Journal of Neonatal-Perinatal Medicine

OBJECTIVE: We sought to determine whether hypocortisolism is associated with preterm birth, using hair cortisol as a marker of long term hypothalamic-pituitary-adrenal axis activity.

STUDY DESIGN: In a prospective, matched, case-control study, 29 women who had a preterm birth at 24–36w5d gestation were compared to 29 women who delivered at term, matched for maternal age, gestational age, and ethnicity. Cases’ samples were collected within 72 h of preterm birth and controls at the same gestational age as the corresponding case. Participants completed validated questionnaires regarding general stress and childhood trauma. The Wilcoxon signed-rank test was used to compare the distribution of mean hair cortisol scores between cases and controls. Conditional logistic regression was used to predict case vs. control by hair cortisol score, controlling for relevant covariates.

RESULTS: Baseline characteristics of cases and controls did not differ. Hair cortisol levels were significantly lower among cases in the adjusted analysis. Hair cortisol level was a predictor of case versus control. Each 10-pg.mg^–1 increase in hair cortisol level was associated with an estimated 33% decreased odds of being a case. The only significant difference in the validated questionnaires was an increased measure of emotional neglect in the preterm group.

CONCLUSION: Our study suggests that women who deliver prematurely may have lower hair cortisol levels than women who deliver at term. Normal hypothalamic-pituitary-adrenal axis activation is a physiologic, adaptive response to stress. One hypothesis to explain our results are that women who are stressed, but unable to mount an adequate stress response could be at particular risk for preterm birth.

OBJECTIVES: First, to determine the feasibility of an ultra-compact wireless device (microEEG) to obtain multichannel electroencephalographic (EEG) recording in the Neonatal Intensive Care Unit (NICU). Second, to identify problem areas in order to improve wireless EEG performance.

STUDY DESIGN: 28 subjects (gestational age 24–30 weeks, postnatal age <30 days) were recruited at 2 sites as part of an ongoing study of neonatal apnea and wireless EEG. Infants underwent 8-9 hour EEG recordings every 2–4 weeks using an electrode cap (ANT-Neuro) connected to the wireless EEG device (Bio-Signal Group). A 23 electrode configuration was used incorporating the International 10–20 System. The device transmitted recordings wirelessly to a laptop computer for bedside assessment. The recordings were assessed by a pediatric neurophysiologist for interpretability.

RESULTS: A total of 84 EEGs were recorded from 28 neonates. 61 EEG studies were obtained in infants prior to 35 weeks corrected gestational age (CGA). NICU staff placed all electrode caps and initiated all recordings. Of these recordings 6 (10%) were uninterpretable due to artifacts and one study could not be accessed. The remaining 54 (89%) EEG recordings were acceptable for clinical review and interpretation by a pediatric neurophysiologist. Of the recordings obtained at 35 weeks corrected gestational age or later only 11 out of 23 (48%) were interpretable.

CONCLUSIONS: Wireless EEG devices can provide practical, continuous, multichannel EEG monitoring in preterm neonates. Their small size and ease of use could overcome obstacles associated with EEG recording and interpretation in the NICU.

OBJECTIVES: To assess whether TSH and fT4 have a role in the angiogenesis of vaso-obliteration and neovascularization which are the basic pathophysiology of ROP.

METHODS: In this retrospective case-control study, the control group (n = 56) included preterm newborns with risk for ROP while the laser group (n = 63) was recruited from cases who developed severe neovascularization and needed laser photocoagulation therapy. Considering the first (vaso-obliteration) and second (neovascularization) phases of the disease, in this study we researched the distribution of thyroid function tests between groups.

RESULTS: With regard to the first phase of the disease, TSH and fT4 showed no significant differences between the control and laser groups accordingly (P > 0.05). Likewise, in the second phase of ROP, there was no significant difference between the control and laser groups with respect to TSH and fT4 levels (P > 0.05).

CONCLUSION: We found that between the study groups, the levels of thyroid function tests did not have any significant differences, either in the first or the second phases of ROP which are the principal pathophysiology of the disease. Therefore, it was concluded that thyroid hormone values were not informative markers in the course of the disease in preterm babies at risk of developing ROP.

BACKGROUND: Alarm overload is a significant concern in the Neonatal Intensive Care Unit (NICU). Selecting a longer oxygen saturation (SpO₂) averaging time will reduce the number of alarms but may mask fluctuations in oxygenation.

OBJECTIVE: Characterize bedside monitor alarms in the NICU and estimate the impact of longer SpO₂ averaging time and alarm delay.

