Factors Affecting the Implementation and Acceptance of the Cocoon Strategy in the NICU in a Tertiary Center in Türkiye.

Pertussis is an important cause of mortality and morbidity in infancy. It is recommended that close contacts of the baby be vaccinated with Tdap, and this practice is called the cocoon strategy. This study aimed to investigate the applicability of the cocoon strategy and to determine the factors affecting the process. Mothers of babies who were hospitalized in the neonatal intensive care unit were included in the study. In the first stage, a face-to-face questionnaire was given to the mothers to measure their level of knowledge about whooping cough and its vaccine. In the second stage, written and verbal information about the cocoon strategy was given, and then vaccination intentions for Tdap were learned. In the third stage, all mothers were contacted 3 weeks after and asked whether they had received a Tdap vaccination and why. Of these mothers, 68% could not answer any questions about pertussis disease and vaccines correctly. After the information, 35% (n = 78) of the mothers stated that they were considering getting vaccinated, while only 2% (n = 5) of the mothers were able to get the Tdap vaccine. The most important reasons for not getting vaccinated were a lack of time (24%) and the cost of vaccination (23%). It is predicted that Tdap vaccination rates may increase if the cost of vaccine, availability of vaccine, and the access of mothers to the vaccine application are facilitated.

A comparison of chlorhexidine and povidone-iodine solutions in neonatal intensive care units.

BACKGROUND: Povidone-iodine (10%; PI) and 2% chlorhexidine in 70% isopropyl alcohol (CHG-IA) solutions are among the most widely used disinfectants in the neonatal intensive care units. This study compares the use of these disinfectants and helps decide which is superior to the other for neonatal use. METHODS: All term and preterm infants born and hospitalized in Bursa Uludag University Hospital between July 2018-March 2020 were included. The infants were randomized into two disinfectant groups before birth. The application site was cleaned with the assigned disinfectant before intervention. The infants were screened for rates of neonatal sepsis, thyroid-stimulating hormone (TSH) levels, free thyroxine (fT4) levels, skin reactions to the assigned solution, and acute neurological side effects. RESULTS: We enrolled 208 term and preterm infants (PI:104 vs. CHG-IA: 104) in the study. The prematurity rates were identical (PI: 74.0%; CHG-IA: 72.1%; p = 0.755). Neonatal sepsis rates among these groups were not statistically different (PI: 8.7%; CHG-IA: 4.8%; p = 0.406). The median TSH value of the PI group was high (4.05 mIU/L) in comparison with that of the CHG-IA group (3.09 mIU/L; p = 0.016). No cutaneous or neurological side effects were recorded in patients treated with CHG-IA solution. CONCLUSIONS: Although these two solutions were equally protective against infections, the CHG-IA solution was a better alternative to PI for neonatal use. Considering that the PI solution may be responsible for impaired thyroid function, the CHG-IA solution is a good alternative because it provides sufficient protection with a safer adverse effect profile.

Radiation Exposure in the Neonatal Intensive Care Unit in Newborns and Staff.

OBJECTIVE: Portable X-rays remain one of the most frequently used diagnostic procedures in neonatal intensive care units (NICU). Premature infants are more sensitive to radiation-induced harmful effects. Dangers from diagnostic radiation can occur with stochastic effects. We aimed to determine the radiation exposure in premature infants and staff and determine the scattering during X-ray examinations in the NICU. STUDY DESIGN: In this prospective study, dosimeters were placed on premature infants who were ≤1,250 g at birth and ≤30 weeks of gestational age who stayed in the NICU for at least 4 weeks. The doses were measured at each X-ray examination during their stay. The measurements of the nurses and the doctors in the NICU were also performed with dosimeters over the 1-month period. Other dosimeters were placed in certain areas outside the incubator and the results were obtained after 1 month. RESULTS: The mean radiation exposure of the 10 premature infants, monitored with dosimeters, was 3.65 ± 2.44 mGy. The mean skin dose of the six staff was 0.087 ± 0.0998 mSV. The mean scattered dose was 67.9 ± 26.5 µGy. CONCLUSION: Relatively high exposures were observed in 90% of the patients and two staff. The radiation exposure levels of premature infants and staff may need to be monitored continuously. KEY POINTS: · The premature infants are exposed to radiation due to the bedside X-rays.. · The radiation exposure levels of premature infants and staff may need to be monitored continuously.. · Measures and alternative methods to reduce radiation exposure should be encouraged..

