Early procalcitonin assays may reduce antibiotic exposure in premature newborn infants.

AIM: The diagnosis of early-onset neonatal sepsis (EOS) remains difficult. The main aim was to study the effect of a new algorithm for EOS, which includes the level of procalcitonin in umbilical cord blood, on the exposure to antibiotic therapy of premature newborn infants. METHODS: This was a monocentric, observational and retrospective study with before-and-after design. The duration and dose of antibiotic therapy provided as well as the morbidity and mortality were compared in two groups, one included 01 May 2015-30 November 2015 when procalcitonin was not used, and one after the change 01 November 2016-30 May 2017 when procalcitonin was used in a hospital setting in Nice, France. RESULTS: Sixty newborn infants were included in the before group and 54 in the after group. Antibiotic therapy was stopped after 24 h for 18 newborn infants in the after group and four in the before group, and after 48 h for 26 newborn infants in the after group and 10 in the before group. CONCLUSION: The implementation of a new decision-making algorithm including early procalcitonin assay of premature newborn infants significantly reduced exposure to antibiotics without modifying mortality or morbidity.

CARPEDIEM® for continuous kidney replacement therapy in neonates and small infants: a French multicenter retrospective study.

BACKGROUND: The Cardio-Renal Pediatric Dialysis Emergency Machine (CA.R.P.E.D.I.E.M.®) device is a continuous kidney replacement therapy (CKRT) equipment dedicated to neonates and small infants. This study aimed to assess the effectiveness, feasibility, outcomes, and technical considerations relating to CARPEDIEM® use. METHODS: This retrospective multicenter study included 19 newborns and six infants receiving CARPEDIEM® in five French pediatric and neonatal intensive care units. Laboratory parameters were collected at the initiation and end of the first CARPEDIEM® session. Results are presented as median [IQR] (range). RESULTS: At initiation, age was 4 days [2-13] (1-1134) with a body weight of 3.3 kg [2.5-4] (1.3-11.1). Overall, 131 sessions and 2125 h of treatment were performed. Treatment duration per patient was 42 h [24-91] (8-557). Continuous veno-venous hemofiltration (CVVH) was performed in 20 children. Blood flow rate was 8 mL/kg/min [6-9] (3-16). The effluent flow rate for CVVH was 74 mL/kg/h [43-99] (28-125) and net ultrafiltration (UF) 6 mL/kg/h [2-8] (1-12). In the five children treated by hemodialysis, the blood and dialysate flow rates were 6 mL/kg/min [5-7] (4-7) and 600 mL/h [300-600] (120-600), respectively, while session duration was 8 h [6-12] (2-24). Most infants required a catheter between 4.5 and 6.5 French. Hemodynamic instability with a need for volume replacement occurred in 31 sessions (23%). Thrombocytopenia was observed in 29 sessions (22%). No hemorrhage occurred; all the patients survived the sessions, but only eight patients (32%) were alive at hospital discharge. CONCLUSIONS: These data confirm that the use of CARPEDIEM® is safe and effective in critically ill neonates and infants. A higher resolution version of the Graphical abstract is available as Supplementary information.

Ultrasound-Guided Subclavian Vein Cannulation in Low Birth Weight Neonates.

OBJECTIVES: Central venous access in critically ill, small infants remains technically challenging even in experienced hands. Several vascular accesses exist, but the subclavian vein is often preferred for central venous catheter insertion in infants where abdominal malformation and/or closure of the vein preclude the use of umbilical venous catheters, as catheterization of the subclavian vein is easier in very short necks than the internal jugular vein for age-related anatomical reasons. The subclavian vein approach is yet relatively undescribed in low birth weight infants (i.e., < 2,500 g), and this study aims to explore the feasibility of this technique in very small infants. DESIGN: Retrospective data collection of prospectively registered data on central venous catheter insertion in infants. SETTING: Neonatal ICU and PICU at a university hospital. PATIENTS: One hundred and five newborn children hospitalized in at the ICU. INTERVENTIONS: An ultrasound-guided supraclavicular approach was applied on all infants who had an subclavian vein catheterization during a 30-month period from January 2013 to July 2015. MEASUREMENTS AND MAIN RESULTS: One hundred seven supraclavicular subclavian vein catheters were placed in 105 children weighing less than 5,000 g. Among those, 40 patients weighed less than 2,500 g and 10 patients weighed less than 1,500 g. Successful central venous catheter insertion, defined as the correct placement of a functional double-lumen catheter (3F or 4F), was obtained in 97.3%. All three registered failed attempts were due to hematomas from venous bleeding and occurred in infants weighing greater than 2,500 g. No case of accidental arterial puncture or pleural puncture was registered. CONCLUSIONS: This large series of subclavian vein catheterizations in small infants demonstrates the feasibility of subclavian vein catheterizations even in very small neonates weighing less than 1,500 g.

An evaluation of the association between lockdown during the SARS-CoV-2 pandemic and prematurity at the Nice University Hospital.

