Neonatal Resuscitation Practices in Turkey: A Survey of the Turkish Neonatal Society and the Union of European Neonatal and Perinatal Societies.

OBJECTIVE: Optimal care in the delivery room is important to decrease neonatal morbidity and mortality. We aimed to evaluate neonatal resuscitation practices in Turkish centers. MATERIALS AND METHODS: A cross-sectional survey consisted of a 91-item questionnaire focused on delivery room practices in neonatal resuscitation and was sent to 50 Turkish centers. Hospitals with <2500 and those with ≥2500 births/year were compared. RESULTS: In 2018, approximately 240 000 births occurred at participating hospitals with a median of 2630 births/year. Participating hospitals were able to provide nasal continuous-positiveairway-pressure/high-flow nasal cannula, mechanical ventilation, high-frequency oscillatory ventilation, inhaled nitric oxide, and therapeutic hypothermia similarly. Antenatal counseling was routinely performed on parents at 56% of all centers. A resuscitation team was present at 72% of deliveries. Umbilical cord management for both term and preterm infants was similar between centers. The rate of delayed cord clamping was approximately 60% in term and late preterm infants. Thermal management for preterm infants (<32 weeks) was similar. Hospitals had appropriate equipment with similar rates of interventions and management, except conti nuous-positive-airway-pressure and positive-end-expiratory-pressure levels (cmH2O) used in preterm infants (P = .021, and P = .032). Ethical and educational aspects were also similar. CONCLUSIONS: This survey provided information on neonatal resuscitation practices in a sample of hospitals from all regions of Turkey and allowed us to see weaknesses in some fields. Although adherence to the guidelines was high among centers, further implementations are required in the areas of antenatal counseling, cord management, and circulation assessment in the delivery room.

First report of surgery for anencephaly in twin pregnancies: Technical notes and postoperative management.

Anencephaly, the most severe form of neural tube defect, has no known cure, and in most cases, patients die before or shortly after birth. To date, no surgical intervention has been reported in the management of anencephaly. This study presents a case of dichorionic-diamniotic twin pregnancy in which 1 twin was anencephalic and describes the surgical management of this complex case. We aimed to share the problems experienced during the follow up of a patient who survived for a long time after surgery. We also aimed to highlight several clinical issues, including the challenges of managing anencephaly in twin pregnancies, problems experienced during the follow up process in our case, diagnosis of brain death in anencephaly cases, and ethical dilemmas related to organ donation. This case is notable because of the challenging nature of the surgical procedure and complexity of postoperative care. By highlighting the difficulties encountered during the follow up period, we hope to provide insights to health professionals that can inform the management of similar cases in the future.

New parameters on prediction of severity of transient tachypnea of the newborn.

BACKGROUND: Transient tachypnea of the newborn (TTN) is a common clinical problem that often occurs in the first hours of life. Although it is considered to be a benign clinical course, some cases may have severe symptoms and require ventilation support. In this study, we aimed to determine the association between the mean platelet volume (MPV), nucleated red blood cells (NRBCs), right ventricular systolic pressure (RVSP), and the severity of TTN. METHODS: Patients with TTN were divided into two groups according to Silverman score (<7: group 1 [n: 34] and ≥7: Group 2 [n: 30]). The groups were compared in terms of demographic characteristics, hematologic parameters, and RVSP within the first 24 hours after admission. RESULTS: Mean birth weight of the patients was 3033.4 ± 364.1 g and median gestational age was 38 weeks (min-max: 34-42). Patients in Group 2 were found to require higher nasal continuous positive airway pressure (nCPAP) support and longer duration of oxygen treatment (p: 0.001). Patients in Group 2 had significantly higher thrombocyte, absolute NRBCs count, NRBCs/100 WBCs, and RVSP levels (p < 0.05). Hemoglobin and hematocrit levels were found significantly higher in group 1(p < 0.05). In logistic regression analysis, NRBCs/100 WBCs was found to be the most important independent parameter that affects Silverman score at admission (OR: 7.065, CI: 1.258-39.670, p: 0.026). DISCUSSION: This is the first study that investigates the association between NRBCs, RVSP, and severity of TTN. We think that elevated NRBCs and RVSP values are helpful for clinicians in decision making for referral of the patients to a secondary or a tertiary level of NICU and also inform the families about prognosis.

