Management of infants born to mothers with suspected or confirmed SARS-CoV-2 infection in the delivery room: A tentative proposal 2020.

Coronavirus disease 2019 (COVID-19) has spread worldwide within a short period, and there is still no sign of an end to the pandemic. Management of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected pregnant women at the time of delivery presents a unique challenge. To fulfill the goal of providing adequate management of such women and their infants, and to decrease the risk of exposure of the healthcare providers, tentative guidelines are needed until more evidence is collected. Practical preventative action is required that takes into account the following infection routes: (i) aerosol transmission from mothers to healthcare providers, (ii) horizontal transmission to healthcare providers from infants infected by their mothers, and (iii) horizontal transmission from mothers to infants. To develop standard operating procedures, briefings/training simulations should be carried out, taking into account the latest information. Briefings should be carefully conducted to clarify the role and procedures. Healthcare providers should wear personal protective equipment. If it is physically possible, neonatal resuscitation should be performed in a separate area next to the delivery room. If a separate area is not available, the infant warmer should be placed at least 2 m away from the delivery table, or partitioned off in the same room. A minimum number of skilled personnel should participate in resuscitation using the latest neonatal resuscitation algorithms.

Relationship between Sedative Antihistamines and the Duration of Febrile Seizures.

Some studies have shown that sedative antihistamines prolong febrile seizure duration. Although the collective evidence is still mixed, the Japanese Society of Child Neurology released guidelines in 2015 that contraindicated the use of sedative antihistamines in patients with febrile seizure. Focused on addressing limitations of previous studies, we conducted a cross-sectional study to evaluate the relationship between febrile seizure duration and the use of sedative antihistamines. Data were collected from patients who visited St. Luke's International Hospital due to febrile seizure between August 2013 and February 2016. Patients were divided into groups based on their prescribed medications: sedative antihistamine, nonsedative antihistamine, and no antihistamine. Seizure duration was the primary outcome and was examined using multivariate analyses. Of the 426 patients included, sedative antihistamines were administered to 24 patients. The median seizure duration was approximately 3 minutes in all three groups. There was no statistical difference in the bivariate (p = 0.422) or multivariate analyses (p = 0.544). Our results do not support the relationship between sedative antihistamine use and prolonged duration of febrile seizure. These results suggest that the use of antihistamines may be considered for patients with past history of febrile seizure, when appropriate.

Summary of Japanese Neonatal Cardiopulmonary Resuscitation Guidelines 2015.

The Japan Resuscitation Council joined the International Liaison Committee on Resuscitation (ILCOR) as a member of the Resuscitation Council of Asia in 2006. In 2007, the Japan Society of Perinatal and Neonatal Medicine (JSPNM), which is a member of an affiliated body, launched the Neonatal Cardiopulmonary Resuscitation (NCPR) program as an authorized project to ensure that all staff involved in perinatal and neonatal medicine can learn and practice neonatal cardiopulmonary resuscitation based on the Consensus on Science with Treatment Recommendations developed by ILCOR. The content of courses in the NCPR program is based on the NCPR guidelines. These guidelines are revised by the Japan Resuscitation Council according to the Consensus on Science with Treatment Recommendations, which is updated by ILCOR every 5 years. The latest updated edition in Japanese was published in 2016 and we translated these Japanese guidelines to English in 2018. Here, we introduce a summary of the NCPR guidelines 2015 in Japan. The NCPR 2015 algorithm has two flows, "lifesaving flow" and "stabilization of breathing flow" at the first branching point after the initial step of resuscitation.

Neonatal cardiopulmonary resuscitation project in Japan.

In July 2007, the Neonatal Cardiopulmonary Resuscitation (NCPR) program in Japan was launched to ensure that all staff involved in perinatal and neonatal medicine can learn and practice NCPR based on the Consensus on Science with Treatment Recommendations developed by the International Liaison Committee on Resuscitation. In 1978 in North America, a working group on pediatric resuscitation was formed by the American Heart Association Emergency Cardiac Care Committee and concluded that the resuscitation of newborns required a different strategy than the resuscitation of adults. The original first edition of the Neonatal Resuscitation Program textbook was published in 1987. The NCPR program consists of three courses for health-care providers and two courses for instructors. A course and B course are for newly certified health-care providers and course S is for health-care providers who are renewing their certification. As of 31 March 2019, 3,227 advanced instructors (I instructor) and 1,877 basic instructors (J instructor) were trained to teach A, B, and S courses to health-care providers on the basis of their license. In total 7,075 A courses and 4,012 B courses were held; 131 651 people attended A course or B course of the NCPR program, and 77 367 were certified. A total of 1,865 S courses, which were developed in 2015, were held and 12 875 people attended this course. Here, we introduce the background, purpose, history, and content of the development of the NCPR program in Japan.

