Journal of Neonatal-Perinatal Medicine - Volume 10, issue 2

Authors: Sawyer, T. | Foglia, E. | Hatch, L. Dupree | Moussa, A. | Ades, A. | Johnston, L. | Nishisaki, A.

Article Type: Editorial

Abstract: Neonatal intubation is one of the most common procedures performed by neonatologists, however, the procedure is difficult and high risk. Neonates who endure the procedure often experience adverse events, including bradycardia and severe oxygen desaturations. Because of low first attempt success rates, neonates are often subjected to multiple intubation attempts before the endotracheal tube is successfully placed. These factors conspire to make intubation one of the most dangerous procedures in neonatal medicine. In this commentary we review key elements in the journey to improve neonatal intubation safety. We begin with a review of intubation success rates and complications. Then, we …discuss the importance of intubation training. Next, we examine quality improvement efforts and patient safety research to improve neonatal intubation safety. Finally, we evaluate new tools which may improve success rates, and decrease complications during neonatal intubation. Show more

Keywords: Endotracheal intubation, tracheal intubation, neonatal intubation, patient safety, quality improvement, intubation associated adverse event

DOI: 10.3233/NPM-171686

Citation: Journal of Neonatal-Perinatal Medicine, vol. 10, no. 2, pp. 125-131, 2017

Authors: Stokes, T.A. | Kuehn, D. | Hood, M. | Biko, D.M. | Pavey, A. | Olsen, C. | Hunt, C.E.

Article Type: Research Article

Abstract: OBJECTIVE: To correlate magnetic resonance imaging (MRI) of body fat in preterm infants at the time of hospital discharge with same-day anthropometric measures, and to assess the clinical utility of body mass index (BMI), waist circumference (WC), and WC/length ratio as indicators of visceral fat. STUDY DESIGN: MRI performed prior to NICU discharge in 25 infants born preterm at <32 weeks gestation. Total body fat and visceral fat were quantified using a commercial software program. The Pearson correlation coefficient (r, 95% C.I.) was used to describe strength of association between MRI fat and anthropometric measures. RESULTS: …BMI and weight at discharge were strongly correlated with total body fat (r  = 0.95 and 0.89 respectively; p  < 0.001). Total body fat as a % of body weight was moderately correlated with weight (r  = 0.53), WC (r  = 0.52), and BMI (r  = 0.47). Weight, BMI, and ponderal index all were found to correlate with total visceral fat (r  = 0.65, 0.64, 0.55 respectively) but WC did not (r  = 0.28). WC/length ratio was not correlated with any MRI fat measurements. CONCLUSIONS: BMI and weight at discharge both correlate with MRI fat measurements. Our findings do not support the usefulness of measuring WC or WC/length ratio in preterm infants at term-equivalent age. Show more

Keywords: Anthropometric measures, body mass index, magnetic resonance imaging (MRI), prematurity

DOI: 10.3233/NPM-171657

Citation: Journal of Neonatal-Perinatal Medicine, vol. 10, no. 2, pp. 133-138, 2017

Authors: Said, M.M. | Rivera, O. | Mikesell, G.T. | Rais-Bahrami, K.

Article Type: Research Article

Abstract: BACKGROUND: Recirculation of oxygenated blood in venovenous extracorporeal membrane oxygenation (VV ECMO) can decrease the oxygen delivery provided by the ECMO support. This study investigated the influence of central hemodynamics and catheter position on the amount of recirculation and oxygen delivery during VV ECMO. METHODS: Recirculation was measured in seven newborn lambs (mean weight 4.7 kg) during VV ECMO using the ELSA Monitor (Transonic Systems, Inc., Ithaca, NY) and using the central venous line (CVL) method. The ECMO pump was set at the prescribed flow of 110–120 mL/kg/min for a targeted oxygen delivery rate of 6cc/kg/min without recirculation. Hemodynamic …status before and during ECMO was also measured by the COstatus Monitor (Transonic Systems, Inc.,Ithaca, NY). RESULTS: Lambs with a higher cardiac index (>160 ml/min/kg), had a tendency to have higher percent oxygen delivery (65–94%, at prescribed flow) while lambs with lower cardiac index (<150 ml/min/kg), tended to have lower percent oxygen delivery (39–62%, at prescribed flow). ELSA recirculation measurements had a squared correlation coefficient R2  = 0.8 with the CVL method. CONCLUSIONS: The ELSA monitor provides an easy to use, non-invasive method to measure recirculation in VV ECMO. The data suggests that cardiac function may play an important prognostic role in achieving effective VV ECMO support. Show more

Keywords: Extracorporeal membrane oxygenation, neonate, animal model, oxygen, cardiac

DOI: 10.3233/NPM-171692

Citation: Journal of Neonatal-Perinatal Medicine, vol. 10, no. 2, pp. 139-145, 2017

Authors: Kaneko, M. | Sato, M. | Ogasawara, K. | Imamura, T. | Hashimoto, K. | Momoi, N. | Hosoya, M.