The prevalence and diagnostic criteria of health-care associated infections in neonatal intensive care units in Turkey: A multicenter point- prevalence study.

BACKGROUND: Healthcare-acquired infections (HAIs) in the neonatal period cause substantial morbidity, mortality, and healthcare costs. Our purpose was to determine the prevalence of HAIs, antimicrobial susceptibility of causative agents, and the adaptivity of the Centres for Disease Control and Prevention (CDC) criteria in neonatal HAI diagnosis. METHODS: A HAI point prevalence survey was conducted in the neonatal intensive care units (NICUs) of 31 hospitals from different geographic regions in Turkey. RESULTS: The Point HAI prevalence was 7.6%. Ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections (CLABSI) and late onset sepsis were predominant. The point prevalence of VAP was 2.1%, and the point prevalence of CLABSI was 1.2% in our study. The most common causative agents in HAIs were Gram-negative rods (43.0%), and the most common agent was Klebsiella spp (24.6%); 81.2% of these species were extended spectrum beta-lactamase (ESBL) (+). Blood culture positivity was seen in 33.3% of samples taken from the umbilical venous catheter, whereas 0.9% of samples of peripherally inserted central catheters (PICCs) were positive. In our study, 60% of patients who had culture positivity in endotracheal aspirate or who had purulent endotracheal secretions did not have any daily FiO2 change (p = 0.67) and also 80% did not have any increase in positive end-expiratory pressure (PEEP) (p = 0.7). On the other hand, 18.1% of patients who had clinical deterioration compatible with VAP did not have endotracheal culture positivity (p = 0.005). CONCLUSIONS: Neonatal HAIs are frequent adverse events in district and regional hospitals. This at-risk population should be prioritized for HAI surveillance and prevention programs through improved infection prevention practices, and hand hygiene compliance should be conducted. CDC diagnostic criteria are not sufficient for NICUs. Future studies are warranted for the diagnosis of HAIs in NICUs.

The danger awaiting premature babies: Portal vein thrombosis.

AIM: Umbilical venous catheters are frequently used in the neonatal period. The incidence of umbilical venous catheter-related thrombosis is between 1.3% and 43% in ultrasound scans. This study aimed to determine the incidence and risk of portal vein thrombosis in patients who were hospitalized in the neonatal intensive care unit and underwent umbilical venous catheter insertion. MATERIAL AND METHODS: Premature infants (≤32 gestational weeks) who were hospitalized in a Level III neonatal intensive care unit and underwent umbilical vein catheter placement between 2016 and 2018, were included in the study. The demographic data, clinical risk factors for thrombosis, number of catheter days, catheter locations, times of detection of thrombosis using Doppler ultrasonography, treatment methods and durations, thrombosis follow-up and examinations were obtained retrospectively from the electronic patient files. RESULTS: Ninety-six patients whose complete data could be reached were enrolled in the study. The mean gestational age of the patients was found as 29±2 weeks and the mean birth weight was 1353±369 g. Portal vein thrombosis was detected in 13.5% (n=13) of the patients. Five of the cases of portal vein thrombose were complete occlusion and eight were partial occlusion. All patients with complete occlusion and six patients with partial occlusion were treated with low-molecular-weight heparin for a mean duration of 31±13.8 days. Thrombosis disappeared in 7-120 days in all patients. A thrombophilia mutation was detected in six patients with thrombosis, four of whom had the PAI-1 4G / 5G mutation. CONCLUSION: Portal vein thrombosis which has a significant place among the causes of portal hypertension in childhood, is mostly asymptomatic in the neonatal period and cannot be recognized clinically. It is important to screen and follow up patients with umbilical vein catheters using Doppler ultrasonography in terms of PVT after catheter removal to prevent long-term complications.

