Journal of Neonatal-Perinatal Medicine

Positive pressure ventilation (PPV) is the most important procedure during neonatal resuscitation. Providing effective PPV seems easy. However, performing the procedure correctly is extremely challenging. Airway obstruction and face mask large leaks are common. It is estimated that two-thirds of continued neonatal respiratory depression after the time of birth is caused by ineffective or improperly provided PPV. Finding methods to improve PPV performance are critically needed. Performance coaching is a simple and easy method of improving performing in procedural skills, and has been used previously to optimize compression technique. We performed the simulation-based pilot study to evaluate the impact of PPV coaching during neonatal bag-mask ventilation.

Randomized cross-over study of nurses performing PPV on a SMART Newborn Resuscitation Training System with, and without, coaching. The PPV coach provided real-time feedback on chest rise, mask hold, and ventilation rate. The SMART system captured data on peak inspiratory pressure (PIP), tidal volume (Vt), mask leak, and ventilation rate. Data were analyzed by a blinded reviewer.

PPV coaching resulted in more appropriate PIPs (34 cmH2O, IQR 32-38 vs. 36 cmH2O, IQR 28–37; P < 0.001), lower Vt (4.7 ml/kg, IQR 4–8 vs. 5.5 ml/kg, IQR 4–13; P < 0.001), and less mask leak (39% leak, IQR 21–70 vs. 45%, IQR 22–98; P = 0.005). There was no difference in respiratory rate (P = 0.93).

Coaching improved PPV performance in this simulation-based pilot study. Further research on PPV coaching during neonatal resuscitation is warranted.

To evaluate the association between the use of nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV) with the development of bronchopulmonary dysplasia (BPD).

This is a single center retrospective cohort analysis of infants born at ≤1000 grams and ≤28 weeks gestation with respiratory distress treated with nCPAP or NIPPV. Groups were compared using Student’s t test or chi-square, and associations estimated by logistic regression.

Compared to nCPAP, infants who received NIPPV had a higher incidence of moderate to severe (M–S) BPD (84.2 vs 65.5%, p = 0.044) and death or severe BPD (75.0 vs 47.6%, p = 0.003). Each day on NIPPV was associated with an increased risk of M-S BPD (OR 1.08, p < 0.001) and an increased risk of death or severe BPD (OR 1.03, p = 0.006). After adjusting for days on oxygen, ventilator days, and days on all respiratory support, the odds of developing M-S BPD increased by 4.9% for each additional week on NIPPV (CI 2.1–7.7%, p = .0001).

In this cohort, use of NIPPV was associated with an increased risk for developing BPD when compared to infants receiving nCPAP, and each additional day on NIPPV carried significant increased risk for developing BPD.

This study investigates trends in methods of surfactant administration and early respiratory management in neonatal intensive care units [NICU] in New South Wales [NSW] and the Australian Capital Territory [ACT] in 2015 and evaluate whether differences in practice translate to variances in short term outcomes.

Surveys were sent to NICUs in NSW and ACT to ascertain their practice of surfactant administration and respiratory management. A retrospective data analysis with data from the NICUS database from 01/01/2013-30/06/2015 was performed. Included were all patients that received Surfactant, were inborn, without major malformation, ≥24 weeks gestational age [GA] and birthweight ≥500 g. Major respiratory outcome measures were time ventilated, air leak, oxygen requirement at 36 weeks corrected gestational age [cGA], home oxygen therapy after discharge and retinopathy of prematurity [ROP]. Along with this data demographic and morbidity data was also obtained for comparison [mortality, necrotizing enterocolitis [NEC], persistent ductus arteriosus [PDA], intraventricular hemorrhage [IVH].

1453 patients met inclusion criteria. Patient data comparing major respiratory outcomes showed patients receiving less invasive Surfactant therapy and respiratory management spent longer time on CPAP [559 vs. 407 hrs, p = 0.01] and in the older gestation subgroups less time on mechanical ventilation [18 vs. 50 hrs p = <0.001] and were discharged earlier [48 vs. 54 days, p = 0.03]. There was however, higher rates of oxygen requirement at 36 weeks cGA [33 vs. 26.3% p = 0.01] and a higher proportion of home oxygen in this patient group [11.3 vs. 7.1% p = 0.03]. Major morbidity outcome data showed no significant differences.

Less invasive Surfactant therapy and gentle early respiratory management should be considered as a viable alternative to established methods of surfactant administration and ventilation.

Thymus size in neonates depend on many factors. We aimed to assess the thymus size radiographically in preterm neonates and its relationship with respiratory distress syndrome (RDS) and other complications of prematurity.

Thymus size was assessed by cardiothymic: thoracic ratio (CT/T), measuring the width of the cardiothymic shadow at the level of carina and dividing it by the width of the thorax at the costophrenic angles, from the first chest radiograph in patients less than 34 weeks gestational age.