Aim: To study the association between lockdown in France due to the SARS-CoV-2 pandemic and premature births at the Nice University Hospital. Methods: Data concerning neonates born at the level III maternity of the Nice University Hospital and immediately hospitalised in the neonatal reanimation unit or the neonatology department of the hospital with their mothers between the 1st of January 2017 and the 31st of December 2020, included. Results: We did not find a significant decrease in the global number of premature births <37 weeks of gestation, in low weight at birth or a significant increase in stillbirths during lockdown compared to a period with no lockdown. The profiles of the mothers and their newborns were compared when birth occurred during lockdown vs. no lockdown. Conclusion: We did not find any evidence of an association between lockdown and prematurity at the Nice University Hospital. This result is in agreement with meta-analyses published in the medical literature. The possible decrease in factors of risk of prematurity during lockdown is controversial.

Early chloride intake does not parallel that of sodium in extremely-low-birth-weight infants and may impair neonatal outcomes.

BACKGROUND AND OBJECTIVE: Accurate data on the optimal chloride (Cl) intake in premature infants are scarce. The aim of the present study was to describe Cl intakes in the first 10 days of life and to assess the relations between high Cl intakes and corrected serum Cl level or markers of severe acidosis in infants <28 weeks' gestation. METHODS: Retrospective cohort study including all of the infants <28 weeks admitted to the neonatal intensive care unit during a 3-year period and cared for from birth until day 10 or more. RESULTS: Fifty-six infants were included. Cumulative total Cl intakes reached 9.6 ± 3.7 mmol/kg at day 3 and 49.2 ± 13.5 mmol/kg at day 10. Inadvertent intakes (from intravenous fluids other than parenteral nutrition) represented on average 70% of total Cl intakes in the first 3 days. Difference between Cl and sodium intakes reached 7.8 ± 4.8 mmol/kg at day 10 and mainly originated from parenteral nutrition. By multivariate analysis, cumulative Cl intake >10 mmol/kg during the first 3 days was an independent risk factor of base excess <-10 mmol/L. Cumulative Cl intake >45 mmol/kg during the first 10 days was an independent risk factor of corrected chloremia >115 mmol/L and of base excess <-10 mmol/L. CONCLUSIONS: Cumulative Cl intake >10 mmol/kg during the first 3 days (ie, 3.3 mmol · kg (-1) · day(-1) on average) and >45 mmol/kg during the first 10 days (ie, 4.5 mmol · kg (-1) · day(-1) on average) may have unwanted metabolic consequences and should be avoided. Imbalance between electrolytes provided by the parenteral nutrition solution need to be detected and corrected.

Procalcitonin in Preterm Neonates: A Different Threshold and Prolonged Interpretation.

Objectives: To evaluate the positive threshold of PCT for neonates of <32 weeks of gestation for the diagnosis of early-onset sepsis and to determine if the level of PCT collected within 6 h of life could be used. Design: Retrospective and bicentric study from May 2016 to April 2018. Setting: Two groups were established, neonates evaluated for PCT at birth (CordPCT) and within 6 h of life (delPCT). Patients: Two hundred and sixty neonates of <32 weeks of gestation born in Nice and South Paris (Bicêtre) University Hospitals, had been evaluated for PCT level. Main Outcomes Measures: The value of the PCT positive threshold was determined for the total population and each groups thanks ROC curves. Results: The threshold level of PCT for the total population was 0.98 ng/mL. The threshold value of cordPCT group was 1.00 vs. 0.98 ng/mL for delPCT group. The area under the Receiver Operating Characteristics curve for PCT sampled in delPCT group was significantly higher than in cordPCT group (0.94 compared to 0.75). Conclusions: The threshold level of PCT was higher in this cohort of neonates of <32 weeks of gestation compared to the value generally described for term neonates. The secondary sampling PCT level seems to be usable in screening algorithm for early-onset neonatal sepsis.

Enterobacteria vaginal colonization among patients with preterm premature rupture of membranes from 24 to 34 weeks of gestation and neonatal infection risk.

AIM: Premature rupture of membranes (PROM) increases the neonatal morbidity and mortality, because of its association with a high risk of prematurity and infection. The group B streptococcus (GBS) prophylaxis using amoxicillin doesn't seem to be adapted to the emergence of new bacteria found in vaginal samples (VS). Our study aim was to assess, for PROM occurring at 23-34 weeks' gestation (WG), if the presence of ampicillin-resistant enterobacteria in the vaginal microbiome is predictive of an increased risk of early-onset neonatal infection. MATERIAL AND METHODS: We conducted a prospective, observational, single-center study at the Nice Academic Hospital (level 3 maternity ward), between March 16, 2014 and May 3, 2015, that evaluated patients with preterm PROM (24-34 WG). Two groups were constituted according to the VS bacteria isolates and the amoxycillin-resistant enterobacteria found. Two groups of newborns were constituted depending on the suspicion of perinatal maternal-fetal bacterial infection (MFI). An intent-to-treat analysis was performed. RESULTS: Among the 67 patients included, 12 newborns presented a strong MFI suspicion, 83% of which were associated to the group of patients with untreated or amoxycillin-resistant enterobacteria VS isolates. CONCLUSION: Our study showed that vaginal colonization of untreated or amoxycillin-resistant enterobacteria constitutes a major risk factor of neonatal infection.

