Neonatal Resuscitation Practices in Turkey: A Survey of the Turkish Neonatal Society and the Union of European Neonatal and Perinatal Societies.

OBJECTIVE: Optimal care in the delivery room is important to decrease neonatal morbidity and mortality. We aimed to evaluate neonatal resuscitation practices in Turkish centers. MATERIALS AND METHODS: A cross-sectional survey consisted of a 91-item questionnaire focused on delivery room practices in neonatal resuscitation and was sent to 50 Turkish centers. Hospitals with <2500 and those with ≥2500 births/year were compared. RESULTS: In 2018, approximately 240 000 births occurred at participating hospitals with a median of 2630 births/year. Participating hospitals were able to provide nasal continuous-positiveairway-pressure/high-flow nasal cannula, mechanical ventilation, high-frequency oscillatory ventilation, inhaled nitric oxide, and therapeutic hypothermia similarly. Antenatal counseling was routinely performed on parents at 56% of all centers. A resuscitation team was present at 72% of deliveries. Umbilical cord management for both term and preterm infants was similar between centers. The rate of delayed cord clamping was approximately 60% in term and late preterm infants. Thermal management for preterm infants (<32 weeks) was similar. Hospitals had appropriate equipment with similar rates of interventions and management, except conti nuous-positive-airway-pressure and positive-end-expiratory-pressure levels (cmH2O) used in preterm infants (P = .021, and P = .032). Ethical and educational aspects were also similar. CONCLUSIONS: This survey provided information on neonatal resuscitation practices in a sample of hospitals from all regions of Turkey and allowed us to see weaknesses in some fields. Although adherence to the guidelines was high among centers, further implementations are required in the areas of antenatal counseling, cord management, and circulation assessment in the delivery room.

Accidental ingestion of 3% hydrogen peroxide in the neonatal period.

Hydrogen peroxide (H2O2) is an oxidizing agent. High concentrations of H2O2 are used in the chemical industry, and 3% concentrations are used in household disinfectants. Severe H2O2 toxicity occurs with a 35% concentration. After poisoning with H2O2, corrosive damage occurs. We describe a 3-day-old male who ingested H2O2 accidentally and was treated with supportive care. Hydrogen peroxide intoxication usually occurs in adults accidentally. This is the first report of a newborn case of H2O2 ingestion.

Supraventricular tachycardia after respiratory syncytial virus infection in a newborn.

Respiratory syncytial virus (RSV) is a common cause of lower respiratory tract infections in newborn infants. RSV can cause cardiac arrhythmias. We present a case of a term newborn with supraventricular tachycardia that developed during RSV infection and was successfully treated with amiodarone. RSV infection increases the risk of cardiac arrhythmia due to its course and the agents used in the treatment; therefore, close cardiac monitoring is required.

Massive upper gastrointestinal bleeding due to a gastric ulcer in a newborn.

Usually, swallowing of maternal blood is the cause of bloody vomiting in healthy term newborns. Other reported causes include gastritis, esophagitis, gastric ulcer, and duodenal ulcer. We report a newborn girl born by cesarean at 372/7 weeks who had hematemesis on postnatal day 1 and hematochezia on day 2. An erythrocyte transfusion was given on day 3. Gastroscopy performed on day 4 showed multiple gastric ulcers. Antacid treatment was given. On day 12, the newborn had a good general condition and stable vital signs and was discharged. Gastric ulcer needs to be considered as the etiology of hematemesis in healthy term newborns.

Astaxanthin Reduces the Severity of Intestinal Damage in a Neonatal Rat Model of Necrotizing Enterocolitis.

