[Does the nursing shortage in neonatal intensive care units (NICU) threaten the warranty of healthcare for newborns? : The "Mary and Joseph" project]. / Gefährdet der Pflegepersonalmangel auf neonatologischen Intensivstationen die Versorgungssicherheit Neugeborener? : Das Projekt "Maria und Josef".

BACKGROUND: Germany has been experiencing a dramatic shortage of nursing staff for years that particularly affects neonatal intensive care units (NICUs). It is assumed that this situation leads to reductions in bed capacities, resulting in negative effects on the healthcare of newborns. These were investigated through a retrospective observational study using the example of three NICUs at the University Hospital of Munich (LMU). METHODS: For the four-year observation period from August 2017 to May 2021, time series data from the "Quality Assurance Guideline for Premature and Mature Infants" (QFR-RL) of the Federal Joint Committee, bed resource analysis, planned personnel statistics, clinical logout data, and rescue service data were mutually examined using descriptive statistics and regression analysis. RESULTS: During the observation period, around 21% of the necessary nursing staff positions were vacant, although the quality of nursing care for newborns seemed to have been guaranteed. However, to ensure quality, given the staff shortage, several available beds had to be blocked. In this context, both an increase in the number of hours the wards were logged off from population care and an increase in the relative risk of neonatal intensive care transfer were observed, resulting in a transfer every three days on average. DISCUSSION: A shortage of nursing staff reduces the neonatal hospital bed capacity, since neonatal nursing care quality is regulated by strict legally binding guidelines, the QFR-RL. This is why the consequences for the security of care for the population through hospital cancellations and a risk of transfer must be accepted on a regular basis.

Lamina cribrosa perforation during nasotracheal intubation in neonates: case series and review of the literature.

Intracranial penetration during attempted nasotracheal intubation is a potentially devastating complication, which should be carefully evaluated and the risk should be addressed in neonatal resuscitation trainings.

Incidence Estimates of Perinatal Arterial Ischemic Stroke in Preterm- and Term-Born Infants: A National Capture-Recapture Calculation Corrected Surveillance Study.

INTRODUCTION: Data on valid incidence estimates of perinatal arterial ischemic stroke (PAIS) are scarce. This analysis aims to determine incidence of PAIS in term- and preterm-born infants and to investigate clinical differences related to prematurity. METHODS: This surveillance study (2015-2017) in all German paediatric hospital estimated incidences for MRI-confirmed PAIS in term and preterm infants. To correct for under-reporting, we performed capture-recapture-calculations (CRC) in the most populous federal state and extrapolated nationwide. Differences in clinical presentation in term- and preterm-born infants were assessed. RESULTS: 126 term- and 19 preterm-born infants with PAIS were reported. CRC corrected incidence of PAIS was 22 (95% confidence interval [CI] 17, 27) per 100,000 live births. Stratified by prematurity, the incidence was 32 (95% CI 15, 49) per 100,000 in preterm-born infants and 21 (95% CI 16, 26) per 100,000 term-born infants (significant difference p = 0.001). In symptomatic cases only (n = 120 term born, n = 12 preterm born), incidences did not differ. Risk factor patterns were similar, but number of risk factors in preterm babies was elevated (mean 3.8 vs. 2.9; p = 0.01) and median age at diagnosis was increased (5 vs. 3 days; p = 0.04). Clinical seizures were observed in 88% (106/120) of symptomatic term infants compared to 33% (4/12) in preterm-born infants (p < 0.0001). CONCLUSION: PAIS incidence rates in Germany, extrapolated from estimates for completeness of reporting in the largest federal state, were within the range of other population-based studies. As a novel finding, we detected symptomatic PAIS in preterm-born infants to be as common as in term-born infants although their symptoms were often unspecific.

Clinical Diversity of Cerebral Sinovenous Thrombosis and Arterial Ischaemic Stroke in the Neonate: A Surveillance Study.

