Neonatal Resuscitation Practices in Portuguese Delivery Rooms: A Cross-Sectional Study.

INTRODUCTION: Data from previous studies have demonstrated inconsistency between current evidence and delivery room resuscitation practices in developed countries. The primary aim of this study was to assess the quality of newborn healthcare and resuscitation practices in Portuguese delivery rooms, comparing current practices with the 2021 European Resuscitation Council guidelines. The secondary aim was to compare the consistency of practices between tertiary and non-tertiary centers across Portugal. METHODS: An 87-question survey concerning neonatal care was sent to all physicians registered with the Portuguese Neonatal Society via email. In order to compare practices between centers, participants were divided into two groups: Group A (level III and level IIb centers) and Group B (level IIa and I centers). A descriptive analysis of variables was performed in order to compare the two groups. RESULTS: In total, 130 physicians responded to the survey. Group A included 91 (70%) and Group B 39 (30%) respondents. More than 80% of participants reported the presence of a healthcare professional with basic newborn resuscitation training in all deliveries, essential equipment in the delivery room, such as a resuscitator with a light and heat source, a pulse oximeter, and an O2 blender, and performing delayed cord clamping for all neonates born without complications. Less than 60% reported performing team briefing before deliveries, the presence of electrocardiogram sensors, end-tidal CO2 detector, and continuous positive airway pressure in the delivery room, and monitoring the neonate's temperature. Major differences between groups were found regarding staff attending deliveries, education, equipment, thermal control, umbilical cord management, vital signs monitoring, prophylactic surfactant administration, and the neonate's transportation out of the delivery room. CONCLUSION: Overall, adherence to neonatal resuscitation international guidelines was high among Portuguese physicians. However, differences between guidelines and current practices, as well as between centers with different levels of care, were identified. Areas for improvement include team briefing, ethics, education, available equipment in delivery rooms, temperature control, and airway management. The authors emphasize the importance of continuous education to ensure compliance with the most recent guidelines and ultimately improve neonatal health outcomes.

Gastrointestinal effects of caffeine in preterm infants: a systematic review and Bayesian meta-analysis.

OBJECTIVE: Caffeine is widely used in preterm infants to prevent or treat apnoea of prematurity. Adverse gastrointestinal effects of caffeine have not been thoroughly researched in preterm infants. With this systematic review and meta-analysis, we aim to summarise the results of trials on the gastrointestinal effects of caffeine in preterm infants. DESIGN: We searched MEDLINE, Web of Science, Scopus and ClinicalTrials.gov up to 21 April 2023. We included randomised controlled trials assessing caffeine versus placebo in preterm neonates and reporting gastrointestinal side effects. Risk of bias was assessed using the Cochrane Risk of Bias tool. A Bayesian meta-analysis was performed to estimate the pooled OR of gastrointestinal side effects. RESULTS: Nine trials involving 2746 preterm infants were analysed. Seven trials assessing necrotising enterocolitis and four trials assessing feeding intolerance in our meta-analysis found no differences between caffeine and placebo (OR=1.007 (95% credible interval 0.021, 5.462), I2=97.4%, and OR=1.266 (95% credible interval 0.064, 28.326), I2=84.8%, respectively). Four trials assessed the outcomes spontaneous intestinal perforation, constipation, gastrointestinal disorder (composite outcome: gastro-oesophageal regurgitation or dilated bowel loops), age at oral feeding and cholestasis syndrome and found no differences between groups. One trial assessed the outcomes gastro-oesophageal symptoms and duration of tube feeding and found that caffeine was associated with a reduced burden of gastro-oesophageal reflux symptoms at 2 weeks (p<0.05), but not at term. CONCLUSIONS: According to this systematic review and meta-analysis, the use of caffeine at usual doses in preterm infants does not seem to be associated with significant gastrointestinal adverse effects.

Lingual Frenotomy in Pediatric Ankyloglossia: A Diode Laser Approach in Two Case Reports.

Ankyloglossia can be related to a number of complications, such as breastfeeding difficulties or alterations in craniofacial development. Treatment can involve surgery to correct the altered lingual frenulum and can be performed by various techniques. The purpose of this paper is to present two case reports of ankyloglossia in pediatric patients of different ages, the diagnostic criteria, and the treatment decision rationale, which led to a lingual frenotomy performed with a diode laser.

