Efficacy of bowel ultrasound to diagnose necrotizing enterocolitis in extremely low birthweight infants.

BACKGROUND: Bowel ultrasound (US) is one of the methods used to enhance diagnostic accuracy of necrotizing enterocolitis (NEC) and its associated complications in premature newborns. AIM: To explore the diagnostic accuracy of BUS in extremely low birth weight (ELBW) infants with NEC. METHODS: A single-center retrospective case-control study included 84 extremely low birth weight (ELBW) infants. The infants were divided into three groups: Group 1 -infants with NEC (n = 26); Group 2 -infants with feeding problems (n = 28); Group 3 -control group (n = 30). RESULTS: The specific BUS findings in premature newborns with NEC (stage 3) included bowel wall thinning, complex (echogenic) ascites, and pneumoperitoneum, p <  0.05. The diagnostic effectiveness of these sonographic signs was 96.8% (sensitivity 75.0% and specificity 97.6%), p <  0.05. These findings with high specificity were associated with the need for surgical intervention, poor outcomes, or increased mortality. Stage 2 NEC which did not require surgery showed impaired differentiation of the bowel wall layers, absent or decreased bowel peristalsis, pneumatosis intestinalis, portal venous gas, or simple ascites, with a diagnostic accuracy of 82.9% (sensitivity 55.6%, specificity 91.4%, p <  0.05). CONCLUSIONS: BUS can be used as an adjunct to abdominal radiography to aid in the diagnosis of infants with suspected NEC by providing more detailed evaluation of the intestine.

Multiple vascular malformations in a newborn.

We describe the case of a term newborn who presented with congenital testicular torsion at 10 hours of age. During the evaluation of this problem, additional malformations were encountered. Diagnostic and therapeutic considerations are addressed.

Recurrent late-onset neonatal sepsis traced to breast milk: A case report.

Breast milk feeding is an important late-onset sepsis reduction strategy in the Neonatal Intensive Care Unit (NICU). However, multiple studies have reported transfer of bacteria-contaminated breast milk to infants. We describe a case of culture-positive breast milk resulting in persistent Enterococcus bacteremia in an infant. Beyond the development of an infant's innate and specific immunity as well as colonization of the gastrointestinal (GI) tract with commensal organisms, the risk of bacterial translocation from the GI tract into the bloodstream is shaped and modified by maternal health, birth history, and an infant's NICU course. While freezing and/or pasteurizing breast milk reduces or eliminates its bacterial load, it also diminishes its immunologic and nutritional benefits.

The challenging airway: Tracheal agenesis in the newborn.

A preterm female presented with severe respiratory distress in the delivery room and was found to have tracheal agenesis with a tracheoesophageal fistula and a congenital heart defect. Tracheal agenesis is uncommon and is often associated with other congenital abnormalities. Although there are surgical options for repair, mortality remains high.

Rescue high frequency ventilation for congenital diaphragmatic hernia.

INTRODUCTION: High frequency jet (HFJV) and oscillatory (HFOV) ventilation were used to rescue newborns with congenital diaphragmatic hernia (CDH), who failed conventional mechanical ventilation (CV). Changes in ventilator settings and pulmonary gas exchange were evaluated following transition to high frequency ventilation (HFV). METHODS: Records of patients with CDH rescued with HFV prior to surgical intervention between 2006 and 2015 were reviewed. Mean airway pressure (Paw) and arterial blood gases during CV and those obtained within the first hour of HFV were compared. A composite repeated measure analysis was performed to evaluate longitudinal and intergroup variances. RESULTS: Twenty-seven patients were rescued from CV, 16 by HFJV and 11 by HFOV. The two groups had similar gestational ages and birth weights. Prior to HFV, both groups had similar Paw, PaCO2, FiO2 and PaO2. HFV was associated with a significant improvement in ventilation, and the rate of decrease of PaCO2 was no different between groups. There was a significantly higher increase in Paw increase with HFOV compared to HFJV. CONCLUSIONS: In newborns with CDH rescued with HFV, ventilation improved but Paw was significantly lower in patients supported with HFJV compared to HFOV.

Should amplitude-integrated electroencephalography be used to identify infants suitable for hypothermic neuroprotection?

