Combination therapy with erythropoietin, magnesium sulfate and hypothermia for hypoxic-ischemic encephalopathy: an open-label pilot study to assess the safety and feasibility.

BACKGROUND: Although therapeutic hypothermia improves the outcome of neonatal hypoxic-ischemic encephalopathy (HIE), its efficacy is still limited. This preliminary study evaluates the safety and feasibility of the combination therapy with erythropoietin (Epo), magnesium sulfate and hypothermia in neonates with HIE. METHODS: A combination therapy with Epo (300 U/kg every other day for 2 weeks), magnesium sulfate (250 mg/kg for 3 days) and hypothermia was started within 6 h of birth in neonates who met the institutional criteria for hypothermia therapy. All patients received continuous infusion of dopamine. Vital signs and adverse events were recorded during the therapy. Short-term and long-term developmental outcomes were also evaluated. RESULTS: Nine patients were included in the study. The mean age at first intervention was 3.9 h (SD, 0.5). Death, serious adverse events or changes in vital signs likely due to intervention were not observed during hospital care. All nine patients completed the therapy. At the time of hospital discharge, eight patients had established oral feeding and did not require ventilation support. Two patients had abnormal MRI findings. At 18 months of age, eight patients received a follow-up evaluation, and three of them showed signs of severe neurodevelopmental disability. CONCLUSION: The combination therapy with 300 U/kg Epo every other day for 2 weeks, 250 mg/kg magnesium sulphate for 3 days and therapeutic hypothermia is feasible in newborn patients with HIE. TRIAL REGISTRATION: ISRCTN33604417 retrospectively registered on 14 September 2018.

Ultrasound-guided hydrostatic enema for meconium obstruction in extremely low birth weight infants: a preliminary report.

Meconium obstruction (MO) in extremely low birth weight (ELBW) infants is a challenging disease to treat. We performed ultrasound-guided hydrostatic enema on six ELBW infants diagnosed with MO. We consider this procedure to be safe and effective, and recommend it as a treatment for MO in ELBW infants.

Nationwide survey of neonatal transportation practices in Japan.

Rapid resuscitation and appropriate transportation of sick infants can greatly improve infant survival and neurological prognosis. To gain an understanding of the status of neonatal transport in Japan, we conducted a survey of neonatal transportation capabilities at perinatal medical centers across the country. Survey content included the number of neonatal transportation cases and the method of transportation. Twenty percent of infants admitted to neonatal intensive care units were transported to the medical centers from other institutions. Half of the level III perinatal medical centers owned an ambulance specialized for neonatal transport. A total of 36% of sick newborns, however, were transported by fire department ambulances that are ill-equipped to care for infants. Thirteen percent of centers reported problems with the emergency transportation of newborns in fire department ambulances. Centers lacked specialized ambulances primarily because of financial constraints. Adequate medical insurance coverage is needed to increase the number of specialized ambulances at perinatal medical centers.

Glucocorticoids and erythropoietin in chronic lung disease of prematurity: Proliferative potential in lung fibroblast and epithelial cells exposed to tracheal aspirates.

BACKGROUND: We investigated the effects of glucocorticoids, erythropoietin (EPO) and spironolactone (SPL) n human fetal lung fibroblasts and human alveolar epithelial cells exposed to tracheal aspirate fluid (TAF) from extremely premature infants with chronic lung disease (CLD), characterized by fibrosis and changes in the alveolar epithelium. METHODS: Fibroblasts and epithelial cells (FHs 738Lu and A549, respectively) were treated with different concentrations of hydrocortisone (HDC), dexamethasone (DEX), betamethasone (BET), SPL, and EPO in the absence or presence of TAF from infants with CLD (gestational age, 25.3 ± 0.8 weeks; birthweight, 658 ± 77 g; postnatal age, 0-28 days) and assayed for proliferation. RESULTS: Exposure to TAF resulted in a concentration-dependent proliferation of fibroblasts and epithelial cells. Proliferation of TAF-exposed fibroblasts was suppressed most significantly by 100 µmol/L DEX (21%, P = 0.046) and 300 mIU/mL EPO (18%, P = 0.02) and promoted most significantly by 0.4 µmol/L HDC (10%, P = 0.04). Epithelial proliferation was promoted by 4 µmol/L HDC (15%, P = 0.04), 10 µmol/L DEX (53%, P < 0.01), 0.2 µmol/L BET (56%, P < 0.01), and 300 mIU/mL EPO (35%, P < 0.01) in the presence of TAF. Treatment with glucocorticoids alone did not significantly affect fibroblast proliferation. CONCLUSIONS: Glucocorticoids and EPO reduced fibroproliferation while promoting epithelial cell growth in vitro within certain dose ranges. Appropriate doses of glucocorticoids and EPO may be useful in the prevention and resolution of CLD in extremely premature infants.

