Congenital and neonatal pneumonia

Thoracic Fluid Content in Neonates Presented with Respiratory Distress as a Predictive Tool for Transient Tachypnea of Newborn

INTRODUCTION

 Respiratory conditions are the most common reason for admission of newborns to a neonatal care unit. The index of contractility (ICON) can be used to measure the thoracic fluid content (TFC) in neonates which is a significant parameter in cases presented with transient tachypnea of newborn (TTN).

OBJECTIVE

 The objective was to compare TFC between newborn infants with TTN compared with other causes of respiratory distress (RD). We tested the hypothesis that TFC would be higher in infants with TTN.

STUDY DESIGN

 In total, 105 newborns were enrolled at the delivery room and were categorized into three groups: TTN, other causes of RD, and control, according to physical examination and Chest X-Ray. TFC was measured within the first 6 hours for all infants and at 24 and 48 hours for the first two groups.

RESULTS

 Demographic data showed higher male participants and use of antenatal steroid therapy in RD groups. TFC within the first 6 hours was higher in RD groups. However, TFC at 24 hours of ≤24 mL/kg, and TFC drop rate at 24 hours of >12% are statistically significant discriminators of TTN from non-TTN, with sensitivity and specificity of 97.1 and 47.1%, and 60 and 82.4%, respectively (Fig 1 and 2).

CONCLUSION

 ICON can be used in conjunction with clinical parameters and CXR as a tool for differentiation between TTN and other causes of RD within the first 24 hours of life by using the cutoff value of TFC at 24 hours and TFC drop rate. This will allow earlier and optimum management of different causes of RD.

KEY POINTS

· Thoracic fluid content. · Neonatal respiratory distress. · Newborn.

Salivary C-reactive protein and mean platelet volume as possible diagnostic markers for late-onset neonatal pneumonia

BACKGROUND

Neonatal sepsis, a formidable threat to newborns, is a leading cause of neonatal mortality, with late-onset sepsis manifesting after 72 hours post-birth being particularly concerning. Pneumonia, a prevalent sepsis presentation, poses a significant risk, especially during the neonatal phase when lung defenses are compromised. Accurate diagnosis of pneumonia is imperative for timely and effective interventions. Saliva, a minimally invasive diagnostic medium, holds great promise for evaluating infections, especially in infants.

AIM

To investigate the potential of serum C-reactive protein (CRP), salivary CRP (sCRP), and mean platelet volume (MPV) as diagnostic markers for late-onset neonatal pneumonia (LONP).

METHODS

Eighty full-term neonates were systematically examined, considering anthropometric measurements, clinical manifestations, radiology findings, and essential biomarkers, including serum CRP, sCRP, and MPV.

RESULTS

The study reveals noteworthy distinctions in serum CRP levels, MPV, and the serum CRP/MPV ratio between neonates with LONP and healthy controls. MPV exhibited a robust discriminatory ability [area under the curve (AUC) = 0.87] with high sensitivity and specificity at a cutoff value of > 8.8. Correlations between serum CRP, sCRP, and MPV were also identified. Notably, sCRP demonstrated excellent predictive value for serum CRP levels (AUC = 0.89), underscoring its potential as a diagnostic tool.

CONCLUSION

This study underscores the diagnostic promise of salivary and serum biomarkers, specifically MPV and CRP, in identifying and predicting LONP among neonates. These findings advocate for further research to validate their clinical utility in larger neonatal cohorts.

Ion channel TRPV2 is critical in enhancing B cell activation and function

The function of transient receptor potential vanilloid (TRPV) cation channels governing B cell activation remains to be explored. We present evidence that TRPV2 is highly expressed in B cells and plays a crucial role in the formation of the B cell immunological synapse and B cell activation. Physiologically, TRPV2 expression level is positively correlated to influenza-specific antibody production and is low in newborns and seniors. Pathologically, a positive correlation is established between TRPV2 expression and the clinical manifestations of systemic lupus erythematosus (SLE) in adult and child SLE patients. Correspondingly, mice with deficient TRPV2 in B cells display impaired antibody responses following immunization. Mechanistically, the pore and N-terminal domains of TRPV2 are crucial for gating cation permeation and executing mechanosensation in B cells upon antigen stimulation. These processes synergistically contribute to membrane potential depolarization and cytoskeleton remodeling within the B cell immunological synapse, fostering efficient B cell activation. Thus, TRPV2 is critical in augmenting B cell activation and function.

SENP1 knockdown-mediated CTCF SUMOylation enhanced its stability and alleviated lipopolysaccharide-evoked inflammatory injury in human lung fibroblasts via regulation of FOXA2 transcription

BACKGROUND

Excessive inflammation is the main cause of treatment failure in neonatal pneumonia (NP). CCCTC-binding factor (CTCF) represents an important node in various inflammatory diseases. In the present study, we tried to clarify the function and underlying molecular mechanism of CTCF on an in vitro cellular model of NP, which was generated by simulating the human lung fibroblast cell line WI-38 with lipopolysaccharide (LPS).

METHODS

The SUMOylation level and protein interaction were verified by Co-immunoprecipitation assay. Cell viability was measured by Cell Counting Kit-8 assay. Inflammatory factors were examined by Enzyme-linked immunosorbent assay. Cell apoptosis was evaluated by TUNEL assay. The binding activity of CTCF to target promoter was tested by chromatin immunoprecipitation and luciferase reporter assay.

RESULTS

LPS treatment restrained cell viability, promoted the production of inflammatory factors, and enhanced cell apoptosis. CTCF overexpression played anti-inflammatory and anti-apoptotic roles. Furthermore, CTCF was modified by SUMOylation with small ubiquitin-like modifier protein 1 (SUMO1). Interfering with sumo-specific protease 1 (SENP1) facilitated CTCF SUMOylation and protein stability, thus suppressing LPS-evoked inflammatory and apoptotic injuries. Moreover, CTCF could bind to the forkhead box protein A2 (FOXA2) promoter region to promote FOXA2 expression. The anti-inflammatory and anti-apoptotic roles of CTCF are associated with FOXA2 activation. In addition, SENP1 knockdown increased FOXA2 expression by enhancing the abundance and binding ability of CTCF.

CONCLUSIONS

SUMOylation of CTCF by SENP1 knockdown enhanced its protein stability and binding ability and it further alleviated LPS-evoked inflammatory injury in human lung fibroblasts by positively regulating FOXA2 transcription.

CIRCESPL1 SILENCING PROTECTS AGAINST LPS-INDUCED LUNG FIBROBLAST DYSFUNCTION PARTLY BY TARGETING THE MIR-146B-3P/TRAF1 AXIS IN PNEUMONIA

ABSTRACT

Background: Neonatal pneumonia is a common disease in the neonatal period with high mortality. The present work concentrated on the role and mechanism of circular RNA extra spindle pole bodies like 1, separase (circESPL1) in LPS-induced dysfunction of lung fibroblasts. Methods: Reverse transcription-quantitative polymerase chain reaction and Western blot assay were conducted to analyze RNA and protein expression, respectively. Cell viability, proliferation, apoptosis, and inflammation were assessed by Cell Counting Kit-8 assay, 5-ethynyl-2'-deoxyuridine assay, flow cytometry, and enzyme-linked immunosorbent assay, respectively. Dual-luciferase reporter assay and RNA immunoprecipitation assay were conducted to verify the intermolecular interactions among circESPL1, miR-146b-3p, and TRAF1. Results: CircESPL1 expression was upregulated in the serum samples of pneumonia patients and LPS-induced lung fibroblasts. CircESPL1 silencing protected lung fibroblasts against LPS-induced dysfunction. CircESPL1 bound to microRNA-146b-3p (miR-146b-3p) in lung fibroblasts. CircESPL1 knockdown-mediated protective effects on LPS-induced lung fibroblasts were largely reversed by the silence of miR-146b-3p. miR-146b-3p directly interacted with the 3' untranslated region of TNF receptor associated factor 1 (TRAF1), and TRAF1 expression was regulated by the circESPL1/miR-146b-3p axis in lung fibroblasts. TRAF1 overexpression largely reversed miR-146b-3p accumulation-mediated protective effects on LPS-induced lung fibroblasts. Conclusion: CircESPL1 knockdown protected lung fibroblasts from LPS-induced injury partly by targeting the miR-146b-3p/TRAF1 axis.

Clinical value of procalcitonin-to-albumin ratio for identifying sepsis in neonates with pneumonia

BACKGROUND

It is possible that neonates with pneumonia also have unrecognized sepsis. Identifying sepsis in neonates with pneumonia may cause some trouble for clinicians. This study aimed to evaluate the clinical value of the procalcitonin-to-albumin ratio (PAR) in identifying sepsis in neonates with pneumonia.