Neonates born between 30–34 weeks of gestation with RDS had smaller CT/T than non RDS group (0.34±0.1 vs 0.36±0.05, p = 0.045). Birth weight has positive correlation with CT/T (r = 0.166, p = 0.03).

Thymus involution in the perinatal period is a complex process and the response is variable in different clinical situations. Activated hypothalamic-pituitary-adrenal (HPA) axis may be responsible for thymic involution in preterm infants between 30–34 weeks of gestation with RDS.

To evaluate the effect of oro-and naso- pharyngeal suction (ONPS) on the SpO2 and heart rate (HR) in healthy term newborns delivered by cesarean section, at the first minutes after birth.

We conducted a prospective randomized trial. Newborns were randomized to ONPS and No-ONSP groups. Continuous readings of SpO2 and HR were performed during the first 10 minutes, and subsequently at 15, 30 and 60 minutes after birth.

A total of 84 newborns were evaluated; 42 in ONPS group and 42 in No-ONPS group, with mean gestational age and birth weight±SD of 38.4 weeks and 3533±403 g in the ONPS group and 38.0 weeks and 3575±568 g in the No-ONPS group. The mean SpO2±SD at the first minute of life in the former group was 52.6±7.6% vs 56.1±10.8% on the latter; with no significant difference (p = 0.28). The mean HR±SD at first minute of life was 137±25 in the No-ONPS and 148±13 in the ONPS group (p = 0.02), but no difference was found in the subsequent minutes.

Not performing ONPS in newborns delivered by cesarean section does not affect SpO2 and HR in the first postpartum hour.

Neonatal tele-homecare implies that parents of clinically stable preterm infants can manage tube feeding and establishment of oral feeding in the home. Support is provided from the neonatal intensive care unit (NICU) through a telehealth service. The aim of this study was to compare growth and breastfeeding rates amongst infants being managed in the NICU (conventional care) and by neonatal tele-homecare.

A total of 96 preterm infants with tube feeding requirements participated in the observational study of neonatal tele-homecare. Retrospective data in 278 preterm infants receiving standard care in the same neonatal intensive care unit prior to implementation of neonatal tele-homecare were used for comparison. Rates of breastfeeding and growth were monitored during neonatal tele-homecare. Infant weights were converted to standard deviation weight-for-age z-scores based on a reference.

There was no significant difference in rates of exclusive breastfeeding between the neonatal tele-homecare infants and the controls. Among the very preterm singleton infants more neonatal tele-homecare infants were exclusively breastfed at discharge compared to the controls (p = 0.04). There was no significant difference in median weight for age z-scores at discharge.

This study demonstrates that neonatal tele-homecare may be an appropriate model of care for the management of preterm infants outside of the hospital environment; with the added benefit of higher rates of breastfeeding at time of discharge for very preterm infants.

To ascertain the rate of in-hospital supplementation as it relates to early breastfeeding (BF) and early formula feeding (FF) and its effects on BF (exclusive and partial) at the time of discharge for infants born to women with pregestational diabetes mellitus (PGDM).

Retrospective cohort investigation of 282 women with PGDM who intended to BF and their asymptomatic infants admitted to the newborn nursery for blood glucose monitoring and routine care. Early feeding was defined by the initial feeding if given within four hours of birth.

Of the 282 mother-infant dyads, for 134 (48%) early feeding was BF and for 148 (52%) early feeding was FF. Times from birth to BF and FF (median 1 hr, 0.3–6) were similar, while the time to first BF for those who FF and supplemented was longer (median 6 hr., 1–24). Ninety-seven infants (72%) who first BF also supplemented. Of these, 22 (23%) BF exclusively, 67 (69%) BF partially and 8 (8%) FF at discharge. One hundred seventeen (79%) who first FF also supplemented. Of these, 21 (18%) BF exclusively, 76 (65%) BF partially and 20 (17%) FF at discharge.

Regardless of the type of first feeding, the majority of infants born to women with PGDM require supplementation. Even when medically indicated, in-hospital supplementation is an obstacle, albeit not absolute, to exclusive BF at discharge. Parents should be reminded that occasional supplementation should not deter resumption and continuation of BF.

The efficacy of macrolide treatment on gastrointestinal motility and acquirement of feeding tolerance in extremely low birth weight (ELBW) infants are controversial. This study aimed to evaluate clinical effects of parenterally administered erythromycin (EM) and clarithromycin (CAM) on gastrointestinal motility in ELBW infants.

ELBW infants treated in Tokyo Medical University Hospital were retrospectively studied. Several outcomes of ELBW infants treated with EM or CAM were compared with those recognized before initiation of the medication, as well as with those of patients with no macrolide treatment. The primary outcomes included average gastric residual volume that was evaluated 3 hours after enteral feeding. Secondary outcomes were the number of patients who developed feeding intolerance, stool frequency, and other adverse events, such as respiratory comorbidities and pyloric stenosis.