Autologous cord blood cell therapy for neonatal hypoxic-ischaemic encephalopathy: a pilot study for feasibility and safety.

Neonatal hypoxic-ischaemic encephalopathy (HIE) is a serious condition; many survivors develop neurological impairments, including cerebral palsy and intellectual disability. Preclinical studies show that the systemic administration of umbilical cord blood cells (UCBCs) is beneficial for neonatal HIE. We conducted a single-arm clinical study to examine the feasibility and safety of intravenous infusion of autologous UCBCs for newborns with HIE. When a neonate was born with severe asphyxia, the UCB was collected, volume-reduced, and divided into three doses. The processed UCB was infused at 12-24, 36-48, and 60-72 hours after the birth. The designed enrolment was six newborns. All six newborns received UCBC therapy strictly adhering to the study protocol together with therapeutic hypothermia. The physiological parameters and peripheral blood parameters did not change much between pre- and postinfusion. There were no serious adverse events that might be related to cell therapy. At 30 days of age, the six infants survived without circulatory or respiratory support. At 18 months of age, neurofunctional development was normal without any impairment in four infants and delayed with cerebral palsy in two infants. This pilot study shows that autologous UCBC therapy is feasible and safe.

Aristaless-related homeobox gene disruption leads to abnormal distribution of GABAergic interneurons in human neocortex: evidence based on a case of X-linked lissencephaly with abnormal genitalia (XLAG).

X-linked lissencephaly with abnormal genitalia (XLAG) is a rare disorder caused by mutations in the aristaless-related homeobox (ARX) gene, located on Xp22.13. Arx-null mice show loss of tangential migration of GABAergic interneurons, presumably being related to caudal ganglionic eminence tangential migration. In the present study, we investigated a subpopulation of GABAergic interneurons in the brain of an infant with XLAG, who had a novel nonsense mutation of the ARX gene, compared with those of age-matched normal controls and Miller-Dieker syndrome. We performed immunocytochemistry for interneuron and migration markers. We found that glutamic acid decarboxylase (GAD)- and calretinin (CR)-containing cells were significantly reduced in the neocortex and located in the white matter and neocortical subventricular zone, while neuropeptide Y- or cholecystokinin-containing cells were normally distributed. Moreover, in the neocortical subventricular region, the GAD- and CR-containing cells expressed the radial migration marker Mash-1 as well as nestin. Our findings suggest that ARX protein controls not only the tangential migration of GABAergic interneurons from the ganglionic eminence, but also may serve to induce radial migration from the neocortical subventricular zone.

Hippocampal BDNF and TrkB expression in young rats after status epilepticus.

BACKGROUND: The immature brain is more susceptible to seizures than mature brains but less vulnerable to seizure-induced neuronal loss. We studied age-related susceptibility and vulnerability to kainic acid-induced status epilepticus (KASE) in rats in terms of hippocampal expression of brain-derived neurotrophic factor (BDNF) and tyrosine kinase B receptor (TrkB). METHODS: Immunohistochemical and Western analysis were performed after kainic acid (KA)-induced status epilepticus (SE). RESULTS: KA doses required to induce SE increased from 1.5 mg/kg in 1-week-old rats to 10 mg/kg at 4 weeks of older. After SE the older rats showed spontaneous seizures and hippocampal pyramidal neuronal loss-unlike rats under 4 weeks old. Hippocampal BDNF protein expression had increased fivefold in 1-week-old rats and threefold in 8-week-old rats 1 day after SE, returning to baseline 2 days after SE. TrkB expression showed little effect from KASE at either age. CONCLUSIONS: These results indicated that the critical period as for vulnerability to SE was the age of 4-week-old and older in the rat. Since the response patterns of BDNF and TrkB to SE were similar between neonatal and the adult rats, our study revealed that the observed transient upregulation of BDNF did not contribute to cause epilepsy in neonatal rats.