OBJECTIVE: Amplitude-integrated electroencephalography (aEEG) has been used adjunctively to identify infants suitable for hypothermic neuroprotection following severe intrapartum asphyxia. To determine whether an early aEEG predicts short-term adverse outcome in infants with significant hypoxic-ischemic encephalopathy (HIE) evaluated for hypothermic neuroprotection. STUDY DESIGN: The aEEG recordings were obtained within 6 h of birth in infants >or=36 weeks' gestational age during evaluation for possible selective head or whole-body cooling. Recordings were subsequently re-evaluated for both background pattern and voltage abnormalities by a certified reader masked to clinical history and brain-oriented interventions. All infants with moderate or severe HIE evaluated for hypothermic neuroprotection also underwent magnetic resonance imaging (MRI) of the brain at a median postnatal age of 7 days. The predictive value using the aEEG for determining short-term dichotomous outcomes, defined as early death related to HIE, or a characteristic pattern of abnormalities consistent with hypoxic-ischemic injury on the MRI brain scans was assessed. RESULT: Fifty-four infants with moderate or severe HIE were evaluated with aEEG for hypothermic neuroprotection; 34 infants received selective head cooling, 12 infants underwent total body cooling and 8 infants were not cooled. Outcome data, available for 46 of the 54 infants, revealed a poor correlation between the early aEEG and short-term adverse outcomes, with a sensitivity of 54.8% and negative predictive value (NPV) of only 44%. CONCLUSION: Because of the poor NPV of an early aEEG for a short-term adverse outcome, its use as an 'additional selection criterion' for hypothermic neuroprotection may not be appropriate.

Medico-legal implications of hypothermic neuroprotection in the newborn.

Hypoxic-ischemic encephalopathy (HIE) continues to be a significant source of long term neurological sequelae in infants born at or near term. In the past decade, selective head or whole body cooling has shown promising benefit in ameliorating some of the brain injury from intrapartum asphyxial insults and has become standard care in most developed countries. A decision to offer neuroprotective hypothermia (NPH) may engender subsequent litigation because it presupposes an acute intrapartum injury. Conversely, failing to offer cooling may be interpreted as a violation in the standard of care. In this paper, we review the clinical aspects of NPH and the medico-legal scenarios often seen after acute birth injury.

Is refractory hypotension in preterm infants a manifestation of early ductal shunting?

BACKGROUND: Clinicians frequently use hydrocortisone (HC) to treat vasopressor-resistant hypotension even before establishing its cause. OBJECTIVE: To identify the etiologic factors leading to development of refractory hypotension, and to assess if patent ductus arteriosus (PDA) is associated with refractory hypotension during the first week of life. STUDY DESIGN: The medical records of 290 consecutively born infants

Minimising ventilator induced lung injury in preterm infants.

Ventilator induced lung injury continues to occur at an unacceptably high rate, which is inversely related to gestational age. Although the "new BPD" may not be entirely avoidable in the extremely premature infant, recognition of risk factors and adoption of an appropriate ventilatory strategy, along with continuous real time monitoring, may help to minimise lung damage. This paper will review the pathogenesis of ventilator induced lung injury and strategies that may mitigate it.

Management of neonatal abstinence syndrome in neonatal intensive care units: a national survey.

AIMS: To determine the monitoring and treatment of neonatal abstinence syndrome (NAS) in neonatal intensive care units (NICUs) following opiate or polydrug exposure in utero. METHODS: A pretested questionnaire was distributed via email to the chiefs of the neonatology divisions with accredited Fellowship programs in Neonatal-Perinatal Medicine in the United States. RESULTS: Of the 102 individuals contacted, 75 participated in the survey. In all, 41 of the respondents (54.5%) have a written policy regarding the management of neonatal NAS. The method of Finnegan is the most commonly used abstinence scoring system (49 of 75, 65%), while only three respondents use the Lipsitz tool. Opioids (tincture of opium, or morphine sulfate solution) are used most commonly for management of both opioid (63% of respondents) and polydrug (52% of respondents) withdrawal, followed by phenobarbital (32 % of respondents) for polydrug withdrawal and methadone (20% of respondents) for opioid withdrawal. In all, 53 respondents (70%) use phenobarbital, and 19 (25%) use intravenous morphine to control opioid withdrawal seizures, while 61 (81%) use phenobarbital in cases of polydrug withdrawal seizures. Only 53 respondents (70%) always use an abstinence scoring system to determine when to start, titrate, or terminate pharmacologic treatment of neonatal NAS. CONCLUSION: The management of neonatal psychomotor behavior consistent with withdrawal varies widely, with inconsistent policies to determine its presence or treatment. Only about half of NICUs have written guidelines for the management of NAS, which may preclude effective auditing of this practice. Educational interventions may be necessary to ensure changes in clinical practice.

Can neutrophil responses in very low birth weight infants predict the organisms responsible for late-onset bacterial or fungal sepsis?