OBJECTIVE: This study aimed to ascertain the effects of astaxanthin (ASX) in an experimental necrotizing enterocolitis (NEC) model using rat pups. STUDY DESIGN: Forty-two pups born from five Wistar albino rats were randomly divided into three groups as the control group, NEC + placebo (saline), and NEC + ASX. Pups in the NEC + ASX group were given 100 mg/kg/day oral ASX from day 1 to day 4 of the study. Saline of 2 mL/kg was given to the NEC + placebo group. Histopathological, immunohistochemical (caspase-3), and biochemical evaluations including the total antioxidant status (TAS), total oxidant status (TOS), superoxide dismutase (SOD), glutathione (GSH), lipid hydroperoxide (LPO), 8-hydroxydeoxyguanosine (8-OHdG), advanced oxidation protein products (AOPP), myeloperoxidase (MPO), tumor necrosis factor-α (TNF-α), interleukin-1ß (IL-1ß), and nuclear factor erythroid 2-related factor 2 (Nfr-2) activities were all performed. RESULTS: A better survival rate and weight gain were demonstrated in the NEC + ASX group (p < 0.05). In the histopathological evaluation, the severity of intestinal damage was significantly reduced in the NEC + ASX group, as well as decreased apoptosis (enzyme-linked immunosorbent assay [ELISA] for caspase-3; p = 0.001). The biochemical analyses of intestinal tissue TOS, oxidative stress index (OSI; TOS/TAS), IL-1ß, LPO, 8-OHdG, AOPP, caspase-3 (p < 0.001 for all), and TNF-α and MPO (p = 0.001 for both parameters) levels were lower in the NEC + ASX group than in the NEC + placebo group. Nrf-2, TAS, GSH, and SOD levels were higher in the NEC + ASX group than in the NEC + placebo group (p = 0.001, 0.001, <0.001, and 0.01, respectively). CONCLUSION: ASX treatment has been shown to effectively reduce the severity of intestinal damage in NEC due to its antioxidant, anti-inflammatory, and antiapoptotic properties. KEY POINTS: · NEC causes extremely high morbidity and mortality, as well as many complications.. · We investigated the effectiveness of ASX in the experimental NEC model created in rat pups.. · First study examining the effect of ASX on the experimental NEC rat model..

Signos vasculares retinianos en recién nacidos con cardiopatía congénita crítica: serie de casos / Retinovascular findings in newborns with critical congenital heart disease: A case series

La cardiopatia congènita crítica (CCC) podría provocar cambios en la vasculatura de la retina. Sin embargo, no se dispone de suficientes datos sobre este problema en los recién nacidos. Se evaluaron los cambios en la vasculatura retiniana en una serie de 43 recién nacidos con CCC. Se los dividió en dos grupos según el tipo de CCC; grupo 1 (n= 18): CCC obstructiva izquierda y grupo 2 (n= 25): CCC obstructiva derecha. Se detectaron enfermedades vasculares retinianas en 21 pacientes (48,8%); estas fueron más frecuentes en el grupo 1 (p= 0,04). La patología más común fue la tortuosidad vascular retiniana, observada en seis pacientes (33,3%) del grupo 1 y en 4 (16,0%) del grupo 2. Ninguno de los 21 pacientes con cambios en la vasculatura de la retina requirió tratamiento durante el seguimiento. En un análisis multivariado, solo la CCC obstructiva izquierda estuvo asociada con el desarrollo de enfermedad vascular retiniana (P= 0,03, razón de probabilidades --#91;OR--#93;: 2,8, intervalo de confianza --#91;IC--#93; del 95%: 1,1-7,4). Los cambios vasculares retinianos son frecuentes en los recién nacidos con CCC.

Critical congenital heart disease (CCHD) may cause changes in retinal vasculature. However, there is lack of data in this issue in newborns. We evaluated retinovascular changes in a series of 43 newborn with CCHD. They were divided into 2 groups according to the type of CCHD; group 1 (n= 18): left obstructive CCHD and group 2 (n= 25): right obstructive CCHD. Retinovascular pathologies were detected in 21 patients (48.8%); it was more frequent in group 1 (p= 0.04). The most common pathology was retinal vascular tortuosity in 6 patients (33.3%) of group 1, and 4 (16.0%) in group 2. None of 21 patients with retinovascular changes required any therapy at follow-up. In multivariate analysis, only having a left obstructive CCHD was associated with the development of any retinovascular pathology (P= 0.03, OR: 2.8, CI95%: 1.1-7.4). Retinovascular changes are frequent in newborn patients with CCHD.