Handheld fetal Doppler device for assessing heart rate in neonatal resuscitation.

BACKGROUND: The use of neonatal three-lead electrocardiograms (Neo-ECG) is suggested for the assessment of heart rate (HR) in neonatal resuscitation, but primary childbirth facilities (i.e. maternity clinics or maternity homes) are not sufficiently equipped for this. The aim of this study was to therefore to confirm the potential of a handheld fetal Doppler device (FDD), widely used to assess HR in labor room resuscitation, and to compare its equivalency to Neo-ECG. METHODS: In low-risk full-term infants, HR was measured five times per minute in minutes 1-5 after delivery using the FDD and Neo-ECG, and their equivalence compared. The equivalence margin was set at a HR difference of <±5 beats/min and <±5%. Moreover, the times at which HR was displayed were measured for both methods. RESULTS: FDD and Neo-ECG HR correlated strongly (r = 0.977) in 155 measurements in 33 cases. The mean HR difference was -0.123 beats/min (95%CI: -0.594 to +0.345), and the logarithmic transformation of the HR ratio was -0.0003 (95%CI: -0.0020 to +0.0015). The mean HR difference and HR ratio were within the equivalence margin. For HR assessment using the FDD, 155 of 165 measurements (93.9%) could be obtained in <10 s. CONCLUSIONS: In HR assessment, FDD is a valid substitute for Neo-ECG in primary childbirth facilities that are not sufficiently equipped for Neo-ECG.

Risk factors of infant anemia in the perinatal period.

BACKGROUND: Infants are at particular risk of iron-deficiency anemia. We investigated changes in the blood count of the mother and infant as well as the relationship between them and the relationship between infant nutrition method and infant anemia. METHODS: This retrospective cohort study included healthy neonates born between August 2011 and July 2014 at St Luke's International Hospital, Tokyo, Japan. Data from maternal blood samples obtained during late pregnancy and those of infants obtained at birth and at the age of 3, 6, and 9 months were analyzed. Using multivariate logistic regression, we investigated nutrition methods, maternal anemia, and other clinically relevant parameters that were potential risk factors for infant anemia. RESULTS: In total, data for 3472 infants and their mothers were analyzed. Nutrition method was the most significant risk factor for infant anemia, with risk of future anemia decreasing in the following order: exclusive breast-feeding, partial breast-feeding, and formula feeding. Furthermore, low umbilical cord blood hemoglobin led to a tendency toward anemia in the child. CONCLUSION: Infant nutrition method was the most significant factor related to anemia in late infancy. Infants with low umbilical cord blood hemoglobin are more likely to develop anemia in late infancy.

Cervical ultrasound and computed tomography of Kawasaki disease: Comparison with lymphadenitis.

BACKGROUND: Differentiating Kawasaki disease (KD) from cervical lymphadenitis (CL) is clinically difficult but essential given that treatment and outcome differ significantly. Research on differentiation between KD and CL using ultrasound (US) and computed tomography (CT) is limited. The purpose of this study was to identify cervical US and CT findings that may differentiate KD from CL. METHODS: We retrospectively reviewed cervical US of 25 KD patients and 25 CL patients, and CT of 14 KD patients, and 14 CL patients. Two radiologists analyzed specific imaging features on US (lymph node size, shape, echogenicity, margins, laterality, necrosis, and presence of normal hilum) and on CT (size and location of enlarged nodes, laterality, perinodal infiltration, and retropharyngeal edema). RESULTS: On US, patients with KD more frequently had lymph nodes with a "cluster of grapes" appearance (KD vs CL: 64% vs 32%, P < 0.05) and less frequently had poorly circumscribed margins (0% vs 36%, P < 0.01), necrosis (0% vs 32%, P < 0.01), or non-visualization of the hilum (4% vs 36%, P < 0.01). On CT, KD patients more frequently had retropharyngeal edema (100% vs 29%, P < 0.001) and less frequently had level 4 lymphadenopathy (14% vs 79%, P < 0.01) than CL patients. CONCLUSIONS: Ultrasound is mainly useful for excluding purulent lymphadenopathy while CT is a useful diagnostic tool for differentiating KD from CL, especially in patients with incomplete KD, who present with prominent cervical lymphadenopathy and other equivocal principal findings.

Survey of delivery room resuscitation practices at tertiary perinatal centers in Japan.