Histologic Chorioamnionitis, Amniotic Fluid Interleukin 6, Krebs von den Lungen 6, and Transforming Growth Factor ß1 for the Development of Neonatal Bronchopulmonary Dysplasia.

BACKGROUND: Chorioamnionitis (CAM) is an important risk factor for the development of bronchopulmonary dysplasia (BPD) in preterm infants. OBJECTIVES: To evaluate the effects of CAM on the development of BPD using interleukin 6 (IL-6), Krebs von den Lungen 6 (KL-6), and transforming growth factor ß1 (TGF-ß1) in the amniotic fluid as markers for inflammation, lung injury, and fibrosis/remodeling, respectively. METHODS: Amniotic fluid concentrations of IL-6, KL-6, and TGF-ß1 were measured with enzyme-linked immunosorbent assay or electro-chemiluminescence immunoassay. RESULTS: Of the 36 preterm infants, 18 were exposed to histologically confirmed CAM. Of these, 12 were later diagnosed as having BPD. The IL-6, KL-6, and TGF-ß1 levels in the amniotic fluid significantly increased with increasing histologic severity of CAM. Moreover, these markers were higher in the BPD group with histologic CAM than those without. CONCLUSIONS: Our study suggests that CAM is likely to induce inflammatory, injury, and remodeling processes in the fetal lung.

Vein of Galen Aneurysmal Malformation in Monozygotic Twin.

BACKGROUND: Vein of Galen aneurysmal malformation (VGAM) is a rare pediatric vascular malformation of the brain. Genetic backgrounds are not well elucidated. We report on a monozygotic twin with VGAM and his endovascular treatment, and the genetic analyses of the twins and their parents. CASE DESCRIPTION: In a monochorionic, diamniotic pregnancy of a 28-year-old healthy woman, monozygotic twins were born by emergency caesarian section because of fetal distress of the smaller twin at 25 weeks' and 4 days' gestation. Although a postnatal cranial ultrasound failed to detect VGAM in the smaller twin, mild heart failure persisted. A brain magnetic resonance (MR) examination of this twin on day 82 revealed choroidal VGAM. The twin was treated successfully by two sessions of embolization at 6 and 8 months of age. An MR examination at 1 year showed minimal residual arteriovenous shunts. He developed normally similar to the normal co-twin, with a follow-up period of 1 year and 6 months. As for the affected twin, no germline mutation or copy number variations were identified in ENG, ALK1, SMAD4, BMPR2, PTEN, RASA1, KRIT1, Marcavernin, or PDCD10 through whole-exome sequencing (WES). CONCLUSION: We have reported a rare combination of a monozygotic twin and VGAM and the successful endovascular treatment. Phenotypic discordance in monozygotic twins established early in embryogenesis could be attributable to environmental or epigenetic factors.

Early and intensive nutritional strategy combining parenteral and enteral feeding promotes neurodevelopment and growth at 18months of corrected age and 3years of age in extremely low birth weight infants.