Neonatal Renal Failure Following Intrauterine Exposure to an Angiotensin-Converting Enzyme Inhibitor.

The renin-angiotensin-aldosterone system (RAAS) plays a crucial role in the normal development of the fetal kidney. Late pregnancy blockage of the RAAS, through in-utero exposure to angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers, is associated with poor fetal outcomes, including oligohydramnios, renal tubular dysplasia, postnatal anuric renal failure, and hypotension. The present case describes a 39-year-old primigravida that was referred to the emergency department, at 37 weeks, for the evaluation of intrauterine growth restriction and suspected coarctation of the aorta (CoA). She was medicated with enalapril since the 35th week of gestation. She delivered a male infant, weighing 2,110 g, with no apparent malformations. CoA was excluded. During his first day of life, the patient developed anuria, acute renal failure, and hypotension, requiring ionotropic support. Renal ultrasound appeared normal. Diuresis was reinitiated at 48 hours of life after continued supportive measures. Kidney function tests progressively normalized. Additional investigations revealed a low concentration of angiotensin-converting enzyme. The patient is currently 12 months old and has had a favorable evolution. This case highlights the fact that even brief exposure to enalapril in the third trimester may cause RAAS blocker fetopathy. As long-term sequelae of ACEI-exposed infants are poorly described, close follow-up of renal complications is essential. Physicians should be aware of the deleterious effects of RAAS blockers in pregnancy.

Impact of advanced maternal age on neonatal morbidity: a systematic review.

OBJECTIVE: This systematic review aimed to understand the impact of advanced maternal age (AMA) on the neonatal morbidity, based on the available scientific evidence. METHODS: A systematic search was conducted on 22 November 2021, using the PubMed and Scopus databases to identify studies that compared the morbidity of neonates delivered to AMA mothers with that of neonates delivered to non-AMA mothers. RESULTS: Sixteen studies that evaluated the effect of AMA on the neonatal morbidity were included in this review. Nine of these studies found some association between AMA and increased neonatal morbidity (with two of them only reporting an increase in asymptomatic hypoglycemia, and one only reporting an association in twins), six found no association between AMA and neonatal morbidity and one study found a decrease in morbidity in preterm neonates. The studies that found an increase in overall neonatal morbidity with AMA considered older ages for the definition of AMA, particularly ≥40 and ≥45 years. CONCLUSION: The current evidence seems to support a lack of association between AMA and the neonatal morbidity of the delivered neonates. However, more studies focusing on the neonatal outcomes of AMA pregnancies are needed to better understand this topic.

Ankyloglossia, Syndactyly and Polydactyly in the Pediatric Patient.

Ankyloglossia is a congenital alteration in the development of the tongue characterized by the presence of a short or thick lingual frenulum, which leads to a limitation in its movements. There is an associative inconsistency between ankyloglossia and complications with breastfeeding, speech, swallowing, breathing, and the development of orofacial structures, and it is urgent to make more scientific research in this area. In the presence of polydactyly and syndactyly may be also present ankyloglossia. The purpose of this paper is to present two ankyloglossia cases with finger alterations, without a syndromic disease, and lead the medical team to research this topic and make an improved treatment plan for these cases.

Survey of transfusion practices in preterm infants in Europe.

BACKGROUND: Preterm infants commonly receive red blood cell (RBC), platelet and fresh frozen plasma (FFP) transfusions. The aim of this Neonatal Transfusion Network survey was to describe current transfusion practices in Europe and to compare our findings to three recent randomised controlled trials to understand how clinical practice relates to the trial data. METHODS: From October to December 2020, we performed an online survey among 597 neonatal intensive care units (NICUs) caring for infants with a gestational age (GA) of <32 weeks in 18 European countries. RESULTS: Responses from 343 NICUs (response rate: 57%) are presented and showed substantial variation in clinical practice. For RBC transfusions, 70% of NICUs transfused at thresholds above the restrictive thresholds tested in the recent trials and 22% below the restrictive thresholds. For platelet transfusions, 57% of NICUs transfused at platelet count thresholds above 25×109/L in non-bleeding infants of GA of <28 weeks, while the 25×109/L threshold was associated with a lower risk of harm in a recent trial. FFP transfusions were administered for coagulopathy without active bleeding in 39% and for hypotension in 25% of NICUs. Transfusion volume, duration and rate varied by factors up to several folds between NICUs. CONCLUSIONS: Transfusion thresholds and aspects of administration vary widely across European NICUs. In general, transfusion thresholds used tend to be more liberal compared with data from recent trials supporting the use of more restrictive thresholds. Further research is needed to identify the barriers and enablers to incorporation of recent trial findings into neonatal transfusion practice.

