Disorders of the Umbilical Cord.

The umbilical cord, a vital conduit between the placenta and the fetus, loses much of its significance after birth. However, newborns can often present with various abnormalities of the umbilicus, such as benign granulomas or more serious lesions due to persistent remnants, many of which can change the normal course of cord separation and may be associated with significant morbidities if left unrecognized and uncorrected. Although not uncommon, sanguineous drainage from the umbilical stump can be quite alarming to new parents. Parental counseling regarding normal umbilical cord changes, as well as abnormal findings, such as discharge and skin changes, are important for the recognition and timely treatment of potentially significant umbilical cord disorders.

Biomarkers of hepatic injury and function in neonatal hypoxic ischemic encephalopathy and with therapeutic hypothermia.

Therapeutic hypothermia (TH) is now provided as standard care to infants with moderate-severe hypoxic ischemic encephalopathy (HIE). The role of TH in limiting neuronal injury is well recognized, but its effect on hepatic injury which occurs frequently in neonatal HIE is not known. Our objective was to characterize biomarkers of liver injury and function in the setting of neonatal HIE and to describe whether HIE severity and provision of TH influence these hepatic biomarkers. We performed a multicenter retrospective study and compared hepatic biomarkers obtained during the first postnatal week, according to the severity of HIE and whether treated with TH. Of a total of 361 infants with HIE, 223 (62%) received TH and 138 (38%) were managed at normal temperature. Most hepatic biomarkers and C-reactive protein (CRP) were significantly associated with the severity of HIE (p < 0.001). Infants treated with TH had lower peak alanine aminotransferase (ALT) concentrations (p = 0.025) and a delay in reaching peak CRP concentration (p < 0.001). CONCLUSION: We observed a significant association between the clinical grade of HIE and biomarkers of liver metabolism and function. Therapeutic hypothermia was associated with delayed CRP responses and with lower ALT concentrations and so may have the potential to modulate hepatic injury. What is Known: • Ischemic hepatic injury occurs frequently as a part of multiorgan dysfunction in infants with hypoxic ischemic encephalopathy (HIE). • The neuroprotective role of therapeutic hypothermia in management of infants with HIE is well recognized, but the potential hepato-protective effects of hypothermia are unclear. What is New/What this study adds: • Therapeutic hypothermia was associated with lower alanine aminotransferase and albumin concentrations and a delayed C-reactive protein (CRP) response and so may have the potential to modulate hepatic injury. • An elevated CRP concentration during the first postnatal week may be regarded as an expected finding in moderate and severe HIE and, in the overwhelming majority of cases, occurs secondary to hepatic hypoxia-ischemia in the absence of blood culture-positive sepsis.

Premedication Use Before Nonemergent Intubation in the Newborn Infant.

OBJECTIVE: In 2010, an American Academy of Pediatrics (AAP) clinical report recommended that except for emergent situations, premedication should be used for all endotracheal intubations in newborns. The purpose of this study is to ascertain the current practice of premedication before elective intubation. STUDY DESIGN: An online, survey-based questionnaire on the practice of premedication before nonemergent intubations was distributed via e-mail to neonatologists who are members of the Perinatal Section of the AAP. RESULTS: Although 72% of respondents believed premedication should be used in nonemergent intubations, only 34% of the respondents report frequently premedicating before intubation with significant variation among the neonatal units (46% among level 4 units and 27% in level 3 and 2 units) p = 0.000. About 44% of respondents report having a written protocol or guideline on premedication which significantly correlated with the use of premedication (62% in level 4, 33% in level 3, and 16% in level 2 units), p = 0.000. CONCLUSION: Despite a recent AAP clinical report recommending the use of premedication before nonemergent endotracheal intubation, only one-third of neonatologists report frequent use of premedication and less than half of the institutions have a written protocol on premedication.

Implementation of ESC QI Initiative in Neonatal Unit Setting and Adaptation During the Pandemic.

