TROPHY registry - status report.

INTRODUCTION: The TROPHY registry has been established to conduct an international multicenter prospective data collection on the surgical management of neonatal intraventricular hemorrhage (IVH)-related hydrocephalus to possibly contribute to future guidelines. The registry allows comparing the techniques established to treat hydrocephalus, such as external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). This first status report of the registry presents the results of the standard of care survey of participating centers assessed upon online registration. METHODS: On the standard of treatment forms, each center indicated the institutional protocol of interventions performed for neonatal post-hemorrhagic hydrocephalus (nPHH) for a time period of 2 years (Y1 and Y2) before starting the active participation in the registry. In addition, the amount of patients enrolled so far and allocated to a treatment approach are reported. RESULTS: According to the standard of treatment forms completed by 56 registered centers, fewer EVDs (Y1 55% Y2 46%) were used while more centers have implemented NEL (Y1 39%; Y2 52%) to treat nPHH. VAD (Y1 66%; Y2 66%) and VSGS (Y1 42%; Y2 41%) were used at a consistent rate during the 2 years. The majority of the centers used at least two different techniques to treat nPHH (43%), while 27% used only one technique, 21% used three, and 7% used even four different techniques. Patient data of 110 infants treated surgically between 9/2018 and 2/2021 (13% EVD, 15% VAD, 30% VSGS, and 43% NEL) were contributed by 29 centers. CONCLUSIONS: Our results emphasize the varying strategies used for the treatment of nPHH. The international TROPHY registry has entered into a phase of growing patient recruitment. Further evaluation will be performed and published according to the registry protocol.

Retinopathy of prematurity screening at ≥30 weeks: urinary NTpro-BNP performance.

AIM: Urinary N-terminal B-type natriuretic peptide NTproBNP levels are associated with the development of retinopathy of prematurity (ROP) in infants <30 weeks of gestation. The incidence of ROP in more mature infants who meet other ROP screening criteria is very low. We therefore aimed to test whether urinary NTproBNP predicted ROP development in these infants. METHODS: Prospective observational study in 151 UK infants ≥30 + 0 weeks of gestation but also <32 weeks of gestation and/or <1501 g, to test the hypothesis that urinary NTproBNP levels on day of life (DOL) 14 and 28 were able to predict ROP development. RESULTS: Urinary NTproBNP concentrations on day 14 and day 28 of life did not differ between infants with and without ROP (medians 144 vs 128 mcg/mL, respectively, p = 0.86 on DOL 14 and medians 117 vs 94 mcg/mL, respectively, p = 0.64 on DOL28). CONCLUSION: The association previously shown for infants <30 completed weeks between urinary NTproBNP and the development of ROP was not seen in more mature infants. Urinary NTproBNP does not appear helpful in rationalising direct ophthalmoscopic screening for ROP in more mature infants, and may suggest a difference in pathophysiology of ROP in this population.

Decreased neonatal pain response after vaginal-operative delivery with Kiwi OmniCup versus metal ventouse.

BACKGROUND: Vaginal delivery, especially operative assisted vaginal delivery, seems to be a major stressor for the neonate. The objective of this study was to evaluate the stress response after metal cup versus Kiwi Omnicup® ventouse delivery. METHODS: The study was a secondary observational analysis of data from a former prospective randomised placebo controlled multicentre study on the analgesic effect of acetaminophen in neonates after operative vaginal delivery and took place at three Swiss tertiary hospitals. Healthy pregnant women ≥35 weeks of gestation with an estimated fetal birth weight above 2000 g were recruited after admission to the labour ward. Pain reaction was analysed by pain expression score EDIN scale (Échelle Douleur Inconfort Nouveau-Né, neonatal pain and discomfort scale) directly after delivery. For measurement of the biochemical stress response, salivary cortisol as well as the Bernese Pain Scale of Newborns (BPSN) were evaluated before and after an acute pain stimulus (the standard heel prick for metabolic testing (Guthrie test)) at 48-72 h. RESULTS: Infants born by vaginal operative delivery displayed a lower pain response after plastic cup than metal cup ventouse delivery (p < 0.001), but the pain response was generally lower than expected and they recovered fully within 72 h. CONCLUSIONS: Neonatal pain response is slightly reduced after use of Kiwi OmniCup® versus metal cup ventouse. TRIAL REGISTRATION: Trial was registered under under NCT00488540 on 19th June 2007.

Neonatal Abstinence Syndrome: Twelve Years of Experience at a Regional Referral Center.