The effects of maternal preeclampsia on inflammatory cytokines and clinical outcomes in premature infants.

OBJECTIVE: To investigate the effects of maternal preeclampsia on inflammatory cytokines and neonatal outcomes in premature infants. METHODS: The study included preterm infants born at gestational age ≤32 weeks in a tertiary university hospital between January 2016 and January 2017. The study group consisted of infants born from mothers with preeclampsia (Group-1), and the control group consisted of infants born from normotensive mothers (Group-2). Demographic characteristics and clinical outcomes of the infants were recorded. IL-6, IL-8, IL-10, and TNF-α cytokine levels were measured from umbilical cord blood samples. RESULTS: A total of 108 infants were included in the study, of which 34 were in the Group-1 and 74 in the Group-2. Gestational ages (29 vs 30 weeks) of the infants in both groups were similar. There was no significant difference between the cytokine levels of infants with and without preeclampsia. The rate of small for gestational age, retinopathy of prematurity, intraventricular hemorrhage, necrotizing enterocolitis, neutropenia, and thrombocytopenia were significantly higher at the infants with preeclampsia. CONCLUSION: Maternal preeclampsia leads to an increase at the neonatal morbidities in premature infants without causing a significant alteration at the cytokine levels in cord blood.

[Evaluation of Micafungin Use in Children]. / Çocuklarda Mikafungin Kullaniminin Degerlendirilmesi.

Micafungin is recommended especially in patients with liver and kidney failure and in the presence of other side effects due to antifungals apart from its known priority indications such as invasive candidiasis. The aim of this study was to evaluate the children who have received micafungin treatment. In the study, 125 children who were hospitalized in the pediatric wards and intensive care units of our hospital and had used micafungin between November 2016 and January 2019 were analyzed retrospectively. Clinical data, micafungin indication, blood values on the first and fourth days of the treatment, side effects of the drug and efficacy were evaluated. Sixty percent (75/125) of the patients were male and the mean age of all the patients were 58 ± 67 (0-215, 30) months. Approximately half of the cases (48%) had malignancy and 13% of them were premature. Sixty-two percent (n= 37) of the malignencies were hematological (27 acute lymphocytic leukemia, nine acute myeloid leukemia, one myelodysplastic syndrome) and 38% (n= 23) were oncological (six neuroblastoma, four Hodgkin lymphoma, two Non-Hodgkin's lymphoma, five sarcomas, one hepatoblastoma, five others) malignencies. The major cause of hospitalization was sepsis (53%). The patients had several risk factors like immunosuppressive therapy (n= 68, 54%), neutropenia (n= 61, 49%), central venous catheter (n= 102, 82%), nasogastric tube (n= 63, 50%), endotracheal intubation tube (n= 49, 39%), urinary catheter (n= 14, 11%) and total parenteral nutrition (n= 81, 65%). Thirteen percent (n= 16) of the cases were post-operative patients. Candida species were cultivated in 97 clinical specimens (blood, endotracheal aspirate, sputum, urine, etc.) among 23 (18%) of the patients. Thirteen (10%) of the patients had candidemia and 62% of them were non-albicans strains. In all candidemias, strains were echinocandin susceptible, and blood cultures were negative within four days. When all the patients (n= 125) were evaluated, a significant decrease in C-reactive protein, an increase in sodium, and a decrease in alanine aminotransferase were observed on the fourth day of micafungin treatment (p<0.05). A total of 39 (31%) patients underwent various antifungal treatments for median seven (1-60) days prior to micafungin treatment. Fourteen (36%) of these 39 patients, had elevated liver function tests (LFT), 10 (26%) of them had hypokalemia, and five (13%) of them had elevated renal function tests. Ten (26%) patients had antifungal-induced hypokalemia previously; and potassium levels were normalized after micafungin treatment (p= 0.0001). The patients for which micafungin treatment was chosen due to elevated liver function tests (n= 47, 38%), whether the antifungalinduced or not; alanine aminotransferase and aspartate aminotransferase levels were decreased after micafungin treatment (p= 0.0001 and p= 0.0001, respectively). Nineteen (15%) of the patients have died within the first 30 days of micafungin treatment and one of them had candidemia. No micafungin treatment related significant side effects were observed in any of the patients. Our study showed that micafungin could be a safe and effective option in pediatric cases including newborns with high liver and kidney function tests.

