Effect of Low Lactose Formula on the Short-Term Outcomes of Neonatal Abstinence Syndrome: A Systematic Review.

The use of low lactose formula (LLF) in term and near-term infants in infants with neonatal abstinence syndrome (NAS) has been increasing recently. However, the clinical evidence of such use is limited. Our aim in this paper was to systematically review the current literature about the use of LLF in infants with NAS. We searched PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Database of Systematic Reviews for articles published between 2015 and 2020. Only randomized controlled trials, prospective, and retrospective studies. The risk of bias was assessed by using published tools appropriate for the study type. The certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Forty-one titles and/or abstracts were screened independently by 2 reviewers (MA and GA). After an indepth review, 4 studies answered the study question (1 randomized controlled trial (RCT), 2 retrospective studies, and 1 quality improvement study). A meta-analysis could not be completed due to the study type difference and how the outcomes were reported. The studies found no benefit to feeding LLF to infants with NAS regarding short-term outcomes (length of stay, duration, and need for pharmacological therapy and growth). Certainty in the evidence is low. In conclusion we found no beneficial effects regarding the need for pharmacological therapy, duration of pharmacological treatment, length of hospital stay, and growth of using LLF compared to the standard formula in infants with NAS.

Bivalirudin and thrombolytic therapy: a novel successful treatment of severe aortic arch thrombosis in a term neonate.

An early-term infant with uncomplicated perinatal history was found to have a large thrombus in the aortic arch after he failed regular newborn critical congenital heart defect screen. He responded well to bivalirudin thrombolytic and tissue-plasminogen activator (tPA) combination therapy, with a significant resolution of the thrombus. The infant tolerated hospital admission well with no significant complications. He was discharged home on daily aspirin at 2 weeks of life. To our knowledge, the combination therapy approach with bivalirudin and tPA is the first one reported in the literature in the neonatal age group.

Glucose Levels during the First 24 Hours following Perinatal Hypoxia.

OBJECTIVE: Hypoglycemia is a significant risk factor for perinatal brain injury and adverse outcomes, particularly in infants requiring resuscitation following hypoxic ischemic (HI) insult. We aimed to study blood glucose (BG) levels in physiologically stressed infants in the presence or absence of epinephrine (Epi) administration at resuscitation in the first 24 hours after birth. STUDY DESIGN: A retrospective chart review of all infants with heart rate (HR) < 100/min at 1 minute requiring positive pressure ventilation (PPV) at birth was performed. Infants were classified into two groups as follows: (1) PPV group: infants' HR improved with PPV only at resuscitation, and Epi group: infants received Epi at resuscitation for persistent bradycardia. Serial measurements of BG levels collected and glucose infusion rate (GIR) calculated at 24 hours. RESULTS: By design, infants in the Epi group had lower cord pH and higher base deficit. BG was significantly lower overtime in premature infants ≤32 weeks of gestation in the Epi group. The BG was markedly higher in near-term and term infants in the Epi group compared with the PPV group. Hypoglycemia was more common despite administration of higher GIR in premature infants ≤32 weeks of gestation. CONCLUSION: In the presence of physiological stress, premature infants are more at risk for hypoglycemia than term infants.

Intravenous Immune Globulin Uses in the Fetus and Neonate: A Review.

Intravenous immune globulin (IVIG) is made after processing plasma from healthy donors. It is composed mainly of pooled immunoglobulin and has clinical evidence-based applications in adult and pediatric populations. Recently, several clinical applications have been proposed for managing conditions in the neonatal population, such as hemolytic disease of the newborn, treatment, and prophylaxis for sepsis in high-risk neonates, enterovirus parvovirus and COVID-19 related neonatal infections, fetal and neonatal immune-induced thrombocytopenia, neonatal hemochromatosis, neonatal Kawasaki disease, and some types of immunodeficiency. The dosing, mechanism of action, effectiveness, side effects, and adverse reactions of IVIG have been relatively well studied in adults but are not well described in the neonatal population. This review aims to provide the most recent evidence and consensus guidelines about the use of IVIG in the fetus and neonate.

Effects of Partially Hydrolyzed Formula on Severity and Outcomes of Neonatal Abstinence Syndrome.