Non-pharmacological management of neonatal pain: a systematic review.

INTRODUCTION: Shortly after birth, neonates are exposed to several painful medical procedures, such as newborn metabolic screening, vaccination and venipuncture, without proper management of pain. Unpleasant experiences during the neonatal period are proven to be associated with negative long-term consequences. Non-pharmacological interventions have been studied, although rarely administered and seldom documented. The aim of this systematic review was to assess non-pharmacological approaches to neonatal pain during diagnostic and treatment procedures. EVIDENCE ACQUISITION: Extensive literature research to access randomized controlled trials on non-pharmacological pain management in neonates was performed in MEDLINE (through PubMed), Scopus and Web of Science from October 2011 to September 2021. First analysis included all article titles and abstracts screening to identify relevant studies, and second analysis included a full-text screening of previously selected studies. Eligibility was assessed independently by two authors, and disagreements were resolved by discussion and consensus. In the end, 19 published studies were included, representing a total of 1930 newborns. Main outcome, neonatal pain, was assessed by different neonatal pain evaluation scales. EVIDENCE SYNTHESIS: Non-pharmacological interventions including sucrose/glucose solutions, non-nutritive sucking, breastfeeding, olfactive stimulus, auditory stimulus and sensory stimulus (skin-to-skin care, kangaroo/maternal holding, heat, therapeutic massage, swaddling/facilitated tucking and acupressure) showed decreased behavioral and physiologic pain responses. CONCLUSIONS: Evidence suggests non-pharmacological approaches are safe, effective and can be easily applied in daily practice. There is the need for continued research on non-pharmacological interventions on neonatal pain to help healthcare providers build a tailored pain treatment plan for neonates submitted to procedural pain.

Prevalence, risk factors and predictors of severity of neonatal thrombocytopenia in neonatal Intensive Care Units: a single center study.

BACKGROUND: Thrombocytopenia is a common hematological disorder seen in the neonatal period, especially in newborns admitted to the Neonatal Intensive Care Unit (NICU). The clinical and laboratorial presentation is heterogeneous, with different underlying causes and risk factors. There are still few studies about some possible risk factors and their influence on the newborn's clinical outcome. The aim of this study was to assess the prevalence, risk factors and predictors of severity of thrombocytopenia in a level III NICU. METHODS: The present analysis was the retrospective study of newborns with thrombocytopenia (platelet count less than 150×109/L) admitted from January 1, 2008, to December 31, 2017. Patients included newborns admitted after the first 72 hours of life and those with thrombocytopenia related to surgical intervention were excluded. RESULTS: Out of 187 neonates with thrombocytopenia, a total of 134 neonates were included in the study, corresponding to a prevalence of 3.3%. One hundred fourteen (85%) neonates had an early onset presentation (EOT), and 20 (15%) neonates had a late onset presentation (LOT); 68 (50.7%) neonates had severe and 66 (49.3%) had non-severe thrombocytopenia. Sepsis was identified as an independent predictor of LOT. Sepsis by gram-negative bacteria was identified as an independent predictor for severe thrombocytopenia. CONCLUSIONS: Identification of risk factors, early diagnosis and treatment of the underlying causes are crucial for a better approach of neonatal thrombocytopenia. A strong association between sepsis and sepsis by gram-negative bacteria with LOT and severe thrombocytopenia, respectively, enhances the importance of nosocomial sepsis control in NICU.

Comparison Between Continuous Positive Airway Pressure and High-Flow Nasal Cannula as Postextubation Respiratory Support in Neonates: A Systematic Review and Meta-Analysis.