Does antenatal magnesium sulphate improve hearing function in premature newborns?

Objective: To evaluate whether antenatal magnesium sulphate (MgSO4) exposure has a neuroprotective effect against hearing impairment in premature newborns. Material and Methods: Retrospective cohort study was performed with prematurely (<37 weeks) delivered newborns at a tertiary university hospital. Newborns of 92 women who received MgSO4 infusions (study group) for various indications were compared to newborns of 147 women who did not receive MgSO4 infusions (control group). All eligible premature newborn underwent hearing screening by auditory brainstem response (ABR) testing before being discharged from the hospital. Results: The fail rate for ABR hearing screening was 3.3% (n=3) in the study group and 10.9% (n=16) in the control group (p=0.034). The rate of concurrent use of betamethasone was higher in the study group (72.8%; n=67) compared to control group (29.2%; n=43) (p<0.001). Other neonatal parameters, such as the number of neonates who were small for gestational age and the rate of microcephaly were similar between the groups (p=0.54, p=0.48, respectively). After adjusting for co-variates including the use of betamethasone and gestational age at delivery, no statistically significant association between antenatal administration of MgSO4 and ABR fail rates were found (p=0.07). Conclusion: These results do not suggest a significant benefit in terms of hearing impairment in premature newborns when antenatal MgSO4 infusion was given.

What should be the protein target for adjustable Human Milk fortification in premature infants?

OBJECTIVE: To assess the short- and long-term effects of the adjustable fortification (ADJ) regimen on growth parameters in premature infants and to evaluate the amount of protein supplements given to reach the targeted blood urea nitrogen (BUN) levels. METHODS: In this retrospective study, preterm babies who were born at ≤32 weeks gestational age and fed with human milk, were evaluated in two groups. Infants in Group-I were fed only standard fortification (STD). Infants in Group-II were fed the ADJ regimen. The study was conducted between 2011 and 2016. RESULTS: There were 123 infants in the STD group and 119 in the ADJ group. The mean gestational age of the patients in Group-I was 29.7±1.8 weeks, and mean birth weight was 1266.1±347.1 g. The mean gestational age of the patients in Group-II was 29.5±1.9 weeks, and the mean birth weight was 1217.5±345.5 g. The daily increase in weight and weekly increase in HC were significantly higher in the ADJ group infants. Weight and HC of infants in the ADJ group were significantly higher at 40 weeks. At one year corrected age, weight, length, and HC measurements of both groups were similar. In Group-II, 63% of patients required additional protein supplementation up to 1.6 g/day to achieve the target BUN levels. CONCLUSION: A higher protein intake through the ADJ regimen improves the physical growth rate of premature infants in the NICU and after discharge. However, sometimes, the targeted growth and BUN values cannot be achieved despite the administration of protein at the recommended increased doses. Increasing protein supplementation up to 1.6 g/day is safe, feasible, and beneficial for these infants.

[Results of the use of micafungin in newborns]. / Yenidoganlarda mikafungin kullanimi sonuçlari.

