[Posthypoxic myocardial ischemia in newborn: diagnosis and treatment of severe type]

Were analyzed publications devoted to the problem of diagnostics and treatment of posthypoxia myocardial ischemia. A description and estimation of the pathophysiological processes occurring in children who had perinatal hypoxia. The analysis of changes in the myocardium, and violations of intracardiac hemodynamics in newborns with posthypoxia myocardial ischemia. Describes modern methods of treatment of myocardial ischemia, including use of phosphokreatinine as a cardiotrophic therapy.

Mortality reduction by heart rate characteristic monitoring in very low birth weight neonates: a randomized trial

OBJECTIVE

To test the hypothesis that heart rate characteristics (HRC) monitoring improves neonatal outcomes.

STUDY DESIGN

We conducted a two-group, parallel, individually randomized controlled clinical trial of 3003 very low birth weight infants in 9 neonatal intensive care units. In one group, HRC monitoring was displayed; in the other, it was masked. The primary outcome was number of days alive and ventilator-free in the 120 days after randomization. Secondary outcomes were mortality, number of ventilator days, neonatal intensive care unit stay, and antibiotic use.

RESULTS

The mortality rate was reduced in infants whose HRC monitoring was displayed, from 10.2% to 8.1% (hazard ratio, 0.78; 95% CI, 0.61-0.99; P = .04; number needed to monitor = 48), and there was a trend toward increased days alive and ventilator-free (95.9 of 120 days compared with 93.6 in control subjects, P = .08). The mortality benefit was concentrated in infants with a birth weight <1000 g (hazard ratio, 0.74; 95% CI, 0.57-0.95; P = .02; number needed to monitor = 23). There were no significant differences in the other outcomes.

CONCLUSION

HRC monitoring can reduce the mortality rate in very low birth weight infants.

The biological basis of injury and neuroprotection in the fetal and neonatal brain

A compromised intrauterine environment that delivers low levels of oxygen and/or nutrients, or is infected or inflammatory, can result in fetal brain injury, abnormal brain development and in cases of chronic compromise, intrauterine growth restriction. Preterm birth can also be associated with injury to the developing brain and affect the normal trajectory of brain growth. This review will focus on the effects that episodes of perinatal hypoxia (acute, chronic, associated with inflammation or as an antecedent of preterm birth) can have on the developing brain. In animal models of these conditions we have found that relatively brief (acute) periods of fetal hypoxemia can have significant effects on the fetal brain, for example death of susceptible neuronal populations (cerebellum, hippocampus, cortex) and cerebral white matter damage. Chronic placental insufficiency which includes fetal hypoxemia, nutrient restriction and altered endocrine status can result in fetal growth restriction and long-term deficits in neural connectivity in addition to altered postnatal function, for example in the auditory and visual systems. Maternal/fetal inflammation can result in fetal brain damage, particularly but not exclusively in the white matter; injury is more pronounced when associated with fetal hypoxemia. In the baboon, in which the normal trajectory of growth is affected by preterm birth, there is a direct correlation between a higher flux in oxygen saturation and a greater extent of neuropathological damage. Currently, the only established therapy for neonatal encephalopathy in full term neonates is moderate hypothermia although this only offers some protection to moderately but not severely affected brains. There is no accepted therapy for injured preterm brains. Consequently the search for more efficacious treatments continues; we discuss neuroprotective agents (erythropoietin, N-acetyl cysteine, melatonin, creatine, neurosteroids) which we have trialed in appropriate animal models. The possibility of combining hypothermia with such agents or growth factors is now being considered. A deeper understanding of causal pathways in brain injury is essential for the development of efficacious strategies for neuroprotection.

[Peripheral blood neutrophil subpopulations and capacities of NBT test in the diagnosis of neonatal diseases]

By analyzing the data available in the literature, the author shows new capacities of the nitroblue tetrazolium (NBT) test in the diagnosis of neonatal diseases and conditions. The findings versus the, data obtained in adult patients are characterized. The NBT test has been used to determine changes in neutrophil subpopulations. The kinetic parameters of the process are analyzed.

