Journal of Neonatal-Perinatal Medicine

Objective: Necrotizing enterocolitis (NEC) causes significant morbidity and mortality in very low birth weight (VLBW) infants. Our objective was to assess the influence of pasteurized donor human milk (PDHM) on the incidence of NEC.

Methods: This is a retrospective chart review of 179 VLBW (< 1500 g) infants born in the pre-PDHM era (January 2001–March 2003) vs 152 born in the post-PDHM era (April 2003–December 2004).

Results: The cohorts had similar demographic characteristics. The overall incidence of NEC was 12% in the pre-PDHM era vs 10% in the post-PDHM. Although not statistically significant, surgical NEC decreased from 7% to 3% respectively. Sepsis decreased from 10% to 6% between the pre and post-PDHM eras (p=0.04). Erythropoietin administration for anemia of prematurity was associated with a protective effect for NEC, even after adjusting for gestational age, indomethacin and mother's own milk intake (OR 0.37, 95% CI 0.16–0.85, p=0.02). The introduction of PDHM did not decrease the amount of mother's own milk use.

Conclusions: The overall incidence of NEC remained unchanged after the introduction of PDHM in a single neonatal intensive care unit, but the cases of surgical NEC had a trend to decrease. Randomized controlled clinical studies evaluating the effect of PDHM on the severity of NEC are warranted.

Background: Early postnatal weight changes are widely variable and unpredictable in the extremely low birth weight infants (ELBW, birth weight < 1000 g). As the fluid volume therapy is calculated based on the body weight these changes could potentially have implications in the hydration related morbidities in them. Early postnatal weight changes have not been systematically investigated in this population.

Objectives: To determine the pattern and magnitude of weight changes early in life and its relationship with maturation and birth weight (BW) in ELBW infants.

Methods: We studied the maximum weight loss (MWL), and the daily body weight changes from birth weight (DΔ bw) during the first 15 days of life. Prospectively entered infants' and maternal demographic and relevant clinical data were retrospectively extracted via computerized reports and chart reviews during a three-year study period. MWL and DΔ bw (calculated as % of birth weight and expressed as mean ± SD) were determined and correlated with gestational age (GA) and BW. Data were analyzed via Pearson's correlation co-efficient and the ordinary least square regression tests.

Results: The mean ± standard deviation of GA and BW in 102 enrolled ELBW infants were 26.1 ± 2 weeks and 779.9 ± 157 g respectively. MWL in the entire cohort was 14.2 ± 5.4%. After initial loss the BW was regained on 14.5 ± 4.2 postnatal days of life. MWL varied widely within unit GA groups and was highest in infants born at 23 weeks. MWL correlated inversely with GA (r= − 0.3, p=0.007) but not with BW (r=0.17, p=0.09). DΔ bw varied widely and was highest on postnatal day 4. DΔ bw correlated negatively and significantly with GA during days 1–8 of life (p 0.05 to < 0.01) except for day 2 (p= 0.06). The slopes of regression coefficients for the two variables were also negative and highly significant during postnatal days 1–8 (p < 0.01) except for day 2 (p= 0.06). DΔ bw did not correlate with GA during 9–15 postnatal days and displayed a positive slope on day 15.

Conclusions: MWL is related inversely to GA and has no relationship with BW in ELBW infant. DΔ bw is predictable by GA during the first but not the second postnatal week. The BW is regained on an average of 14 days of postnatal life.

Objectives: The environment plays a key role in survival and brain development for premature infants. Recent interest lends consideration to non pharmacological interventions as a beneficial alternative. This study seeks to investigate the effect of lullaby music on the physiological response and weight gain of premature infants in Mashhad, Iran.

Method: In this study, 44 very low birth weight infants ⩽ 34 weeks of gestational age that were admitted to the Neonatal Intensive Care Unit (NICU) of Imamreza Hospital in Mashhad, Iran were enrolled. Infants were randomly assigned to one of two groups: the Music group and the Control group. Lullaby music was played through earphones for the Music group. This continued for 8 days at 20 minutes per day. The Control group received routine auditory stimulation. Neonates in the two groups were in stable condition and kept in their isolettes. Infants were monitored for 40 minutes; 10 minutes baseline, 20 minutes into the intervention and 10 minutes post intervention. Data measures were heart rate, respiration rate, oxygen saturation and body weight.

Result: The two groups differed significantly in the respiratory rate (p= 0.01) and oxygen saturation (p= 0.001). There were no significant differences in the heart rate (p= 0.24) and weight gain (p= 0.093) between the two groups.