OBJECTIVE: To examine neutrophil counts and various neutrophil indices in preterm very low birth weight (VLBW) newborn infants (birth weight <1500 g) with culture-proven late-onset sepsis to determine whether the neutrophil responses could predict the responsible infectious agent. STUDY DESIGN: Neutrophil parameters were examined during episodes of culture-proven sepsis in a cohort of 1026 VLBW infants, born over a 6-year period and admitted to two different neonatal intensive care units. Revised reference ranges of Mouzinho et al. for circulating neutrophil counts in VLBW infants were used to define the abnormal neutrophil indices. RESULTS: One hundred sixty-two of 1026 (15.8%) VLBW infants had blood culture-proven late-onset infection. Infections included Gram-positive bacteria (113/162, 70%), Gram-negative bacteria (30/162, 18%) and fungi (19/162, 12%). Of the 162 sepsis episodes, only nine (5.5%) were associated with neutropenia (absolute total neutrophil (ATN) <1100/mm3). Six of the 30 (20%) infants with Gram-negative bacterial sepsis were neutropenic compared to 2.6% infants with Gram-positive bacterial sepsis and none with fungal sepsis (odds ratio: 11; 95% confidence interval: 2.6, 47.3). Neutrophil counts and various neutrophil indices were similar in infants with late-onset Gram-positive bacterial and fungal sepsis; but total white blood cells, and ATN count were significantly lower (P = 0.004 and 0.001, respectively) in infants with late-onset Gram-negative bacterial sepsis. CONCLUSIONS: In VLBW infants, common organisms causing infection have different effects on neutrophil responses. Occurrence of neutropenia during evaluation of sepsis in sick VLBW infants is more common with Gram-negative bacterial infection.

Are newborns receiving premedication before elective intubation?

AIMS: To determine the extent and type of premedication used for elective endotracheal intubation in neonatal intensive care units (NICUs). METHODS: A pretested questionnaire was distributed via e-mail to the program directors of the neonatology divisions with accredited fellowship programs in Neonatal-Perinatal Medicine in the United States. RESULTS: Of the 100 individuals contacted, 78 (78%) participated in the survey. Only 34 of the 78 respondents (43.6%) always use any premedication for elective intubation. Nineteen respondents (24.4%) reported to have a written policy regarding premedication. Morphine or fentanyl was used most commonly (57.1%), with a combination of opioids and midazolam or other benzodiazepines used less frequently. Fourteen respondents (25%) also use muscle relaxants with sedation for premedication, but only nine respondents combined paralysis with atropine and sedation. CONCLUSION: Most neonatology fellowship program directors do not report always using premedication for newborns before elective endotracheal intubation despite strong evidence of physiologic and practical benefits. Only a minority of the NICUs has written guidelines for sedation, which may preclude effective auditing of this practice. Educational interventions may be necessary to ensure changes in clinical practice.

Impact of warmed inhaled gas from the mechanical ventilator on esophageal temperature during therapeutic whole body hypothermia.

OBJECTIVE: During therapeutic whole body cooling (WBC), the core temperature is usually monitored with an esophageal probe. Most infants receive mechanical ventilation while being cooled. As the temperature in the esophagus responds rapidly to changes in the ambient temperature, inhalation of warmed gas from ventilator may lead to overestimation of ventilated patients' actual temperature, causing automated cooling devices to overcool patients well below the desired set temperature targets. To determine if the esophageal temperature recordings during therapeutic WBC differ between ventilated and non-ventilated infants. STUDY DESIGN: Twenty-two consecutively cooled infants had simultaneous esophageal and rectal temperatures recorded every 4 h during 72 h of WBC. Other clinical monitoring and treatment during hypothermia were provided under an established protocol. RESULTS: Fourteen infants received mechanical ventilation throughout the duration of cooling. The remaining eight infants were initially ventilated but were extubated later and were not on ventilator between 32 and 72 h of WBC. The esophageal temperatures across every 4 h time points during the 32-72 h interval of WBC did not differ between the ventilated and non-ventilated infants. The magnitude (median, interquartile range) of the difference between esophageal and rectal temperatures was also similar between the two groups. CONCLUSION: Warmed inhaled gas does not interfere with the esophageal temperature during WBC.

Early increase in intracranial pressure in preterm infants.

Noninvasive measurement of intracranial pressure is now available via the anterior fontanel in newborn infants. We measured intracranial pressure during the first week of life in 18 preterm infants and found a statistically significant increase from birth to age 24 hours and a significant decrease by 48 hours (13.8 vs. 24.4 vs. 14.3 cm H2O). This did not seem to be the result of postnatal head shrinkage. There were no other apparent correlations. We suspect that hypoxia may play an important role in the etiology of increased intracranial pressure. We believe that these findings may have important implications for intracranial hemorrhage in preterm infants.

Association of septic shock caused by early-onset group B streptococcal sepsis and periventricular leukomalacia in the preterm infant.