METHODS: All bedside monitor alarms were analyzed over a 12-month period in the University of Virginia NICU, using the default averaging time (8 seconds) and SpO₂ alarm limits set at 88–95% for infants on supplemental oxygen. In 10 VLBW infants, SpO₂ averaging time was lowered to 2 seconds for 24 hours and events of SpO₂ out of the target range were estimated with 2-, 8-, or 16-second averaging time, with and without a 15-second alarm delay.

RESULTS: There were 3,263,590 alarms in the unit over 12 months. Low or high SpO₂ alarms constituted 79% of the total, and 55% of these events lasted <15 seconds. In 10 infants we estimated that increasing SpO₂ averaging time from 2 to 16 seconds would have led to 53% fewer SpO₂ alarms but the mean duration of alarms would have been 2.15-fold longer. Adding a 15-second alarm delay to 2-second SpO₂ averaging in this analysis decreased SpO₂ alarms by 67%.

CONCLUSION: Longer SpO₂ averaging times mask the number and severity of events of aberrant oxygenation in preterm infants without decreasing total alarm time. Incorporating an alarm delay with shorter SpO₂ averaging times can reduce alarm number and duration, and allow more accurate assessment of oxygenation, which may be important for research into consequences of aberrant oxygenation in this vulnerable population.

OBJECTIVES: A new guideline for the early respiratory management of preterm infants that included early nCPAP and INSURE was recently introduced in our NICU. This case series describes the clinical courses of a group of preterm infants managed according to this guideline, and reports the rates of successful extubation within 30 minutes of surfactant administration with and without the use of naloxone and adverse events encountered.

STUDY DESIGN: Descriptive case series of all preterm babies admitted to our unit who were candidates for INSURE procedure with premedication from August 2012 to August 2013.

RESULTS: A total of 31 infants were included with a mean birth weight of 1178 grams and a mean gestational age of 28.4 weeks. Twelve out of thirteen (92%) infants in the naloxone group were extubated within 30 minutes of surfactant administration while only 12/18 (67%) in the non-naloxone group were extubated within the same time frame. No adverse reactions were noted with naloxone usage in this context.

CONCLUSION: Naloxone can be effective in reversing the respiratory depressive effect of analgesic premedication and in turn facilitates expeditious extubation in some preterm infants intubated for INSURE procedure.

OBJECTIVE: To assess the changes on various physiological cardio-respiratory parameters with a single chest physiotherapy session in mechanically ventilated and extubated preterm neonates with respiratory distress syndrome.

STUDY DESIGN: This is a prospective observational study in a neonatal intensive care unit setting. Sixty preterm neonates with respiratory distress syndrome, thirty mechanically ventilated and thirty extubated preterm neonates requiring chest physiotherapy were enrolled in the study. Parameters like heart rate (HR), respiratory rate (RR), Silverman Anderson score (SA score in extubated), oxygen saturation (SpO₂) and auscultation findings were noted just before, immediately after chest physiotherapy but before suctioning, immediately after suctioning and after 5 minutes of the session.

RESULTS: The mean age of neonates was 9.55±5.86 days and mean birth weight was 1550±511.5 g. As there was no significant difference in the change in parameters on intergroup comparison, further analysis was done considering two groups together (n = 60) except for SA score. As SA score was measured only in extubated neonates. HR did not change significantly during chest physiotherapy compared to the baseline but significantly decreased after 15 minutes (p = 0.01). RR and SA score significantly increased after suctioning (p = 0.014) but reduced after 15 minutes (p = <0.0001). SpO₂ significantly reduced post-suctioning compared to the baseline and increased after positioning and 15 minutes of chest physiotherapy (p = <0.0001). Clinically, there was a reduction in HR, RR and SA score with an improvement in SpO₂. This signifies that chest physiotherapy may help facilitate the overall well-being of a fragile preterm neonate. Lung auscultation finding suggests that after suctioning, there was a significant reduction in crepitation (p = 0.0000) but significant increase in crepitation after 15 minutes (p = <0.01), suggesting the importance of around-the-clock chest physiotherapy.

CONCLUSION: Chest physiotherapy is safe in preterm neonates. Suctioning causes significant cardio-respiratory parameter changes, but within normal physiological range. Thus, chest physiotherapy should be performed with continuous monitoring only when indicated and not as a routine procedure. More research is needed to study the long term effects of chest physical therapy.

OBJECTIVES: To determine the accuracy of weighing ventilated infants on incubator scales and whether the accuracy can be improved by the addition of a ventilator tube compensator (VTC) device to counterbalance the force exerted by the ventilator tubing.

STUDY DESIGN: Body weights on integral incubator scales were compared in ventilated infants (with and without a VTC), with body weights on standalone electronic scales (true weight). Individual and series of trend weights were obtained on the infants. The method of Bland and Altman was used to assess the introduced bias.