Basics and dynamics of neonatal and pediatric pharmacology

Understanding the role of ontogeny in the disposition and actions of medicines is the most fundamental prerequisite for safe and effective pharmacotherapeutics in the pediatric population. The maturational process represents a continuum of growth, differentiation, and development, which extends from the very small preterm newborn infant through childhood, adolescence, and to young adulthood. Developmental changes in physiology and, consequently, in pharmacology influence the efficacy, toxicity, and dosing regimen of medicines. Relevant periods of development are characterized by changes in body composition and proportion, developmental changes of physiology with pathophysiology, exposure to unique safety hazards, changes in drug disposition by major organs of metabolism and elimination, ontogeny of drug targets (e.g., enzymes, transporters, receptors, and channels), and environmental influences. These developmental components that result in critical windows of development of immature organ systems that may lead to permanent effects later in life interact in a complex, nonlinear fashion. The ontogeny of these physiologic processes provides the key to understanding the added dimension of development that defines the essential differences between children and adults. A basic understanding of the developmental dynamics in pediatric pharmacology is also essential to delineating the future directions and priority areas of pediatric drug research and development.

Cognitive abilities and language comprehension in preschool children with perinatal brain lesion

Perinatal brain lesion is a risk factor for development, making parents of such children particularly worried about consequences it may have on the child's cognitive and language development. Although literature findings on the outcome of perinatal brain lesion are inconsistent, most of the studies have found a positive general outcome, but also subtle deficits that affect the child's academic success. Since language comprehension and cognitive abilities influence learning abilities at school, we wanted to know how six-year olds who were selected based on pathological ultrasonographical findings (ischemic or hemorrhagic brain lesion) would perform on subtests of Wechsler battery (WISC) and language comprehension measures (Reynell Developmental Language Scale and Peabody Picture Vocabulary Test), compared with controls. The second issue we investigated was whether in children who suffered a perinatal brain lesion cognitive abilities predicted the level of language comprehension in the same way as in children without perinatal brain lesion. The relation between cognitive and linguistic abilities is still a controversial one, and a different relation would mean that these two groups of children have different structure of abilities probably due to perinatal brain lesion. Forty children who suffered a perinatal brain lesion and forty age-matched children without perinatal risk factors were examined. Our results showed that the groups differed more in linguistic than in cognitive variables. Also, the two groups showed different relation patterns between cognitive abilities and language comprehension. Cognitive abilities were statistically significantly associated with language comprehension in children who suffered a perinatal brain lesion, while this association was not statistically significant within the control group. Since a number of participants with perinatal brain lesion had language difficulties, it is presumed that they rely on cognitive abilities in order to overcome and compensate for language shortcomings.

Perinatal hypoxic-ischemic encephalopathy

Perinatal hypoxic-ischemic encephalopathy (HIE) is an important cause of brain injury in the newborn and can result in long-term devastating consequences. Perinatal hypoxia is a vital cause of long-term neurologic complications varying from mild behavioural deficits to severe seizure, mental retardation, and/or cerebral palsy in the newborn. In the mammalian developing brain, ongoing research into pathophysiological mechanism of neuronal injury and therapeutic strategy after perinatal hypoxia is still limited. With the advent of promising therapy of hypothermia in HIE, this paper reviews the pathophysiology of HIE and the future potential neuroprotective strategies for clinical potential for hypoxia sufferers.

Pain in neonates is different

Pain processing and management in neonates, especially preterm neonates, differs from older populations. In this review, a brief background on pain processing in neonatal life, pain exposure in Neonatal Intensive Care Units (NICU), the consequences of untreated pain, and the difficulties in treating procedural pain pharmacologically will be presented. A more detailed review of non-pharmacological interventions for procedural pain in neonates will include sensory stimulation approaches, oral sweet solutions, and maternal interventions. Some possible mechanisms for the effectiveness of non-pharmacological interventions are offered. Finally, avenues of research into similar interventions as adjuvant therapies or drug-sparing effects in older populations are suggested.

