Journal of Neonatal-Perinatal Medicine

During labor, the obstetrician's role is to prevent maternal and fetal morbidity and mortality. High on the list of potential complications is intrapartum fetal acidemia leading to asphyxia. Factors that increase the risk of acidemia and poor fetal outcome include conditions that had affected the fetus prior to labor such as: intrauterine growth restriction, oligohydramnios and placental abruption. Recent advances in the antepartum assessment of fetal and placental reserve provide us with a better ability to predict the fetal tolerance of labor and delivery. Using this information helps to decrease the risk of intrapartum fetal injury and death.

Background: The management of the patent ductus arteriosus in the preterm neonate continues to be a major factor affecting morbidity and mortality.

Objectives: To identify factors that may be important in determining which patients respond to medical therapy and which would suggest that surgical management is likely necessary.

Methods: A total of 117 patients' charts were retrospectively reviewed. Twenty-two were excluded due to incomplete data. Ninety-five patients were divided into medical responders (R) and non-responders (NR). Demographics and clinical data were compared using independent t-testing and ANOVA. A Ductal Response Score (DRS) was developed using factors known to be of significance for successful medical closure. This score was calculated on a subset of patients where all necessary data were present.

Results: Responders had higher gestational age (GA), body surface area (BSA) and left ventricular Z-score (LVZ-score). The interaction between groups showed significant difference between R and NR in LA/AO (P < 0.001), LV Z-score (P < 0.001), and BUN/Cr (P = 0.046), where NR had higher values compared to R. The effect of time on the DRS regardless of the group (10 patients) showed statistically insignificant difference (P= 0.263). Interaction between the groups (R = 6, NR = 4) showed significant worsening of the DRS in NR (P = 0.047). Extrapolation of data was performed. Independent t-test on DRS between groups, post-extrapolation (R = 19, NR = 9), showed statistically insignificant difference between the groups (P = 0.144).

Conclusion: The concept of determining a DRS may prove to be useful in evaluating response to medical therapy. However, further prospective study is needed.

Background: Recent studies demonstrate a neuroprotective effect of therapeutic hypothermia following newborn hypoxic-ischemic encephalopathy; however, initiation of cooling must begin within 6 hours of birth. Evidence from animal models suggests that the earlier treatment is begun, the more efficacious hypothermia is in preventing brain injury. Unfortunately, timely initiation of therapy is often practically difficult to achieve for outborn neonates. Currently, there is no standardized methodology to safely initiate and regulate hypothermia during neonatal transport.

Methods: This study evaluated the effectiveness of the Electri-Cool II Cold Therapy Unit (Cincinnati Sub-Zero®) to induce and regulate mild whole body hypothermia (33.5°C) in a neonatal porcine model. Seven healthy neonatal piglets (2–3.5 kg) were initially allowed to passively cool from baseline in an open air isolette over 1 hour. Following this, animals were rewarmed to baseline (if necessary) and then actively cooled to 33.5°C using the Electri-Cool II. Once the target temperature was achieved, temperature was closely monitored using rectal and skin temperature probes over the next 1 hour.

Results: None of the study animals significantly lowered their temperature from baseline during the passive cooling period. By comparison, piglets actively cooled with the Electri-Cool II reached 33.5°C in a mean of 38 ± 19.7 minutes. Once at target temperature, hypothermia was maintained in the piglets with minimal average variation (0.3 ± 0.1°C) for the duration of the active study cooling period.

Conclusion: The Electri-Cool II is superior to passive cooling for inducing and maintaining mild whole body hypothermia in a neonatal piglet model. Further evaluation of this device to include its potential utility during transport of newborn infants is warranted.

Introduction: Surfactant dosing in extremely premature infants is not based on rigorous human pharmacokinetic data. Beractant (Survanta®) is an animal-derived surfactant. The manufacturer's package insert suggests a dosing interval of "no sooner than 6 hours" after a preceding dose. Other animal-derived surfactant preparations are commonly dosed at 12 hour intervals. We evaluated Survanta use following a change in the re-treatment dosing interval from no less than 6 (Q6 h) to no less than 12 hours (Q12 h) in June 2007.

Method: We used a retrospective comparison of two cohorts, Q6 h and Q12 h, born at <31 weeks' gestation or with birth weights < 1100 grams treated with Survanta for respiratory distress syndrome (RDS). Infants could receive up to 4 doses, if clinically indicated.