Nucleated red blood cell levels in the diagnosis of patients with indirect hyperbilirubinemia.

BACKGROUND: Nucleated red blood cells (NRBCs) are progenitores of red blood cells that are physiologically seen in the peripheral blood of the fetus and newborn at birth. The increased numbers of NRBCs in the circulation is associated with pathologic conditions such as prematurity, hemolytic diseases and bleeding, intrauterine growth restriction. We aimed to evaluate the relationship between NRBCs and the demographic and clinical characteristics of the patients with indirect hyperbilirubinemia who were followed up in the neonatal intensive care unit. METHODS: In this retrospective study we evaluated 134 patients with indirect hyperbilirubinemia between January 2017 and December 2018. Patients were divided into two groups as those with ABO and/or Rh incompatibility and those without. Groups were compared in terms of demographic, clinical characteristics and for the hematological parameters. RESULTS: A total of 134 infants were evaluated in the study, including 68 (50%) infants with ABO incompatibility, 12 (8.9%) with Rh incompatibility and 3 (2.2%) with ABO and Rh incompatibility. Coombs test results were positive for 34 patients. There were no differences between ABO and/or Rh incompatibility group and non incompatibility group with regards to birth weight, gestational age and gender. In terms of hematologic parameters, there were no differences between the hemoglobin, hematocrit and mean platelet volumes of the patients at the time of hospitalization, while red cell distribution width, NRBCs per 100 white blood cells (NRBCs/100 WBCs) and absolute NRBC count were statistically higher in patients with ABO and/or Rh incompatibility. It was found that NRBCs/100 WBC and absolute NRBC count were statistically higher in patients with positive direct coombs test than patients with negative coombs test (p <0.05). CONCLUSIONS: Early diagnosis of indirect hyperbilirubinemia is essential, as it can prevent to occur serious neurological sequelas. Elevated levels of NRBCs in infants with blood group incompatibilities could alert clinicians about the severity of jaundice and should increase awareness in terms of hemolysis.

A Comparative Trial of the Effectiveness of Nasal Interfaces Used to Deliver Continuous Positive Airway Pressure for a Brief Period in Infants With Transient Tachypnea of the Newborn / Estudio comparativo sobre la eficacia de las interfaces nasales para la administración de presión positiva continua de la vía aérea durante un periodo breve de tiempo en neonatos con taquipnea transitoria del recién nacido

INTRODUCTION: There is insufficient data on the effectiveness of the interfaces used for nasal continuous airway pressure (nCPAP) in newborn infants. Transpulmonary pressure (PTP) calculated from a measured esophageal pressure (Pes) could be used as a surrogate for the pressure transmitted to the distal airways during nCPAP. We aimed to compare the effectiveness of two nasal interfaces, the nasal mask and bi-nasal short prongs, during a relatively brief period of respiratory support by calculated PTP (cPTP) in infants with transient tachypnea of the newborn (TTN). METHODS: Newborns with TTN who needed respiratory assistance with nCPAP were randomized to use either bi-nasal short prongs or a nasal mask. Esophageal pressure measurements were done in order to calculate PTP with either interface. The primary outcome was the cPTP transmitted with each nasal interface. Esophageal pressure measurements were recorded and PTP values were calculated from Pes measurements at the 1st, 6th, 12th and 24th hours in each patient as long as the respiratory support lasted. RESULTS: Sixty-two newborns with TTN and on nCPAP were randomized into two groups: Group 1 to use bi-nasal short prongs (n: 31) and Group 2 to use a nasal mask (n: 31). Inspiratory and expiratory Pes and cPTP values at the 1st, 6 th, 12 th and 24 th hours were similar with the two interfaces (P < .05). CONCLUSIONS: A nasal mask is similarly effective and safe as bi-nasal short prongs during a brief period of non-invasive respiratory support with nCPAP in late preterm and term neonates with TTN