BACKGROUND: The aim of this study was to determine the current neonatal resuscitation practices for term infants in Japan, immediately before the 2010 publication of the international neonatal resuscitation consensus. METHODS: In January 2010, a 26-question survey was mailed to neonatal department directors. RESULTS: A total of 287 neonatal departments were identified. Four surveys were returned as undeliverable. A total of 191 surveys were returned completed, but four departments had no labor and delivery rooms (66.6% response rate, 65.2% survey available response rate). Flow-inflating bags were most commonly used (63.2%), followed by self-inflating bags (35.8%), and T-piece resuscitators (1.0%). Among the participants, 42.1% used oxygen blenders, 56.2% used pure oxygen for initial resuscitation, and 79.5% used a pulse oximeter to change the fraction of inspired oxygen. Among the participants, 45.3% used carbon dioxide detectors to confirm intubation, 42.5% routinely used the detectors, and 55.2% used them when confirming a difficult intubation. In addition, 42.5% of the participants used continuous positive airway pressure to treat breathing problems, most commonly with flow-inflating bags (93.2%). CONCLUSIONS: The equipment and techniques used in Japanese perinatal center delivery room resuscitation practices are highly varied. Further research is required to determine which devices and techniques are appropriate for this important and common intervention.

Correlation between umbilical cord hemoglobin and rate of jaundice requiring phototherapy in healthy newborns.

BACKGROUND: Delay of umbilical cord clamping by at least 1 min is recommended for newborns not requiring resuscitation in the International Liaison Committee On Resuscitation-Consensus on Science with Treatment Recommendations (ILCOR-CoSTR) 2010 guidelines. The delay in clamping improves iron status through early infancy but may increase the likelihood of jaundice requiring phototherapy. The present study investigated the relationship between umbilical cord hemoglobin and the rate of jaundice requiring phototherapy in healthy Japanese newborns. METHODS: Cord hemoglobin was measured in healthy newborns and the rate of infants receiving phototherapy for jaundice and other data were obtained from medical records. RESULTS: Jaundice requiring phototherapy mostly occurred in association with high cord blood hemoglobin, which is increased by delayed cord clamping. CONCLUSIONS: Higher cord hemoglobin may increase neonatal jaundice in newborns in Japan, therefore the present results support the Japan Resuscitation Council guideline 2010, which does not recommend delay of umbilical cord clamping by at least 1 min, in contrast to the ILCOR guidelines.

Factors influencing timing of neonatal discharge in Japan: retrospective study.

BACKGROUND: The aim of this study was to evaluate the birth and discharge dates of neonates and analyze their distribution over days of the week and the old lunar calendar. METHODS: A retrospective study of the neonates discharged in the years 1990, 2000, 2005, and 2010 was conducted in a general hospital in Tokyo, Japan. Data are represented as odds ratios (OR) of the total number of discharges per day divided by the expected number of days per year, for each day of the week as well as each 6 day cycle of the lunar calendar. RESULTS: The timing of discharge has an uneven distribution across the days of the week, with weekday discharge rates significantly lower than weekend discharge rates. This uneven distribution is particularly significant in the preterm subgroup. In contrast, there is a minor uneven distribution of births across the days of the week and that of discharges across the 6 day cycle of the lunar calendar. Logistic regression analysis for 2005 and 2010 identified admission fee paid by insurance and prematurity as significant factors associated with weekend/holiday discharge (OR, 1.84; 95% confidence interval [CI]: 1.23-2.75; OR, 1.71; 95% CI: 1.15-2.55, respectively). The average length of stay of neonates discharged on the weekend was longer than that for those discharged on a weekday, in both term and preterm infants. CONCLUSIONS: Japanese parents prefer the convenience of weekends over old superstitions about using the lunar calendar to determine the discharge date.

Efficacy of Cranial Orthosis for Plagiocephaly Based on 2D and 3D Evaluation.

Background With the advent of cranial orthoses as therapeutic medical devices for the treatment of severe positional head deformities in Japan, an increasing number of patients are being treated with them. However, assessing the effectiveness of a treatment is often difficult due to the use of different metrics. This study aimed to evaluate the effectiveness of cranial orthoses for deformational plagiocephaly using two- (2D) and three-dimensional (3D) evaluation metrics. Methods We conducted a retrospective study of infant patients with deformational plagiocephaly who underwent cranial orthosis treatment. We evaluated the severity of deformational plagiocephaly using cranial asymmetry (CA) and the cranial vault asymmetry index (CVAI) as 2D metrics, and anterior and posterior symmetry ratios as 3D metrics. The patients were divided into 24 subgroups based on the initial severity of each outcome and their age at the start of treatment. We analyzed the changes in outcomes and correlations within improvements across the age and severity categories. Results Overall, 1,038 infants were included in this study. The mean CA, CVAI, and anterior and posterior symmetry ratios improved significantly after cranial orthosis treatment. The improvement in each score was greater in patients with more severe initial deformities and in those who underwent treatment at a younger age. Conclusion Cranial orthosis treatment was effective in correcting deformational plagiocephaly in infants, as demonstrated by improvements in both 2D and 3D metrics. Patients with more severe initial deformities and those who underwent treatment at a younger age showed greater improvement.