Retinovascular findings in newborns with critical congenital heart disease: A case series. / Signos vasculares retinianos en recién nacidos con cardiopatía congénita crítica: serie de casos.

Critical congenital heart disease (CCHD) may cause changes in retinal vasculature. However, there is lack of data in this issue in newborns. We evaluated retinovascular changes in a series of 43 newborn with CCHD. They were divided into 2 groups according to the type of CCHD; group 1 (n= 18): left obstructive CCHD and group 2 (n= 25): right obstructive CCHD. Retinovascular pathologies were detected in 21 patients (48.8%); it was more frequent in group 1 (p= 0.04). The most common pathology was retinal vascular tortuosity in 6 patients (33.3%) of group 1, and 4 (16.0%) in group 2. None of 21 patients with retinovascular changes required any therapy at follow-up. In multivariate analysis, only having a left obstructive CCHD was associated with the development of any retinovascular pathology (P= 0.03, OR: 2.8, CI95%: 1.1-7.4). Retinovascular changes are frequent in newborn patients with CCHD.

La cardiopatia congènita crítica (CCC) podría provocar cambios en la vasculatura de la retina. Sin embargo, no se dispone de suficientes datos sobre este problema en los recién nacidos. Se evaluaron los cambios en la vasculatura retiniana en una serie de 43 recién nacidos con CCC. Se los dividió en dos grupos según el tipo de CCC; grupo 1 (n= 18): CCC obstructiva izquierda y grupo 2 (n= 25): CCC obstructiva derecha. Se detectaron enfermedades vasculares retinianas en 21 pacientes (48,8%); estas fueron más frecuentes en el grupo 1 (p= 0,04). La patología más común fue la tortuosidad vascular retiniana, observada en seis pacientes (33,3%) del grupo 1 y en 4 (16,0%) del grupo 2. Ninguno de los 21 pacientes con cambios en la vasculatura de la retina requirió tratamiento durante el seguimiento. En un análisis multivariado, solo la CCC obstructiva izquierda estuvo asociada con el desarrollo de enfermedad vascular retiniana (P= 0,03, razón de probabilidades [OR]: 2,8, intervalo de confianza [IC] del 95%: 1,1-7,4). Los cambios vasculares retinianos son frecuentes en los recién nacidos con CCC.

Umbilical cord asymmetric dimethylarginine levels and ultrasound assessment of carotid arteries in neonates born small for gestational age.

BACKGROUND: To examine asymmetric dimethylarginine (ADMA) level as an endothelial function parameter in addition to ultrasonographic evaluation of carotid arteries in babies born small for gestational age (SGA). METHODS: Twenty-six neonates born SGA and 34 appropriate for gestational age (AGA) controls were included in the study. The serum levels of ADMA were measured. Intima-media thickness (cIMT) and resistive index (cRI) of the both carotid arteries were determined by ultrasonography. RESULTS: The mean ADMA level was higher in SGA neonates compared to AGAs (16 267.7 ± 6050 versus 12 810.2 ± 3302 ng/L; p = 0.01). The mean cIMT (0.34 ± 0.02 versus 0.31 ± 0.03 mm; p = 0.001) and cRI (0.66 ± 0.07 versus 0.61 ± 0.04, p = 0.003) were also higher in SGAs. Serum ADMA levels were positively correlated to the mean cIMT (r = 0.41, p = 0.001). Although there was a weak correlation between cIMT and mean cRI (r = 0.26, p = 0.04), no correlation was found between ADMA and mean cRI (r = 0.17, p = 0.18). CONCLUSIONS: Neonates born SGA have elevated cord blood ADMA level in addition to thicker IMT and higher RI of carotid arteries at birth. ADMA was correlated to cIMT, suggesting that higher ADMA levels might influence vascular health in later life in these neonates.