OBJECTIVE: The interest in noninvasive respiratory support has been increasing, including continuous positive airway pressure and recent respiratory methods, namely high-flow nasal cannula. It is discussed if high-flow nasal cannula can reduce continuous positive airway pressure or invasive ventilation use. This systematic review and meta-analysis aimed to compare continuous positive airway pressure and high-flow nasal cannula as postextubation respiratory support in neonates. MATERIALS AND METHODS: A literature search, based on Preferred Reporting of Items of Systematic Reviews and Meta-Analyses guidelines, was conducted across MEDLINE (through PubMed), Scopus, and Web of Science in 15 years (2006-2021) assessing randomized controlled trials that compared continuous positive airway pressure with high-flow nasal cannula as postextubation interventions in neonates. The primary outcome was extubation failure at 72 hours and/or at 7 days and the secondary outcomes included air leak syndrome, pneumothorax, bronchopulmonary dysplasia, nasal trauma, abdominal distension, and mortality. RESULTS: Seven studies were included, comprising 1044 neonates. No statistically significant differences were found between high-flow nasal cannula and continuous positive airway pressure in extubation failure (at 72 hours and 7 days), air leak syndrome, pneumothorax, bronchopulmonary dysplasia, abdominal distension, and mortality. High-flow nasal cannula was associated with a lower incidence of nasal trauma (odds ratio = 0.21; 95% CI 0.08-0.52; P = .0008). Studies assessing extreme premature infants (<28 weeks) raised some efficacy and safety concerns. CONCLUSION: High-flow nasal cannula may be as effective and safe as continuous positive airway pressure, with similar extubation failure and risk of air leak syndrome, pneumothorax, bronchopulmonary dysplasia, abdominal distension, and mortality with the advantage of less nasal trauma. High-flow nasal cannula should be considered as an alternative to continuous positive airway pressure in postextubation settings in neonates. Further studies are needed to establish efficacy and safety in lower gestational ages.

Perforación de la córnea: una complicación poco común del traumatismo del nacimiento / Corneal perforation: A rare complication of birth trauma

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Cat-Eye Syndrome: A Report of Two Cases and Literature Review.

Cat-eye syndrome is a rare genetic disease that involves the proximal long (q) arm of chromosome 22. The classic clinical triad includes coloboma of the iris, ears, and anal malformations. This syndrome was named "cat eye" due to the vertical coloboma of the iris. However, the spectrum of clinical manifestations is variable, and the iris coloboma may be absent in 40-50% of cases. Association with congenital heart disease is also frequent and its diagnosis should raise suspicion of a genetic condition. We describe two cases of male infants affected by the cat-eye syndrome, of which no one presented the classic clinical triad. One of them had unpredictable complications that led to prolonged neonatal intensive care unit stay. Although having distinct phenotypes, the diagnosis in both cases was made through nonobstructive total anomalous pulmonary venous return, anal imperforation, and craniofacial anomalies. Iris coloboma was an important clue only in one of them. Prenatal diagnosis is a challenge, such that a genetic study is essential for a final diagnosis in the absence of the classic triad.

Large congenital pulmonary airway malformation with mucinous cell clusters - a case report.

We report the clinical case of a 38 weeks gestational age neonate, antenatally diagnosed with a left large macrocystic pulmonary malformation conditioning dextrocardia. At birth, he presented with respiratory distress requiring non-invasive ventilation with high-flow nasal cannula (HFNC). A left inferior lobectomy was performed via thoracotomy on day 21 of life. Histological features of the lesion were compatible with congenital pulmonary airway malformation (CPAM) type I with muci- nous cell clusters. No surgical complications were reported and the neonate was discharged six days after surgery. Follow-up two months after surgery was unremarkable.

Lupus Pneumonitis: Case Report of a Rare Manifestation of Neonatal Lupus.