Infants exposed to opiates antenatally display withdrawal symptoms after birth referred to as neonatal abstinence syndrome (NAS).A total of 366 newborns (166 females, 10 twins) from 361 mothers were diagnosed with NAS from 2000 to 2011 at a single large metropolitan referral center.Retrospective chart review of all newborn infants exposed to opiates in utero.20% were premature (gestational age<37 weeks), 32% were small-for-gestational-age (<10th percentile). 70% of infants (195/278) antenatally exposed to methadone (racemic methadone or levomethadone) required pharmacological treatment for 11 (1-55) days (median; range); however, 45% of infants (28/62) exposed to buprenorphine required pharmacological treatment for a median of only 5 (1-20) days (p=0.014). Pharmacological treatment of infants with phenobarbital (n=189) took a median of 9 (1-53) days, but treatment with morphine (n=39) took 19 (3-55) days (p<0.001). The median duration of hospitalization increased from 11 days in 2000-2004 to 19 days in 2008-2011 (p<0.001). The increased durations of neonatal hospitalization were associated with similar increases in the average dosages of maternal methadone.Use of buprenorphine, rather than methadone, for treatment of opiate-addicted pregnant women is associated with fewer and shorter neonatal withdrawal symptoms. The duration of hospitalization and treatment for NAS has increased over time.

[Survival, Medical Care and Quality of Life in Children with Trisomy 13 and 18]. / Überleben, medizinische Betreuung und Lebensqualität von Kindern mit Trisomie 13 und 18.

BACKGROUND: While infants with trisomy 13 (T13) and trisomy 18 (T18) are known to die early, parents want to know more about life expectancy and quality of life. METHODS: 30-year single-center retrospective chart analysis (1980-2010) of cytogenetically confirmed T13 and T18 cases. Mothers of infants who had lived 3 months or longer were approached to judge their infant's quality of life and talk about their experiences with medical staff. RESULTS: Data of 18/20 T13 infants and 18/21 T18 infants could be retrieved. Median survival times were 5 d for T13 and 19 d for T18. One T13 and 2T18 children survived past 1 year. Out of 5 mothers whose infants had survived at least 3 months, 4 described their infant as friendly, happy and peaceful. They observed some degree of psychomotor development and were in favour of the numerous medical and surgical interventions performed. They wished to have had a doctor coordinating these interventions and missed an active offer for psychological help. CONCLUSION: While most infants with T13 or T18 die as neonates, mothers of infants surviving longer periods of time have positive memories about their infants' quality of life.

Primary palliative care in the delivery room: patients' and medical personnel's perspectives.

OBJECTIVE: To investigate circumstances of primary palliative care (PPC) in the delivery room (DR), medical personnel's experience with neonates who died under PPC in the DR and perceived sources of care-related distress in DR staff. STUDY DESIGN: Retrospective chart review of all neonates who were cared for under PPC in the DR during the years 2000-2010 at Charité University Medical Center Berlin, and structured face-to-face interviews with DR nursing staff and physicians. RESULT: Neonates undergoing PPC could be grouped as preterm infants at the limits of viability with a gestational age between 22 (0)/7 and 23 (6)/7 weeks (n=86, 76%) and newborn infants with complex chronic conditions (n=27, 24%). The median age of neonates at death was 59 min (interquartile range [IQR] 28-105 min). Most of DR staff did not report relevant signs of distress in dying neonates, and providing palliative care was not named as a relevant care-related source of distress by medical personnel. However, half of the participants reported on high degrees of caregiver's emotional distress in PPC situations, identifying insecurity of how to communicate with parents and to provide emotional support as the most common source of distress. CONCLUSION: Caregiver's emotional distress primarily originates from providing support to parents and not from providing medical care to the dying newborn. Implications for future practice include the need for structured education to improve DR staff's communication and counselling skills related to parents in PPC situations.

[Age-related characteristics of the efficacy of different glucocorticosteroids in the therapy of acute lymphoblastic leukemia].