METHODS

We retrospectively included 912 neonates with pneumonia from January 2016 to July 2021. Clinical and laboratory data were collected from electronic medical records. Among neonates with pneumonia, 561 neonates were diagnosed with sepsis, according to the International Pediatric Sepsis Consensus. Neonates were divided into a sepsis group and a pneumonia group. A multivariate logistic regression analysis was used to evaluate whether PAR was a potential independent indicator for identifying sepsis in neonates with pneumonia. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic value of PAR in sepsis.

RESULTS

Neonates with sepsis have a higher PAR (p < 0.001). Correlation analysis showed that PAR was positively correlated with the level of C-reactive protein (r = 0.446, p < 0.001). Multiple logistic regression analysis showed that PAR was an independent predictor of the presence of sepsis in neonates with pneumonia. ROC curve analysis revealed that PAR had good power in identifying sepsis in neonates with pneumonia (area under curve (AUC) = 0.72, 95% confidence interval (CI), 0.68-0.75, p < 0.001).

CONCLUSION

PAR can be used as a new biomarker to identify sepsis in neonates with pneumonia.

An audit of autopsy-confirmed diagnostic errors in perinatal deaths: What are the most common major missed diagnoses

Perinatal autopsies are essential to establish the cause of stillbirth or neonatal death and improve clinical practice. Limited studies have provided detailed major missed diagnoses of perinatal deaths in current clinical practice. In this retrospective audit of 177 perinatal autopsies including 99 stillbirths and 78 neonatal deaths with complete pathologic evaluation, 66 cases (21 Class I and 45 Class II diagnostic errors) were revealed as major discrepancies (37.3%), with complete agreements in 80 cases (45.2%). The difference in major discrepancies between stillbirth and neonatal death groups was significant (P < 0.001), with neonatal deaths being more prone to Class I errors. Various respiratory diseases (25/66, 37.9%) and congenital malformations (16/66, 24.2%) accounted for the majority of missed diagnoses (41/66, 62.1%). More importantly, neonatal respiratory distress syndrome (NRDS) was the most common type I missed diagnosis (7/8, 87.5%), markedly higher than the average 11.9% of all Class I errors. Our findings suggest that there are high disparities between clinical diagnoses and autopsy findings in perinatal deaths, and that various respiratory diseases are mostly inclined to cause major diagnostic errors. We first demonstrated that NRDS is the most common type I missed diagnosis in perinatal deaths, which clinicians should pay special attention to in practice.

A Modern Look at the Development of Intrauterine Pneumonia in Premature Newborns: Literature Review

Infectious diseases such as malaria, pneumonia, diarrhea and preventable neonatal diseases are common causes of death in children. Globally, neonatal mortality is 44% (2.9 million) annually, with up to 50% of babies dying within the first day of life. Pneumonia kills between 750000 and 1.2 million infants in the neonatal period each year in developing countries. Premature birth, pneumonia, and labor complications are common causes of neonatal mortality. The objective of the study is to present the general characteristics of congenital pneumonia, vitamin D deficiency and micronutrient deficiencies in premature infants. To date, numerous studies confirm the relationship between the inadequate supply of the body with macro- and microelements and the development of diseases of varying severity, including metabolic disorders. Based on this, primary screening, aimed at identifying metabolic disorders of macro- and microelements and further drug correction, should become the main concept for the management of patients in modern times.

The diagnostic value of n-terminal probrain natriuretic peptides to differentiate neonatal pneumoniae and transient tachypnea of the newborn

BACKGROUND

The primary objective of the study was to determine the diagnostic value of serum N-terminal probrain natriuretic peptide (NT-proBNP) levels to differentiate neonatal pneumonia (NP) and transient tachypnea of the newborn (TTN). The secondary objective was to investigate the prognostic role of NT-proBNP levels in neonates with severe respiratory distress (RD).

METHODS

A prospective, observational, single-blinded study involving 58 late preterm and term newborns who were diagnosed with TTN or NP was conducted between June 2020 and June 2021 at a level-3 neonatal intensive care unit in Kırıkkale University Faculty of Medicine. TTN and NP groups were compared for serum NT-proBNP levels measured at the 1st and 24th hours of life. Optimal cut-off NT-proBNP value was determined by Youden index to predict the diagnosis of NP. Lung ultrasound was used to support the diagnosis of TTN and NP. In addition, lung ultrasound score (LUS) was used to determine severe RD.

RESULTS

The median of NT-proBNP level was significantly higher at the 24th hour of life in the NP group than in the TTN group, respectively 7263.5 pg/mL (1643-35,000) and 3308 pg/mL (69-19,746), p = 0.004. At a cut-off value of 5515.5 pg/mL, NT-proBNP had a sensitivity of 75% and specificity of 73.8% to predict NP [AUC= 0.749 (95% CI: 0.602-0.895; p = 0.004)]. The study population was divided into two groups as high score group (n: 23, LUS ≥ 7) and low score group (n: 35, LUS < 7) according to the LUS at the 6th hour of life. NT-proBNP values at 24th hour of life were 6320 pg/mL (69-35,000) in high score group and 3500 pg/mL (570-15,948) in low score group, p = 0.044. Duration of oxygen support (p = 0.006), noninvasive ventilation (p = 0.008) and NICU stay (p = 0.004) were higher in high-score group.

DISCUSSION

NT-proBNP values at 24th hour of life can be used as a relatively early predictor in the differentiation between NP and TTN in late preterm and term neonates. In addition, elevated NT-proBNP values are related to the higher LUS which reflects the severity of RD regardless of diagnosis.

DNA methyltransferase inhibition induces dynamic gene expression changes in lung CD4+ T cells of neonatal mice with E. coli pneumonia

Bacterial pulmonary infections are a major cause of morbidity and mortality in neonates, with less severity in older children. Previous studies demonstrated that the DNA of CD4+ T cells in the mouse lung, whose primary responsibility is to coordinate the immune response to foreign pathogens, is differentially methylated in neonates compared with juveniles. Nevertheless, the effect of this differential DNA methylation on CD4+ T cell gene expression and response to infection remains unclear. Here we treated E. coli-infected neonatal (4-day-old) and juvenile (13-day-old) mice with decitabine (DAC), a DNA methyltransferase inhibitor with broad-spectrum DNA demethylating activity, and performed simultaneous genome-wide DNA methylation and transcriptional profiling on lung CD4+ T cells. We show that juvenile and neonatal mice experienced differential demethylation in response to DAC treatment, with larger methylation differences observed in neonates. By cross-filtering differentially expressed genes between juveniles and neonates with those sites that were demethylated in neonates, we find that interferon-responsive genes such as Ifit1 are the most down-regulated methylation-sensitive genes in neonatal mice. DAC treatment shifted neonatal lung CD4+ T cells toward a gene expression program similar to that of juveniles. Following lung infection with E. coli, lung CD4+ T cells in neonatal mice exhibit epigenetic repression of important host defense pathways, which are activated by inhibition of DNA methyltransferase activity to resemble a more mature profile.

Efficiency of Lung Ultrasonography in the Diagnosis and Follow-up of Viral Pneumonia in Newborn

OBJECTIVE

Lung ultrasonography (LUS) is a useful method for diagnosis of lung diseases such as respiratory distress syndrome, transient tachypnea of the newborn, pneumonia, and pneumothorax in the neonatal period. LUS has become an important tool in the diagnosis and follow-up of lung diseases. LUS is easy to apply at the bedside and is a practical and low-cost method for diagnosing pneumonia.

STUDY DESIGN

This study was conducted in neonatal intensive care unit of Dr. Sami Ulus Obstetrics, Children's Health and Diseases Training and Research Hospital. From September 2019 to April 2020, 50 patients who were diagnosed with viral pneumonia were included in the study. Also, 24 patients with sepsis-related respiratory failure were included in the study as a control group. LUS was performed at the bedside three times, by a single expert, once each before treatment for diagnosis, on discharge, and after discharge in outpatient clinic control.

RESULTS

Before treatment, LUS findings were lung consolidation with air bronchograms (50/50), pleural line abnormalities (35/50), B-pattern (25/50), disappearance of lung sliding (21/50), lung pulse (5/50), and pleural effusion (9/50). During discharge, we found significant changes: lung consolidation with air bronchograms (6/50), pleural line abnormalities (7/50), B-pattern (12/50), and pleural effusion (1/50) (p < 0.05). Outpatient clinic control LUS findings were lung consolidation with air bronchograms (0/50), pleural line abnormalities (0/50), B-pattern (0/50), disappearance of lung sliding (0/50), and pleural effusion (0/50) (p < 0.05). Also, B-pattern image, disappearance of lung sliding, and pleural line abnormalities were higher in control group (p < 0.05).

CONCLUSION

Ultrasound gives no hazard, and the application of bedside ultrasonography is comfortable for the patients. Pneumonia is a serious infection in the neonatal period. Repeated chest radiography may be required depending on the clinical condition of the patient with pneumonia. This study focuses on adequacy of LUS in neonatal pneumonia.