INTRODUCCIÓN: No hay datos suficientes sobre la eficacia de las interfaces que se utilizan para la administración de presión positiva continua de la vía aérea por vía nasal (CPAPn) en neonatos. La presión transpulmonar (PL), calculada a partir de la medición de la presión esofágica (Pesof), podría utilizarse como alternativa para medir la presión transmitida a la vía aérea distal durante la CPAPn. Nuestro objetivo fue comparar la eficacia de 2 interfaces nasales, la mascarilla nasal y las cánulas binasales cortas, durante un periodo relativamente corto de soporte respiratorio mediante la PL calculada (PLc) en neonatos con taquipnea transitoria del recién nacido (TTRN). MÉTODOS: Los neonatos con TTRN que requirieron ventilación con CPAPn se aleatorizaron para el uso de cánulas binasales cortas o mascarilla nasal. Se realizaron mediciones de la presión esofágica para calcular la PL con cada interfaz. La variable de resultado fue la PLc transmitida con cada interfaz nasal. Las mediciones de presión esofágica se registraron y los valores de PL se calcularon a partir de las mediciones de la Pesof en las 1.ª, 6.a, 12.a y 24.a horas en cada paciente durante el tiempo que durara la ventilación mecánica. RESULTADOS: Se aleatorizaron 62 neonatos con TTRN y tratados con CPAPn en 2 grupos: el grupo 1 usó las cánulas binasales cortas (n = 31) y el grupo 2 usó la mascarilla nasal (n = 31). Los valores inspiratorios y espiratorios de Pesof y PLc en las 1.a, 6.a, 12.a y 24.a horas fueron similares con ambas interfaces (P < 0,05). CONCLUSIONES: La máscara nasal tiene una eficiencia similar a las cánulas binasales cortas durante la administración breve de ventilación mecánica no invasiva mediante CPAPn en neonatos prematuros tardíos y neonatos a término con TTRN

A Comparative Trial of the Effectiveness of Nasal Interfaces Used to Deliver Continuous Positive Airway Pressure for a Brief Period in Infants With Transient Tachypnea of the Newborn.

INTRODUCTION: There is insufficient data on the effectiveness of the interfaces used for nasal continuous airway pressure (nCPAP) in newborn infants. Transpulmonary pressure (PTP) calculated from a measured esophageal pressure (Pes) could be used as a surrogate for the pressure transmitted to the distal airways during nCPAP. We aimed to compare the effectiveness of two nasal interfaces, the nasal mask and bi-nasal short prongs, during a relatively brief period of respiratory support by calculated PTP (cPTP) in infants with transient tachypnea of the newborn (TTN). METHODS: Newborns with TTN who needed respiratory assistance with nCPAP were randomized to use either bi-nasal short prongs or a nasal mask. Esophageal pressure measurements were done in order to calculate PTP with either interface. The primary outcome was the cPTP transmitted with each nasal interface. Esophageal pressure measurements were recorded and PTP values were calculated from Pes measurements at the 1st, 6th, 12th and 24th hours in each patient as long as the respiratory support lasted. RESULTS: Sixty-two newborns with TTN and on nCPAP were randomized into two groups: Group 1 to use bi-nasal short prongs (n: 31) and Group 2 to use a nasal mask (n: 31). Inspiratory and expiratory Pes and cPTP values at the 1st, 6th, 12th and 24th hours were similar with the two interfaces (P<.05). CONCLUSIONS: A nasal mask is similarly effective and safe as bi-nasal short prongs during a brief period of non-invasive respiratory support with nCPAP in late preterm and term neonates with TTN.

Placenta, Secret Witness of Infant Morbidities: The Relationship Between Placental Histology and Outcome of the Premature Infant.

OBJECTIVE: The microscopic and macroscopic features of the placenta can contribute to the clinical understanding of premature delivery. The aim of our study was to figure out the relationship between the histopathological findings of the placentas of premature deliveries and its effects on neonatal morbidity and mortality. MATERIAL AND METHOD: The placentas of 284 singleton preterm infants with < 35 weeks of gestation were examined. Three groups were created as the normal, chorioamnionitis and vasculopathy groups according to the histopathological findings in the placentas of the subjects. RESULTS: The mean gestational age of the infants in the study group was 30.5 ± 3.2 weeks, and the mean birth weight was 1588 ± 581 g. The pathology was normal in ninety-six (33.8%), vasculopathy in 153 (53.9%) and chorioamnionitis in 35 (12.3%). The gestation age of the infants was lower in the chorioamnionitis group. Moreover, retinopathy of prematurity, early onset neonatal sepsis, and duration of respiratory support were found to be higher in the chorioamnionitis group. In the vasculopathy group, preeclampsia and small for gestational age were found to be significantly higher. CONCLUSION: Histopathological findings of the placentas from preterm deliveries provided important data in determining the etiology of preterm delivery and outcomes of infants. Infants delivered by mothers with chorioamnionitis were particularly found to be more preterm, and these preterm infants would have a longer hospital stay, higher respiratory support requirement, and more serious morbidities.