Article Type: Research Article

Abstract: OBJECTIVE: To investigate the relationships between serum cytokine concentrations and chorioamnionitis (CAM) and CAM-related bronchopulmonary dysplasia (BPD) in premature infants. METHODS: Serum was collected at 0 and 7 days after birth from 36 premature infants born at <32 weeks of gestation. We examined the relationships between 30 cytokine concentrations and CAM, BPD, and other perinatal factors. RESULTS: On day 0, GM-CSF, IL-15, IL-17, IL-2, IL-2R, VEGF, and MIG concentrations were significantly higher in the CAM group (n  = 17) than in the non-CAM group (n  = 19). These concentrations had decreased by day 7 and were similar …in both groups. The IL-12p70 concentration on day 0 was significantly lower in the BPD group (n  = 16) than in the non-BPD group (n  = 15). BPD incidence was similar between the CAM and non-CAM groups. CONCLUSIONS: These data support the hypothesis that intrauterine inflammation is not a primary risk factor for BPD. The immunological environment at birth or soon after, rather than intrauterine fetal inflammation (e.g., CAM), is a primary risk factor for BPD onset in preterm infants. Decreased inflammatory responses are particularly relevant, as indicated by the relationship between BPD and low serum IL-12p70 concentrations on day 0. Show more

Keywords: Cytokines, inflammation, interleukin-12, neonatal prematurity

DOI: 10.3233/NPM-171669

Citation: Journal of Neonatal-Perinatal Medicine, vol. 10, no. 2, pp. 147-155, 2017

Authors: Clevenger, L. | Britton, J.R.

Article Type: Research Article

Abstract: OBJECTIVE: To assess the association between delivery room (DR) continuous positive airway pressure (CPAP) and pneumothorax (PT) in term newborns. METHODS: Two studies performed in community hospitals used data extracted from computerized records of term newborns. Infants receiving positive pressure ventilation in the DR were excluded. Tabulated data included receipt of DR CPAP, PT on the day of birth, and gestational age (GA). In a case-control study from 2001–2013, infants with PT were compared to controls without PT but with respiratory distress or hypoxia persisting from birth for receipt of DR CPAP. In a cohort study from …2014–2016, infants receiving and not receiving DR CPAP were compared for the incidence of PT. RESULTS: In the case-control study, data were obtained for 169 cases and 850 controls. Compared to controls, PT infants were more likely to have received DR CPAP (16.8% vs. 40.2%, respectively, P  < 0.001). Logistic regression revealed DR CPAP (Adjusted Odds Ratio [AOR] = 3.30, 95% confidence interval [CI] = 2.31, 4.72, P  < 0.001) and GA (AOR = 1.21, 95% CI = 1.05, 1.39, P  = 0.009) to be independent predictors of early PT. In the cohort study, PT was observed in 0.1% of 9255 control infants not receiving DR CPAP and 4.8% of 228 infants receiving DR CPAP (P  < 0.001). In logistic regression analyses, DR CPAP significantly predicted PT (OR = 59.59, 95% CI = 23.34, 147.12, P  < 0.001) and remained a significant predictor of PT after controlling for gestational age. CONCLUSION: Respiratory conditions treated with CPAP in delivery rooms are associated with increased risk of PT. A cause-and-effect relationship between CPAP and PT cannot be claimed in this study. Further research is needed to better understand this relationship. Show more

Keywords: CPAP, resuscitation, air leak, pneumothorax

DOI: 10.3233/NPM-171694

Citation: Journal of Neonatal-Perinatal Medicine, vol. 10, no. 2, pp. 157-161, 2017

Authors: Al-Hathlol, K. | Bin Saleem, N. | Khawaji, M. | Al Saif, S. | Abdelhakim, I. | Al-Hathlol, B. | Bazbouz, E. | Al Anzi, Q. | Al-Essa, A.