KEY POINTS

· Lung ultrasound is a practical and low-cost method in diagnosing pneumonia.. · Neonatal pneumonia is a very important cause of morbidity and mortality in NICU.. · We can evaluate neonatal pneumonia with combination of clinical presentations and LUS findings..

Neonatal Outcomes since the Implementation of No Routine Endotracheal Suctioning of Meconium-Stained Nonvigorous Neonates

OBJECTIVE

 This study aimed to evaluate the effect of the 2015 Neonatal Resuscitation Program recommendations of no routine endotracheal suctioning for nonvigorous neonates on the incidence of meconium aspiration syndrome (MAS) and death. We hypothesized that the revised guidelines have not changed the outcome of MAS/death.

STUDY DESIGN

 This was a single-center retrospective cohort study. We recorded data on nonvigorous neonates born at gestational age > 37 weeks, who were divided into period 1, n = 95 (before the new guidelines, January 1, 2013-December 31, 2015) and prospective period 2, n = 91 (after the implementation of new guidelines, January 1, 2017-December 31, 2020). Primary outcomes included MAS and death. Secondary outcomes included respiratory neonatal intensive care unit (NICU) admission, length of NICU stay, and feeding difficulties.

RESULTS

 No significant differences in the occurrence of MAS (11 vs. 17%) (odds ratio [OR] of 1.46 [95% confidence interval [CI]: 0.59-3.55]) or death (1 vs. 3%) (OR of 2.00 [95% CI: 0.18-21.57]) among the two periods were observed. In period 2, there was an increased NICU respiratory admission (37 vs. 61%), with an OR of 2.31 (95% CI: 1.10-4.84). More neonates in period 2 required subsequent intubation for respiratory failure in the delivery room (12 vs. 28%) with an OR of 2.03 (95% CI: 1.02-4.51); p-value of 0.05.

CONCLUSION

 Our study did not observe a significant difference in the incidence of MAS or death between the two periods since the 2015 guidelines. However, the incidence of NICU respiratory admission increased.

KEY POINTS

· Non-vigorous neonates born through MSAF who did not undergo ET suctioning soon after birth did not have increased incidence of MAS or death, but had increased NICU respiratory admissions.. · A large Multi-center RCT may give more clear verdict on the outcomes of these newborns..

Can surfactants affect mortality and morbidity in term infants with respiratory failure?

BACKGROUND

We aimed to discuss term infants who are given surfactant due to respiratory disorder according to the underlying etiology, the dose of surfactant administration, and the need for repeated surfactant administration.

METHODS

In this retrospective study infants hospitalized in the 4th level neonatal intensive care unit during January 2019 and December 2021 and administered surfactant due to respiratory distress were included. Term infants given surfactant due to respiratory failure were included in the study through the data recording system. The number of surfactant doses, indications for administration, mortality, duration of hospitalization, intubation time, and inotrope use were recorded in the infants included in the study.

RESULTS

: During the two-year period, 1250 infants were hospitalized in our neonatal intensive care unit. Of those, 56 infants received surfactant replacement therapy for severe respiratory failure. There were 30 infants with pneumonia, 4 infants with meconium aspiration syndrome (MAS), and 22 infants with transient tachypnea of the newborn (TTN). It was seen that single-dose administration was higher in patients with TTN (p = 0.01), while multiple-dose surfactant administration was more common in patients with MAS, resulting in a statistical difference (p = 0.02). Mortality was lower, especially in cases given early surfactant administration and this situation was statistically significant (p < 0.001). Duration of intubation was 5.05 ± 4.7 days in early surfactant administration group and 8.0 ± 6.1 days in late surfactant administration group. This difference was statistically significant (p = 0.04). While early surfactant application was statistically higher in the TTN group (p = 0.007), late surfactant application was statistically higher in the pneumonia group (p = 0.001).

DISCUSSION

Despite the difference on administration time and repeat dose interval due to etiology, surfactant treatment is improving the respiratory distress of term infants.

Knockdown of circ_0038467 alleviates lipopolysaccharides-induced 16HBE cell injury by regulating the miR-545-3p/TRAF1 axis in neonatal pneumonia

BACKGROUND

Neonatal pneumonia is a common illness in the neonatal period with a high fatality rate. Accumulating proofs have attested to the crucial role of circular RNAs (circRNAs) in pneumonia. This study was intended to expound on the function of circ_0038467 and the underlying mechanism in lipopolysaccharide (LPS)-stimulated 16HBE cell injury in neonatal pneumonia.

METHODS

16HBE cells were exposed to LPS to establish an in vitro neonatal pneumonia cell model. Quantitative real-time polymerase chain reaction (qRT-PCR) was implemented for detecting the levels of circ_0038467, microRNA-545-3p (miR-545-3p), and tumor necrosis factor receptor-associated factor 1 (TRAF1) in neonatal pneumonia serums and LPS-treated 16HBE cells. Cell Counting Kit-8 (CCK-8), 5-ethynyl-2'-deoxyuridine (EdU) incorporation, and flow cytometry assays were used to examine cell viability, proliferation, and apoptosis, respectively. The protein abundances of proliferation/apoptosis/inflammation-correlated makers and TRAF1 were tested by Western blot. RNase R and Actinomycin D assays were implemented to determine the features of circ_0038467. The mutual effect between miR-545-3p and circ_0038467 or TRAF1 was affirmed by a dual-luciferase reporter and RNA pull-down assay assays.

RESULTS

Circ_0038467 was upregulated in neonatal pneumonia serum specimens and LPS-triggered 16HBE cells. LPS administration restrained 16HBE cell proliferation and promoted apoptosis and inflammation, whereas circ_0038467 silence recovered these influences. Meanwhile, miR-545-3p was targeted by circ_0038467, and circ_0038467 could modulate LPS-treated 16HBE cell injury through absorbing miR-545-3p. Furthermore, circ_0038467 controlled TRAF1 level via segregating miR-545-3p. Moreover, TRAF1 overexpression relieved the suppressive impact of circ_0038467 silence in LPS-triggered 16HBE cell detriment.

CONCLUSION

Circ_0038467 knockdown mitigated LPS-exposed 16HBE cell damage through regulating miR-545-3p/PPARA axis.

The oncogene ABL1 regulates the inflammatory response of innate immunity via mediating TRAF6 ubiquitination

The oncogene ABL1 plays an important role in various cancers, while its roles remain unclear in pneumonia. This study aims to investigate the roles of ABL1 in pneumonia and the underlying mechanisms. RNA sequencing was used to determine the expressions of multiple kinases in the PBMCs. A series of overexpression and knockout cell lines were constructed. Besides, an intranasal lung infection mouse model was pre-treated with asciminb. ELISAs and qPCR were used to determine the levels of target genes. In addition, STRING Interaction Network and Immunoblotting assays were used to determine the interaction between target proteins. An elevation in ABL1 was observed in the infant with Ecoli pneumonia. ABL1 was positively correlated to the levels of inflammatory cytokines and the activation of the NF-kB pathways. In vivo data demonstrated that the inhibition of ABL1 suppressed the inflammatory cytokines, reduced the lung bacterial burden, and ameliorated the lung injury score. ABL1 inhibited the phosphorylation of IκBα and p38 and regulated the ubiquitination of TRAF6. ABL1 regulates the inflammatory response in pneumonia in part by the regulation of MAPK and NF-κB pathways and TRAF6 ubiquitination.

C-Reactive Protein-to-Albumin Ratio as an Early Biomarker to Identify Sepsis in Neonates with Pneumonia

Objectives

Neonates with pneumonia often also have sepsis, and the identifying sepsis from pneumonia may be a challenge for clinicians. However, there are no available data regarding the clinical value C-reactive protein-to-albumin ratio (CAR) in identifying sepsis in neonates with pneumonia. The aim of this study was to evaluate the clinical value of CAR in identifying sepsis in neonates with pneumonia.

Methods

847 neonates with pneumonia were included in this study, of which 511 neonates were diagnosed with sepsis. Neonates were divided into the sepsis group and the nonsepsis group. All neonates underwent extensive and necessary clinical and laboratory tests. CAR was calculated as serum C-reactive protein (ng/ml)/albumin (mg/ml). All statistical analyses were performed using the statistical package SPSS 24.0, as appropriate.

Results

Compared with the nonsepsis group, neonates with sepsis have a higher CAR (P < 0.001). Further analysis showed that the prevalence of neonates with sepsis increased significantly from 41.0% in the low CAR group (CAR ≤ 0.024 × 10⁻³) to 80.0% in the high CAR group (CAR > 0.024 × 10⁻³) (P < 0.001). Correlation analysis showed that there was a strong positive correlation between CAR and PCT (r = 0.452, P < 0.001), nSOFA (r = 0.267, P < 0.001), and the prolonged length of hospital stay (r = 0.311, P < 0.001). Multiple logistic regression showed that CAR was an independent risk factor for the presence of sepsis in neonates with pneumonia. Receiver operating characteristic curve analysis revealed that CAR had adequate discriminatory power in predicting sepsis in neonates with pneumonia (area under curve (AUC) = 0.76, 95% CI 0.73-0.79, P < 0.001).