Health care-associated infection surveillance: A prospective study of a tertiary neonatal intensive care unit.

INTRODUCTION: Health care-associated infection (HCAI) is a serious problem of neonatal intensive care units (NICUs) which is related to morbidity, mortality and increased cost of medical care. This study aimed to determine the incidence of HCAI in a tertiary NICU and identify the risk factors. METHODOLOGY: This prospective cohort study was conducted between July 1, 2011 and June 30, 2012. All newborns admitted to the NICU except for those who died or were discharged within 48 hours after admission were included. The definitions of Centers for Disease Control and Prevention (CDC) were used to diagnose specific types of infections. The incidence, causative organisms, risk factors and mortality of HCAIs were evaluated. RESULTS: Among 352 newborns, a total of 60 HCAI episodes were evaluated in 37 (10.5%) of the patients over 5,212 patient-days. The overall incidence of HCAI was 17%, and the rate was 11.5/1,000 patient-days. Blood stream infection (BSI) was the most common HCAI (n = 42, 70%). In a multivariable logistic regression analysis, the presence of a central venous catheter/umbilical catheter (CVC/UC), the presence of a urinary catheter, and gestational age (< 32 weeks of gestation) were identified as significant independent risk factors. Gram-negative pathogens were the most common isolates. The overall mortality rate was 4%. The HCAI-related mortality rate was 10.8%. CONCLUSIONS: Patient care quality can be improved with surveillance of HCAI. The incidence and rate of HCAI in our NICU were found to be higher than international reports with a direct impact on mortality of preterm infants.

A rare chromosomal disorder in a newborn: Trisomy 3q.

Kahvecioglu D, Tatar-Aksoy H, Yildiz E, Bakir A, Alioglu B. A rare chromosomal disorder in a newborn: Trisomy 3q. Turk J Pediatr 2019; 61: 271-274. Trisomy 3q is a rare chromosomal disorder that leads to multiple congenital abnormalities. We hereby present a patient with chromosomal karyotype 46, XY, dup (3)(q23-29), which can be classified as pure 3q duplication and has thin sclera and iris dysgenesis, anterior and posterior segment dysgenesis besides the previously identified specific facial features. To the best of our knowledge only 12 cases have been reported with pure duplication in the literature. Our case is the 13th one reported and has noval findings concerning eye involvement. The ocular manifestations of the 3q duplication syndrome provide additional evidence of the involvement of genes which are responsible for eye development in this chromosomal region.

Influence of platelet count, platelet mass index, and platelet function on the spontaneous closure of ductus arteriosus in the prematurity.

BACKGROUND: This study aims at evaluating the influence of platelet count, platelet mass index, and platelet function on the spontaneous closure of ductus arteriosus in prematurity. METHODS: All preterm babies were divided into two groups, including Group 1 with "open PDA" and Group 2 with "closed PDA". The variables of platelet count, mean platelet volume, platelet mass index, and platelet function were analyzed and compared between two groups of patients to identify the factors that significantly influenced spontaneous closure of ductus arteriosus. RESULTS: Twenty-four patients were in the "open PDA" group, whereas 36 patients were in the "closed PDA" group. Mean GA and BW were 27.6 ± 1.8 (23.1-30.4) and 28 ± 1.6 (23.4-30.6) weeks and 1009 ± 270 (585-1480) g and 1035 ± 298 (505-1500) g in "open PDA" and "closed PDA" groups, respectively (p > 0.05). The incidence of "Collagen-ADP > 130 s" was significantly higher in the "open PDA" group, and the levels of hemoglobin and hematocrit were significantly lower in the "open PDA" group (p < 0.05). Multivariate logistic regression analysis showed that respiratory distress syndrome (OR: 9, CI: 1.5-51.8) and collagen-ADP > 130 s (OR: 5.7 CI: 1.55-21.3) are two independent factors associated with ductal patency. CONCLUSION: This is the first study in the English literature providing evidence of the influence of platelet dysfunction on the spontaneous closure of ductus arteriosus in prematurity. Longer collagen-ADP duration is identified as a risk factor of ductal closure.