OBJECTIVE: This study compares the effect of partially hydrolyzed formula (PHF) and standard formula (SF) on the severity and short-term outcomes of neonatal abstinence syndrome (NAS). STUDY DESIGN: We performed a retrospective chart review of 124 opioid-dependent mothers and their term or near-term infants. Infants were categorized according to the predominant type of formula consumed during the hospital stay. Finnegan's scale was used to assess symptoms of withdrawal. RESULTS: A total of 110 infants met our inclusion criteria. Thirty-four (31%) infants were fed predominantly PHF, 60 (54%) infants were fed SF, and 16 (15%) infants were fed maternal breast milk. There was no difference between the infants in the PHF and SF groups with respect to requirement of morphine (MSO4) therapy, maximum dose of MSO4 used, duration of MSO4 treatment or length of hospital stay after performing multivariate analyses to control for type of drug used by the mother, maternal smoking, regular prenatal care, inborn status, and maximum Finnegan score prior to MSO4 treatment. CONCLUSION: Use of PHF failed to impact short-term outcomes in infants treated for NAS including maximum MSO4 dose, duration of MSO4 treatment, and length of hospital stay. A prospective randomized controlled trial may be indicated to confirm this finding.

Hydrocortisone Improves Oxygenation Index and Systolic Blood Pressure in Term Infants With Persistent Pulmonary Hypertension.

Persistent pulmonary hypertension of the newborn (PPHN) is an essential cause for hypoxic respiratory failure with significant morbidity and mortality in term and near-term neonates. Hydrocortisone has been shown to decrease oxygen dependency and pulmonary hypertension in neonates with meconium aspiration syndrome and animal studies, respectively. We hypothesize that hydrocortisone will improve oxygenation in term and near-term infants with pulmonary hypertension. We performed a retrospective chart review of all infant with PPHN who received intravenous hydrocortisone therapy as a rescue for severe PPHN. Clinical response was objectively measured using, oxygenation index (OI), PaO2/FiO2 ratio, and inotrope score before, during, and after the hydrocortisone course. We found that hydrocortisone administration resulted in significant improvement of systolic blood pressure, OI, and PaO2/FiO2. In conclusion, hydrocortisone increased systolic blood pressure and improved oxygenation in term and near-term infants with persistent pulmonary hypertension. Prospective randomized trials are required to evaluate these findings further.

Infantile refractory seizures due to de novo KCNT 1 mutation.

We describe a term female infant who presented with multiple seizures early in infancy. The clinical and electrical seizures were refractory to traditional antiepileptic medications. After extensive workup, seizure panel testing revealed KCNT1 gene mutation, which is associated with nocturnal frontal lobe epilepsy and epilepsy of infancy with migrating focal seizures. The infant's condition improved with the combination of traditional as well non-traditional antiepileptic therapy.

Subcutaneous fat necrosis, a rare but serious side effect of hypoxic-ischemic encephalopathy and whole-body hypothermia.

Objective To describe the clinical characteristics and risk factors in infants with subcutaneous fat necrosis (SFN) following therapeutic hypothermia for hypoxic-ischemic encephalopathy (HIE). Methods A case-control study was performed by a retrospective chart review of infants with moderate or severe HIE admitted to a level IV regional perinatal center and who underwent whole-body cooling. Results A total of 14 (8.1%) of 171 infants with moderate or severe HIE who underwent whole-body cooling developed SFN during hospitalization. There were more females [71% (10/14)] and large-for-gestational age (LGA) infants [28% (4/14)] in the SFN group vs. 36% females (57/157) and 8% LGA infants (13/157) in the group without SFN (P-values of 0.009 and 0.015, respectively). The mean lowest platelet count was lower 108 ± 55 109/L vs. 146 ± 62 109/L and the mean highest calcium level was higher 11.3 ± 2.5 vs. 10.6 ± 0.8 mg/dL in infants with SFN vs. infants without SFN, respectively (P-values of 0.0078 and 0.006, respectively). Distribution of skin lesions followed distinctive patterns representing the areas with direct contact with the cooling blanket. One infant developed severe, life-threatening hypercalcemia that required aggressive management, including diuretics, corticosteroids and bisphosphonates. Conclusion Although SFN is a rare complication of therapeutic hypothermia, it can be a life-threatening condition if complicated by severe hypercalcemia. Infants who undergo therapeutic hypothermia for HIE need regular skin examinations to evaluate for SFN. If SFN is identified, monitoring of serum calcium levels to prevent life-threatening hypercalcemia is recommended.