Conclusions

CAR can be used as a new marker to identify sepsis in neonates with pneumonia.

Chest ultrasound in neonates: What neonatologists should know

For many years, ultrasound was thought to have no indications in pulmonary imaging because lungs are filled with air, creating no acoustic mismatch, as encountered by ultrasound wave beam. Lung ultrasound (LUS) was started in adult critical care settings to detect pleural effusion and acquired more indications over time. In the neonatal intensive care unit (NICU), the use of chest ultrasound has gained more attention during the last two decades. Being a radiation-free, bedside, rapid, and handy tool, LUS started to replace chest X-rays in NICU. Using LUS depends upon understanding the nature of normal lungs and the changes induced by different diseases. With the help of LUS, an experienced neonatologist can detect many of the respiratory problems so fast that interventional therapy can be introduced as early as possible. LUS can diagnose pleural effusion, pneumothorax, pneumonia, transient tachypnoea of the newborn, respiratory distress syndrome, pulmonary atelectasis, meconium aspiration syndrome, bronchopulmonary dysplasia, and some other disorders with very high accuracy. LUS will be helpful in initial diagnosis, follow-up, and predicting the need for further procedures such as mechanical ventilation, diuretic therapy, surfactant therapy, etc. There are some limitations to using LUS in some respiratory disorders such as bullae, interstitial emphysema, and other conditions. This review will highlight the importance of LUS, its uses, and limitations.

Utility of umbilical cord blood 25-hydroxyvitamin D levels for predicting bronchopulmonary dysplasia in preterm infants with very low and extremely low birth weight

BACKGROUND AND OBJECTIVE

There remains controversy regarding vitamin D deficiency and bronchopulmonary dysplasia (BPD) in very low birth weight (VLBW) and extremely low birth weight (ELBW) preterm infants. This study aimed to determine the prevalence of vitamin D deficiency assessed by umbilical cord blood 25-hydroxyvitamin D [25(OH)D] in preterm infants in northeast China and to evaluate the ability and optimal threshold of 25(OH)D for predicting BPD.

METHODS

The clinical data of VLBW and ELBW preterm infants with known cord-blood 25(OH)D levels were analyzed retrospectively. Infants were divided into groups based on their cord-blood 25(OH)D levels and BPD diagnosis. Logistic regression was performed to assess the risk factors for BPD and a nomogram was established. Receiver operating characteristic (ROC) curve analysis was used to evaluate the optimal threshold of cord-blood 25(OH)D concentration for predicting BPD.

RESULTS

A total of 267 preterm infants were included, of which 225 (84.3%) exhibited vitamin D deficiency and 134 (50.2%) were diagnosed with BPD. The incidence of BPD was lower in the group with a 25(OH)D level of >20 ng/ml than in the other groups (P = 0.024). Infants with BPD had lower cord-blood 25(OH)D levels than those without BPD (11.6 vs. 13.6 ng/ml, P = 0.016). The multivariate logistic regression model revealed that 25(OH)D levels (odds ratio [OR] = 0.933, 95% confidence interval [95% CI]: 0.891-0.977), gestational age (OR = 0.561, 95% CI: 0.425-0.740), respiratory distress syndrome (OR = 2.989, 95% CI: 1.455-6.142), and pneumonia (OR = 2.546, 95% CI: 1.398-4.639) were independent risk factors for BPD. A predictive nomogram containing these four risk factors was established, which had a C-index of 0.814. ROC curve analysis revealed that the optimal cutoff value of 25(OH)D for predicting BPD was 15.7 ng/ml (area under the curve = 0.585, 95% CI: 0.523-0.645, P = 0.016), with a sensitivity of 75.4% and a specificity of 42.9%.

CONCLUSIONS

A cord-blood 25(OH)D level of <15.7 ng/ml was predictively valuable for the development of BPD. The nomogram established in this study can help pediatricians predict the risk of BPD more effectively and easily.

Salivary Interleukin-6 and C-Reactive Protein/Mean Platelet Volume Ratio in the Diagnosis of Late-Onset Neonatal Pneumonia

Neonatal pneumonia is a serious respiratory infectious disease with a high rate of case fatality in developing countries. Salivary cytokines could serve as interesting noninvasive markers in the diagnosis of neonatal pneumonia. The aim was to assess the diagnostic role of salivary and serum interleukin-6 (IL-6), C-reactive protein/mean platelet volume (CRP/MPV) ratio, and the combination of these markers in the diagnosis of late-onset neonatal pneumonia in full-term neonates. Seventy full-term neonates, 35 with late-onset neonatal pneumonia and 35 controls, were enrolled in this prospective case-control study. Complete blood count (CBC), salivary and serum IL-6, and CRP concentrations were measured for all the study subjects. The sensitivity, specificity, positive predictive value, and negative predictive value of salivary IL-6, serum IL-6, and CRP/MPV ratio for the diagnosis of late-onset neonatal pneumonia were determined. At the cutoff point of >34 pg/ml, salivary IL-6 showed 82.86% sensitivity and 91.43% specificity. CRP/MPV ratio showed a sensitivity of 97.14% and specificity of 85.71% at a cutoff value > 0.88. The combination of salivary IL-6 and CRP/MPV ratio improved the sensitivity and specificity to 100%. The current study shows for the first time that both salivary IL-6 and CRP/MPV ratio are suitable markers for the diagnosis of late-onset neonatal pneumonia in full-term neonates.

Lung Ultrasound in Pediatrics and Neonatology: An Update

The potential role of ultrasound for the diagnosis of pulmonary diseases is a recent field of research, because, traditionally, lungs have been considered unsuitable for ultrasonography for the high presence of air and thoracic cage that prevent a clear evaluation of the organ. The peculiar anatomy of the pediatric chest favors the use of lung ultrasound (LUS) for the diagnosis of respiratory conditions through the interpretation of artefacts generated at the pleural surface, correlating them to disease-specific patterns. Recent studies demonstrate that LUS can be a valid alternative to chest X-rays for the diagnosis of pulmonary diseases, especially in children to avoid excessive exposure to ionizing radiations. This review focuses on the description of normal and abnormal findings during LUS of the most common pediatric pathologies. Current literature demonstrates usefulness of LUS that may become a fundamental tool for the whole spectrum of lung pathologies to guide both diagnostic and therapeutic decisions.

Tracheal aspirate presepsin: a promising biomarker in early onset neonatal pneumonia

The early recognition and management of early-onset neonatal pneumonia is a challenge facing intensivists. Presepsin is an emerging immunologic and inflammatory biomarker that has been used for early non-culture-based detection of infection. We aimed to clarify the potential of presepsin assessed in tracheal aspirate of newborns to identify pneumonia. This prospective case - control study was conducted on 60 intubated neonates: Thirty neonates with pneumonia diagnosed according to clinical, radiological, and laboratory criteria as pneumonia group and thirty age and sex-matched intubated neonates without pneumonia as a control group. All neonates underwent full clinical evaluation and laboratory investigations. Plasma and tracheal aspirate presepsin was determined on the first day of life. The means of tracheal aspirate and plasma presepsin and CRP (525.55 ± 94.62 pg/mL, 670.95 ± 120.38 pg/mL and 26.4 ± 11.2 mg/L, respectively) were significantly higher in pneumonia group than control group (252.51 ± 104.95 pg/mL, 553.79 ± 117.48 pg/mL, 15.1 ± 3.1 mg/L, respectively) (p < .001 each). Receiver operating characteristic curve analysis for tracheal aspirate and plasma presepsin and CRP levels for the prediction of early-onset neonatal pneumonia was designed. Sensitivity was 86.6, 70 and 56.7%, respectively, while specificity was 90, 73.3, 53.3%, respectively, at a cut-off point of 385 pg/mL, 605 pg/mL and 36 mg/L, respectively [area under the curve (AUC) = 0.97, 0.74 and 0.51, respectively, p < .001, .001 and .44, repectively]. In conclusion, tracheal aspirate presepsin is increased in early-onset neonatal pneumonia and outperformed other plasma biomarkers in diagnosing neonatal pneumonia.

Correlation between serum levels of C-reactive protein and neonatal pneumonia: A protocol for systematic review and meta-analysis

BACKGROUND

Few studies have reported the correlation between serum levels of C-reactive protein (CRP) and neonatal pneumonia. The purpose of the present meta-analysis was to clarify whether an increased serum level of CRP accelerates the development of neonatal pneumonia.

METHODS

This protocol is conducted according to the preferred reporting items for systematic reviews and meta-analysis protocol (PRISMA-P) statement guidelines. Related articles were identified by searching PubMed, Embase, Cochrane Library, Web of Science, Science Direct, and CNKI databases. Two investigators extracted information according to the selection criteria and used a set of predefined criteria based on the Newcastle-Ottawa Scale (NOS) criteria to assess the studies. All calculations were carried out with Stata 12.0 (Stata Corp, College Station, TX).