AIM: To determine predictors for decision-making on a differential approach to choosing glucocorticosteroids (GCS) for children and adolescents with acute lymphoblastic leukemia (ALL). SUBJECTS AND METHODS: The analysis covered 1064 primary patients aged to 1 to 18 years with ALL who had been registered at the clinics of Russia and Belorussia in April 2002 to November 2006. Before induction therapy, the patients were randomized into a dexamethasone (DEXA) 6 mg/m2 group (n=539) and a methylprednisolone (MePRED) 60 mg/m2 one (n=525). RESULTS: The entire group showed no statistically significant differences in survival rates between the patients receiving DEXA or MePRED. However, an analysis of age groups revealed the benefits of DEXA in children younger than 14 years (the event-free survival (EFS) was 76±2 and 71±2%, respectively (p=0.048); the overall survival (OS) was 81±2 and 77±2%, respectively (p=0.046); therapy-induced mortality was 6.4% (DEXA) andl 1.1% (MePRED) (p=0.01 4); the rate of isolated extramedullary relapses was 1.5% (DEXA) and 4.4% (MePRED) (p=0.009). At the same time, EFS and OS in 14-to-18-year-old adolescents were statistically significantly higher than in those who used MePRED (EFS, 65±6 and 52±6%, respectively (p=0.087); OS, 72±6 and 61±6%, respectively; (p=0.l 7). CONCLUSION: The findings suggest that it is possible that the choice of a GCS for ALL therapy must be also based on a patient's age. There is a need for further studies of this matter in prospective randomized multicenter trials in children and adolescents.

Blood flow assessed by color Doppler imaging in retinopathy of prematurity.

OBJECTIVE: To quantify central retinal arterial and venous blood flow using ultrasound color Doppler imaging. STUDY DESIGN: In this prospective observational study, eyes of eight preterm infants with retinopathy of prematurity stage 2 and of eight preterm infants without retinopathy (gestational age <30 weeks, birth weight <1500 g) were evaluated by color Doppler imaging. RESULT: Ocular blood flow velocities measured at 28±1 days of life did not differ significantly in the eyes of preterm infants who subsequently did and did not develop retinopathy. Development of retinopathy was associated with highly significant (P<0.0001 each) increases in central retinal vein maximum velocities (from 1.99±0.36 to 3.72±0.61 cm s(-1)), central retinal artery systolic flow velocities (from 6.44±1.52 to 9.87±1.99 cm s(-1)) and flow velocity integrals (from 1.27±0.30 to 2.17±0.50 cm) at 64±13 days of life. In infants without retinopathy, no significant changes were observed except for an increase in central retinal vein maximum velocities (from 1.96±0.22 to 2.62±0.44 cm s(-1), P=0.003). CONCLUSION: Retinopathy of prematurity appears to be accompanied by increased retinal blood flow.

Electrocortical Activity at 7 Days of Life is Affected in Extremely Premature Infants with Patent Ductus Arteriosus.

BACKGROUND: The aim of this study was to determine whether the aEEG at 7 days of life is influenced by the presence of a PDA in non-sedated extremely low gestational age preterm infants. PATIENTS: We prospectively recruited infants born at less than 28 weeks of gestation between 11/2007 and 12/2009. METHOD: aEEGs were recorded at seven days of life and assessed by using the Burdjalov score and the electronically assessed lower border (eLBA). Kruskal-Wallis-Test and linear regression analysis were performed to determine how GA and a PDA affect the aEEG score and the eLBA. Using linear regression analysis we tested which components of the score are affected by a PDA. RESULTS: We recruited 44 infants with a GA of 26.5/7 (23.4/7-27.6/7) weeks and a birth weight of 837 (461-1230) g. The total sum of score points increased from 4 (1-6) to 8 (5-9) points in infants born at 23/24 weeks and 27 weeks of gestation, respectively. In infants with relevant PDA the aEEG scored lower with 8 (3-10) points compared to those with PDA: 5 (1-8) points. Linear regression analysis showed a positive influence of GA and a negative influence of a PDA on the total score. GA had a positive influence on SWC and the visually assessed LBA. A PDA had a negative influence on continuity. The eLBA increased from 4.61 (3.18-5.53) µV to 5.27 (3.38-6.51) µV in infants of 23/24 vs. 27 gestational weeks, but was not significantly influenced by a PDA. CONCLUSION: A PDA has a negative influence on the total Burdjalov score and continuity at 7 days of age in infants born at less than 28 weeks of gestation. The electrocortical disturbances may be the consequence of a diminished cerebral perfusion in the presence of a PDA.

Characterization of the vitamin A transport in preterm infants after repeated high-dose vitamin A injections.