Conclusion: Preterm infants respond to lullaby music as evidenced by the changes in their respiratory rates and oxygen saturations. Although this study did not demonstrate an improvement in weight gain, further studies are recommended to examine the effect of music on other growth and developmental aspects

Objective: To examine the relationship between high altitude and microtia in Ecuador.

Methods: We evaluated the epidemiological issues of 1298 cases of microtia reported in Ecuador from 2001 to 2007. It used data arising from the Vital Statistics National Reports: Annual Survey of Admissions and Discharges in this 7 year period. The register is national and population based, run and funded by the government.

Results: It reported a total of 1298 cases of microtia out of 34654 cases of congenital malformations described in the registries. The overall prevalence was 2.38/10000 admissions/discharges calculated out of 5462263 admissions. An overall percentage (of 90.22%) were admitted before 19 years of age with the most prevalent group between 5 to 9 years of age (31.90%). There was progressive increase of cases every year; from 132 cases in 2001 to 304 in 2007. Total male cases in this study were 723 (55.70%) and female cases were 575 (44.30%). Tungurahua reported the highest prevalence of 18.31/10000 births, followed by Chimborazo, Azuay, Pichincha and Cotopaxi; all of them located over 2500 meters above sea level. It found that highest prevalence was 10.21 over 2700 meters above sea level followed by 8.28 over 2800 meters above sea level; with both having a cumulative prevalence of 8.81.

Conclusion: There is a higher prevalence of microtia in patients living above 2500 meters above sea level. This study was not able to establish a clear relationship between microtia and different ethnic groups.

Objective: To review the epidemiology of late-onset bloodstream infections (LOBSI), evaluate risk factors associated with LOBSI and to compare our findings with the literature in light of new National Healthcare Safety Network (NHSN) birth weight categories.

Design/methods: A retrospective case-controlled study of infants with LOBSI at ⩾ 72 hours of life admitted to the NICU between 2000 and 2005. Infection rates were determined for birth weight categories adopted by the NHSN. The exposures of cases and controls to established risk factors were compared. Antimicrobial susceptibility patterns were evaluated.

Results: A total of 4061 neonates were studied. LOBSI occurred in 150 (3.7%) of infants. Out of these 150, 196 episodes of infection occurred with 210 isolated pathogens. Most cases of LOBSI were in the infants whose birth weight was < 1000 grams (ELBW). Sepsis was associated with increased mortality (23%) in very low birth weight infants (p< 0.05). Coagulase-negative staphylococci were responsible for most cases; LOBSI due to Candidal infections were less common but associated with high mortality rates (37%) in the ELBW infant. Rates of methicillin-resistant Staphylococcus aureus remained low. Infants who developed LOBSI had prolonged exposures to a number of established risk factors. In the logistic regression analysis, bacteremia was associated with use of parenteral nutrition (OR =5.9) and umbilical catherization (OR= 32).

Conclusions: ELBW infants had the highest rates of LOBSI. There was a low overall incidence of LOBSI due to yeast. However, infections with a Candida species were more common in ELBW infants and were associated with a higher mortality.

Objective: To study feasibility of a simplified method of head cooling using ice water filled rubber gloves in full term infants with moderate to severe hypoxic-ischemic encephalopathy and whether very early induced hypothermia would decrease mortality and incidence of convulsions in this group of infants.

Study Design: In this single center prospective cohort study, full term inborn infants were assigned to intervention cohort or control cohort based on the 24 hours on call staff physician preference. Patient selection was based on perinatal evidence of hypoxic-ischemic insult and clinical neurological findings on admission suggestive of moderate to severe hypoxic-ischemic encephalopathy. Hypothermia was passively initiated at delivery and was actively induced on admission. A simplified approach to induced head cooling was used by applying ice water filled rubber gloves. Combined selective head cooling and mild systemic hypothermia approach was applied. Cooling was continued for 72 hours. Short term outcomes of infants in the two cohorts were compared.

Results: 106 infants were enrolled, 54 infants in intervention cohort and 52 infants in control cohort. Active cooling was initiated in the intervention cohort at a median postnatal age of 57 minutes. The method of cooling was easy to learn and adopt by our unit members. The mortality rate was not significantly different between the two cohorts; 8/54 intervention cohort vs. 11/52 in the control cohort, p value 0.45. Infants in the intervention cohort had statistically significant reduction in the incidence of clinical convulsions, 14/54 vs. 25/52, p value 0.026. Fewer infants in the intervention group had abnormal electroencephalogram; 12/46 (26%) vs. 18/43 (42%) in the control group, however this did not reach statistical significance.

Conclusion: This simplified method of head cooling is feasible and might be helpful to treat newborn infants with hypoxic-ischemic encephalopathy in centers where sophisticated equipments are not available.