Continued Enteral Feeding Is Beneficial in Hypoglycemic Infants Admitted to Intensive Care for Parenteral Dextrose Therapy.

There is variability in practice among care providers on feeding infants admitted with neonatal hypoglycemia (NH) for parenteral dextrose. We compared clinical outcomes in infants who were fed (NH-Fed) and hypoglycemic infants who were kept nothing per os (NPO) (NH-NPO) at the time of initiation of intravenous (IV) dextrose. We performed a retrospective review of all newborn infants admitted to the neonatal intensive care unit with NH for IV dextrose. Infants were grouped as per the feeding approach at initiation of IV dextrose: NH-Fed or NH-NPO infants. We found that infants in the NH-Fed group had lower maximum glucose infusion rate, less duration of glucose infusion therapy compared with the NH-NPO group, and significantly less number of days of hospital stay compared with the NH-NPO group (5.87 ± 1.4 days vs 4.9 ± 1.4 days, P < .006). In conclusion, feeding infants with hypoglycemia who require IV dextrose offers tangible benefits of shorter duration of parenteral dextrose and shorter length of hospitalization.

Oxygenation and Hemodynamics during Chest Compressions in a Lamb Model of Perinatal Asphyxia Induced Cardiac Arrest.

The current guidelines recommend the use of 100% O2 during resuscitation of a neonate requiring chest compressions (CC). Studies comparing 21% and 100% O2 during CC were conducted in postnatal models and have not shown a difference in incidence or timing of return of spontaneous circulation (ROSC). The objective of this study is to evaluate systemic oxygenation and oxygen delivery to the brain during CC in an ovine model of perinatal asphyxial arrest induced by umbilical cord occlusion. Pulseless cardiac arrest was induced by umbilical cord occlusion in 22 lambs. After 5 min of asystole, lambs were resuscitated with 21% O2 as per Neonatal Resuscitation Program (NRP) guidelines. At the onset of CC, inspired O2 was either increased to 100% O2 (n = 25) or continued at 21% (n = 9). Lambs were ventilated for 30 min post ROSC and FiO2 was gradually titrated to achieve preductal SpO2 of 85-95%. All lambs achieved ROSC. During CC, PaO2 was 21.6 ± 1.6 mm Hg with 21% and 23.9 ± 6.8 mm Hg with 100% O2 (p = 0.16). Carotid flow was significantly lower during CC (1.2 ± 1.6 mL/kg/min in 21% and 3.2 ± 3.4 mL/kg/min in 100% oxygen) compared to baseline fetal levels (27 ± 9 mL/kg/min). Oxygen delivery to the brain was 0.05 ± 0.06 mL/kg/min in the 21% group and 0.11 ± 0.09 mL/kg/min in the 100% group and was significantly lower than fetal levels (2.1 ± 0.3 mL/kg/min). Immediately after ROSC, lambs ventilated with 100% O2 had higher PaO2 and pulmonary flow. It was concluded that carotid blood flow, systemic PaO2, and oxygen delivery to the brain are very low during chest compressions for cardiac arrest irrespective of 21% or 100% inspired oxygen use during resuscitation.

Neonatal isolated ACTH deficiency (IAD): a potentially life-threatening but treatable cause of neonatal cholestasis.

Isolated ACTH deficiency (IAD) is a rare cause of neonatal cholestasis and hypoglycaemia. This diagnosis has a 20% mortality potential if unrecognised. We describe a case of an infant presenting with cholestatic jaundice and hypoglycaemia. The patient had laboratory findings suggestive of IAD, which was later confirmed with molecular genetic testing. One of the mutations this patient had is a new finding. The patient was started on glucocorticoid replacement therapy after which his bilirubin and glucose levels normalised.