AIM: To evaluate whether aggressive nutrition can improve long-term neurodevelopmental outcomes and growth in extremely low birth weight (ELBW) infants born appropriate for gestational age (AGA). METHODS: This single-center cohort study included 137 ELBW AGA infants born in two epochs. The first group received standard nutrition (SN; n=79) consisting of amino acids started at 0.5g/kg/day on Day 4 of life and increased to 1.0g/kg/day. The second aggressive nutrition (AN) group received amino acids started at 1.5-2.0g/kg/day within 24h of life and increased to 3.5g/kg/day. Parenteral and enteral feedings were combined in both groups. Neurodevelopmental outcomes by the Kyoto Scale of Psychological Development and growth were followed up to 18months of corrected age or 3years of age and compared by univariate and multivariate analyses. RESULTS: Baseline characteristics were similar between the two groups. At 3years of age, AN children had a significantly greater mean value of head circumference, but not length or weight, than SN children (49.1 vs 48.0cm, p=0.014). The cognitive-adaptive (C-A) score in the AN group was also significantly higher than that in the SN group (98.3 vs 91.9 at 18months, p=0.039 and 89.5 vs 83.1 at 3years, p=0.047). AN infants born ≥26weeks of gestation were less likely to develop borderline disability in C-A, language-social and overall developmental scores compared to gestational age-matched SN infants. CONCLUSION: Parenteral and enteral AN after birth improved the long-term cognitive neurodevelopment in ELBW AGA infants, especially in those born ≥26weeks of gestational age, however results need to be confirmed in a larger, multi-site randomized trial.

Amniotic fluid transforming growth factor-beta1 and the risk for the development of neonatal bronchopulmonary dysplasia.

Chorioamnionitis (CAM) can initiate fetal lung injury resulting in neonatal bronchopulmonary dysplasia (BPD). While neonates with BPD have higher amniotic fluid concentrations of proinflammatory cytokines, overexpression of transforming growth factor (TGF)-beta(1) also appears important in the pathogenesis of BPD. The aim of this study was to investigate the relationship between TGF-beta(1) and CAM-induced fetal lung injury. Forty-four amniotic fluid samples were obtained at delivery of preterm infants (median gestation, 28 weeks; birth weight, 908 g). TGF-beta(1) and interleukin (IL)-6 concentrations in the amniotic fluid were measured with ELISA. Both TGF-beta(1) and IL-6 concentrations in the amniotic fluid increased with increasing histological severity of CAM (each p < 0.0001). The presence of both BPD and histological CAM was associated with significantly higher amniotic fluid TGF-beta(1) and IL-6 concentrations than the presence of BPD without histological CAM, or the absence of both (each p < 0.0001). Both concentrations also correlated with the duration of oxygen administration in the neonates (each p < 0.0001). Amniotic fluid TGF-beta(1) seems to be important in CAM-induced fetal lung injury progressing to neonatal BPD.

Neurodevelopmental outcome of infants with birth asphyxia treated with magnesium sulfate.

BACKGROUND: A neuroprotective effect of MgSO(4) has been shown in some animal models of perinatal hypoxic-ischemic brain damage. The aim of the present paper was to determine whether postnatal MgSO(4) infusion (250 mg/kg per day i.v. for 3 days, in combination with dopamine) is safe in infants with severe birth asphyxia, and also observe effects on neurodevelopmental outcome at 18 months. METHODS: Inclusion criteria were clinical history consistent with perinatal asphyxia; gestational age at least 37 weeks; 5 min Apgar score < or =6; failure to initiate spontaneous respiration within 10 min after birth; and symptoms of encephalopathy. On each day MgSO(4) was infused over 1 h in combination with dopamine (5 microg/kg per min). Changes in vital signs, clinical course of encephalopathy, laboratory variables, and adverse events were monitored. Infants were followed for 18 months. RESULTS: Thirty infants were studied. Mean birthweight was 2878 g; mean gestational age, 39.6 weeks, and median 5 min Apgar score, 3. All required endotracheal intubation for resuscitation. Median age at MgSO(4) initiation was 5 h. All infants had moderate or severe hypoxic-ischemic encephalopathy. Mean serum Mg(2+) concentration remained at least 1.3 mmol/L. MgSO(4) caused no change in physiological variables including mean arterial pressure. Two infants died as neonates, while six of 28 survivors had severe neurodevelopmental disability at 18 months; the remaining 22 had no neurodevelopmental disability. CONCLUSION: Postnatal infusion of MgSO(4) with dopamine caused no change in physiological variables. Deaths and severe sequelae were less frequent than in reported cases with the same grade of hypoxic-ischemic encephalopathy severity, and this treatment may improve neurodevelopmental outcome in infants with severe birth asphyxia.