INTRODUCTION: Incidence, risk factors, clinical presentation, onset of symptoms, and age at diagnosis differ between neonatal arterial ischaemic stroke (AIS) and cerebral sinovenous thrombosis (CSVT). A more accurate and earlier discrimination of these two entities can be of eminent importance. METHODS: Active surveillance for AIS and CSVT was performed in 345 German paediatric hospitals. Only MRI confirmed cases were included in our analysis. Patients with AIS were compared to CSVT cases with regard to age at diagnosis, pattern of clinical symptoms, and case characteristics. RESULTS: Data on 144 AIS and 51 CSVT neonatal cases were collected from 2015 to 2017. The frequency of reported AIS cases was 2.8 [95% CI 2.1; 3.9] times higher compared to reported CSVT cases. CSVT patients were more likely to be born premature (CSVT 14/48, 29.2%; AIS 19/140, 13.2%; p = 0.02) and to have signs of perinatal acidosis (30.2% CSVT vs. 13.5% AIS; p = 0.01). Generalized seizures and lethargy were more likely to occur in infants with CSVT (p < 0.0001). Age at onset of symptoms and at time of diagnosis were shifted to older ages in CSVT (p < 0.0001). DISCUSSION/CONCLUSION: In the neonatal period, AIS is about three times more common than CSVT. A higher proportion of critically ill infants in CSVT and a later onset of symptoms may indicate that perinatal and postnatal complications are more important for CSVT than for AIS.

Incidence and risk factors of cerebral sinovenous thrombosis in infants.

AIM: To describe the incidence of term and preterm neonatal cerebral sinovenous thrombosis (CSVT) and identify perinatal risk factors. METHOD: This was a national capture-recapture calculation-corrected surveillance and nested case-control study. Infants born preterm and at term with magnetic resonance imaging-confirmed neonatal CSVT were identified by surveillance in all paediatric hospitals in Germany (2015-2017). Incidence was corrected for underreporting using a capture-recapture method in one federal state and then extrapolated nationwide. We reviewed PubMed for comparisons with previously reported incidence estimators. We used a population-based perinatal database for quality assurance to select four controls per case and applied univariate and multivariable regression for risk factor analysis. RESULTS: Fifty-one newborn infants (34 males, 17 females; 14 born preterm) with neonatal CSVT were reported in the 3-year period. The incidence of term and preterm neonatal CSVT was 6.6 (95% confidence interval [CI] 4.4-8.7) per 100 000 live births. Median age at time of confirmation of the diagnosis was 9.95 days (range 0-39d). In the univariate analysis, male sex, preterm birth, hypoxia and related indicators (umbilical artery pH <7.1; 5-minute Apgar score <7; intubation/mask ventilation; perinatal asphyxia), operative vaginal delivery, emergency Caesarean section, and pathological fetal Doppler sonography were associated (p<0.05) with neonatal CSVT. Multivariable regression yielded hypoxia (odds ratio=20.3; 95% CI 8.1-50.8) as the independent risk factor. INTERPRETATION: Incidence of neonatal CSVT was within the range of other population-based studies. The results suggest that hypoxia is an important perinatal risk factor for the aetiology of neonatal CSVT.

[Decrease in Group B Streptococcal Infections in Neonates: Analysis of Health Insurance Data 2005 to 2017]. / Rückgang von Infektionen durch Streptokokken der Gruppe B bei Neugeborenen: Analyse von Krankenversicherungsdaten 2005 bis 2017.

BACKGROUND: In the German guidelines for prophylaxis of group B streptococcal (GBS) early onset sepsis in neonates (EOS), GBS screening of all pregnant women has been recommended, but is not yet included in the Maternity Directives. Aim of the study was to identify temporal trends in incidence of EOS and their association to GBS Screening. METHODS: The analysis based on health insurance data of the statutory health insurance provider Barmer from 2005 to 2017 of 313,385 mother-child pairs. Annual frequency of GBS infections in newborns was determined by ICD-10 P36.0. The frequency of maternal GBS colonization was indicated by ICD-10 B95.1, which was used as surrogate for GBS screening. Temporal trends of the risk of EOS in neonates were assessed in logistic regression models. Pearson's correlation coefficient of EOS incidence and the surrogate marker for maternal GBS colonization was calculated. RESULTS: The risk of EOS in neonates caused by GBS has decreased annually by 9.3%, resulting in an overall decrease in the observation period of 72.0%. There was no statistical significant change in the risk for LOS (Late Onset Sepsis). The decrease of EOS could not be explained by temporal changes in Caesarian section, risk factors or preterm delivery. The 3.5 fold increase in the proportion of mothers with documented positive GBS colonization in the same period correlated inversely with the incidence of EOS (r=- 0.75; p=0.002). CONCLUSION: The decrease of EOS in neonates caused by GBS in Germany and the unchanged risk of LOS in neonates may be explained by the increasing application of the GBS Screening in pregnant women.