RESULTS

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

CONCLUSION

We hypothesized that a higher serum CRP level is closely correlated with the progression of neonatal pneumonia. CRP as a general systemic inflammation biomarker may help clinicians to make difficult therapeutic decisions for neonatal pneumonia.

OPEN SCIENCE FRAMEWORK REGISTRATION NUMBER

10.17605/OSF.IO/RGBMX.

Gambogic acid protects LPS-induced apoptosis and inflammation in a cell model of neonatal pneumonia through the regulation of TrkA/Akt signaling pathway

Objective

In this work, we investigated the effects of gambogic acid (GA) on lipopolysaccharide (LPS)-induced apoptosis and inflammation in a cell model of neonatal pneumonia.

Method

Human WI-38 cells were maintained in vitro and incubated with various concentrations of GA to examine WI-38 survival. GA-preincubated WI-38 cells were then treated with LPS to investigate the protective effects of GA on LPS-induced death, apoptosis and inflammation. Western blot assay was utilized to analyze the effect of GA on tropomyosin receptor kinase A (TrkA) signaling pathway in LPS-treated WI-38 cells. In addition, human AKT serine/threonine kinase 1 (Akt) gene was knocked down in WI-38 cells to further investigate the associated genetic mechanisms of GA in protecting LPS-induced inflammation and apoptosis.

Results

Pre-incubating WI-38 cells with low and medium concentrations GA protected LPS-induced cell death, apoptosis and inflammatory protein productions of IL-6 and MCP-1. Using western blot assay, it was demonstrated that GA promoted TrkA phosphorylation and Akt activation in LPS-treated WI-38 cells. Knocking down Akt gene in WI-38 cells showed that GA-associated protections against LPS-induced apoptosis and inflammation were significantly reduced.

Conclusions

GA protected LPS-induced apoptosis and inflammation, possibly through the activations of TrkA and Akt signaling pathway. This work may broaden our understanding on the molecular mechanisms of human neonatal pneumonia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40360-021-00496-9.

Can immature platelet fraction be an early predictor for congenital pneumonia?

Aim:

Timely diagnosis and treatment of congenital pneumonia are crucial. A new hematologic parameter, immature platelet fraction, has been used to gather clinical information on the prognosis of thrombocytopenia, as well as to measure inflammatory activity in adult patients. This study aimed to compare immature platelet fraction and sepsis biomarkers in late-preterm infants diagnosed as having congenital pneumonia and to evaluate its predictive value for congenital pneumonia.

Material and Methods:

Late-preterms were categorized based on infectious vs. non-infectious etiology of respiratory distress. Two sets of blood samples for markers were taken at 12–24 (sample-1) and 48–72 hours (sample-2) after birth. Immature platelet fraction was measured using a Sysmex XN-3000 analyzer.

Results:

From a total of 30 non-thrombocytopenic late-preterms, 16 were included in the congenital pneumonia group and 14 comprised the transient tachypnea group. The groups were comparable in terms of gestational age, birth weight, and cesarean section rate. The proportion of prolonged membrane rupture was significantly higher in the congenital pneumonia group. Values of immature platelet fraction-1, immature platelet fraction-2, and procalcitonin-2 were significantly higher in the congenital pneumonia group than in the transient tachypnea group. No significant differences were found between the groups in other biomarkers. It was determined that an immature platelet fraction-1 cut-off value of 2.9% could predict congenital pneumonia with a sensitivity of 65%, a specificity of 71.4%, a positive predictive value of 70.5%, and negative predictive value of 63.7% (area under the curve=0.724; p=0.028).

Conclusion:

Immature platelet fraction may have an early predictive role in the diagnosis of congenital pneumonia.

Emodin relieved lipopolysaccharide-evoked inflammatory damage in WI-38 cells by up-regulating taurine up-regulated gene 1

BACKGROUND

Neonatal pneumonia (NP) has a high fatality rate in neonatal illness. This research investigated the functions of emodin on lipopolysaccharide (LPS)-evoked inflammatory injury in WI-38 cells.

METHODS

Cell counting kit-8 (CCK-8) assay and flow cytometry were utilized for examining the impacts of LPS and emodin on viability and apoptosis, respectively. Taurine up-regulated gene 1 (TUG1) level was altered through cell transfection and investigated by reverse transcription quantitative polymerase chain reaction (RT-qPCR). Moreover, RT-qPCR, western blot and enzyme-linked immunosorbent assay (ELISA) were utilized for investigating expressions of monocyte chemoattractant protein-1 (MCP-1) and interleukin (IL)-6. Western blot was carried out for investigating the levels of Bcl-2, Bax, pro-Caspase-3, cleaved-Caspase-3 and NF-κB and p38MAPK pathway-related proteins.

RESULTS

LPS treatment restrained cell viability, enhanced apoptosis, and expressions of inflammation-related IL-6 and MCP-1. Emodin alleviated LPS-evoked inflammatory injury and restrained the NF-κB and p38MAPK pathways. Furthermore, emodin positively regulated TUG1 expression and TUG1 silencing could reverse the efficacy of emodin on IL-6 and MCP-1 expressions. Finally, TUG1 regulates the expression of inflammatory factors through NF-κB and p38MAPK pathways.

CONCLUSION

Emodin alleviated LPS-evoked inflammatory injury by raising TUG1 expression via NF-κB and p38MAPK pathways in WI-38 cells.

Challenging the "Culture" of the Tracheal Aspirate

The tracheal aspirate (TA) culture is commonly ordered in the NICU, but it has low sensitivity and specificity, limited by contamination. Interpretation of a TA culture out of context can lead to antibiotic overuse, which should be avoided. Clinicians should practice caution in the diagnosis of congenital pneumonia and use newer, published approaches to the diagnosis of ventilator-associated pneumonia in neonates. A subset of neonatal patients with risk factors of maternal fever or chorioamnionitis requiring intubation may benefit from TA culture performed within 12 hours after birth, to help identify an organism when blood culture may be negative, and tailor antimicrobial therapies. The more invasive, but more sensitive, technique of nonbronchoscopic bronchoalveolar lavage should be considered in older infants when bacterial isolation from the lower respiratory tract is necessary, because TA culture cannot distinguish between colonization and infection in that population.

Neonatal outcome in 29 pregnant women with COVID-19: A retrospective study in Wuhan, China

BACKGROUND

As of June 1, 2020, coronavirus disease 2019 (COVID-19) has caused more than 6,000,000 infected persons and 360,000 deaths globally. Previous studies revealed pregnant women with COVID-19 had similar clinical manifestations to nonpregnant women. However, little is known about the outcome of neonates born to infected women.

METHODS AND FINDINGS

In this retrospective study, we studied 29 pregnant women with COVID-19 infection delivered in 2 designated general hospitals in Wuhan, China between January 30 and March 10, 2020, and 30 neonates (1 set of twins). Maternal demographic characteristics, delivery course, symptoms, and laboratory tests from hospital records were extracted. Neonates were hospitalized if they had symptoms (5 cases) or their guardians agreed to a hospitalized quarantine (13 cases), whereas symptom-free neonates also could be discharged after birth and followed up through telephone (12 cases). For hospitalized neonates, laboratory test results and chest X-ray or computed tomography (CT) were extracted from hospital records. The presence of antibody of SARS-CoV-2 was assessed in the serum of 4 neonates. Among 29 pregnant COVID-19-infected women (13 confirmed and 16 clinical diagnosed), the majority had higher education (56.6%), half were employed (51.7%), and their mean age was 29 years. Fourteen women experienced mild symptoms including fever (8), cough (9), shortness of breath (3), diarrhea (2), vomiting (1), and 15 were symptom-free. Eleven of 29 women had pregnancy complications, and 27 elected to have a cesarean section delivery. Of 30 neonates, 18 were admitted to Wuhan Children's Hospital for quarantine and care, whereas the other 12 neonates discharged after birth without any symptoms and had normal follow-up. Five hospitalized neonates were diagnosed as COVID-19 infection (2 confirmed and 3 suspected). In addition, 12 of 13 other hospitalized neonates presented with radiological features for pneumonia through X-ray or CT screening, 1 with occasional cough and the others without associated symptoms. SARS-CoV-2 specific serum immunoglobulin M (IgM) and immunoglobulin G (IgG) were measured in 4 neonates and 2 were positive. The limited sample size limited statistical comparison between groups.

CONCLUSIONS

In this study, we observed COVID-19 or radiological features of pneumonia in some, but not all, neonates born to women with COVID-19 infection. These findings suggest that intrauterine or intrapartum transmission is possible and warrants clinical caution and further investigation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000031954 (Maternal and Perinatal Outcomes of Women with coronavirus disease 2019 (COVID-19): a multicenter retrospective cohort study).