Morbidity and mortality of infants with very low birth weight in Japan: center variation.

OBJECTIVES: The objectives of this study were to describe the characteristics and morbidity of very low birth weight infants, to identify the medical intervention for these infants, and to evaluate the factors affecting the mortality of these infants among the participating hospitals. METHODS: A large multicenter neonatal research network that included level III NICUs from throughout Japan was established. A standardized mortality rate was formulated by giving a ratio of the observed deaths and the predicted deaths based on a 100-g birth weight interval mortality. A regression model was used to predict the factors that affect neonatal mortality. RESULTS: The network included 37 centers and 2145 infants weighing < or = 1500 g, born or admitted to the centers in 2003. Gestational age and birth weight of studied infants were 28.6 +/- 3.6 gestational weeks (mean +/- SD) and 1025 +/- 302 g, respectively. Overall, 11% of the infants died before being discharged from hospitals (range: 0%-21%). The standardized mortality rate varied among the facilities (range: 0%-30%). No association between the annual number of patients admitted and standardized mortality rate was found. Among all of the very low birth weight infants, 14% were outborn infants, 72% were delivered by cesarean sections, 27% had patent ductus arteriosus, 3% had gastrointestinal perforation, 8% had bacterial sepsis, and 13% had intraventricular hemorrhage. Medical interventions involved were: 41% antenatal corticosteroids, 54% surfactant therapy, 18% postnatal steroids for chronic lung disease, and 29% high-frequency oscillatory ventilation. We found variations in the medical interventions and the clinical outcomes among the centers. CONCLUSIONS: The overall survival rate for very low birth weight infants among neonatal centers in Japan was approximately 90%. However, differences in the morbidity and mortality were observed among these centers.

Trophic effect of multiple growth factors in amniotic fluid or human milk on cultured human fetal small intestinal cells.

OBJECTIVES: To evaluate the role of growth factors in amniotic fluid and in human milk on gastrointestinal adaptation of the fetus and very low-birth-weight infants, the effects of these fluids and multiple growth factors were investigated in a human fetal small intestinal cell line (FHs 74 Int). METHODS: After FHs 74 Int cells were incubated with amniotic fluid, human milk, or recombinant growth factors, growth-promoting activity was measured by [3H]-thymidine incorporation into cells. RESULTS: Incubating cells with amniotic fluid or human milk promoted growth dose dependently. Genistein almost completely inhibited growth-promoting activity in amniotic fluid P = 0.002), and growth was partially inhibited by antibodies against epidermal growth factor (EGF) (P = 0.047), insulin-like growth factor-1 (IGF-1, P = 0.047), or fibroblast growth factor (FGF, P = 0.014). This activity in human milk was inhibited almost completely by genistein (P < 0.0001) and partially inhibited by antibodies against EGF (P = 0.036), IGF-1 (P = 0.009), FGF (P = 0.004), hepatocyte growth factor (HGF, P = 0.001), or transforming growth factor-alpha (TGF-alpha, P = 0.001). Although recombinant EGF, IGF-1, FGF, HGF, and TGF-alpha elicited a synergistic trophic response on cultured cells, the response was much less than with amniotic fluid or with human milk. CONCLUSION: In aminiotic fluid and in human milk, EGF, IGF-1, FGF, HGF, and TGF-alpha have a strong trophic effect on immature intestinal cells and may be involved in perinatal gastrointestinal adaptation.

Three-year follow up of term and near-term infants treated with inhaled nitric oxide.