Transient tachypnea of the newborn: are there bedside clues for predicting the need of ventilation support?

Decision making to transfer a late preterm or term neonate with the diagnosis of transient tachypnea of the newborn (TTN) to an intensive care unit for respiratory support is a challenge for caregivers in level one and two NICUs. The aim of this study was to identify "practical bedside clinical clues" that may help to predict the severity of disease and need for respiratory support in patients with the diagnosis of TTN. Newborns having the diagnosis of TTN were classified into two groups according to the intensity of the respiratory support. Infants receiving only supplemental oxygen and infants requiring nasal continuous positive airway pressure or mechanical ventilation constituted group 1 (mild) and group 2 (severe), respectively. Demographic, clinical and laboratory characteristics were compared between the two groups. Patients in group 2 had lower gestational age, higher Silverman and Richardson scores, longer mean duration of oxygen support and hospitalization. A positive correlation was found between subcostal and xiphoid retractions, asynchrony in chest-abdomen movements, arterial pH < 7.30, ratio of PaO < sub > 2 < /sub > / % inspired O < sub > 2 < /sub > < 1.2 and need of respiratory support (p < 0.05). We suggest that simple scores can help physicians to get a good sense of a given baby's likelihood of deterioration.

Impact of Prophylactic Continuous Positive Airway Pressure on Transient Tachypnea of the Newborn and Neonatal Intensive Care Admission in Newborns Delivered by Elective Cesarean Section.

OBJECTIVE: This study aims to evaluate the effect of the prophylactic continuous positive airway pressure (CPAP) administration in the delivery room to newborns who were delivered by elective cesarean section (CS). STUDY DESIGN: Inborn infants with gestational age between 34(0/7) to 38(6/7) and born by elective CS were prospectively randomized to receive either prophylactic CPAP for 20 minutes via face mask or standardized care without CPAP in the delivery room. Primary outcomes were the incidence of transient tachypnea of the newborn (TTN) and neonatal intensive care unit (NICU) admission due to respiratory distress. RESULTS: A total of 259 infants with a mean gestational age of 37.7 ± 0.8 weeks and birth weight of 3,244 ± 477 g were included. A total of 134 infants received prophylactic CPAP and 125 received control standard care. The rate of NICU admission was significantly lower in prophylactic CPAP group (p = 0.045). Although the rate of TTN was lower in the prophylactic CPAP group, the difference was not statistically significant (p = 0.059). The rate of NICU admission due to respiratory distress was significantly higher in late-preterm cohort than early-term cohort (p < 0.0001). CONCLUSION: Prophylactic CPAP administration decreases the rate of NICU admission without any side effect in late-preterm and early-term infants delivered by elective CS.

Report of a case of neonatal chylothorax that responded to long-term octreotide treatment, and review of the literature.

Chylothorax is a relatively uncommon condition defined as an abnormal collection of lymphatic fluid within the pleural space. Morbidity of congenital chylothorax (CC) is high, and prognosis is very poor if CC is associated with hydrops fetalis. Although the optimal treatment of CC has not been determined, conservative treatment and surgical intervention are employed. However, there is still little experience with the use of octreotide therapy for this condition, and optimal duration of the treatment for response evaluation is not known. We report a newborn with CC who presented with intrauterine bilateral pleural effusion and was resistant to conservative treatments. Octreotide (6 µg/kg/h) infusion was started on the 10th postnatal day due to ongoing pleural drainage. Although the patient improved rapidly with continuous administration of octreotide, we had to continue the drug for 151 days, even subcutaneously on outpatient follow-up. To the best of our knowledge, this patient is unique in receiving octreotide treatment for such a long time, with a successful outcome and a safe profile.

Portal Vein Thrombosis of a Newborn with Corrected Total Anomalous Pulmonary Venous Return.