Results: Infants in the Q12 group (n=77) and the Q6 group (n=140) had similar birth weight (mean ± SD; 1079 ± 351 vs. 1117 ± 326 g, p=0.44), birth in a tertiary center (inborn) (84% vs. 84%, p=1.0), prenatal treatment with steroids (88% vs 81%, p=0.17), Cesarean section delivery (78% vs. 73%, p=0.51), and singleton birth (64% vs. 62%, p=0.93). However, infants in the Q12 group had a slightly lower gestational age (mean ± SD; 27 ± 2 vs 28 ± 2 wk, p=0.014) and had a higher proportion of male infants (62% vs 48%, p=0.047.The Q12 group also had a higher but not statistically significant proportion of white infants (82% vs. 69%, p=0.053) than the Q6 group. Infants in the Q12 group received fewer surfactant doses per patient (mean ± SD; 1.91 ± 0.54 vs. 2.11 ± 0.63, p=0.018) and less frequently received more than two doses of surfactant (8% vs. 21%, p=0.012) compared to the Q6 group. The Q12 and the Q6 groups had similar rates of chronic lung disease (CLD) (23% vs. 18%, p=0.25), death (18% vs. 14%, p=0.44), duration of mechanical ventilation (mean ± SD; 21 ± 21 vs. 18 ± 25 days, p=0.477), and total hospital length of stay (mean ± SD; 58 ± 39 vs. 59 ± 33 days, p=0.94).

Conclusions: Administering Survanta to premature infants at 12 hour intervals was associated with using less surfactant to treat RDS compared to dosing at 6 hour intervals and similar measured respiratory parameters, including duration of hospitalization and mechanical ventilation and rates of death and CLD. We speculate that using a longer Survanta dosing interval would also result in significant cost savings.

The lower extremity veins are less utilized for the insertion of central catheter for prolonged venous access and the provision of total parenteral nutrition. We compared the complication rates for catheters inserted from the lower extremity veins in relation to their tip placement. During a 48-month period, 90 catheters inserted from the lower extremity veins were identified and their tip placement was documented. Catheter tips were placed in the upper portion of the inferior vena cava below the right atrium in 65, and just above or below the renal veins in 25. Data was analyzed for gestational age, birth weight, duration of catheters in place, duration of total parenteral nutrition, complications, necrotizing enterocolitis, serum direct bilirubin, liver enzyme, serum creatinine, length of hospitalization, and survival rate.

The median birth weight and gestational age, duration of catheter in place, duration of total parenteral nutrition infusion were similar between the two groups. Catheter related infections, occlusions, phlebitis, and leakage; necrotizing enterocolitis, intraventricular hemorrhage, serum direct bilirubin, liver enzyme and serum creatinine were also similar between the two groups.

We suggest that the lower extremity veins inserted catheters, with their tips at a lower position of the inferior vena cava may be as safe as those with their tips at the upper part of the inferior vena cava below the right atrium.

Objective: To ascertain the safety and the efficacy of amikacin-heparin lock technique in the prevention of catheter-related-bloodstream infection (CRBSI) in neonates with extended umbilical venous catheters (UVCs) use and to determine the applicability of keeping UVCs in situ for 14 days.

Methods: A randomized controlled – blind trial was conducted on neonates who were expected to require UVC for at least 48 hours. Babies were randomized to have the catheter locked twice daily for 20 minutes either with heparinized normal saline (n=42) or heparinized saline containing amikacin 1.5 mg/mL (n=41). The blood glucose level was measured at the end of indwelling time and any episode of hypoglycemia was recorded. Doppler ultrasound was performed for the umbilical, portal and inferior vena cava veins. Surveillance cultures were taken from enrolled patients' skin to detect colonization by amikacin-resistant organisms. The UVCs were removed whenever their use was deemed unnecessary or at the 14th day after insertion.

Results: There were 4 CRBSI episodes (definite, probable) in amikacin-heparin lock group and 12 episodes in the saline-heparin lock group [RR: 0.34; 95% CI: (0.02–0.65); p=0.01]. Density incidence of CRBSIs was 3.6 per 1000 catheter days in amikacin-heparin lock group and 18.4 per 1000 catheter days in saline-heparin lock group [RR: 0.19 CI: (0.08–0.67), p= 0.02]. No amikacin-resistant organisms were recovered from any of the cultures. Transient asymptomatic hypoglycemia occurred in 13 (15.6%) neonates at the end of catheter-lock period. No portal or inferior vena cava thrombosis was detected in any of our babies.