Isoprostanes in fetal and neonatal health and disease

Isoprostanes are prostaglandin-like bioactive molecules generated via nonenzymatic peroxidation of lipid membrane-derived arachidonic acid by free radicals and reactive oxygen species. Their cognate receptors, biological actions, and signaling pathways are poorly understood. Aside from being sensitive and specific biomarkers of oxidative stress, E- and F-ring isoprostanes have important biological functions and likely mediate many of the disease-related pathological changes for which they are used as indicators. The biochemical pathways involved in isoprostane formation, their pathogenetic relevance to adult disease states, and their biological function are addressed. Developmentally, plasma and tissue content data show that isoprostane levels are highest during fetal and early neonatal life, when compared with adults. As such, the available data suggesting that isoprostanes play an important biological role, as well as possibly actively participate in the regulation of pulmonary vascular tone and the transition from fetal to postnatal life, are here reviewed. Lastly, the association between isoprostanes and certain neonatal clinical conditions is addressed. Although its existence has been recognized for almost 20 years, little is known about the critical importance of isoprostanes during fetal life and immediate neonatal period. This review is an attempt to bridge this knowledge gap.

Perinatal endocrinology: common endocrine disorders in the sick and premature newborn

Endocrine disorders are common in infants in the neonatal ICU. They often are associated with prematurity, low birth weight or very low birth weight, and small size for gestational age. They also frequently occur in infants who are critically ill or stressed. This article describes the most common conditions and current knowledge regarding management.

Congenital disorders of the thyroid: hypo/hyper

This article summarizes the ontogenesis and genetics of the thyroid with regards to its possible congenital dysfunction and briefly refers to the roles of the mother-placenta-fetal unit, iodine effect, and organic and functional changes of the negative feedback mechanism, as well as maturity and illness, in some forms of congenital hypo- and hyperthyroidism. This article also describes the published literature and the authors' data on the clinical aspects of congenital hypothyroidism, on the alternating hypo- and hyperthyroidism in the neonatal period, and on neonatal hyperthyroidism.

An expanded phenotype of maternal SSA/SSB antibody-associated fetal cardiac disease

OBJECTIVES

Conventional manifestations of fetal Sjogren's antibodies (SSA/SSB) associated cardiac disease include atrioventricular block (AVB), transient sinus bradycardia, endocardial fibroelastosis (EFE) and dilated cardiomyopathy. We describe other manifestations of cardiac disease.

METHODS

We describe three fetuses with unique myocardial and conduction system disease.

RESULTS

One had isolated EFE with subsequent mitral and tricuspid valve chordal avulsion, the second had sinoatrial and infrahissian conduction system disease, and in both, neonatal progression to life threatening disease occurred. The third had sinus node dysfunction and atrial flutter.

CONCLUSION

These findings expand the clinical phenotype of maternal SSA/SSB antibody associated fetal cardiac disease.

Soluble intercellular adhesion molecule-1 (slCAM-1) for early diagnosis of neonatal infections

We investigated the validity of circulating soluble intercellular adhesion molecule-1 (slCAM-1) as an early immunological marker of neonatal sepsis as compared to C-reactive protein (CRP), immature to total neutrophils ratio (IlT) and blood culture assays. The study included 28 full term neonates with clinical manifestations of sepsis, 10 of them had suspected sepsis "Group I" with negative blood culture, positive CRP during 1st week of life and one or more risk factors for infections. The other 18 neonates had proven sepsis "Group II"; with positive blood culture and positive CRP. 14 normal age and sex matched controls "Group III" were also included. Serum slCAM-1 concentrations (ng/ml) were measured using enzyme linked immunosorbent assay (ELISA) in two successive blood samples; before (S1) and one week after (S2) the start of antibiotics respectively. The mean value of I/T ratio was significantly higher in both SI and S2 (P<0.05; P<0.001 respectively) in septic neonates compared with controls. In addition, a significant difference (P<0.05) was detected in S2 between mean CRP levels in group I (9.6+/-15.7 mg/dl) and group II (17.3+/-30.0 mg/dl). The mean values of slCAM-1 in (Sl) of septic groups I and II (445.7+/-138.5 and 512.8+240.9 ng/ml respectively) were significantly higher (P<0.05) than those of control group (364.0+/-67.4). In contrast, in (S2) insignificant differences were detected between both groups (392.6+/-149.8 and 420.0+/-184.7 respectively) and controls. A positive correlation was revealed between CRP and slCAM-1 values in (Sl) (r=0.3, P<0.05). Positive correlations were also detected between slCAM-1 levels and leukocytic counts (r=0.3, P<0.05) and CRP (r=0.5, P<0.001) in (S2) while, negative correlation was detected between slCAM-1 levels and platelet counts (r= -0.5, P<0.001). In conclusion, serum concentration of ICAM-1 is a potential marker for diagnosis of neonatal sepsis at its early stages.