Early-onset group B streptococcal sepsis frequently produces shock in preterm infants, a condition also felt to be contributory to the development of periventricular leukomalacia. During a 2-year study period, 628 preterm infants who were admitted to the neonatal intensive care unit underwent serial sonographic brain scanning; periventricular leukomalacia was diagnosed in eight infants (1.2%). The four infants (100%) who survived group B streptococcal sepsis with septic shock developed periventricular leukomalacia, whereas none of the four survivors (0%) of septic shock caused by other organisms and three of 27 survivors (11%) of shock not caused by infection developed periventricular leukomalacia. Because of the frequency of this lesion, it is suggested that all preterm survivors of group B streptococcal sepsis with septic shock should have serial sonography screening for detection of periventricular leukomalacia. Early detection will not assure cure but may facilitate prognostication, follow-up, and earlier institution of rehabilitative therapy to produce a better outcome.

Lumbar cisternography in evaluation of hydrocephalus in the preterm infant.

Radionuclide lumbar cisternography using indium 111-diethylenetriamine pentaacetic acid (111In-DTPA) and a mobile gamma-camera with a converging collimator was utilized as a bedside procedure to evaluate CSF dynamics and the patency of the cerebral ventricular system in 30 preterm infants with hydrocephalus. Serial images of the brain were obtained at 0, 1, 2, 6, 24, and 48 hours after instillation of the isotope in the lumbar subarachnoid space. Three distinct patterns were seen. Infants with posthemorrhagic hydrocephalus displayed prompt ventricular filling but markedly delayed emptying with minimal flow over the cerebral convexities. Infants with ventriculomegaly secondary to suspected brain atrophy or periventricular leukomalacia demonstrated a pattern of prompt ventricular filling, delayed emptying, but with flow present over the convexities. An infant with noncommunicating hydrocephalus secondary to an Arnold-Chiari malformation showed a pattern of complete obstruction with no ventricular filling. Radionuclide lumbar cisternography appears to be a safe, well-tolerated procedure which produces images of sufficient resolution to provide valuable information about CSF dynamics, delineating basal cisternae, ventricles, and subarachnoid flow paths.

Safety of a higher loading dose of phenobarbital in the term newborn.

The conventional loading dose of phenobarbital for newborn infants with hypoxic-ischemic seizures, 20 mg/kg, often fails to control convulsive activity. To determine the safety of a higher loading dose and to establish the pharmacokinetic parameters of a higher loading dose, ten severely asphyxiated term newborns were given 30 mg/kg of phenobarbital intravenously over 15 minutes. The mean serum concentration of phenobarbital two hours after loading was 30.0 +/- 3.2 micrograms/mL, the apparent volume of distribution was 0.97 +/- 0.18 L/kg, total clearance was 0.08 +/- 0.03 mL/min/kg, and mean serum half-life was 148 +/- 55 hours. The higher loading dose was not associated with any short-term adverse effects on cardiorespiratory function, even in spontaneously breathing infants.

Right-sided brain lesions in infants following extracorporeal membrane oxygenation.

In retrospective review of survivors of neonatal extracorporeal membrane oxygenation, eight patients with varying degrees of right hemispheric brain injury were identified. The extent of preextracorporeal membrane oxygenation hypoxia and ischemia was documented: five of eight patients had arterial PO2 values of less than 40 mm Hg, seven of eight required dopamine for blood pressure support, and five of eight required cardiopulmonary resuscitation. Two patients had proven neurologic abnormalities before extracorporeal membrane oxygenation. Postextracorporeal membrane oxygenation CT brain scans showed right hemispheric focal abnormalities in three patients. Seven infants had neuromotor abnormalities which were lateralizing in nature; all were left sided, suggesting right-sided brain injury. EEGs showed an increased incidence of slowing and attenuation over the right hemisphere. These findings indicate that right-sided brain abnormalities exist after extracorporeal membrane oxygenation and that carotid artery ligation for extracorporeal membrane oxygenation is not without risk.

Rapid detection of neonatal intracranial hemorrhage by transillumination.

Using transillumination and a sensitive cadmium sulfide light meter, 145 newborns were screened for the presence of intracranial hemorrhage. Intracranial hemorrhage (ICH) was suspected when the light meter could not detect any light passing through the anterior fontanel when the light beam was directed through the frontal eminence. ICH was confirmed by branial computed tomography or postmortem examination in all 17 infants not transmitting light. Spectrophotometry was performed on samples of cerebrospinal fluid (CSF) to demonstrate the mechanism through which blood in the CSF blocks light transmission.

Massive intracerebral hemorrhage in utero: sonographic appearance and pathologic correlation.

A case of massive fetal intracerebral hemorrhage diagnosed by sonography in the 32nd week of pregnancy is reported. The stillborn male fetus, electively delivered two days later, underwent postmortem examination, which confirmed the sonographic findings. The lesion appeared to arise from both the internal carotid and basivertebral arterial systems.