BACKGROUND/OBJECTIVES: Preterm infants have low vitamin A stores at birth, and parenteral administration of high-dose vitamin A reduces pulmonary morbidity. The aim was to characterize vitamin A transport and status. SUBJECTS/METHODS: Prospective study of 69 preterm infants (median birth weight 995 g, gestational age 28 weeks), in which 51 received 5000 IU vitamin A three times per week intramuscular (i.m.) for 4 weeks and 18 infants without i.m. vitamin A served as controls. Serum retinol, retinyl palmitate, total retinol-binding protein 4 (RBP4), retinol-unbound RBP4 (apo-RBP4) and transthyretin concentrations were determined at days 3 (D3) and 28 (D28) of life. RESULTS: D3 retinol concentrations were low for the entire group (382 (285/531) nmol/l; median/interquartile range) and unrelated to gestational age. D28 retinol was unchanged in controls (382 (280/471) nmol/l), but increased in the vitamin A group (596 (480/825) nmol/l; P<0.001). A similar pattern was observed for RBP4. The calculated retinol-to-RBP4 ratio rose in vitamin A infants (D3: 0.81 (0.57/0.94), D28: 0.98 (0.77/1.26); P<0.01) but not in controls. In the vitamin A group, the retinol-to-RBP4 ratio was >1 in 15% of all infants on D3 and in 45% of infants on D28, but was ⩽1 in all, but one, controls on D28. CONCLUSIONS: In preterm infants receiving a 4-week course of high-dose i.m. vitamin A, serum retinol concentrations increased by 55%, with molar concentrations of retinol exceeding those of RBP4 in 45% of the infants suggesting transport mechanisms other than RBP4.

Postnatal maturation of skin barrier function in premature infants.

BACKGROUND: In preterm infants, skin barrier maturation entails regional variability. OBJECTIVES: To characterize postnatal skin barrier development in covered, uncovered and diapered regions in healthy premature infants over a longitudinal observation period. METHODS: Transepidermal water loss (TEWL), stratum corneum hydration (SCH), pH and sebum were measured at postnatal ages of 1-7 days and 2-7 weeks on the forehead, abdomen, thigh and buttock of preterm infants (gestational age 30-37 weeks; n = 48) under monitored ambient conditions. A standard minimal skin care regimen was practised. RESULTS: TEWL increased significantly on the buttock (p = 0.007), while remaining stable on the forehead, abdomen and thigh. SCH and sebum remained stable in all studied body regions with increasing age. On the buttock, pH increased (p = 0.049), while other body regions exhibited a significant decrease (p ≤ 0.019). TEWL (p < 0.001) and SCH (p ≤ 0.002) revealed significantly higher values on the buttock, compared to other body regions. CONCLUSIONS: Stable TEWL, SCH and sebum values may indicate a lack of skin barrier maturation. Postnatal decrease in skin pH suggests an adaptation process with acid mantle formation. Differences in skin barrier development were observed between anatomical regions. SCH, TEWL and pH values demonstrated a distinct course in the diaper area, indicating an impaired skin barrier function in this region.

[Google translate is not sufficient to overcome language barriers in neonatal medicine]. / Erste Erfahrungen mit Google Translate in der Neonatologie.

Language barriers hinder the interaction with patients and relatives. The use of language services increases knowledge, satisfaction and the use of medical care and thus improves patient's clinical outcome. The recommended use of professional interpreters (PI) is not always feasible. We tested an online translation tool as an alternative for PI for the transla-tion of standardized sentences from a neonatal doctor-/nurse-relative-interview.Translation of 20 sentences from a German neonatal intensive care unit parent information brochure to English, Portuguese and Arabic, using Google Translate (GT). Assessment of accuracy concerning grammar and content, in a second step simplification of all incorrect sentences, translation by GT and critical re-assessment and evaluation.An average of 42% of the sentences was correctly translated concerning grammar and content. The proportion of incorrectly translated sentences varied between 45-70%. By simpli-fication another 23% were translated correctly.Translations by GT were often incorrect in content and grammar. We suppose that the design of GT, which is a statistical translation engine, might be an explanation for this phenomenon. Presently, GT cannot guarantee unambiguous translations and cannot substitute PIs, only in particular circumstances, the use of GT or similar engines may be justified. For future use of electronic translation services, we suggest to compile a catalogue of sentences containing central information, which can be translated into defined foreign languages without misinterpretation or loss of information.

[Individual neonatal end-of-life care and family-centred bereavement support]. / Familienzentrierte Sterbe- und individuelle Trauerbegleitung an einem Perinatalzentrum.