OBJECTIVES: To improve outcomes in infants with neonatal opioid withdrawal syndrome (NOWS) admitted to NICU by implementing a quality improvement (QI) initiative incorporating "eat, sleep, console" (ESC) as a withdrawal evaluation tool and promotion of nonpharmacological interventions. Secondarily, we evaluated the impact of the coronavirus disease 2019 pandemic on QI initiative and outcomes. METHODS: We included infants born ≥ 36 weeks gestation and admitted to NICU with a primary diagnosis of NOWS between December 2017 and February 2021. (preintervention; December 2017-January 2019, postintervention; February 2019-February 2021). We compared cumulative dose, duration of opioid treatment, and length of stay (LOS) as our primary outcomes. RESULTS: The average duration of opioid treatment decreased from 18.6 days in the preimplementation cohort (n = 36) to 1.5 days in the first-year postimplementation (n = 44) with a reduction in cumulative opioid dose from 5.8 mg/kg to 0.6 mg/kg and decrease in the proportion of infants treated with opioids from 94.2% to 41.1%. Similarly, the average LOS decreased from 26.6 to 7.6 days. In the second-year postimplementation during the coronavirus disease 2019 pandemic (n = 24), there was an increase in average opioid treatment duration and LOS to 5.1 and 12.3 days respectively, but cumulative opioid dose (0.8 mg/kg) remained significantly lower than the preimplementation cohort. CONCLUSIONS: ESC-based quality improvement initiative led to a significant decrease in LOS and opioid pharmacotherapy in infants with NOWS in NICU setting. Despite the impact of the pandemic, some of the gains were sustained with adaptation to ESC QI initiative.

Cardiac troponin I concentrations in neonates with hypoxic-ischaemic encephalopathy.

AIM: Myocardial dysfunction is a frequent sequel of perinatal asphyxia. Cardiac troponin I (cTnI) is a marker of myocardial injury and a surrogate marker of myocardial dysfunction in adults, but there are few data in neonates. Our aim was to compare serum cTnI concentrations with clinical severity of encephalopathy and with duration of inotropic support in asphyxiated neonates. METHODS: Retrospective study of 60 neonates admitted with hypoxic-ischaemic encephalopathy (HIE). cTnI concentrations measured within 36 h of birth were compared with clinical grade of HIE (Sarnat-Sarnat classification) and with duration of inotropic support. RESULTS: Serum cTnI concentrations and duration of inotropic support were significantly greater with increasing severity of HIE. Median (95% CI) cTnI concentrations were 0.04 µg/L (0.02-0.07 µg/L) in grade 1 HIE, 0.12 µg/L (0.08-0.20 µg/L) in grade 2 HIE and 0.67 µg/L (0.41-1.35 µg/L) in grade 3 HIE. Median (95% CI) duration of inotropic support required was 0 h (0-24 h) in grade 1 HIE, 28 h (0-118 h) in grade 2 HIE and 48 h (0-140 h) in grade 3 HIE. CONCLUSION: In asphyxiated neonates, cTnI concentrations within 36 h of birth correlate strongly with clinical grade of HIE and with duration of inotropic support. Early cTnI concentrations may provide a useful proxy marker for the anticipated severity of myocardial dysfunction.

Successful ultrasound guided percutaneous drainage of pneumatocele in an extremely preterm infant.

Pneumatoceles are air filled, thin-walled cystic lesions with in the lung parenchyma that occur infrequently in neonates and infants, often as a complication of positive pressure ventilation, air leak syndrome or ventilator associated pneumonia. Whilst majority of pneumatoceles regress spontaneously over days to weeks, few large pneumatoceles may lead to acute cardiorespiratory insufficiency and may require drainage under computerized tomography or fluoroscopic guidance. We present a case report of an unstable extreme preterm infant with a large pneumatocele and respiratory failure, that was treated successfully by drainage under bedside ultrasound guidance.

A systematic review and meta-analysis of gestational diabetes mellitus and mental health among BAME populations.