The development of animal models for the study of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the leading cause of death and long-term disability from gastrointestinal disease in preterm infants, and is characterized by acute and chronic intestinal inflammation that may lead to systemic sepsis and multi-system organ failure. NEC typically develops in the preterm infant after the administration of tube feeds, although it may occasionally be seen in full-term babies. Despite extensive clinical experience in the management of patients with NEC, the underlying cellular and molecular mechanisms leading to its development remain incompletely understood. Several animal models have therefore been developed in a variety of species in order to study the pathogenesis of NEC and to develop more effective treatment strategies. This review seeks to examine the pros and cons of animal models that have been developed in the study of NEC over the past 30 years. It will highlight the various strengths and weaknesses of experimental approaches that have been used, and discuss potential directions for the development of such models for the future.

Neonatal lupus erythematosus: an acquired autoimmune disorder and its cutaneous manifestations

Neonatal lupus erythematosus is an uncommon transplacentally acquired autoimmune disorder. The most common clinical manifestations are skin rash, congenital atrioventricular block, thrombocytopenia, leukopenia, anemia, and hepatosplenomegaly. Usually, the skin rash resembles subacute cutaneous lupus, but different forms of rash have been reported in neonatal lupus erythematosus and some are rare forms. NLE should be suspected in babies with atypical skin lesions, even if present at birth.

Thyroid gland development and defects

During the functional ontogenesis of the thyroid gland an increasing number of transcription factors play fundamental roles in thyroid-cell differentiation, maintenance of the differentiated state, and thyroid-cell proliferation. The early growth and development of the fetal thyroid appears to be generally independent of thyroid-stimulating hormone (TSH). TSH and thyroxine (T4) levels increase from the 12th week of gestation until delivery, whereas triiodothyronine (T3) levels remain relatively low. At birth, a cold-stimulated short-lived TSH surge is observed, followed by a TSH decrease until day 3 or 4 of life by T4 feedback inhibition. Disorders of thyroid gland development and/or function are relatively common, affecting approximately one newborn infant in 2000-4000. The most prevalent disease, congenital hypothyroidism, is frequently caused by genetic defects of transcription factors involved in the development of the thyroid or pituitary gland. A major cause of congenital hyperthyroidism is the transplacental passage of stimulating thyrotropin antibodies from the mother to the fetus. Hypothyroxinaemia or hypotriiodthyroninaemia is frequently observed in preterm infants with or without severe non-thyroidal illness. Whereas congenital hypo- and hyperthyroidism may be treated successfully with T4 or thyrostatic drugs, there is still insufficient evidence on whether the use of T4 for treatment of the latter condition results in changes in neonatal morbidity or reductions in neurodevelopmental impairment.

Clinical signs that predict severe illness in children under age 2 months: a multicentre study

BACKGROUND

Neonatal illness, particularly in the first week of life, is a leading cause of death worldwide. Improving identification of young infants who require referral for severe illness is of major public-health importance.

METHODS

Infants under 2 months of age brought with illness to health facilities in Bangladesh, Bolivia, Ghana, India, Pakistan, and South Africa were recruited in two age-groups: 0-6 days and 7-59 days. A trained health worker recorded 31 symptoms and clinical signs. An expert paediatrician assessed each case independently for severe illness that required hospital admission. We examined the sensitivity, specificity, and odds ratio (OR) for each symptom and sign individually and combined into algorithms to assess their value for predicting severe illness, excluding jaundice.