Risk factors for perinatal arterial ischaemic stroke: a large case-control study.

AIM: To identify maternal, obstetric, and neonatal risk factors related to perinatal arterial ischaemic stroke (PAIS) diagnosed within 28 days after birth and to understand the underlying pathophysiology. METHOD: For case and control ascertainment, we used active surveillance in 345 paediatric hospitals and a population-based perinatal database for quality assurance of hospital care. We analysed complete cases of PAIS using logistic regression. Multivariate analysis was guided by a directed acyclic graph. RESULTS: After exclusion of records with missing data, we analysed 134 individuals with PAIS and 576 comparison individuals. In univariate analysis, male sex, preterm birth (<37wks gestational age), small for gestational age (SGA), low umbilical artery pH (<7.1), low 5-minute-Apgar score (<7), multiple pregnancies, hypoxia, intubation/mask ventilation, nulliparity, Caesarean section, vaginal-operative delivery, chorioamnionitis, and oligohydramnios were associated with an increased risk. Mutual adjustment yielded male sex (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.20-2.73), multiple birth (OR 3.22; 95% CI 1.21-8.58), chorioamnionitis (OR 9.89; 95% CI 2.88-33.94), preterm birth (OR 1.86; 95% CI 1.01-3.43), and SGA (OR 3.05; 95% CI 1.76-5.28) as independent risk factors. INTERPRETATION: We confirmed the increased risk in males and the role of chorioamnionitis and SGA for PAIS, pointing to the importance of inflammatory processes and fetal-placental insufficiency. Multiple birth and preterm birth were additional risk factors. WHAT THIS PAPER ADDS: Chorioamnionitis and small for gestational age (SGA) precede perinatal arterial ischaemic stroke (PAIS). Chorioamnionitis and SGA are independent risk factors for PAIS. Inflammatory processes and fetal-placental insufficiency are the likely underlying mechanisms. Multiple birth and preterm birth are additional risk factors.

[Long-Term Development of Infants after Extracorporeal Membrane Oxygenation (ECMO)]. / Langzeitentwicklung von Kindern nach Extra Corporaler Membran Oxygenierung (ECMO).

BACKGROUND: After neonatal lung failure and especially after ECMO therapy long-term morbidities are common. The follow-up of these seriously ill neonates is an indispensable quality criterion for an ECMO centre and beyond that follow-up data are important for counselling parents. Yet, ECMO-centres often cover a large service area and follow-up is difficult due to long travel distances for parents. In this study, we therefor evaluated the applicability of questionnaires sent out to parents. METHODS: We performed a follow-up examination and development screening for long-term morbidities in a cohort of former newborns with severe lung failure (n=31/41) using a questionnaire. In addition, doctor's letters and telephone interviews were evaluated by a systematic, partly computer-assisted approach RESULTS: Questionnaires were sent out to 28 families of the 31 surviving children. Of those, 23 were returned (82% response). Four children had conspicuous questionnaire results, i. e. they were below the 90th percentile of the age-related values and thus had a risk of developmental delay. Of these, 3 children were 2 years old and did not need ECMO at birth due to respiratory failure. Another child (6 years) who was on ECMO after birth had abnormal findings on the questionnaire. CONCLUSION: In this study specific questionnaires were used for the first time in children with severe neonatal lung failure allowing the detection of abnormal development. This pilot trial shows that application of structured questionnaires seems feasible and should be further evaluated in a large cohort, controlled by established developmental tests.