Neonatal lupus is a rare entity, secondary to placental transfer of antibodies from mothers with immune-mediated conditions. While pulmonary involvement is common in lupus, its incidence in neonates is extremely rare, with very few cases being reported in the literature. The authors report a case of a neonate whose mother was diagnosed with systemic lupus erythematosus, with a prenatal diagnosis of third-degree atrioventricular block. While initially admitted in the neonatal intensive care unit with no need for organ support, he presented progressive respiratory failure, initially attributed to sepsis. Favorable clinical progression after pacemaker placement allowed ventilatory weaning, but respiratory failure was again apparent. Chest computer tomography revealed areas of ground-glass lesions, raising the suspicion for lupus pneumonitis. He was started on immunoglobulin and corticosteroids, with clinical improvement. The authors consider this case to be relevant due to the rarity of acute lupus pneumonitis in neonates, alerting that it must be considered a differential diagnosis in neonates with prolonged ventilator dependency.

Congenital Dislocation of the Knee: Idiopathic or Arthrogryposis?

Fetal akinesia associated with fixed joints is a common cause for suspicion of arthrogryposis multiplex congenita, a severe condition with heterogeneous etiology. We present the case of a rarer but more benign condition, congenital knee dislocation. The authors report the case of a 27-year-old woman medicated with levetiracetam for epilepsy whose prenatal ultrasound at 22 weeks of gestational age revealed bilateral clubfoot, permanent extension of the inferior limbs with internal knee rotation, normal amniotic fluid quantity, and fetal echocardiography. The remaining ultrasounds revealed similar results. Prenatal genetic testing revealed no pathological findings. The pregnancy was otherwise uneventful. A female newborn was delivered at 39 weeks by cesarean section, with no need for resuscitation. She presented with bilateral knee hyperextension and clubfoot, spontaneous movements, and normal mobility in all other joints. The remaining physical examination and brain and hip ultrasound on the second day of life were normal. These findings were compatible with idiopathic congenital dislocation of the knee (CDK). The patient was undergoing treatment with favorable evolution and adequate neurodevelopment, at the time of this report.  This case describes a diagnostic workup with the exclusion of severe syndromic pathologies, namely arthrogryposis. Despite the initial suspicion of arthrogryposis, a condition with a poor prognosis, this infant presented a more benign disease with favorable evolution.

Upper Airway Obstruction in a Newborn: A Rare Cause of Respiratory Distress.

Newborns are considered obligate nasal breathers until the eighth week of life. Therefore, upper nasal obstruction in a newborn can present as a potentially life-threatening complication. Congenital nasal pyriform aperture stenosis (CNPAS) is a rare form of upper airway obstruction caused by a narrowing without occlusion in the most anterior opening of the bony nasal airways. According to the severity of this stenosis, early onset of respiratory symptoms can arise in the newborn. In this article, we present the case of a male term newborn with no prior relevant family history and uneventful gestation delivered in a eutocic manner with an adequate transition to the extra-uterine environment. On his first day of life, progressive respiratory distress, inability to breastfeed, and impossibility to make nasogastric probe progress through both sides of the nose were observed, leading the newborn to be admitted to a neonatal intensive care unit. During imagiological assessment with perinasal computerized tomography (CT) scan, an almost total occlusion of the pyriform aperture and a solitary median maxillary central incisor (SMMCI) were identified. Additional evaluation with brain magnetic nuclear resonance imaging (MRI) was unremarkable with no midline defects identified. Endocrine laboratory assessment was also normal. The newborn underwent pyriform aperture permeabilization surgery via a sublabial approach with bilateral nasal stent introduction, enabling total resolution of the initial respiratory symptoms. No incurrences were reported during the post-operatory follow-up period. With the present case report, the authors are trying to raise awareness for CNPAS not only as a rare cause of respiratory distress in the newborn but also as a clinical entity that can be associated with midline defects, which require further additional investigation and intervention.

Short and Medium-term Outcomes of Omphalocele and Gastroschisis: A Survey from a Tertiary Center.