Total anomalous pulmonary venous return (TAPVR) is a rare and frequently isolated defect identified in 1% to 3% of all congenital heart diseases. To the best of our knowledge, portal vein thrombosis (PVT) associated with TAPVR has not been reported in the literature. We report a successfully managed PVT in a newborn with infracardiac-type TAPVR and review the literature. Anticoagulation therapies were used during the neonatal period to prevent thrombus progression. PVT should be kept in mind in TAPVR patients who have open heart repair with total correction. The treatment in each neonate should be individualized with consideration of the risk/benefit ratio.

Extra-lobar Pulmonary Sequestration Requiring Intrauterine Thoracentesis.

Congenital lung malformations can result in significant morbidity and mortality in children. Pulmonary sequestration is an uncommon congenital malformation of the lung that can cause complications even in fetal life. We herein present a newborn with extra-lobar sequestration (ELS) that lead to hydrops fetalis necessitating fetal intervention.

Efficacy and safety of intravenous colistin in preterm infants with nosocomial sepsis caused by Acinetobacter baumannii.

OBJECTIVES: To describe the efficacy of intravenous colistin on clinical and microbiological outcomes in preterm infants with nosocomial sepsis in neonatal intensive care unit (NICU) and define adverse events observed with this treatment. METHODS: The records of preterm infants who received colistin with or without positive cultures in the NICU were retrospectively reviewed. Patients were evaluated for response to therapy and side effects. RESULTS: A total of 21 preterm infants with medians of 28 weeks (23-36) gestational age and 870 g (620-2,650) birth weight were included. The median duration and dose of colistin therapy were 9 days (3-26) and 3 mg/kg/d (2-5). Recovery rate in patients including all with/without positive culture was 81% (17/21). Microbiological clearance by colistin was 69% (9/13). The major side effect observed was acute kidney injury (19%). At least 24% of infants required electrolyte supplementation during the colistin therapy. Magnesium levels were significantly lower at the end of the colistin therapy (p < 0.001). Acute kidney injury and electrolyte disturbances including hypomagnesemia were reversible in all surviving patients. CONCLUSION: We suggest that renal function tests and serum electrolytes should be monitored closely and replaced in case of any need during the colistin therapy in preterm infants.

The impact of evaluating platelet transfusion need by platelet mass index on reducing the unnecessary transfusions in newborns.

INTRODUCTION: Almost 95% of the platelet transfusions (PTs) conducted in the neonatal intensive care unit (NICU) are prophylactic transfusions. Guidelines for prophylactic PTs are based on platelet counts, but not on platelet functions. Nowadays, in order to reduce unnecessary transfusions, utilizing platelet mass index (PMI) was investigated. The aim of study is to find out whether PTs performed in our NICU during last 2 years were in accordance with the current guideline and to evaluate whether the frequency of PTs should be reduced if PMI was considered. METHODS: Forty-three infants who received 96 prophylactic PTs were enrolled in the study. The guideline utilized in our NICU advocate keeping the platelet count: (a) >100 000 in pre/post-operative, (b) >50 000 in unstable and (c) >20 000 in stable patients. According to PMI criteria, PT should be performed if PMI: (a) <800 in pre/post-operative, (b)<400 in unstable and (c) <160 in stable patients. RESULTS: In all, 53.2% of PTs should not be given if the decision was in accordance with the current guideline. If decision for every PT was made according to the current guideline and taking PMI into consideration, an additional 11.5% reduction in total PTs could be achived. CONCLUSION: We suggest that better compliance with the new guidelines which take platelet functions into account may yield lower transfusion rate, lower costs and better conservation of blood bank resources.

A rare cause of congenital diarrhea in a Turkish newborn: tufting enteropathy.

Tufting enteropathy is an autosomal recessive congenital enteropathy presenting with early-onset severe intractable diarrhea. It presents with watery diarrhea that develops in the first days after birth and persists despite bowel rest. Growth is impaired, and most patients require total parenteral nutrition. The histological characteristic of tufting enteropathy is the presence of epithelial tufts. We hereby present a patient who was referred to our neonatal intensive care unit because of chronic diarrhea and diagnosed with tufting enteropathy according to histological examination. To the best of our knowledge, the newborn case presented here is the first one reported from Turkey. As TE is a very rare disease, it should be considered in patients with continuing diarrhea beginning in the first days of life.