Perinatal Antibiotic Exposure Affects the Transmission between Maternal and Neonatal Microbiota and Is Associated with Early-Onset Sepsis

Perinatal antibiotic prophylaxis is an effective method for preventing group B Streptococcus (GBS) infection in newborns. Antibiotic exposure unbalances women’s vaginal microbiota, which is associated with the establishment of the newborn gut microbiota. However, the influence of perinatal antibiotic exposure on neonatal gut microbiota colonization and health outcomes remains unclear. In this study, we found that perinatal antibiotic exposure induced microbiota dysbiosis in a woman’s vagina and the neonatal gut, and we highlight a significant decrease in the abundance of Lactobacillus spp. The influence of antibiotic use on the microbiota was greater than that from gestational age. Additionally, full-term newborns without antibiotic exposure had no evidence of early-onset sepsis, whereas in full-term or preterm newborns with antibiotic exposure before birth, at least one infant was diagnosed with early-onset sepsis. These results suggest an association between perinatal antibiotic exposure and microbial dysbiosis in maternal vaginal and neonatal gut environments, which may be related to the occurrence of early-onset sepsis.

Intrapartum antibiotic prophylaxis reduces the risk of infection to a mother and neonate, but antibiotic-mediated maternal and neonatal microbiota dysbiosis increases other health risks to newborn infants. We studied the impact of perinatal antibiotic prophylaxis on the microbiota in mothers and newborns with full-term or preterm delivery. Ninety-eight pregnant women and their neonates were divided into the following four groups: full term without antibiotic exposure (FT), full term with antibiotic exposure (FTA), preterm without antibiotic exposure (PT), and preterm with antibiotic exposure (PTA). Bacterial composition was analyzed by sequencing the 16S rRNA gene from maternal vaginal swabs (V) and neonatal meconium (F). The results showed that in maternal vaginal and neonatal meconium microbiota, FT and PT groups had a higher load of Lactobacillus spp. than did the FTA and PTA groups. In addition, whether in the mother or newborn, the dissimilarity in microbiota between FT and PT was the lowest compared to that between other groups. Compared to the FT and PT groups, the dissimilarity in microbial structures between the vagina and meconium decreased in the FTA and PTA groups. The health outcome of infants reveals an association between early-onset sepsis and antibiotic-mediated microbiota dysbiosis. In conclusion, perinatal antibiotic exposure is related to the establishment of gut microbiota and health risks in newborns. Promoting the rational usage of antibiotics with pregnant women will improve neonatal health.

IMPORTANCE Perinatal antibiotic prophylaxis is an effective method for preventing group B Streptococcus (GBS) infection in newborns. Antibiotic exposure unbalances women’s vaginal microbiota, which is associated with the establishment of the newborn gut microbiota. However, the influence of perinatal antibiotic exposure on neonatal gut microbiota colonization and health outcomes remains unclear. In this study, we found that perinatal antibiotic exposure induced microbiota dysbiosis in a woman’s vagina and the neonatal gut, and we highlight a significant decrease in the abundance of Lactobacillus spp. The influence of antibiotic use on the microbiota was greater than that from gestational age. Additionally, full-term newborns without antibiotic exposure had no evidence of early-onset sepsis, whereas in full-term or preterm newborns with antibiotic exposure before birth, at least one infant was diagnosed with early-onset sepsis. These results suggest an association between perinatal antibiotic exposure and microbial dysbiosis in maternal vaginal and neonatal gut environments, which may be related to the occurrence of early-onset sepsis.

Maternal hypertension, preeclampsia, and risk of neonatal respiratory disorders in a large-prospective cohort study

BACKGROUND

Possible impact of maternal hypertension and preeclampsia on neonatal respiratory disorders was unknown. We investigated the association of maternal hypertension and preeclampsia with neonatal respiratory disorders in preterm and full-term newborns.

METHOD

In this study, we used a large Chinese population-based study which includes 185,687 singleton livebirths with gestational weeks between 28 and 42 weeks. The "exposure" was maternal hypertension and preeclampsia. The outcome was neonatal respiratory disorders including neonatal respiratory distress syndrome (NRDS), pneumonia and low Apgar scores. Logistic regression was used to examine the association between the maternal hypertensive disorders and the risk for neonatal respiratory disorders. We further evaluated the association in preterm and full-term infants.

RESULTS

As a result, the incidence of neonatal RDS, pneumonia, and low Apgar score in hypertensive group was higher than that in normotensive group. Preeclampsia was associated with RDS [(adjusted relative risk (aRR): 1.85, 95% confidence interval (CI): 1.22-3.05)]. Both maternal hypertension and preeclampsia increased risks for neonatal pneumonia (aRR: 1.79, 95%CI: 1.48-2.17; aRR: 1.81, 95%CI: 1.36-2.40, respectively), for low Apgar score at 1 min (aRR: 1.20, 95%CI: 1.13-1.27; aRR: 1.53, 95%CI: 1.41-1.67, respectively), and for low Apgar score at 5 min (aRR: 1.30, 95%CI: 1.17-1.45; aRR: 1.70, 95%CI: 1.46-1.99, respectively). The risk for neonatal respiratory disorders increased with severity of maternal hypertension. The observed associations were present in both full-term and preterm birth.

CONCLUSION

Maternal hypertension and preeclampsia are risk factors for neonatal respiratory disorders in full-term and preterm newborns.

Long noncoding RNA MIAT2 alleviates lipopolysaccharide-induced inflammatory damage in WI-38 cells by sponging microRNA-15

Neonatal pneumonia is a high neonatal mortality disease. We studied the function and mechanism of long noncoding RNA myocardial infarction-associated transcript 2 (lncRNA MIAT2) on lipopolysaccharide (LPS)-induced inflammation in WI-38 cells. Cell Counting Kit-8 and apoptosis assay were respectively used to detect the functions of LPS, MIAT2, and microRNA-15 (miR-15) on viability and apoptosis. MIAT2 and miR-15 expressions were changed by cell transfection. Moreover, reverse transcription-quantitative polymerase chain reaction (RT-qPCR), western blot, and enzyme-linked immunosorbent assay were used to detect the expressions of interleukin (IL)-6 and monocyte chemoattractant protein-1 (MCP-1). The levels of Bax, cleaved-caspase-3, and cell pathways-related proteins were tested by western blot. Besides, the levels of miR-15 and MIAT2 were tested by RT-qPCR. We found that LPS declined cell viability and heightened apoptosis and levels of Bax, cleaved-caspase-3, IL-6, and MCP-1. MIAT2 was negatively regulated by LPS and it alleviated LPS-induced damage. Furthermore, MIAT2 reversely regulated miR-15 and miR-15 mimic could reverse the effects of MIAT2. Finally, MIAT2 restrained the p38MAPK and NF-κB pathways by downregulating miR-15. In conclusion, MIAT2 alleviated LPS-induced inflammation damage in WI-38 cells by sponging miR-15 via p38MAPK and NF-κB pathways.

Neonatal neuroblastoma presented with respiratory distress, a case report

Background

The most common neonatal tumor is neuroblastoma and adrenal gland is the most common site of involvement. 11-26% of this tumor is seen in the thorax of neonates. Due to a similar appearance of the mediastinal tumor with pneumonia, a high index of suspicion is necessary for early diagnosis of this disorder.

Case report

A 17-day -old female and term neonate delivered by caesarian section was reported in the study. The mother had a normal pregnancy without any reported complications. The newborn admitted to a neonatal intensive care unit (NICU) in her hometown, because of respiratory distress, stridor, and tachypnea which was started from 7 days of life and due to lack of recovery and persistent respiratory symptoms, the patient referred to our hospital. In chest X-ray, opacity in the right upper lobe of the lung was seen. In barium study, a mass like lesion in the size of 35.34 mm adjacent to upper intra-thoracic esophagus with mild mass effect was observed and in CTS a posterior mediastinal mass with severe compression on the trachea and extension to the spinal canal was reported. Due to severe obstruction on the airway, the baby underwent emergency surgery and a mediastinal mass with adhesion and involvement of the ribs and spinal cord was resected. The final diagnosis of poorly differentiated neuroblastoma was confirmed by biopsy.

Conclusion

In every neonate with persistent respiratory distress, stridor and abnormal chest X-ray, diagnosis of neonatal neuroblastoma should be considered.