BACKGROUND: The present study describes the outcome at 3 years in term and near-term infants treated with inhaled nitric oxide (iNO) for persistent pulmonary hypertension of the newborn (PPHN). METHODS: The study population consisted of 18 infants delivered at 34 weeks by best obstetric estimate who were admitted to the neonatal intensive care units with a diagnosis of PPHN. RESULTS: Eighteen infants (mean gestational age 38.5 +/- 2.6 weeks, mean birthweight 3015 +/- 587 g) were treated with iNO. The mean oxygenation index before iNO was 27.2 +/- 15.2. Responses to iNO were classified into three groups: (i) early response in eight infants; (ii) late response in two; and (iii) poor response in eight infants. Three infants died within seven postnatal days. Fifteen surviving infants were followed up to 3 years. The mean developmental scale was 98.4 +/- 9.0. One infant was diagnosed with severe neurodevelopmental disability due to cerebral palsy. Another infant was diagnosed with mild neurodevelopmental disability because of a low developmental scale. No infant showed significant hearing loss. Five infants had reactive airway disease (RAD) at 18 months, these infants required a significantly longer duration of mechanical ventilation in their neonatal period than non-RAD infants (P = 0.02). The frequency of survival with normal neurodevelopmental outcome was significantly higher in the early response group than the late or poor response groups (P = 0.03). CONCLUSION: In iNO-treated PPHN, mortality and neurodevelopmental outcome were associated with response to iNO, and pulmonary outcome was associated with duration of mechanical ventilation.

Mitogenic activity of tracheal effluents from premature infants with chronic lung disease.

Lung injury alters the expression and release of growth factors that disrupt postnatal pulmonary development in newborns and causes chronic lung disease (CLD). The effect of these factors, released into the airways of newborns with CLD, on cell proliferation and collagen production was characterized in vitro. Human fetal lung fibroblast and alveolar-epithelial-like cell lines (FHs 738Lu and A549, respectively) were exposed to tracheal effluents from infants with CLD (mean gestation, 24.7 +/- 0.9 wk; birth weight, 666 +/- 85 g; postnatal age, 0-62 d). In both cell types, proliferation was assessed by measuring [(3)H]-thymidine uptake; in fibroblasts, collagen production was analyzed by measuring [(3)H]-proline incorporation. The activity of specific growth factors in effluents was determined using anti-growth factor antibodies and the growth factors themselves. Growth factors in tracheal effluents promoted proliferation in a dose-dependent manner and caused up to a 10.2- and 3.1-fold increase in thymidine uptake by fibroblasts and epithelial cells, respectively. Collagen production by fibroblasts increased dose dependently, peaking at 177% of baseline. Antibody against transforming growth factor beta-1 (TGF-beta(1)) inhibited proliferation and the increase in collagen production by 31% (p = 0.01) and 14% (p = 0.045), respectively. Antibody against hepatocyte growth factor (HGF) inhibited proliferation of epithelial cells (25%, p = 0.039). The effects of exogenous TGF-beta(1) on fibroblasts and HGF on epithelial cells resembled those of tracheal effluents. Potent mitogenic and differentiating substances are released into the tracheal effluents of newborns with CLD. TGF-beta(1) may worsen CLD by inducing fibrosis whereas HGF may favor resolution by promoting epithelialization.

Randomized controlled trial of magnesium sulfate infusion for severe birth asphyxia.

OBJECTIVE: To determine whether postnatal MgSO(4) infusion (250 mg/kg per day) for 3 days is both safe and able to improve outcome in infants with severe birth asphyxia, as had been suggested by a small pilot study. METHODS: A multicenter randomized controlled trial was conducted. Entry criteria included 5-min Apgar score of seven or less and either failure to initiate spontaneous respiration at 10 min after birth because of asphyxia, or occurrence of clinically apparent seizures within 24 h after birth. Number of subjects was calculated to detect a 50% reduction in incidence of adverse outcomes. RESULTS: Distributions of perinatal factors, neonatal baseline characteristics and severity of hypoxic-ischemic encephalopathy were similar in treated and control groups. No significant differences were observed in duration of clinical seizures, or need for assisted ventilation. Survival with normal results of cranial computed tomography, electroencephalography and establishment of oral feeding by 14 days of age, was significantly more frequent in the treated group than in the control group (12/17 vs 5/16, P = 0.04). No significant differences in blood pressure, heart rate or respiratory rate were observed between groups. CONCLUSION: Postnatal MgSO(4) infusion as above is safe and can improve short-term outcome in infants with severe birth asphyxia.