibition of apoptosis through cardiac glycosides may represent an effective strategy against excitotoxicity-mediated neuronal injury.

Failure to sustain recovery of Na,K-ATPase function is a possible mechanism for striatal neurodegeneration in hypoxic-ischemic newborn piglets.

Hypoxia-ischemia (HI) in the newborn can lead to a variety of sensorimotor abnormalities, including movement and posture disorders. Striatal neurons undergo necrosis after HI in piglets, but mechanisms for this neuronal death are not understood. We tested the hypothesis that Na,K-ATPase is defective in striatum early after HI. Piglets (1 week old) were subjected to 30 min hypoxia (arterial oxygen saturation 30%) and then 7 min of airway occlusion (oxygen saturation 5%), producing asphyxic cardiac arrest. Animals were resuscitated and recovered for 3, 6, 12, and 24 h, respectively. Neuronal necrosis in the striatum is progressive [14]. Na,K-ATPase activity (percent of control) was 60, 98, 51, and 54% at 3, 6, 12, and 24 h after HI, respectively. Intrastriatal differences in enzyme activity were detected histochemically, with the putamen showing greater loss of Na,K-ATPase activity than caudate after 12 h recovery. Immunoblotting showed that the levels of the alpha(3) isoform (localized exclusively to neurons) were 85, 115, 101, and 79% of sham control at 3, 6, 12, and 24 h, respectively. Levels of beta(1), the predominant beta isoform, were similar to alpha(3), while levels of the alpha(1) subunit, the catalytic isoform found in neurons and glia, were 182, 179, 226, and 153% at the same recovery times. We conclude that early inactivation of Na,K-ATPase function participates in the pathogenesis of striatal neuron necrosis, but that loss of enzyme function early after HI is not caused by depletion of composite alpha/beta subunits.

Case report: congenital rubella syndrome: a rare but persistent concern in the United States.

In countries such as the United States where rubella virus infections are rare, congenital rubella syndrome (CRS) may not be recognized in a timely manner. However, the syndrome still appears in this country, often in infants of mothers emigrating from countries with absent or suboptimal national vaccination programs. We describe a case of CRS in a term baby born to a recent US immigrant who developed a primary varicella infection in late pregnancy and demonstrated IgG titers to rubella at delivery. At presentation, the neonate had both classical findings as well as less reported vascular and neurological abnormalities seen in infants with CRS.

Underimmunization at discharge from the neonatal intensive care unit.

OBJECTIVE: The objectives of this study are to determine immunization rates at discharge from the neonatal intensive care unit (NICU) among infants 2 months of age and above and to evaluate risk factors for underimmunization. STUDY DESIGN: A retrospective cohort study was performed for infants in six NICUs in the Northern California Kaiser Permanente Medical Care Program. Immunization status at discharge was determined for all infants discharged on or after age 60 days. Logistic regression was used to identify risk factors for underimmunization at the time of discharge. RESULT: Of 668 infants discharged on or after age 60 days from the NICU, 51% were up-to-date for routine immunizations. Twenty-seven percent of infants had received no vaccines. Factors associated with higher immunization rates at discharge include history of mechanical ventilation, congenital heart disease and a diagnosis of apnea or bronchopulmonary dysplasia during the NICU stay, whereas surgery was associated with lower immunization rates. CONCLUSION: A significant proportion of infants discharged on or after 2 months of age in the NICU in this health system was unimmunized or underimmunized at discharge. Further efforts should be made to improve immunization rates prior to discharge.

Risk of fever and sepsis evaluations after routine immunizations in the neonatal intensive care unit.

OBJECTIVE: Premature infants can experience cardiorespiratory events such as apnea after immunization in the neonatal intensive care unit (NICU). These changes in clinical status may precipitate sepsis evaluations. This study evaluated whether sepsis evaluations are increased after immunizations in the NICU. STUDY DESIGN: We conducted a retrospective cohort study of infants older than 53 days who were vaccinated in the NICU at the KPMCP (Kaiser Permanente Medical Care Program). Chart reviews were carried out before and after all immunizations were administered and for all sepsis evaluations after age 53 days. The clinical characteristics of infants on the day before receiving a sepsis evaluation were compared between children undergoing post-immunization sepsis evaluations and children undergoing sepsis evaluation at other times. The incidence rate of sepsis evaluations in the post-immunization period was compared with the rate in a control time period not following immunization using Poisson regression. RESULT: A total of 490 infants met the inclusion criteria. The rate of fever was increased in the 24 h period after vaccination (2.3%, P<0.05). The incidence rate of sepsis evaluations was 40% lower after immunization than during the control period, although this was not statistically significant (P=0.09). Infants undergoing a sepsis evaluation after immunization were more likely to have an apneic, bradycardic or moderate-to-severe cardiorespiratory event in the day before the evaluation than were infants undergoing sepsis evaluations at other times (P<0.05). CONCLUSION: Despite an increase in fever and cardiorespiratory events after immunization in the NICU, routine vaccination was not associated with increased risk of receiving sepsis evaluations. Providers may be deferring immunizations until infants are clinically stable, or may have a higher threshold for initiating sepsis evaluations after immunization than at other times.