May we use ibuprofen as doses against courses in the treatment of patent ductus arteriosus in premature infants?

OBJECTIVE: We aimed to investigate the efficacy of ibuprofen doses in closing patent ductus arteriosus (PDA) and the possibility of reducing drug-related complications by reducing dose number. METHODS: We performed a prospective study with 60 premature infants (≤33 weeks) who were treated with enteral ibuprofen for hsPDA. Echocardiographic examinations were performed before each dose. Treatment was stopped when PDA was closed and patients were followed for reopening and complications. RESULTS: Rates of closure were 28.3%, 44.1%, 54.1%, 36.3%, 42.8% and 50.0% with the 1st, 2nd, 3rd, 4th, 5th and 6th doses. No closure was observed with 7th, 8th and 9th doses. Reopening was observed only in patients whose PDA closed with the 1st (3.3%), 2nd (1.6%) and 3rd (1.6%) doses. PDA diameters were higher in patients who required >4 doses. Complications were rare (6.6%) but unrelated with dose number. CONCLUSIONS: We conclude that it is possible to minimize ibuprofen exposure and achieve high closure rates of PDA in premature infants by performing echocardiography before each dose. PDA diameter should be used to estimate the duration of treatment. This approach is not effective in reducing complication rates and must be performed in attention to reopening especially for the first three doses.

Rotura y desplazamiento de catéter arterial umbilical: obstrucción arterial bilateral en un prematuro de muy bajo peso al nacer / Rupture and displacement of umbilical arterial catheter: Bilateral arterial occlusion in a very low birth weight preterm

La canalización de los vasos umbilicales es un procedimiento frecuente en las unidades de cuidados intensivos neonatales, especialmente en los recién nacidos de muy bajo peso al nacer. Raras veces el catéter arterial umbilical se rompe; los fragmentos retenidos pueden provocar trombosis, infección, embolización distal e incluso la muerte. En este artículo, describimos el caso de un recién nacido con isquemia bilateral, clínicamente significativa, de las extremidades que se manifestó después de la extracción de un catéter arterial umbilical roto. Estaba recibiendo tratamiento vasodilatador junto con fibrinolíticos y anticoagulantes. La evolución fue favorable.

Umbilical vessel catheterization is a common procedure in Neonatal Intensive Care Units, especially in very low birthweight infants. Rarely, umbilical artery catheters break, and the retained fragments can cause thrombosis, infection, distal embolization, and even death. Herein, we describe a neonate with clinically significant bilateral limb ischemia developing after removal of a broken umbilical artery catheter. He was under vasodilator treatment in addition to fibrinolytic and anticoagulants. The evolution was favourable.

Rupture and displacement of umbilical arterial catheter: Bilateral arterial occlusion in a very low birth weight preterm.

Umbilical vessel catheterization is a common procedure in Neonatal Intensive Care Units, especially in very low birthweight infants. Rarely, umbilical artery catheters break, and the retained fragments can cause thrombosis, infection, distal embolization, and even death. Herein, we describe a neonate with clinically significant bilateral limb ischemia developing after removal of a broken umbilical artery catheter. He was under vasodilator treatment in addition to fibrinolytic and anticoagulants. The evolution was favourable.

The propre-save study: effects of probiotics and prebiotics alone or combined on necrotizing enterocolitis in very low birth weight infants.