High Neutrophil-to-Lymphocyte Ratio Is an Early Predictor of Bronchopulmonary Dysplasia

Background and Objective: Bronchopulmonary dysplasia (BPD) is a common complication in preterm infants; predicting the degree of BPD at an early life stage is difficult. Inflammation is a crucial risk factor for BPD pathogenesis, and the neutrophil-to-lymphocyte ratio (NLR) is a potential systemic inflammatory biomarker. We aimed to assess the predictive value of the NLR for BPD. Methods: We carried out a retrospective, single-center, observational study of neonates with gestational ages (GAs) <32 weeks and assessed the association between the NLR and BPD. Results: The study population included 296 preterm infants with BPD (n = 144) or without BPD (n = 152). Among the infants, 75 (25.3%) had mild BPD, 37 (12.5%) had moderate BPD, and 32 (10.8%) had severe BPD. The BPD group had a higher NLR at birth and at 72 h than the non-BPD group. The NLR cutoff value at 72 h for the prediction of BPD was 3.035 (sensitivity = 0.519, specificity = 0.964), and the area under the curve (AUC) was 0.714. The NLR cutoff value at 72 h for predicting severe BPD was 3.105 (sensitivity = 0.607, specificity = 0.819), with an AUC of 0.756. At the NLR cutoff value at 72 for the prediction of BPD, the AUCs were 0.640 and 0.970 in the preterm infants with EOS and congenital pneumonia, respectively. Conclusions: The NLR is an inexpensive, accessible and convenient tool; an increase in the NLR at 72 h could be an early predictor of BPD, especially severe BPD. Additionally, the NLR at 72 h could be a predictor of BPD in preterm infants with intrauterine infections.

TLR Activation Alters Bone Marrow-Derived Macrophage Differentiation

Early exposure to inflammatory signals may have a lasting impact on immune function. Present throughout embryogenesis, macrophages are key cells providing innate immune protection to the developing fetus and newborn. Here, we have used an established model of macrophage development to test how early inflammatory signals can impact cellular differentiation and function. Bone marrow-derived macrophages were treated with Escherichia coli lipopolysaccharide (LPS) 2 days after initial isolation and culture. LPS treatment during this early stage of differentiation decreased the expression of CSF1R and increased that of the mature macrophage marker F4/80. These early changes in macrophage differentiation were also measured in cells from mice lacking IKKβ, but the change in CSF1R expression after LPS treatment was blocked with MAPK inhibition. LPS-induced changes in macrophage marker expression persisted following LPS removal, suggesting that early inflammatory activation could induce a lasting developmental impact. Early LPS exposure inhibited macrophage phagocytosis of labeled E. coli while LPS had no effect on fully differentiated macrophages. Our data demonstrate that early inflammatory exposure to a microbial stimulus induce lasting phenotypic changes in macrophages.

Cell Count Analysis from Nonbronchoscopic Bronchoalveolar Lavage in Preterm Infants

OBJECTIVES

To establish the reference values, diagnostic accuracy, and effect of various factors on cell count in intubated preterm neonates subjected to nonbronchoscopic bronchoalveolar lavage.

STUDY DESIGN

This prospective, cross-sectional, blinded study included preterm neonates ventilated for any reason who underwent nonbronchoscopic bronchoalveolar lavage if they had not previously received postnatal antibiotics or steroids. Lavage was performed before surfactant replacement, if any. A gentle ventilation policy was applied. Pneumonia was diagnosed using clinical criteria, without considering cell count. Investigators performing cell counts were blinded to the clinical data.

RESULTS

There were 276 neonates enrolled; 36 had congenital or ventilator-associated pneumonia. In the 240 noninfected babies, median neutrophil count increased significantly after the first 2 days of ventilation (day 1, 2 cells per field [IQR, 0.0-9.5 cells per field]; day 2, 2 cells per field [IQR, 0-15 cells per field]; day 3, 20 cells per field [IQR, 2-99 cells per field]; day 4, 15 cells per field [IQR, 2-96 cells per field]; P < .0001). No significant difference was seen over time in infected babies. Multivariate analysis indicated pneumonia (standardized β = 0.134; P = .033) and the time spent under mechanical ventilation before nonbronchoscopic bronchoalveolar lavage as factors significantly influencing neutrophil count (standardized β = 0.143; P = .027). Neutrophil count was correlated with the duration of ventilation (rho = 0.28; P <.001). Neutrophil counts were higher in infected (24 cells/field [IQR, 5-78] cells/field) than in noninfected babies (4 cells/field [IQR, 1-24 cells/field]; P <.001) and had an moderate reliability for pneumonia within the first 2 days of ventilation (area under the curve, 0.745; (95% CI, 0.672-0.810; P = .002).

CONCLUSIONS

We provide reference values for airway neutrophil counts in ventilated preterm neonates. Bronchoalveolar lavage neutrophils significantly increase after 2 days of ventilation. Neutrophil count has moderate accuracy to diagnose pneumonia, but only within the first 2 days of ventilation.

Etiologic and Pathogenic Perinatal Factors for the Development of Intrauterine Infections in Newborns (Review)

For many decades, the world community’s efforts have been aimed at reducing the neonatal and infant mortality from intrauterine infections. In 1990, the United Nations and the World Health Organization set out the priority of decreasing children mortality by 2015 году. In spite of impressive success in newborn treatment, mortality due to sepsis decreases slowly; when survive, postnatal children develop central nervous system impairments of different level of severity. In the recent decade, new data have emerged concerning the methods of intrauterine infections prophylaxis, diagnosis, and treatment. The purpose of the review is to present data concerning specifics of pregnancy course when infections develop, contemporary diagnostic methods including studies of interleukins, placenta morphology, allelic genes, and to reflect the current approach to the treatment of intrauterine infections in newborns. 

Ultrasound in neonatal lung disease

Lung diseases in neonates can be life-threatening condition and may result in respiratory failure and death. Chest X-ray is a traditional diagnostic technique that results in radiation exposure to patients. Lung ultrasound is a user-friendly imaging technique that has been increasingly used in clinical practice in recent years and presents the advantages of real-time imaging and without radiation. Here we review the sonographic appearances of common neonatal lung diseases and present demonstration of typical cases.

Epidemiology, microbiology, and treatment patterns of pediatric patients hospitalized with pneumonia at two hospitals in China: a patient chart review study

Background

The etiology, epidemiology, treatment patterns, and clinical outcomes of neonatal and pediatric pneumonia patients in China are not well reported. This retrospective chart review study aimed to describe such information among neonatal (0 to 27 days) and pediatric (28 days to <18 years) pneumonia patients in two regions of China.

Methods

Electronic medical records of pneumonia hospitalizations (aged <18 years) admitted between 2008 and 2013 from four hospitals under Guangdong Provincial Hospital of Chinese Medicine (Southern China) and between 2010 and 2014 at Peking University People's Hospital (Beijing, Northern China) were reviewed.

Results

The average age of neonatal hospitalizations in Beijing (n=92) was 3.5 days. The mean length of hospital stay was 11.2 days, and no deaths occurred. Staphylococcus epidermidis was the most common bacteria found in Beijing patients, whereas Mycoplasma pneumoniae was the most common bacteria found in Guangdong patients. The average age of pediatric hospitalizations was 3.3 (±3.1) and 6.5 (±5.6) years in Guangdong (n=3,046) and Beijing (n=222), respectively. The mean length of hospital stay was 17.4 and 5.8 days, and overall mortality rates were 0.2% and 0.5%.

Conclusion

The findings revealed a low level of bacterial isolation and hence microbiological diagnoses. There was a low level of in-hospital mortality due to pneumonia, and the majority of hospitalizations were discharged from hospital, suggesting that current practice was generally effective. Neonatal hospitalizations were greater than pediatric hospitalizations in Beijing along with disparity in bacterial profile when compared with Guangdong, intending a need to improve neonatal pneumonia prophylaxis and selection of appropriate treatment.

Seroprevalence of anti-Chlamydia trachomatis IgM in neonatal respiratory tract infections in Hungary

Purpose. To determine the seroprevalence of specific IgM indicative of respiratory tract infection (RTI) due to Chlamydia trachomatis (CT) among symptomatic infants.Methodology. A descriptive study was conducted on young infants up to 5 months old at the Bacterial Sexually Transmitted Infections Reference Laboratory, National Centre for Epidemiology, Budapest, covering the period 2008-2016. Serum samples from infants suffering from RTIs were screened with a micro-immunofluorescence test (Focus, Cypress, USA) for the presence of anti-Chlamydia trachomatis-specific IgM. A parallel Bordetella pertussis screening was performed by an indirect immunofluorescence test (Euroimmun, Lübeck, Germany) that detected specific IgM.Results.The CT-specific serum IgM was highly reactive in 50 (19.1 %) of the 262 neonates with RTIs, while all proved negative for Bordetella pertussis-specific IgM.Conclusion. Vertically transmitted C. trachomatis must be regarded as a common pathogen among symptomatic neonates with RTIs in Hungary. Routine screening and treatment of pregnant women could be one option to help prevent these conditions. Focused laboratory testing based on raised clinical awareness should enable early diagnosis and appropriate therapy for symptomatic infants.

Surfactant Therapy for Early Onset Pneumonia in Late Preterm and Term Neonates Needing Mechanical Ventilation

INTRODUCTION

Pathophysiology of pneumonia involves leakage of plasma proteins into the airways and accumulation of cytokines within the lung. Several in vitro and in vivo studies have demonstrated that this proteinaceous material and lung inflammation inhibit surfactant function.