Conclusions: Amikacin-heparin lock reduced the incidence of CRBSI in neonates with extended UVCs use, without promoting amikacin resistance.

Objective: The prophylactic use of phenobarbital for the prevention of intraventricular hemorrhage (IVH) in premature infants remains controversial. In order to objectively assess the effect of phenobarbital on IVH, nine large-scale hospitals participated in a nearly two year investigation of brain injuries in premature Infants in China.

Study Design: All premature infants with gestational age less than 34 weeks in three hospitals and less than 37 weeks in two other hospitals received intravenous phenobarbital (loading dose of 20 mg/kg) as early as possible before 6 hours of age. A maintenance dose of 5 mg/kg daily was given 24 hours after the loading dose and continued for 5 days. Premature infants in 4 other hospitals did not receive phenobarbital. All infants in nine hospitals were subjected to routine cranial ultrasound scanning within seven days after birth, and then repeated every 3∼7 days until discharge. The study period lasted from Jan. 2005 to Aug. 2006.

Chorioangioma is a benign growth of the placenta. Diffuse placental chorioangioma is termed as chorioangiomatosis. We report a case of placental chorioangiomatosis with hydrops fetalis and frontal horn cystic lesions. Frontal horn cystic lesions are considered as benign lesions. Contrary to expectations, this neonate with frontal horn cysts developed seizures at 2~months of age.

Pulmonary artery embolism (PE) is a rare and life-threatening complication in the neonate. We describe two previously stable infants who incurred respiratory failure from PE. The first case is a late preterm infant with gastroschisis with autopsy confirmation of PE presumably as a result of a central venous line (CVL) with thromboembolism. The second case is an extreme low birth weight infant with sudden onset of respiratory failure, abnormal chest x-ray, disseminated intravascular coagulation (DIC), and echocardiographic confirmation of a thrombus at the junction of the superior vena cava and right atrium at the site of a previous CVL. This infant was successfully managed with thrombolytic therapy and anticoagulation. We suggest that PE be considered in an infant with a history of a CVL who presents with otherwise unexplained respiratory failure.

Methemoglobinaemia is an infrequent cause of neonatal cyanosis. Methemoglobinaemia can be life threatening. Rapid diagnosis and early treatment of methemoglobinaemia are life-saving. Methemoglobinemia occurs following the intake of some drugs and some foods or water that contain high levels of nitrate, gastrointestinal infection and sepsis. We report a case of methemoglobinemia associated with Staphylococcus aureus sepsis in a newborn.

Beckwith-Wiedemann Syndrome (BWS) is a condition associated with macroglossia, omphalocele, macrosomia and hypoglycemia, in addition to increased susceptibility to malignancies, especially Wilm's tumor and hepatoblastoma. Over the past few years, a clear pattern is emerging revealing a close link between the genetic pattern, clinical presentation and risk of developing malignancies. We report two cases of BWS seen recently in our neonatal unit to illustrate this aspect of the condition.

Beckwith-Wiedemann Syndrome (BWS) is a condition associated with macroglossia, omphalocele, macrosomia and hypoglycemia, in addition to increased susceptibility to malignancies, especially Wilm's tumor and hepatoblastoma. This overgrowth-malformation syndrome has been linked to chromosome 11 p15, a region with many imprinted genes [1]. There has been a great deal of interest in the underlying genetic pattern in BWS especially since it has been shown to influence the clinical presentation as well as the risk of developing tumors (Wilm's tumor and Hepatoblastoma).

We report two cases of BWS seen recently in our neonatal unit to illustrate the varied clinical presentation and underlying genetics of the condition. This is followed by a discussion focused on the various genetic patterns underlying the problem, and its possible influence on the clinical presentation.

Riga-Fede disease is a rare condition characterized by traumatic ulceration occurring on the ventral surface of the tongue of neonates and infants. It is most often associated with natal and neonatal teeth in newborns but may also occur in older infants after eruption of primary lower incisors. It is important to diagnose the lesion early and treat it by eliminating the cause of trauma to avoid untoward complications. Here we report a case of a thirty-three day old female baby with Riga-Fede disease associated with a natal tooth. After extraction of the mobile natal tooth, the ulcerative lesion healed satisfactorily in four days.