A left ventricular noncompaction in a patient with long QT syndrome caused by a KCNQ1 mutation: a case report.

A 5-year-old girl developed cardiopulmonary arrest after crying. From the electrocardiogram and echocardiography, a left ventricular noncompaction (LVNC) with long QT syndrome (LQT) was suspected as the cause of the cardiopulmonary arrest, and treatment with a ß-blocker and a calcium antagonist was then begun. A genetic screening of LQT-related genes revealed a previously reported heterozygous KCNQ1 mutation. The association of LVNC and LQT is an extremely rare condition, and long-term treatment based on the characteristics of both disorders is required. Also, the association of cardiomyopathy and LQT could become a new clinical entity in the future.

Japanese guidelines for the management of intussusception in children, 2011.

BACKGROUND: The Japanese Society of Emergency Pediatrics has formulated evidence-based guidelines for the management of intussusception in children in order to diagnose intussusceptions promptly, to initiate appropriate treatment as early as possible, and to protect intussuscepted children from death. METHODS: Literature was collected systematically via the Internet using the key words "intussusception" and "children." The evidence level of each paper was rated in accordance with the levels of evidence of the Oxford Center for Evidence-based Medicine. The guidelines consisted of 50 clinical questions and the answers. Grades of recommendation were added to the procedures recommended on the basis of the strength of evidence levels. RESULTS: Three criteria of "diagnostic criteria,""severity assessment criteria," and "criteria for patient transfer" were proposed aiming at an early diagnosis, selection of appropriate treatment, and patient transfer for referral to a tertiary hospital in severe cases. Barium is no longer recommended for enema reduction (recommendation D) because the patient becomes severely ill once perforation occurs. Use of other contrast media, such as water-soluble iodinated contrast, normal saline, or air, is recommended under either fluoroscopic or sonographic guidance. Delayed repeat enema improves reduction success rate, and is recommended if the initial enema partially reduced the intussusception and if the patient condition is stable. CONCLUSIONS: The guidelines offer standards of management, but it is not necessarily the purpose of the guidelines to regulate clinical practices. One should judge each individual clinical situation in accordance with experiences, available devices, and the patient's condition.

Preterm toddlers have low nighttime sleep quality and high daytime activity.

A number of studies have been made on the sleep characteristics of children born preterm in an attempt to develop methods to address the sleep problems commonly observed among such children. However, the reported sleep characteristics from these studies vary depending on the observation methods used, i.e., actigraphy, polysomnography and questionnaire. In the current study, to obtain reliable data on the sleep characteristics of preterm-born children, we investigated the difference in sleep properties between 97 preterm and 97 term toddlers of approximately 1.5 years of age using actigraphy. Actigraphy units were attached to the toddlers' waists with an adjustable elastic belt for 7 consecutive days, and a child sleep diary was completed by their parents. In the study, we found that preterm toddlers had more nocturnal awakenings and more daytime activity, suggesting that preterm-born children may have a different process of sleep development in their early development.

Influence of repeated painful procedures on prefrontal cortical pain responses in newborns.

AIM: We examined whether previous experience of repeated skin punctures altered the correlation between prefrontal cortical pain responses and Premature Infant Pain Profile (PIPP) scores, compared with infants who had no experience of skin puncture. METHODS: Eighty infants at 37-42 weeks of gestational age were observed during clinically required blood sampling: full-term infants with no experience of painful skin-breaking procedures before data collection (controls; n = 30), full-term infants with the experience of painful skin-breaking procedures (n = 20) and preterm infants with the experience of painful skin-breaking procedures (n = 30). RESULTS: We found no significant differences in PIPP scores among groups. In controls, prefrontal activation in both hemispheres correlated with facial expression score of the PIPP (r = 0.53 for right prefrontal area; r = 0.37 for left prefrontal area) and the total score. In full-term infants with the experience of pain, there was no correlation between cortical activation and clinical pain scores. In preterm infants, prefrontal activation in both hemispheres correlated with the physiological component of the PIPP score (r = 0.36 for right prefrontal area; r = 0.41 for left prefrontal area). CONCLUSION: Our findings may be useful in considering the effects of cumulative painful experience on emotion and stress in neonates.