OBJECTIVE: To test the efficacy of probiotic and prebiotic, alone or combined (synbiotic), on the prevention of necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants. STUDY DESIGN: A prospective, randomized, controlled trial was conducted at 5 neonatal intensive care units in Turkey. VLBW infants (n = 400) were assigned to a control group and 3 study groups that were given probiotic (Bifidobacterium lactis), prebiotic (inulin), or synbiotic (Bifidobacterium lactis plus inulin) added to breastmilk or formula for a maximum of 8 weeks before discharge or death. The primary outcome was NEC (Bell stage ≥2). RESULTS: The rate of NEC was lower in probiotic (2.0%) and synbiotic (4.0%) groups compared with prebiotic (12.0%) and placebo (18.0%) groups (P < .001). The times to reach full enteral feeding were faster (P < .001), the rates of clinical nosocomial sepsis were lower (P = .004), stays in the neonatal intensive care unit were shorter, (P = .002), and mortality rates were lower (P = .003) for infants receiving probiotics, prebiotics, or synbiotic than controls. The use of antenatal steroid (OR 0.5, 95% CI 0.3-0.9) and postnatal probiotic (alone or in synbiotic) (OR 0.5, 95% CI 0.2-0.8) decreased the risk of NEC, and maternal antibiotic exposure increased this risk (OR 1.9, 95% CI 1.1-3.6). CONCLUSIONS: In VLBW infants, probiotic (Bifidobacterium lactis) and synbiotic (Bifidobacterium lactis plus inulin) but not prebiotic (inulin) alone decrease NEC.

Is higher 25-hydroxyvitamin D level preventive for respiratory distress syndrome in preterm infants?

OBJECTIVE: The objective of this study was to investigate the relationship between cord blood 25-hydroxyvitamin D (25(OH)D) levels and respiratory distress syndrome (RDS) development in preterm infants. STUDY DESIGN: Between January 2012 and January 2013, 81 preterm infants, gestational age below 32 weeks, were prospectively enrolled into the study. Cord bloods of these newborns were tested for 25(OH)D levels. Low level was defined as ≤ 15 ng/mL (Group 1) and normal level as > 15 ng/mL (Group 2). Patients in Group 1 were also divided further into two subgroups as severe deficiency (Group 1a, ≤ 5 ng/mL) and mild deficiency (Group 1b, 5-15 ng/mL). RESULTS: In this study, 57 infants had low 25(OH)D levels (Group 1, median 8.0 ng/mL [interquartile range, IQR, 5-10]; Group 2, median 21 ng/mL [IQR, 19-24.7]). RDS rate was significantly higher in Group 1a (n = 18, 32.7%) and Group 1b (n = 34, 61.8%) compared with Group 2 (n = 3, 5.4%) (p = 0.001). There were no difference of having RDS between Group 1a (94.7%) and Group1b (89.5) (p = 0.512). Multivariate analysis showed that higher 25(OH)D level can be preventive for the development of RDS (odds ratio, 0.6; 95% confidence interval (0.5-0.8); p = 0.001). CONCLUSION: Lower cord blood 25(OH)D levels might be associated with increased risk of RDS in preterm infants with very low birth weight.

Effect of therapeutic hypothermia on C-reactive protein levels in patients with perinatal asphyxia.

OBJECTIVE: To determine the changes in serum C-reactive protein (CRP) levels during therapeutic hypothermia. STUDY DESIGN: Between January 2011 and June 2013, 133 hypoxic-ischemic encephalopathy patients being followed up in the neonatal intensive care unit of Dr. Sami Ulus Maternity and Children's Hospital are prospectively evaluated. Group 1; patients that received therapeutic hypothermia (n = 74) and group 2; patients that did not required therapeutic hypothermia (n = 59). All the patients underwent serial complete blood cell count and CRP assessments; blood cultures were obtained from all the cases at the time of admission and when CRP levels were elevated. RESULTS: Positive blood cultures were encountered in five cases (6.7%) in group 1 while no blood culture-proven septicemia was encountered in group 2. The CRP levels elevated gradually reaching a peak level on the 4th day and then decreased during the therapeutic hypothermia in patients with no blood culture-proven septicemia in group 1. The CRP levels showed statistically significant changes reaching a peak level on the 7th day in patients with blood culture-proven septicemia in group 2. Also, the CRP levels showed no alteration with time in group 2. CONCLUSION: Therapeutic hypothermia itself might be associated with CRP elevation rather than an actual infection.