FINDINGS

3177 children aged 0-6 days and 5712 infants aged 7-59 days were enrolled. 12 symptoms or signs predicted severe illness in the first week of life: history of difficulty feeding (OR 10.0, 95% CI, 6.9-14.5), history of convulsions (15.4, 6.4-37.2), lethargy (3.5, 1.7-7.1), movement only when stimulated (6.9, 3.0-15.5), respiratory rate of 60 breaths per minute or more (2.7, 1.9-3.8), grunting (2.9, 1.1-7.5), severe chest indrawing (8.9, 4.0-20.1), temperature of 37.5 degrees C or more (3.4, 2.4-4.9) or below 35.5 degrees C (9.2, 4.6-18.6), prolonged capillary refill (10.5, 5.1-21.7), cyanosis (13.7, 1.6-116.5), and stiff limbs (15.1, 2.2-105.9). A decision rule requiring the presence of any one sign had high sensitivity (87%) and specificity (74%). After we reduced the algorithm to seven signs (history of difficulty feeding, history of convulsions, movement only when stimulated, respiratory rate of 60 breaths per minute or more, severe chest indrawing, temperature of 37.5 degrees C or more or below 35.5 degrees C), mainly on the basis of prevalence of each sign or symptom, sensitivity (85%) and specificity (75%) were much the same. These seven signs also did well in 7-59-day-old infants (sensitivity 74%, specificity 79%).

INTERPRETATION

A single simple algorithm could be recommended for identifying severe illness in infants aged 0-2 months who are brought to health facilities. Further research is needed on screening newborn children for illness in the community during routine home visits.

Leptin, insulin, and glucose serum levels in large-for-gestational-age infants of diabetic and non-diabetic mothers

BACKGROUND

It has been suggested that hyperleptinemia could be caused by hyperinsulinemia in infants of diabetic mothers (IDMs).

AIM

To compare leptin, insulin, and glucose levels in large-for-gestational-age (LGA) and appropriate-for-gestational-age (AGA) infants.

METHODS

A cross-sectional study was conducted in IDMs, infants of non-diabetic mothers (INDM) and AGA infants.

RESULTS

Seventy-seven newborns were studied (11 IDM, 16 INDM, and 50 AGA infants). Leptin levels were significantly higher in LGA infants than in the AGA group and a trend for higher levels in IDM than NIDM was observed. Insulin levels and insulin resistance were significantly higher in IDMs. Glucose levels were lower in both groups of LGA infants.

CONCLUSIONS

We found insulin resistance, hyperinsulinism and hyperleptinemia in IDMs, and the trend of higher leptin levels in IDMs than INDMs shows that leptin could be related to insulin resistance in these infants.

The extent to which genotype information may add to the prediction of disturbed perinatal adaptation: none, minor, or major?

Studies have been performed to describe the significance of genetic polymorphisms in complications associated with disturbed perinatal adaptation. Due to the large number of interacting factors, the results of classic statistical methods are often inconsistent. The random forest technique (RFT) is a robust nonparametric statistical approach that overcomes this problem through the calculation of the importance of each factor. We used RFT to reanalyze the importance of 24 genetic polymorphisms in the classification of preterm infants (birth weight, 680-1460 g, n = 100) to affected and unaffected groups according to the presence of acute perinatal complications. The accuracy of classification was between 0.5 and 0.8 for each complication when only birth data were considered. However, when genetic polymorphisms with the highest importance scores (ISs) were included in the analysis, the accuracy of classification according overall morbidity, necrotizing enterocolitis (NEC), acute renal failure (ARF), infant respiratory distress syndrome (IRDS), cardiac failure (CF), and patent ductus arteriosus (PDA) improved from 0.69, 0.60, 0.70, 0.72, 0.68, and 0.57 to 0.77, 0.70, 0.76, 0.77, 0.76, and 0.64, respectively. Our findings suggest that genetic polymorphisms identified by RFT as predictors may improve the risk assessment of preterm infants. RFT is a suitable tool to develop risk factor patterns in this population.