Invasive candidiasis is a common and serious infection in premature newborns. Preventing and treating fungal infections is very important to improve the prognosis of premature infants. Fluconazole and amphotericin B are used as the first choice in the treatment of invasive fungal infections of the newborns. In some cases, fluconazole and amphotericin B cannot be used due to nephrotoxicity, hepatotoxicity or resistant strains. Micafungin, which is among recently developed echinocandins, is the drug of choice in these cases. The use of micafungin in newborns is new and there is a limited experience about the effect of high dose usage in the central nervous system. The aim of this study was to evaluate the electronic files of patients who used micafungin for the treatment of culture-proven or possible invasive fungal infection during their hospital stay in the neonatal intensive care unit during a 24-month period (2016-2017) in the third-level intensive care unit. A total of 15 patients (10 premature and 5 term babies) were included in the study. The mean birth weight of the patients was 1732 ± 999 g and the mean gestational age was 32.2 ± 5.8 weeks. All patients had long-term intensive care and increased risk of invasive candidiasis infection. Central venous catheterization and multiple antibiotics usage were the most common risk factors in these patients. The other risk factors included intubation, total parenteral nutritional use and surgical procedure application. Candida species were isolated from the cultures of four patients. Candida species isolated from patients were Candida albicans, Candida glabrata, Candida catenulata, Candida parapsilosis. The mean time for onset of micafungin was 29.9 ± 16.6 days. Mean duration of micafungin therapy was 22.4 ± 11.2 days. Eight patients received amphotericin B, three patients received fluconazole therapy and four patients did not receive any antifungal therapy before the onset of micafungin. None of these patients had an abnormal kidney or liver function tests due to micafungin use. As a conclusion, high dose (10 mg/kg/day) micafungin is a safe and effective treatment choice both in the treatment of neonatal culture proven or probable invasive candida infections that were caused by refractory Candida strains, and in the case of nephrotoxicity and hepatotoxicity.

Recombinant Activated Factor VIIa (rFVIIa) Treatment in Very-Low-Birth-Weight (VLBW) Premature Infants with Acute Pulmonary Hemorrhage: A Single-Center, Retrospective Study.

AIM: We aimed to evaluate the efficacy of intravenous administration of recombinant activated factor VIIa (rFVIIa) for acute pulmonary hemorrhage treatment in very-low-birth-weight (VLBW) premature infants. PATIENTS AND METHODS: This study was carried out retrospectively in premature infants with pulmonary hemorrhage that were ≤30 weeks gestational age or <1250 g birth weight. The data of all VLBW premature infants with pulmonary hemorrhage who were hospitalized in our neonatal intensive care unit between 01 January 2013 and 31 December 2015 were evaluated. Group 1 (n = 21) received rFVIIa support within the first 30 min of pulmonary hemorrhage plus conventional treatment, while Group 2 (n = 21) received conventional treatment only. RESULTS: The number of patients whose pulmonary hemorrhage was stopped within the first 2 h was significantly higher in Group 1 than Group 2 (n = 14 vs n = 4; p = 0.002). After pulmonary hemorrhage, hemoglobin values of Group 1 were higher than Group 2 (11.12 ± 1.06 vs 10.14 ± 1.59 g/dL; p = 0.024). Erythrocyte suspension (1.43 ± 4.51 vs 5.71 ± 7.46 mL/kg; p = 0.030) and fresh frozen plasma use (5.71 ± 8.10 vs 19.52 ± 12.44 mL/kg; p < 0.001) in Group 1 were lower than those of Group 2. Prothrombin time, activated partial thromboplastin time, and international normalized ratio values in Group 1 were lower than those of Group 2 (p < 0.05). No statistically significant difference was identified in recurrence of pulmonary hemorrhage after 72 h, overall mortality, mortality from pulmonary hemorrhage, surfactant use, intubation time, hospitalization duration, intraventricular hemorrhage (IVH), severe IVH, patent ductus arteriosus rates, or short-term complication rates. CONCLUSION: rFVIIa administration was observed to be effective in stopping pulmonary hemorrhage, reducing blood product requirement, and improving coagulation test parameters. Prospective studies are needed to evaluate the efficacy, reliability, and long-term results of rFVIIa in the prevention and treatment of pulmonary hemorrhage in premature infants.