Management of postoperative pulmonary hypertension by inhaled nitric oxide in a newborn with congenital diaphragmatic hernia.

Postero-lateral congenital diaphragmatic hernia (CDH) is a life threatening anomaly characterized by diaphragmatic defect and intrathoracic herniation of abdominal viscera. In patients with CDH, the lungs are hypoplastic and persistent pulmonary hypertension develops in most cases. Although, inhaled nitric oxide (iNO) results in a reduction in pulmonary hypertension with improvement in oxygenation, its benefit in the patients with CDH remains controversial. In this report, the authors present successful management of postoperative pulmonary hypertension by iNO in a newborn with CDH.

Surfactant for acute respiratory distress syndrome caused by near drowning in a newborn.

BACKGROUND: Near drowning is the term for survival after suffocation caused by submersion in water or another fluid. Pulmonary insufficiency may develop insidiously or suddenly because of near drowning. AIM: We want to present a newborn case of acute respiratory distress syndrome caused by near drowning. CASE: A 26-day-old boy was brought to the emergency department because of severe respiratory distress. Two hours before admission, the baby suddenly slipped out his mother's hands and fell in the bathtub full of water while bathing. After initial resuscitation, he was transferred to the neonatal intensive care unit for mechanical ventilation. PaO2/FIO2 ratio was 97, with SaO2 of 84%. Bilateral heterogeneous densities were seen on his chest x-ray film. The baby was considered to have acute respiratory distress syndrome. Antibiotics were given to prevent infection. Because conventional therapy failed to improve oxygenation, a single dose of surfactant was tested via an intubation cannula. Four hours later, poractant alfa (Curosurf) administered repeatedly at the same dosage because of hypoxemia (PaO2/FIO2 ratio, 124; SaO2, 88%). Oxygen saturation was increased to more than 90% in 24 hours, which was maintained for 3 days when we were able to wean him from mechanical ventilation. After 7 days, the x-ray film showed considerable clearing of shadows. He was discharged home on the 15th day after full recovery. CONCLUSIONS: This case report describes a rapid and persistent improvement after 2 doses of surfactant in acute respiratory distress syndrome with severe oxygenation failure caused by near drowning in a newborn.

The influence of fish-oil lipid emulsions on retinopathy of prematurity in very low birth weight infants: a randomized controlled trial.

OBJECTIVE: To compare the effect of two lipid emulsions on the development of retinopathy of prematurity in very low birth weight infants. DESIGN: Randomized controlled study. PATIENTS AND METHODS: Eighty very low birth weight infants receiving parenteral nutrition from the first day of life were evaluated. One of the two lipid emulsions were used in the study infants: Group 1 (n=40) received fish-oil based lipid emulsion (SmofLipid®) and Group 2 (n=40) soybean oil based lipid emulsion (Intralipid®). MAIN OUTCOME MEASURES: The development of retinopathy of prematurity and the need for laser photocoagulation were assessed. RESULTS: The maternal and perinatal characteristics were similar in both groups. The median (range) duration of parenteral nutrition [14days (10-28) vs 14 (10-21)] and hospitalization [34days (20-64) vs 34 (21-53)] did not differ between the groups. Laboratory data including complete blood count, triglyceride level, liver and kidney function tests recorded before and after parenteral nutrition also did not differ between the two groups. In Group 1, two patients (5.0%) and in Group 2, 13 patients (32.5%) were diagnosed with retinopathy of prematurity (OR: 9.1, 95% CI 1.9-43.8, p=0.004). One patient in each group needed laser photocoagulation, without significant difference. Multivariate analysis showed that only receiving fish-oil emulsion in parenteral nutrition decreased the risk of development of retinopathy of prematurity [OR: 0.76, 95% CI (0.06-0.911), p=0.04]. CONCLUSIONS: Premature infants with very low birth weight receiving an intravenous fat emulsion containing fish oil developed less retinopathy of prematurity.