BACKGROUND: Gestational diabetes mellitus (GDM) is a common complication of pregnancy and is associated with an increased risk of mental health (MH) disorders including antenatal and postnatal depression (PND), anxiety and post-traumatic-stress-disorder (PTSD). We hypothesized GDM and MH disorders will disproportionately affect individuals from Black, Asian and Minority Ethnic backgrounds. METHODS: A systematic methodology was developed, and a protocol was published in PROSPERO (CRD42020210863) and a systematic review of publications between 1st January 1990 and 30th January 2021 was conducted. Multiple electronic databases were explored using keywords and MeSH terms. The finalised dataset was analysed using statistical methods such as random-effect models, subgroup analysis and sensitivity analysis. These were used to determine odds ratio (OR) and 95% confidence intervals (CI) to establish prevalence using variables of PND, anxiety, PTSD and stress to name a few. FINDINGS: Sixty studies were finalised from the 20,040 data pool. Forty-six studies were included systematically with 14 used to meta-analyze GDM and MH outcomes. A second meta-analysis was conducted using 7 studies to determine GDM risk among Black, Asian and Minority Ethnic women with pre-existing MH disorders. The results indicate an increased risk with pooled adjusted OR for both reflected at 1.23, 95% CI of 1.00-1.50 and 1.29, 95% CI of 1.11-1.50 respectively. INTERPRETATION: The available studies suggest a MH sequalae with GDM as well as a sequalae of GDM with MH among Black, Asian and Minority Ethnic populations. Our findings warrant further future exploration to better manage these patients. FUNDING: Not applicable.

A Review on Non-invasive Respiratory Support for Management of Respiratory Distress in Extremely Preterm Infants.

Majority of extremely preterm infants require positive pressure ventilatory support at the time of delivery or during the transitional period. Most of these infants present with respiratory distress (RD) and continue to require significant respiratory support in the neonatal intensive care unit (NICU). Bronchopulmonary dysplasia (BPD) remains as one of the major morbidities among survivors of the extremely preterm infants. BPD is associated with long-term adverse pulmonary and neurological outcomes. Invasive mechanical ventilation (IMV) and supplemental oxygen are two major risk factors for the development of BPD. Non-invasive ventilation (NIV) has been shown to decrease the need for IMV and reduce the risk of BPD when compared to IMV. This article reviews respiratory management with current NIV support strategies in extremely preterm infants both in delivery room as well as in the NICU and discusses the evidence to support commonly used NIV modes including nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), bi-level positive pressure (BI-PAP), high flow nasal cannula (HFNC), and newer NIV strategies currently being studied including, nasal high frequency ventilation (NHFV) and non-invasive neutrally adjusted ventilatory assist (NIV-NAVA). Randomized, clinical trials have shown that early NIPPV is superior to NCPAP to decrease the need for intubation and IMV in preterm infants with RD. It is also important to understand that selection of the device used to deliver NIPPV has a significant impact on its success. Ventilator generated NIPPV results in significantly lower rates of extubation failures when compared to Bi-PAP. Future studies should address synchronized NIPPV including NIV-NAVA and early rescue use of NHFV in the respiratory management of extremely preterm infants.

Parental perceptions of the impact of neonatal unit visitation policies during COVID-19 pandemic.

OBJECTIVES: To ascertain parental perceptions of the impact of restricted visiting policies to neonatal intensive care units during the current COVID-19 pandemic. DESIGN: Cross-sectional survey of parents impacted by visitation policies. SETTING: Six tertiary level neonatal units, four from the UK and two from the USA, participated in the study. PARTICIPANTS: Parents and families of infants hospitalised in the participating centres between 1 May 2020 and 21 August 2020. METHODS: Online-based and/or paper-based survey, querying the visitation policies and their impact on parents' ability to visit, care for and bond with their infants. RESULTS: A total of 231 responses were received. Visitation limited to a single visitor with no restrictions on duration was the most frequently reported policy; 140/217 (63%). Visitation policies were perceived as being restrictive by 62% (138/219) of the respondents with 37% (80/216) reporting being able to visit less often than desired, 41% (78/191) reporting being unable to bond enough and 27% (51/191) reporting not being able to participate in their baby's daily care. Mild to severe impact on breast feeding was reported by 36% (75/209) of respondents. Stricter policies had a higher impact on families and were significantly associated with a lack of bonding time, inability to participate in care and an adverse impact on breast feeding. CONCLUSIONS: Visitation policies during the COVID-19 pandemic varied between centres and over time with stricter restrictions implemented earlier on in the pandemic. Parents reported significant impacts on their ability to visit, care for and bond with their infants with perceived severity of impact worse with stricter restrictions.