Among a total of 53 infants, 20 and 13 were treated with EM and CAM, respectively, whereas 20 infants were not administered macrolides. The gastric residual volume was significantly decreased after initiation of medication compared with before medication in the EM group, whereas that of the untreated group showed no change. When the EM and CAM groups were combined, the gastric residual volume was also significantly decreased after treatment compared with before treatment. An increase in stool frequency and pyloric stenosis were not observed in the groups.

EM might be effective for acquiring feeding tolerance in ELBW infants. A future prospective study with a larger population is required to determine the efficacy of CAM.

Neonatal antibiotic use is associated with a greater risk of nosocomial infection, necrotizing enterocolitis, and mortality. It can induce drug-resistant pathogens that contribute to increased neonatal morbidity/mortality, healthcare costs, and length of stay. Prior to the antibiotic stewardship program, decisions to obtain blood cultures and empiric antibiotics for possible Early-onset Sepsis (EOS) in late preterm and term infants upon NICU admission were provider-dependent rather than algorithm-based. We aimed to decrease empiric antibiotic prescription from 70% to 56% (20% decrease) in infants ≥34 weeks gestation admitted to the NICU.

The stewardship initiative comprised the following practice changes: (1) use of the Neonatal Sepsis Risk Calculator (SRC); and (2) a 36-hour time-out for prescribed empiric antibiotics. Data was retrospectively collected and analyzed for inborn infants pre-intervention (January 2015–December 2015; n = 263) and post-intervention (August 2016–September 2017; n = 279). Data regarding compliance with the new antibiotic guideline were collected and disseminated to the team every week. Overlap between CDC guidelines and calculator recommendations were studied.

Pre-and post-intervention outcomes were analyzed using chi-square tests. There was a significant post-intervention reduction in the rate of both antibiotic prescriptions (29.4% decline; 70.3% vs. 49.6%; p < 0.001) and sepsis evaluations (24.3% decline; 90.9% vs. 68.8%; p < 0.001). No difference (p = 0.271) in culture-positive EOS cases was observed. There was 92% overlap in blood culture recommendations and 95% overlap between antibiotic recommendations when current CDC guidelines were compared to the SRC.

A significant reduction in antibiotic use and sepsis evaluations was achieved for late preterm and term infants upon NICU admission. No clinical deterioration occurred in post-intervention infants who did not receive antibiotics. There is significant overlap between CDC guidelines and SRC recommendations.

Microvillus Inclusion Disease (MVID) was first described in the literature in 1978 with presentation of severe watery diarrhea, failure to thrive, and metabolic acidosis. Mutations in the myosin Vb (MYO5B) gene have been identified as causative for MVID, but other clinical manifestations and associations with novel mutations are lacking.

We report a full-term infant admitted to the neonatal intensive care unit (NICU) with abdominal distension and inability to sustain full enteral feeds. A retrospective chart review and review of the literature was performed.

An infant with abnormal, mucoid-like stringy stools was incidentally found to have severe metabolic acidosis on routine lab monitoring. Acidosis corrected with total parenteral nutrition (TPN), but the infant experienced recurrent episodes of acidosis with enteral feeds. He was also noted to have abnormal ocular movements, fluctuating tonicity, and staring spells. He underwent an extensive workup and the diagnosis of microvillus inclusion disease was made by findings on electron microscopy. The diagnosis was confirmed with whole exome sequencing, showing a rare homozygous mutation in the syntaxin 3 (STX3) gene. This is the fifth reported patient with microvillus inclusion disease with a mutation in this gene, and the first with abnormal neurologic findings.

It is important to consider MVID in the differential diagnosis of a neonate or infant with abnormal stools, metabolic acidosis, with and without neurologic symptoms for prompt referral and treatment.

Ovarian cysts are relatively common prenatal findings in female fetuses. The aim of this study is to evaluate the ability of antenatal ultrasound in predicting spontaneous regression or a need for surgery.

All cases of fetal ovarian cysts treated in our Department between 2007 and 2016 were included. Patients underwent a sonographic monitoring in utero and after birth until spontaneous or surgical resolution. Subjects were divided into two groups according to their postnatal management. Receiver-operating characteristics (ROC) curves were used to test the predictive ability for postnatal surgery of the cyst’s mean and maximum diameters; their optimal cut off points were also determined.

38 cases of antenatally-detected fetal ovarian cysts were included. 12/38 cases underwent surgery (Group A). 26/38 cases were resolved spontaneously (Group B). Cyst size of those which were surgically excised significantly differed from those that regressed spontaneously. ROC curve pointed to 45 mm and 47 mm as optimal cut off points for the mean and the maximum cystic diameters, respectively.

Cyst size and echo-structure seemed good predictors for prognosis after birth. The optimal cut off points of the cysts mean and maximum diameters in predicting postnatal surgery have been identified as 45 mm and 47 mm, respectively.