RESULTS: The study included 60 ventilated infants; 66% of them weighed <1000 g. A total of 102 paired-weight datasets for 30 infants undergoing conventional ventilation and 30 undergoing high frequency oscillator ventilation (HFOV) supported by a SensorMedics oscillator, (with and without a VTC) were obtained. The mean differences and (95% CI for the bias) between the integral and true scale weighing methods was 60.8 g (49.1 g to 72.5 g) without and –2.8 g (–8.9 g to 3.3 g) with a VTC in HFOV infants; 41.0 g (32.1 g to 50.0 g) without and –5.1 g (–9.3 g to –0.8 g) with a VTC for conventionally ventilated infants. Differences of greater than 2% were considered clinically relevant and occurred in 93.8% without and 20.8% with a VTC in HFOV infants and 81.5% without and 27.8% with VTC in conventionally ventilated infants.

CONCLUSIONS: The use of the VTC device represents a substantial improvement on the current practice for weighing ventilated infants, particularly in the extreme preterm infants where an over- or underestimated weight can have important clinical implications for treatment. A large-scale clinical trial to validate these findings is needed.

BACKGROUND: Kangaroo mother care (KMC) is associated with positive neonatal outcomes. Studies demonstrated significant influence of maternal factors on the success of applying KMC.

AIM: To determine maternal factors that influence on anthropometric parameters in low birth weight babies that received kangaroo mother care.

METHODS: This is a randomized controlled study that involved low birth weight newborns. We randomly assigned newborns into two groups; a group who received KMC and a group who received conventional care. Maternal factors were recorded. We followed weight, length, and head circumferences of newborns for thirty days.

RESULTS: A total of 40 newborns were included. Weight parameters were significantly higher in the KMC group than the conventional group. From maternal characteristics, only gestational age was found to influence increased head circumference in KMC group (p = 0.035); however, it did not affect the increase in weight or length. Maternal age, parity, education, mode of delivery, fetal sex, and initial Apgar score did not influence growth parameters in either groups.

CONCLUSION: KMC was associated with increased weight gain in LBW infants. Gestational age influences head growth in infants who received KMC.

OBJECTIVE: Determine content of antenatal prematurity consultations and identify factors associated with satisfaction.

DESIGN: This is an observational study of consultations for possible preterm delivery. Consultations were audio-recorded and analyzed. Parents and physicians were surveyed post-consultation.

RESULTS: We analyzed 17 audio-recordings. Mean gestation was 28 weeks. Frequency of topics discussed were: antenatal steroids 82%, intubation 82%, breast milk 76%, time in NICU 65%, development 59%, and survival 53%. Parents frequently asked about length of hospitalization stay, feeding, and separation concerns. Parents’ greatest fears were developmental problems, survival, separation from baby, infant health, and length of hospitalization. The parent satisfaction score was 8.9, and physician satisfaction score was 4.8 on a ten-point scale. No factors were found to be associated with satisfaction. Physicians felt 82% of consultations could be improved.

CONCLUSIONS: In consultations for possible preterm delivery, physicians discussed resuscitation details and initial neonatal care. Parental greatest fears involved more global issues. Despite content variability, parents were highly satisfied. No specific factors (such as topics discussed or length of consultation) were found to be statistically associated with parent satisfaction. Physicians were less satisfied. Providing too much/too little information was a repeated physician concern.

BACKGROUND: In the US, at the time of discharge from the hospital, 79% of women had initiated breastfeeding. Intention to breastfeed is a strong predictor of breastfeeding initiation; however, we reported initiation failure in 45% of women with pregestational diabetes who intended to breastfeed. Information regarding intention and initiation among women with other high risk obstetrical conditions (HROB) remains scarce.

OBJECTIVE: To ascertain demographic and clinical factors associated with breastfeeding initiation failure among women with HROB conditions who intended to breastfeed.

METHODS: The study population is comprised of 89 women with diabetes (DM), 57 who were receiving treatment for substance abuse (SA), 51 women diagnosed with miscellaneous (MISC) conditions and 32 with history of preterm labor/delivery (PTL/D). Intention to exclusively breastfeed or in combination with formula (breastfed/FF) was ascertained prenatally. Breastfeeding was considered initiated if at discharge ≥50% of their infant feedings were maternal milk. Statistics include chi-square, Wilcoxon’s and logistic regression (p < 0.05).

RESULTS: Of all women, 59% initiated any breastfeeding. Intention to breastfeed/FF, lack of mother-infant contact during the first hour following birth and limited lactation consultation were predictive of initiation failure. The odds of initiation failure were 2.3 times higher among women who wished to breastfeed/FF as compared to those who wished to exclusively breastfeed. Women from the SA group had lower rates of initiation failure than the other three HROB groups.