Sepsis risk factors in infants with congenital diaphragmatic hernia.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a rare congenital anomaly and remains among the most challenging ICU-managed disease. Beside severe pulmonary hypertension, lung hypoplasia and major abdominal surgery, infective complications remain major determinants of outcome. However, the specific incidence of sepsis as well as associated risk factors is unknown. METHODS: This prospective, 4-year observational study took place in the pediatric intensive care and neonatal medicine department of the Paris South University Hospitals (Le Kremlin-Bicêtre, France), CDH national referral center and involved 62 neonates with CDH. MAIN RESULTS: During their ICU stay, 28 patients (45%) developed 38 sepsis episodes. Ventilator-associated pneumonia (VAP: 23/38; 31.9 VAP per 1000 days of mechanical ventilation) and central line-associated blood stream infections (CLABSI: 5/38; 5.5 per 1000 line days) were the most frequently encountered infections. Multivariate analysis showed that gestational age at birth and intra-thoracic position of liver were significantly associated with the occurrence of sepsis. Infected patients had longer duration of mechanical and noninvasive ventilation (16.2 and 5.8 days, respectively), longer delay to first feeding (1.2 days) and a longer length of stay in ICU (23 days), but there was no difference in mortality. CONCLUSIONS: Healthcare-associated infections, and more specifically VAP, are the main infective threat in children with CDH. Sepsis has a significant impact on the duration of ventilator support and ICU length of stay but does not impact mortality. Low gestational age and intra-thoracic localization of the liver are two independent risk factors associated with sepsis.

Transcutaneous bilirubinometry is not influenced by term or skin color in neonates.

BACKGROUND: The utility of transcutaneous bilirubin measurements (TcB) in screening for hyperbilirubinemia in preterm infants (<34 weeks) and in non-white infants remains a matter of debate. AIM: To evaluate accuracy of TcB in preterm and term infants of different ethnic backgrounds, using a second generation bilirubinometer. STUDY DESIGN: The Draeger JM-103® device was used to measure TcB. Eighty five measurements of TcB and total serum bilirubin (TSB) were retrospectively compared. Neonates were stratified into groups according to gestational age: <34 weeks (group 1, n=44) and >34 weeks (group 2, n=41), and according to ethnic origin: Caucasians (group A, n=49) and non-Caucasians (group B, n=36). Statistical analysis, using Pearson's correlation coefficient (r) and Bland-Altman analysis were performed to evaluate correlation and agreement between TSB and TcB values. Multiple linear regression was used to control for confounders for TSB values. RESULTS: Correlation between TSB and TcB was high. Pearson's correlation coefficients were over 0.9 in all groups (0.910, 0.908, 0.916 and 0.934, p<0.0001 in groups 1, 2, A, and B respectively). Bland-Altman plots showed acceptable and close limits of agreements (56.8/-57.7, 54.2/-67.2, 57.7/-55.8, and 51.3/-69.9µmol/L in groups 1, 2, A and B respectively) with a trend for TcB to overestimate TSB in groups 2 and B. Birth term and skin color were not identified as confounding factors for predicting TSB in multiple linear regression. CONCLUSIONS: TcB measurements using the Draeger JM-103® device correlate significantly with TSB, regardless of term and skin color. Transcutaneous bilirubinometry seems to be a safe and cost-effective screening method for severe hyperbilirubinemia in newborns of different terms and ethnic origins.

Postnatal docosahexaenoic acid deficiency is an inevitable consequence of current recommendations and practice in preterm infants.

BACKGROUND: Very preterm infants are particularly susceptible to nutrient deficiencies. Although a lot of attention has been focused on the early nutrient supply, they are at high risk of long-chain polyunsaturated fatty acid deficiency. OBJECTIVES: To estimate docosahexaenoic acid (DHA) intake, the metabolizable (i.e. absorbed) DHA, the DHA available for accretion and to quantify the DHA deficit, if any, during the first month of life of preterm infants born ≤28 weeks of gestation. METHODS: Monocentric study. Nutritional data for the first 28 days of life were collected in 40 preterm infants born with a gestational age ≤28 weeks. RESULTS: The metabolizable DHA intake (i.e. parenteral DHA + absorbed DHA) during the 1st, 2nd, 3rd and 4th weeks of life increased significantly over time (p < 0.0001), but corresponded to 7, 21, 30 and 39% of the fetal DHA accretion rate, respectively. Assuming endogenous synthesis, all infants exhibited a severe DHA deficit which reached on average 661 ± 100 mg/kg, which represents at least half of the DHA that should have been accumulated. The DHA deficit was highly correlated with birth weight, demonstrating that the smaller the infant, the larger the DHA deficit. CONCLUSIONS: The current nutritional management of preterm infants is likely to lead to an early and severe DHA deficit which may represent, at 1 month of age, about half of the fetal DHA accumulation.