Article Type: Research Article

Abstract: OBJECTIVE: To identify the clinical outcomes and the potential predictive factors of early extubation failure (EEF) in very low birth weight (VLBW) infants. METHODS : A retrospective study of VLBW infants admitted to the neonatal intensive care unit (NICU) over fifteen years. Neonates were intubated and mechanically ventilated on the first day of life, and early extubated within the first 3 days. EEF was defined as the need for re-intubation within 3 days of the first extubation. A composite outcome of mortality or any major morbidity (grade 3-4 intraventricular hemorrhage or periventricular leukomalacia; stage 3-4 retinopathy of prematurity, …moderate-severe bronchopulmonary dysplasia or stage 2-3 necrotizing enterocolitis) was assessed. RESULTS: In total, 394 infants were extubated early. Of those, 347 (88%) had early extubation success (EES), whereas 47 (12%) had EEF. Incidence of the composite outcome was significantly higher in the EEF group than the EES group, even after adjusting for confounding factors. Logistic regression indicated that birth weight < 1000 g (p  < 0.01), administration of≥2 doses of surfactant (p  < 0.01) and administration of≥2 inotropic agents (p  < 0.01) were all significantly associated with EEF. The area under the curve (AUC) for the combination of these three factors (AUC = 0.77) indicated significantly higher predictive value (p  < 0.01) for EEF in VLBW infants, compared with individual factors (AUC = 0.59 for≥2 inotropic agents, AUC = 0.64 for birth weight≤1000 g and AUC = 0.66 for≥2 doses of surfactant). CONCLUSION: EEF is associated with poor clinical outcomes in VLBW infants. The combination of birth weight and the requirement for surfactants and inotropic agents can predict EEF. Show more

Keywords: Respiratory distress syndrome, neonatal, hypotension, surfactant, inotropes

DOI: 10.3233/NPM-171647

Citation: Journal of Neonatal-Perinatal Medicine, vol. 10, no. 2, pp. 163-169, 2017

Authors: Viswanathan, S. | Merheb, R. | Wen, Xintong | Collin, M. | Groh-Wargo, S.

Article Type: Research Article

Abstract: BACKGROUND: Compared to early enteral feeds, delayed introduction and slow enteral feeding advancement to reduce necrotizing enterocolitis (NEC) is not well studied in micropremies (<750g birth weight). METHODS: Pre-post case control study. Micropremies who followed a standardized slow enteral feeding (SSEF) protocol (September 2009 to March 2015) were compared with a similar group of historical controls (PreSSEF, January 2003 to July 2009). Enteral feeding withheld for first 10–14 days and advanced at <10 ml/kg/day in the SSEF group. RESULTS: Ninety-two infants in the SSEF group were compared with 129 PreSSEF group. Birth weight and gestational age …in SSEF and PreSSEF were similar. Breast milk initiation rate was higher in SSEF (87.0 vs. 72.0%, p  = 0.01) compared to PreSSEF, but were similar at full enteral feeds. Compared with PreSSEF, feeding initiation day, full enteral feeding day, parenteral nutrition days, and total central line days were longer in SSEF. There was significant reduction in NEC (1.1 vs. 16.2%, p  < 0.01), surgical NEC (0.0 vs. 7.8%, p  < 0.01) and NEC/death (7.6 vs. 29.5%, p  < 0.01), in SSEF compared to PreSSEF. SSEF, compared to PreSSEF, had more cholestasis (41.8 vs 28.8%, p  = 0.04), higher peak serum alkaline phosphatase (638 vs. 534 IU/dL, p  < 0.01), but similar rates of late-onset sepsis (39.1 vs 43.4%, p  = 0.53). In infants who survived to discharge, SSEF had higher discharge weight, lower extra-uterine growth restriction, and similar length of stay, compared to PreSSEF. CONCLUSIONS: A SSEF protocol significantly reduces the incidence of NEC and combined NEC/death in micropremies. Show more

Keywords: Enteral feeding, necrotizing enterocolitis, premature infants, micropremies

DOI: 10.3233/NPM-171680

Citation: Journal of Neonatal-Perinatal Medicine, vol. 10, no. 2, pp. 171-180, 2017

Authors: Al-Omran, A. | Al-Abdi, S. | Al-Salam, Z.