OBJECTIVE: To characterize and compare the outcomes of omphalocele and gastroschisis from birth to 2 years of follow-up in a recent cohort at a tertiary center. METHODS: This is a retrospective clinical record review of all patients with gastroschisis and omphalocele admitted to the Neonatal Intensive Care Unit between January 2009 and December 2019. RESULTS: There were 38 patients, 13 of whom had omphalocele, and 25 of whom had gastroschisis. Associated anomalies were present in 6 patients (46.2%) with omphalocele and in 10 (41.7%) patients with gastroschisis. Compared with patients with omphalocele, those with gastroschisis had younger mothers (24.7 versus 29.6 years; p = 0.033), were born earlier (36 versus 37 weeks, p = 0.006), had lower birth weight (2365 ± 430.4 versus 2944.2 ± 571.9 g; p = 0.001), and had a longer hospital stay (24 versus 9 days, p = 0.001). The neonatal survival rate was 92.3% for omphalocele and 91.7% for gastroschisis. Thirty-four patients were followed-up over a median of 24 months; 13 patients with gastroschisis (59.1%) and 8 patients with omphalocele (66.7%) had at least one adverse event, mainly umbilical hernia (27.3% vs 41.7%), intestinal obstruction (31.8% vs 8.3%), or additional surgical interventions (27.3% vs 33.3%). CONCLUSION: Despite the high proportion of prematurity, low birth weight, and protracted recovery, gastroschisis and omphalocele (without chromosomal abnormalities) may achieve very high survival rates; on the other hand, complications may develop in the first years of life. Thus, a very positive perspective in terms of survival should be transmitted to future parents, but they should also be informed that substantial morbidity may occur in the medium term.

OBJETIVO: Caracterizar e comparar os desfechos do onfalocelo e gastrosquisis desde o nascimento até aos 2 anos de seguimento numa coorte recente de um centro terciário. MéTODOS: Este é um estudo retrospectivo em que foi feita uma revisão dos registos clínicos de todos os pacientes com gastrosquisis e onfalocelo que foram internados na unidade de cuidados intensivos neonatais, entre janeiro de 2009 e dezembro de 2019. RESULTADOS: Identificamos 38 pacientes, 13 dos quais tinham onfalocelo e 25 dos quais tinham gastrosquisis. Anomalias associadas estavam presentes em 6 pacientes (46.2%) com onfalocelo e 10 (41.7%) com gastrosquisis. Comparativamente com os pacientes com onfalocelo, os pacientes com gastrosquisis tinham mães mais jovens (24.7 versus 29.6 anos; p = 0.033), nasceram mais precocemente (36 versus 37 semanas, p = 0.006), com menor peso ao nascimento (2,365 ± 430.4 versus 2,944.2 ± 571.9 g; p = 0.001), e o internamento teve uma duração mais longa (24 versus 9 dias, p = 0.001). A taxa de sobrevivência neonatal foi de 92.3% para o onfalocelo e 91.7% para a gastrosquisis. Trinta e quatro pacientes foram seguidos durante um tempo mediano de seguimento de 24 meses: 13 com gastrosquisis (59.1%) e 8 com onfalocelo (66.7%) apresentaram pelo menos um evento adverso, sobretudo hérnia umbilical (27.3% vs 41.7%), obstrução intestinal (31.8% vs 8.3%) ou intervenções cirúrgicas adicionais (27.3% vs 33.3%). CONCLUSãO: Apesar da alta proporção de prematuridade, de baixo peso e de recuperação lenta, os gastrosquisis, assim como os onfalocelos (sem anomalias cromossómicas), podem ter uma taxa de sobrevivência muito alta; por outro lado, nos primeiros anos de vida, podem surgir complicações não desprezíveis. Assim, aos futuros pais pode ser transmitida uma perspectiva muito positiva em termos de sobrevivência, embora eles também devam ser informados de que pode ocorrer morbidade substancial no médio prazo.

Developmental hemostasis in the neonatal period.

BACKGROUND: The hemostatic system is complex and evolves continuously since gestation and well into the adult years, in a process known as "developmental hemostasis." DATA SOURCES: A comprehensive review was performed after an extensive literature search on PubMed/MEDLINE concerning developmental hemostasis during the neonatal period. Relevant cross references were also included. RESULTS: Although part of a system, each component of the hemostatic system evolves differently, with many displaying both quantitative and qualitative age-related differences. This leads to drastic disparities between the coagulation system of neonates and both other children's and adults', while still maintaining a generally balanced and physiological hemostasis. The motives behind this process remain to be fully elucidated but may be, at least in part, related to non-hemostatic factors. CONCLUSIONS: Knowledge regarding "developmental hemostasis" is essential for everyone caring for newborns or even children in general and in this review, we describe each hemostatic system component's neonatal characteristics and age-related progression as well as explore some of the possible physiological motives behind the process.