Objective: Oxygen saturation (SpO $_{2}$ ) monitoring is an integral part of patient care in intensive care units. Unfortunately, the clinical application of this technology has been adversely affected by the unacceptably high rate of false alarms, which has resulted in desensitizing the clinicians to SpO $_{2}$ alarms The SatSeconds™ alarm management feature (Nellcor™) incorporates an integral alarm. The primary hypothesis is that there will be progressive reduction in percentage saturation using the SatSeconds™ alarm feature depending on the integral settings.

Study design: 29 patients were monitored for 2 hours each with the study monitor. Upper and lower oxygen saturation alarm limits were determined individually and manually recorded and preset on the test oximeter for later analysis of alarm events. Test oximeter display values were not used for patient management. Audible alarms were silenced throughout the study.

Results: Alarm events were recorded while the SatSeconds™ alarm management feature was set at various points. With application of the SatSeconds™ alarm management feature, there was an overall decrease in alarms to 40% with a setting of 50 SatSeconds™.

Conclusion: Application of an integrated alarm system such as SatSeconds™ alarm management feature allows caregivers to respond to clinically relevant alarms.

Background: The onset of response to inhaled nitric oxide (INO) vary in the literature. It is important to identify non responders from those who respond to the INO in order to formulate management plans.

Objective: To define a time limit for the acute effects of inhaled nitric oxide (INO) on systemic oxygenation beyond which the response to the inhaled therapy is unlikely to take place in sick newborn infants suffering from persistent pulmonary hypertension.

Methods: This study was a hospital-based retrospective chart review. All infants who received INO for the treatment of pulmonary hypertension with acute sever hypoxemic respiratory failure over a period of four years were analyzed using the oxygenation index (OI) as an indicator for starting the therapy and following the response for total period of gas exposure. The OI was measured before and every one to six hours after initiating the therapy. The starting time of the gas, timing of first response, course of responses, blood gases, calculated OI before, during, and after initiation of the gas were also recorded until INO was discontinued.

Results: Seventy-six infants were studied: 35 infants were born at 24 to 32 weeks gestation age, and 41 at 33 weeks gestation to full term. Mean duration time of exposure to INO was 53 hours in the preterm group and 84 hours in the near and full term group. The mean age at starting the therapy was 59 hours in the preterm group and 23 hours in the near and full term group. The degree of response to INO was as follows: 52.2% full response, 27.5% partial response, and 20.3% no response. The first two (2) hours contained the highest number of responders, 64%; while the response was 15% in the second two hours. No responders were recorded after eight hours of exposure.

Conclusion: Exposure to INO for eight (8) hours could be carefully considered as a time limit to determine the type of response to such gas and to help in making a decision of ``wean to discontinue'' in non-responders.

Necrotizing fasciitis (NF) in premature infants is a rare, yet life-threatening, soft tissue infection. We report four cases of NF that were encountered over a seven-year period. The onset of the disease was between four and twelve days of age. Predisposing factors were omphalitis in two infants and intestinal perforation in the other two infants, one of whom had necrotizing enterocolitis. Surgical biopsies from the affected sites showed mucormycosis in one infant and bipolaris fungi in another. One of these infants was treated with antifungal therapy in addition to broad spectrum antibiotics. This infant survived, even without surgical intervention while the other three died. We conclude that intestinal perforation and omphalitis are important predisposing factors of NF in premature infants. Fungal infection should be considered as one of the possible causes of NF in preterm infants. Early initiation of antifungal therapy, in addition to broad spectrum antibiotics, is justifiable in this disease entity.

We report a case of left hemispheric cerebral stroke and occlusion of right axillary artery in a newborn with fetal last trimester parvovirus B19 infection detected by polymerase chain reaction for viral DNA. Thromboembolic occlusion of cervical and cerebral arteries was demonstrated on MRI. Excluding vasculitis or prothrombotic condition, data suggest neonatal stroke arising from the congenital parvovirus B19 infection.

Brain abscesses can be bacterial or fungal. It is usually difficult to distinguish between the two clinically as well as radiologically. However, careful scrutiny of the radiological images for subtle radiological signs and proper analysis of serial images can help in narrowing down the diagnosis and preventing delay in specific treatment.

We report an infant who initially presented with a small parietal hemorrhage and subsequently evolved into multiple brain abscesses. Since fungi and not bacteria are preferentially known to invade blood vessels, the infant had a radiological diagnosis of fungal abscess in the brain. Although the cerebrespinal fluid did not grow any fungal micro-organism, the infant clinically improved after the administration of anti-fungal antibiotics. Blood and urine cultures later grew Candida albicans.