Eyelid myoclonia with absences related to epileptic negative myoclonus.

Eyelid myoclonia with absences (EMA) is an epileptic syndrome characterised by eyelid myoclonia with or without absences, eye closure-induced paroxysms, and photosensitivity. The relationship between EMA and epileptic negative myoclonus has not previously been reported. Herein, we describe a case of a 10-year-old girl who presented with eyelid myoclonia, eye closure-induced paroxysms, and photosensitivity, which was compatible with the diagnosis of EMA. Ictal EEG depicted an eye closure-induced diffuse 3.0-4.5-Hz polyspike-and-wave complex, which was accompanied by eye fluttering (eyelid myoclonia). EMG disclosed a brief interruption (60-140 mseconds) of tonic contraction of the orbicularis oculi muscle, which was associated with the polyspike-and-wave complex on EEG. The findings led to the diagnosis of epileptic negative myoclonus. Eye closure-induced eyelid epileptic negative myoclonus, demonstrated in this patient, may be an atypical seizure type of EMA that represents an intermediate between eyelid myoclonia and epileptic negative myoclonus.

Daytime nap and nighttime breastfeeding are associated with toddlers' nighttime sleep.

The purpose of the present study is to examine the association between toddlers' sleep arrangements and their nighttime sleep duration and other sleep variables. For this investigation, we performed a study in which child activity and sleep levels were recorded using actigraphy. The parents of 1.5-year-old toddlers (n = 106) were asked to attach an actigraphy unit to their child's waist with an adjustable elastic belt and complete a sleep diary for 7 consecutive days. Questionnaires were used to assess the sleep arrangements of the toddlers. There was a significant negative correlation between nap duration and nighttime sleep duration, suggesting that longer nap sleep induces shorter nighttime sleep duration. Among the sleep arrangements, such as nighttime breastfeeding or co-sleeping, only nighttime breastfeeding predicted shorter nighttime sleep duration. Our findings indicate that shorter naps induce a longer nighttime sleep in 1.5-year-old toddlers while nighttime breastfeeding decreases their nighttime sleep duration.

Sleep maturation influences cognitive development of preterm toddlers.

Our recent study on full-term toddlers demonstrated that daytime nap properties affect the distribution ratio between nap and nighttime sleep duration in total sleep time but does not affect the overall total amount of daily sleep time. However, there is still no clear scientific consensus as to whether the ratio between naps and nighttime sleep or just daily total sleep duration itself is more important for healthy child development. In the current study, to gain an answer to this question, we examined the relationship between the sleep properties and the cognitive development of toddlers born prematurely using actigraphy and the Kyoto scale of psychological development (KSPD) test. 101 premature toddlers of approximately 1.5 years of age were recruited for the study. Actigraphy units were attached to their waist with an adjustable elastic belt for 7 consecutive days and a child sleep diary was completed by their parents. In the study, we found no significant correlation between either nap or nighttime sleep duration and cognitive development of the preterm toddlers. In contrast, we found that stable daily wake time was significantly associated with better cognitive development, suggesting that sleep regulation may contribute to the brain maturation of preterm toddlers.

Postural change for supine position does not disturb toddlers' nap.

This study examined whether forced postural change from prone to supine during toddlers' nap, a preventative measure taken in Japan for sudden unexplained death in childhood (SUDC), disturbs toddlers' sleep. When the "Back to Sleep" campaign (BSC) was introduced to Japan in 1996, its recommendations were also applied to infants aged 1 year old and over with the expectation that the BSC recommendations may also contribute to a decrease in the occurrence rate of SUDC. Since then, Japanese nurseries have routinely conducted sleeping position checks and positional adjustments of toddlers every 5-10 min during naps. A total of 52 toddlers (age 18.4 ± 3.3 months, means ± SD) were continuously monitored for 8 h during daytime at nursery schools for wake-sleep status and body position (prone, supine and lateral) with actigraphs and 3-orthogonal-axis accelerometers. Out of the 52 toddlers, 24 toddlers adopted prone positions during naps, which were adjusted by nursery staff back to supine. When nursery staff manually changed the toddlers position from prone to supine, the toddlers either did not wake or woke only briefly (3.1 ± 4.9 min) and returned to sleep soon after the positional change. Our study indicates that manual change of toddlers' sleeping position from prone to supine, a potential SUDC prevention method, does not disturb toddlers' sleep during their naps.