CONCLUSION: Intention to breastfeed among women with diverse HROB conditions is similar to that of the general population; however, initiation rates are disappointingly low. Intention to exclusively breastfeed results in fewer initiation failures. Prenatal intention to combine breast and formula feeding characterize women who may benefit from specific educational programs.

OBJECTIVE: In this study, we aimed to evaluate whether the changes in the first and second trimester maternal serum biochemical markers used for prenatal screening are associated with euploid pregnancies complicated by intrahepatic cholestasis of pregnancy (ICP).

METHODS: A total of 94 pregnant women were included in this retrospective comparative study. Thirty-seven women whose pregnancy was complicated with ICP constituted the study group whereas 57 of them constituted the control group. All hospital records were examined in terms of combined first trimester screening test and second trimester triple test parameters. Perinatal outcomes were also recorded.

RESULTS: No significant difference was observed between the two groups in term of age, BMI, and obstetric history (all p > 0.05). Mean serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) and serum bile acid concentrations in the study group were significantly higher than in the controls (p < 0.001). There were no significant differences between the two groups in terms of first and second trimester serum biochemical markers. Newborn gender, route of birth, and NICU admission rates were also similar in the two groups. Mean birth weight of the control group was statistically significantly higher than the ICP group (p = 0.012).

CONCLUSION: We report no significant differences between pregnancies complicated by ICP and healthy pregnancies in terms of first and second trimester maternal serum screening test results.

OBJECTIVES: This study was carried out to determine the incidence, clinical features, etiology and outcome of functional and intrinsic acute kidney injury (AKI) in preterm neonates.

METHODS: This is a prospective observational study on premature infants admitted to the neonatal intensive care unit (NICU) over an eight month period. All biochemical parameters of renal function tests were monitored and statically analyzed.

RESULTS: The study included 450 infants; of them 300 were inborn and 150 infants were outborn and transported to the NICU. Mean gestational age, weight, and age at the time of AKI diagnosis were 32.3 weeks, 1.66 kg and 3.23 days respectively. The male: female ratio was 1.84:1. Incidence of AKI was higher in low birth weight babies. Sluggishness and refusal for feed were most common symptoms. Birth asphyxia and septicemia were the most common early and late cause of AKI. Hyponatremia was the most common electrolyte disturbance. The incidences of AKI, functional renal failure, and intrinsic renal failure were 12%, 48.14%, and 51.85% respectively.

CONCLUSIONS: AKI is not uncommon in preterm infants. The early recognition and aggressive management of episodes of shock which often precede AKI could be life-saving.

We report a new clinical manifestation of neonatal Behcet’s disease. A newborn from a mother with active Behcet’s disease during pregnancy, who develops vasomotor phenomena (Raynaud) with oral ulcerations in the second day of life. Neonatal mucocutaneous lesions have been reported previously in few newborns of pregnant women with active Behçet disease. Although neonatal disease is a very infrequent situation, with a mostly transient and favorable course, clinicians should be aware of serious potential complications associated with this entity.

Mydriatic drops are routinely administered to premature neonates to screen for retinopathy of prematurity. Adverse anticholinergic side effects, particularly convulsions and tachycardia have been reported in the pediatric age group following instillation of mydriatics for diagnostic fundus examination [1, 2]. Caffeine is frequently used for apnea of prematurity. In the neonatal intensive care unit, the combined use of caffeine and mydriatic drops is a common practice. Here we report two cases of atrial arrhythmias after neonatal eye exam that improved with conservative management. Both patients were receiving caffeine at the time of events.

AIM: To evaluate readmission data in a level IV neonatal intensive care unit (NICU) to identify patient characteristics and process failures which serve as drivers for readmission.

METHODS: Our center is a primary referral center in Central and Southeast Ohio, providing us a unique opportunity to evaluate readmissions. We studied our current discharge process, caregiver perception of discharge readiness, parental comfort and the pre-discharge and post-discharge characteristics of infants.

RESULTS: Our readmission rate during the 4 year period has remained stable at 9.8%. 74% of the caregivers rated that their perception of their baby’s medical readiness for discharge was good to excellent. Duration of hospitalization and public insurance coverage (Medicaid) were significant risk factors for readmission (p = 0.00). In our setting, the majority of the patients are readmitted through the emergency department and nearly half of all readmissions were for 3 or fewer days. Patients discharged from our Comprehensive Center for BPD had similar readmission rate despite characteristics which should increase their readmission rate.

CONCLUSIONS: Readmission rate is a poor indicator of the quality of care provided in the NICU. In addition to patient factors such as longer length of stay and Medicaid, our data suggests that preventing readmission depends on having systems in place to help families cope with transition of care after discharge.