Article Type: Research Article

Abstract: BACKGROUND: Hyperbilirubinemia is one of the most common causes of neonatal readmission to hospital. AIMS: To assess risk factors for hyperbilirubinemia among neonates readmitted for this condition and the ratio of the mean corpuscular hemoglobin concentration (MCHC) to the mean corpuscular volume (MCV). METHODS: We retrospectively studied the clinical and laboratory findings, management and possible risk factors for hyperbilirubinemia in 301 neonates born at ≥35 weeks gestation and readmitted to hospital owing to hyperbilirubinemia over five years. RESULTS: No risk factors for hyperbilirubinemia were identified in 64 (21.3%) neonates, and one or more …risk factors were found in 237 neonates (78.7%). The most prevalent risk factor (41.9%) was G6PD deficiency, which occurred in 11 of the 15 neonates with a serum bilirubin level ≥427 μmol/l. A double-volume exchange blood transfusion was performed in two neonate boys in whom G6PD deficiency was the single risk factor for hyperbilirubinemia. One of them developed kernicterus later. The MCHC/MCV ratio of neonates with idiopathic hyperbilirubinemia, unexplained hemolysis, or other risk factors overlapped. CONCLUSIONS: This study confirmed that in an area where G6PD deficiency is prevalent, it is the most common and most severe risk factor for hyperbilirubinemia. This finding supports routine neonatal screening for G6PD deficiency in such areas. The usefulness of determining the MCHC/MCV ratio in the management of hyperbilirubinemia is uncertain. Show more

Keywords: Neonatal hyperbilirubinemia, glucose-6-phosphate dehydrogenase deficiency, hereditary spherocytosis, phototherapy, erythrocyte indices

DOI: 10.3233/NPM-171696

Citation: Journal of Neonatal-Perinatal Medicine, vol. 10, no. 2, pp. 181-189, 2017

Authors: Allen, K.M. | Smith, B. | Iliev, I. | Evans, J. | Werthammer, J.

Article Type: Research Article

Abstract: OBJECTIVE: To determine the hospital cost and distribution of financial charges for the initial hospitalization of the surviving periviable neonate. STUDY DESIGN: In this retrospective case series, we analyzed medical records and financial data for neonates 23–25 weeks’ gestational age in a single tertiary care NICU over 42 months. A detailed breakdown of hospital cost components and charges was determined for all survivors during their initial hospitalization. Statistical significance was determined using the Bonferroni-Sidak method. RESULTS: Overall survival was 78% in infants born at 23–25 weeks’ gestational age. Survival increased and length of stay and …hospital costs decreased with increased gestational age (p  < 0.05 for all). Hospital charges were distributed as: NICU 56%, respiratory 11%, pharmacy 6%, laboratory 6%, radiology 6%, surgery 1%, neonatology 13% and miscellaneous 1%. CONCLUSION: Our study describes the hospital cost and distribution of charges for the periviable neonate during the initial hospitalization. These economic data may guide clinicians in quality improvement and cost management. Show more

Keywords: Neonatology, economics, charges, finances

DOI: 10.3233/NPM-171655

Citation: Journal of Neonatal-Perinatal Medicine, vol. 10, no. 2, pp. 191-194, 2017

Authors: Yokoi, K. | Kobayashi, S. | Muramatsu, K. | Suzuki, S. | Gotou, H.

Article Type: Case Report

Abstract: Neonatal spinal cord injury is an extremely rare perinatal complication that often occurs concurrently with hypoxic ischemic encephalopathy (HIE), further complicating diagnosis of spinal cord injury. Although therapeutic hypothermia for moderate to severe HIE is widely recommended in Japan, it is difficult to determine whether it satisfies the neurological findings-related entry criteria in some patients. We describe a female infant with neonatal spinal cord injury after forceps delivery, who underwent therapeutic hypothermia upon diagnosis of HIE. The Apgar scores were 5 at 1 min, 6 at 5 min, and not recorded at 10 min. Blood gas analysis of her umbilical artery was …not performed. Since respiratory failure, hypotonia and the absence of primitive reflexes were found at 2 hours after birth, she was initially diagnosed with moderate HIE and underwent a therapeutic hypothermia. Magnetic resonance imaging after therapeutic hypothermia revealed the spinal cord was narrowed from the lower medulla oblongata to the upper cervical cord. Thus she was diagnosed with an upper spinal cord injury at that time. Some patients with neonatal spinal cord injuries satisfy the criteria for therapeutic hypothermia. When neonates with asphyxia present with prolonged respiratory failure and hypotonia, spinal cord injury should be considered in the differential diagnosis. Thus, an early MRI is vital for the diagnosis of spinal cord injury. Show more

Keywords: Spinal cord injury, birth injury, hypoxic ischemic encephalopathy, therapeutic hypothermia, neonate

DOI: 10.3233/NPM-171695

Citation: Journal of Neonatal-Perinatal Medicine, vol. 10, no. 2, pp. 195-198, 2017