Neonatal Arterial Ischemic Stroke - A Hospital Based Active Surveillance Study in Germany.

Background Neonatal arterial ischemic stroke (NAIS) accounts for substantial long term sequelae in children. The potential effectiveness of neuroprotective therapies needs to be evaluated in appropriate studies with sufficient power. Objective To identify annual number of NAIS cases in Germany potentially eligible for randomized interventional trials. Methods Active surveillance for NAIS in 345 pediatric hospitals with questionnaire based validation of reported cases. Results Incidence of NAIS (7.1/100000 births) was in the range of other population-based studies. To design future clinical trials with anticoagulative or regenerative therapies, it is of major importance to distinguish between cases with or without relevant perinatal pathology. Children without underlying disease or premature birth accounted for 56% of all reported NAIS cases (primary NAIS). In 69% of the primary cases clinical seizures were observed. Although 31% showed other, less pathognomonic symptoms, NAIS was diagnosed. Mean time span between onset of symptoms and diagnosis was 2.9 days. The sensitivity of the initial ultrasound performed in all cases was 69%. Conclusions NAIS is a rare but not negligible morbidity in newborns. Asymptomatic children account for 56% of NAIS in all neonates. In these, not only seizures but also other unexplained symptoms should trigger diagnostic work-up with cUS and cMRI. Negative initial ultrasound results do not exclude NAIS.

Lung disease caused by ABCA3 mutations.

BACKGROUND: Knowledge about the clinical spectrum of lung disease caused by variations in the ATP binding cassette subfamily A member 3 (ABCA3) gene is limited. Here we describe genotype-phenotype correlations in a European cohort. METHODS: We retrospectively analysed baseline and outcome characteristics of 40 patients with two disease-causing ABCA3 mutations collected between 2001 and 2015. RESULTS: Of 22 homozygous (15 male) and 18 compound heterozygous patients (3 male), 37 presented with neonatal respiratory distress syndrome as term babies. At follow-up, two major phenotypes are documented: patients with (1) early lethal mutations subdivided into (1a) dying within the first 6 months or (1b) before the age of 5 years, and (2) patients with prolonged survival into childhood, adolescence or adulthood. Patients with null/null mutations predicting complete ABCA3 deficiency died within the 1st weeks to months of life, while those with null/other or other/other mutations had a more variable presentation and outcome. Treatment with exogenous surfactant, systemic steroids, hydroxychloroquine and whole lung lavages had apparent but many times transient effects in individual subjects. CONCLUSIONS: Overall long-term (>5 years) survival of subjects with two disease-causing ABCA3 mutations was <20%. Response to therapies needs to be ascertained in randomised controlled trials.

Very low birth weight preterm infants are at risk for hypoglycemia once on total enteral nutrition.

OBJECTIVE: To determine the occurrence of hypoglycemic episodes in very low birth weight preterm infants under total enteral nutrition and identify potential risk factors. METHODS: In this single centre cohort study, we analyzed the patients' charts of preterm infants with a gestational age <32 weeks (n = 98). Infants were analyzed in two groups (group 1: birth weight <1000 g, n = 54; group 2: birth weight 1000-1499 g, n = 44). A total of 3640 pre-feeding blood glucose measurements were screened. Risk factors for the development of hypoglycemia were identified by linear and multiple logistic regression analyses. RESULTS: In group 1, 44% (24 of 54) of infants experienced at least one asymptomatic episode of blood glucose <45 mg/dl (<2.5 mmol/l) as compared with 23% (10 of 44) in group 2. Regression analysis identified low gestational age and high carbohydrate intake as potential risk factors for the development of hypoglycemia. CONCLUSIONS: Our results indicate that numerous preterm infants experience hypoglycemic episodes once on total enteral nutrition, especially those who are <1000 g at birth and those with a higher carbohydrate intake. Further studies evaluating a possible impact of these common although asymptomatic episodes on later development could help to better define thresholds that should be considered as "hypoglycemia" in this population.