Neonatal end-of-life care and family-centred bereavement support in perinatal medicine are a multiprofessional challenge directed to the dying newborn and the parents as well as to the care-givers. Clinical experience shows that many aspects of individual neonatal end-of-life care and family-centred bereavement support are not well known to the health-care providers. This is especially true for a standardised quality management and the components of bereavement support offered to parents. An interdisciplinary concept for an individual neonatal end-of-life care and famlily-centred bereavement support has been developed at the Center of Perinatal Medicine at the Charité, Berlin. The concept aims for two main aspects: (1) meeting the individual medical, psychological, emotional and spiritual needs of the dying newborn, the parents and family, and (2) facilitating standardised and process-orientated preparation, evaluation and reflexion of every case of end-of-life care. In this article some recommendations for implementing a basic care concept for families and their dying newborns are presented.

Low immature platelet fraction suggests decreased megakaryopoiesis in neonates with sepsis or necrotizing enterocolitis.

OBJECTIVE: In order to conclude on the megakaryopoietic activity during thrombocytopenia in sepsis or necrotizing enterocolitis (NEC), we analyzed the immature platelet fraction (IPF). STUDY DESIGN: Serial measurements of platelet counts and IPF in neonates with blood culture-proven late-onset sepsis (n=21) or surgical NEC (n=12) at T0: prior to the diagnosis of sepsis/NEC; T1: at diagnosis; T2: days 3 to 5 after onset; T3: days 8 to 12 after onset. RESULT: In parallel to declining platelet counts, the median absolute IPF significantly decreased between T0 and T2 in neonates with sepsis or NEC. We found a significant positive correlation between the platelet count and absolute IPF (r=0.71; P<0.001). In patients with low IPF (<2 per nl), the platelet count did not subsequently increase. Neonates with NEC who died exhibited significantly lower IPF compared with survivors (P<0.05). CONCLUSION: Low absolute IPF values during the course of neonatal sepsis/NEC suggest suppression of megakaryopoietic activity.

Pilot study of experiences and needs of 111 fathers of very low birth weight infants in a neonatal intensive care unit.

OBJECTIVE: To study the experiences and needs of the fathers of very low birth weight (VLBW, <1500 g) infants in a neonatal intensive care unit (NICU). STUDY DESIGN: An anonymous self-report questionnaire was administered to fathers of VLBW infants born between Jan 1, 2008 and December 31, 2009 at two tertiary NICUs. RESULT: A total of 111 of 273 fathers responded to the questionnaire. Responses to a variety of items, including self-perception, parenting attitudes, confidence, emotional pressure to satisfaction and self-efficacy as a parent were similar for the fathers of this survey and previous results for mothers of VLBW infants. Fathers judged direct bedside support by the NICU team as sufficient. However, 54.4% of fathers reported missing nonbedside interventions such as VLBW father-specific baby care courses, seminars or workshops, and platforms or chatrooms on the internet. CONCLUSION: Bedside support of fathers, accomplished by the NICU team, could be complemented by additional father-specific non-bedside support, such as peer-education measures or interactive mass media.

Urinary NT-proBNP and ductal closure in preterm infants.

OBJECTIVE: To explore the association of urinary N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations and closure of patent ductus arteriosus (PDA) in preterm infants. STUDY DESIGN: Blinded prospective study involving 136 preterm infants (median (interquartile range) gestational age 28 (26 to 30) weeks; birth weight 1030 (780 to 1270) g). NT-proBNP was determined in urine collected on day of life (DOL) 2, 7, 14 and 28. RESULT: Urinary NT-proBNP/creatinine ratios declined continuously between DOL 2 (74 (17 to 248) µg g(-1)) and DOL 28 (4 (2 to 12) µg g(-1)) and were significantly elevated in ventilated infants on DOL 2, 7 and 14, and in ventilated infants with a hemodynamically significant PDA on DOL 2. Furthermore, urinary NT-proBNP/creatinine ratios on day 14 were higher in 14 ventilated infants who did not respond to pharmacological treatment and subsequently required surgical PDA closure (247 (214 to 547) µg g(-1)) than in ventilated infants (n=7) with successful pharmacological PDA closure (55 (21 to 114) µg g(-1); P<0.05). A cutoff >210 µg g(-1) on day 14 had a sensitivity of 75% and specificity of 100% for predicting non-responsiveness to pharmacological treatment. CONCLUSION: Measurement of urinary NT-proBNP is a new and simple non-invasive test for preterm infants, which may be helpful in guiding PDA treatment decisions.