Evaluation of Oxygen Saturation Index Compared With Oxygenation Index in Neonates With Hypoxemic Respiratory Failure.

Importance: Oxygenation index (OI), an invasive measurement, is routinely used as a marker of severity of hypoxemic respiratory failure in neonates. Oxygen saturation index (OSI) is a noninvasive measurement and has been shown to be a reliable surrogate marker of OI in children and adults with respiratory failure. Objectives: To evaluate the correlation of OI with OSI and to derive and validate predictive OI from noninvasive OSI measurements for clinically relevant OI values. Design, Setting, and Participants: For this retrospective cohort study, 220 neonates requiring invasive mechanical ventilation for hypoxic respiratory failure during the first 3 days of admission were recruited from a level III neonatal intensive care unit during a 6-year period, from January 1, 2012, to December 31, 2017. Data were analyzed from January 2017 to December 2017. Main Outcomes and Measures: The primary outcome was correlation of OI with OSI, analyzed using Pearson correlation coefficient. The secondary outcome was derivation and validation of OI from OSI. The data were split into derivative samples, from which a predictive equation for OI was derived using generalized linear model, and a validation sample was used to assess the predictive ability of the derived OI. Bland-Altman plot was used to assess agreement between derived OI and measured OI. Results: A total of 1442 paired OI and OSI measurements from 220 infants (190 preterm and 30 term; median [interquartile range] gestational age, 29 [26-33] weeks; mean [SD] birth weight, 1602 [1092] g) were recorded during the study. The median (interquartile range) number of samples was 5 (3-9) per patient. Overall, OI and OSI showed strong correlation (r = 0.89). The correlation was stronger in preterm infants (<28 weeks, r = 0.93; 28-33 weeks, r = 0.93) and within an oxygen saturation range of 85% to 95% (r = 0.94). The predictive derivative equation showed a strong linear association and good agreement in both derivation and validation data sets, with strong accuracy measures of derived OI for OI cutoffs of 5, 10, 15, 20, and 25. Conclusions and Relevance: A strong correlation of OI with OSI was found. Derived OI from OSI was in good agreement and strongly predictive of clinically relevant OI cutoffs from 5 to 25. Oxygenation index derived from noninvasive sources may be useful to reliably assess severity of respiratory failure and response to therapy on a continuous basis.

Medicolegal cases involving periviable births from a major United States legal database.

OBJECTIVE: The management of expectant mothers and infants born at the threshold of viability is challenging. We describe medicolegal cases from a major United States legal database involving periviable births in an effort to identify areas for improvement. STUDY DESIGN: We conducted a retrospective review of all United States state and federal cases in the Westlaw database from 1980 through 2016 involving peripartum and immediate post-delivery management of infants born between 22 0/7 and 25 6/7 weeks' gestation. RESULTS: Our search criteria returned 736 results, and 15 cases met full inclusion criteria. Eight cases involved conflicts on resuscitation contrary to parental directives. Eleven cases comprised alleged miscommunication between families and providers. Of these, seven cases alleged inadequate prenatal counseling of infant's chances of survival and neurological outcome, whilst four cases alleged miscommunication of infant's condition post-delivery. CONCLUSIONS: Miscommunication between providers and families during prenatal counseling and after birth was a major component of malpractice cases regarding infants born at the threshold of viability. The infant's immediate post-delivery condition and long term prognosis were of primary interest to parents, and improving effective communication may aid toward more genuinely informed resuscitation directives.