AIM

To evaluate whether exogenous surfactant therapy improves oxygenation and gas exchange in late preterm and term neonates with early onset pneumonia and respiratory failure.

MATERIALS AND METHODS

This prospective interventional cohort study was conducted at a tertiary care neonatal unit. Twenty four late preterm and term neonates with early onset pneumonia requiring mechanical ventilation for respiratory failure were included and received surfactant therapy. Oxygenation index, arterial/alveolar PO₂ (a/A ratio), mean airway pressure and fraction of inspired oxygen were calculated from arterial blood gases obtained before and after surfactant therapy. Wilcoxon signed rank sum test was used for assessment of change in oxygenation variables 12 hours after surfactant therapy. Data regarding clinical outcomes and complications were collected and analysed.

RESULTS

Just over half (54.2%) of the study neonates were of term gestation. After surfactant therapy, the median Oxygenation Index (OI) decreased from 11.15 to 3.7 at one hour and the change was sustained and significant at 12 hours (p<0.05). The median a/A PO₂ ratio improved from 0.09 to 0.3 within one hour of surfactant replacement and the improvement was significant at 12 hours (p<0.01). Twenty two neonates (92%) survived to discharge. Median duration of hospital stay was 15 days.

CONCLUSION

Significant and rapid improvement in oxygenation in late preterm and term neonates with early onset pneumonia was seen after surfactant therapy, which is sustained for a longer period. There could be a substantial role for the use of surfactant in early onset pneumonia, although larger controlled trials are needed before definite recommendations can be made.

Morbidity and mortality of preterm infants less than 26 weeks of gestational age

BACKGROUND

Extreme preterm infants have a high risk of morbidity and mortality. Newborns delivered between 23+0 and 25+6 weeks, are considered to be in the "gray zone" and have uncertain prognosis. For these children medical decision-making becomes complex and controversial. The present study intends to evaluate the neonatal morbidity and mortality of preterm infants born between 23 weeks and 25+6 weeks of gestational age.

METHODS

A retrospective study was conducted including all inborn preterm infants, with a gestational age between 23+0 and 25+6 weeks, admitted to a level IIIC NICU, between January 1st, 1996 and December 31st, 2014.

RESULTS

A total of 72 preterm neonates were included, 18.1% had a full cycle of antenatal steroids. The most frequent major morbidities were RDS (95.4%), patent ductus arteriosus (81.3%), sepsis (55.7%, being 19.7% early sepsis, and 36.1% late sepsis), intraventricular hemorrhage (34.4%), retinopathy of prematurity (21.9%) and necrotizing enterocolitis (10.9%). Fifty-four (75%) children died. The only factor adjusted to age associated with high mortality founded was hypotension (OR=4.99, P<0.019). Morbidity at discharge was: severe bronchopulmonary dysplasia (77.8%), retinopathy of prematurity (72.2%), intraventricular hemorrhage (16.7%), cystic periventricular leukomalacia (11.1%), and sequalae of necrotizing enterocolitis (5.6%).

CONCLUSIONS

The survival rate was 25% and a high morbidity at discharge was observed, which leave us with the huge responsibility to improve this result in a near future. Extreme prematurity is still a very controversial and complex issue and particular challenge for neonatologists. The use of antenatal steroid in the more immature preterm infants should be encouraged.

IL-1β and Inflammasome Activity Link Inflammation to Abnormal Fetal Airway Development

Inflammation in the developing preterm lung leads to disrupted airway morphogenesis and chronic lung disease in human neonates. However, the molecular mechanisms linking inflammation and the pathways controlling airway morphogenesis remain unclear. In this article, we show that IL-1β released by activated fetal lung macrophages is the key inflammatory mediator that disrupts airway morphogenesis. In mouse lung explants, blocking IL-1β expression, posttranslational processing, and signaling protected the formation of new airways from the inhibitory effects ofEscherichia coliLPS. Consistent with a critical role for IL-1β, mice expressing a gain-of-functionNlrp3allele and subsequent overactive inflammasome activity displayed abnormal saccular-stage lung morphogenesis and died soon after birth. Although the early-stage fetal lung appeared capable of mounting an NF-κB-mediated immune response, airway formation became more sensitive to inflammation later in development. This period of susceptibility coincided with higher expression of multiple inflammasome components that could increase the ability to release bioactive IL-1β. Macrophages fromNlrp3gain-of-function mice also expressed higher levels of more mature cell surface markers, additionally linking inflammasome activation with macrophage maturation. These data identify developmental expression of the inflammasome and IL-1β release by fetal lung macrophages as key mechanisms and potential therapeutic targets for neonatal lung disease.

Common respiratory conditions of the newborn

KEY POINTS

Respiratory distress is a common presenting feature among newborn infants.Prompt investigation to ascertain the underlying diagnosis and appropriate subsequent management is important to improve outcomes.Many of the underlying causes of respiratory distress in a newborn are unique to this age group.A chest radiograph is crucial to assist in diagnosis of an underlying cause.

EDUCATIONAL AIMS

To inform readers of the common respiratory problems encountered in neonatology and the evidence-based management of these conditions.To enable readers to develop a framework for diagnosis of an infant with respiratory distress. The first hours and days of life are of crucial importance for the newborn infant as the infant adapts to the extra-uterine environment. The newborn infant is vulnerable to a range of respiratory diseases, many unique to this period of early life as the developing fluid-filled fetal lungs adapt to the extrauterine environment. The clinical signs of respiratory distress are important to recognise and further investigate, to identify the underlying cause. The epidemiology, diagnostic features and management of common neonatal respiratory conditions are covered in this review article aimed at all healthcare professionals who come into contact with newborn infants.

Evaluation of the maternal and fetal risk factors associated with neonatal care unit hospitalization time

OBJECTIVE

To evaluate maternal and neonatal risk factors associated with the length of hospital stay in the neonatal intensive care unit (NICU).

MATERIAL AND METHOD

This retrospective observational study was based on 3607 newborns who were admitted to the NICU of a tertiary teaching hospital from January 2012 through December 2014. Known obstetric risk factors associated with duration of hospitalization in NICUs were assessed including intrauterine growth restriction, maternal diabetes, oligohydramnios, chorioamnionitis, premeture rupture of membranes, preeclampsia, congenital malformations, neonatal sepsis, premature retinopathy, intracranial bleeding, necrotizing enterocolitis, meconium aspiration, maternal hypertension, fetal congenital cardiac malformations, congenital metabolic diseases, congenital hypothyroidism, pneumonia, pulmonary hypertension, bronchopulmonary dysplasia, pneumothorax and respiratory distress syndrome.

RESULTS

Gestational age (beta coefficient: -0.244, p<0.001) and birth weight (beta coefficient: -0.237, p<0.001) were significant confounders for duration of hospitalization in newborns.

CONCLUSION

Gestational age and the birth weight were the most important confounders for duration of hospitalization. Neonate care in developing countries would further benefit from additional large population-based long-term studies with broad parameters.

Role of presepsin in the diagnosis of late-onset neonatal sepsis in preterm infants

OBJECTIVE

One of the most challenging aspects in the management of neonates with late-onset neonatal sepsis (LOS) is to make the diagnosis. Presepsin is a novel and promising marker of sepsis. The aim of this study was to assess the role of presepsin in the diagnosis of LOS in preterm infants.

METHODS

Forty-two premature newborns ≤32 weeks gestational age with a diagnosis of LOS were prospectively involved in the study. Forty gestational and postnatal age-matched infants without sepsis served as controls. Levels of presepsin, C-reactive protein, and procalcitonin were measured at enrollment and on the third and seventh days of sepsis.

RESULTS

Initial presepsin levels in the LOS group were significantly higher than in the control group (1024 pg/mL, min-max: 295-8202; versus 530 pg/mL, min-max: 190-782; p < 0.0001). The area under the receiver-operating curve for presepsin was 0.864. A presepsin value of 800.5 pg/mL was established as a cut-off value, with 67% sensitivity and 100% specificity. Presepsin levels gradually decreased during treatment.

CONCLUSION

Presepsin can be used as a reliable biomarker for LOS and treatment response in preterm infants. However, we could not demonstrate the efficacy of presepsin for the detection of disease severity or prognosis.

Correlation between serum levels of C-reactive protein and infant pneumonia: A meta-analysis

Experimental data imply that serum C-reactive protein (CRP) is a marker of general systemic inflammation, and inflammation may have a role in the development of pneumonia. The aim of the present study was to investigate the associations of serum CRP levels in infant patients with pneumonia by meta-analysis. The Science Citation Index, Cochrane Library, PubMed, Embase, CINAHL, Current Contents and two Chinese (CMB and CNKI) databases were searched. Studies were pooled and standard mean difference (SMD) and the corresponding 95% confidence interval (CI) were calculated. Subgroup analyses and publication bias detection were also conducted. The statistical analysis was conducted using Stata software version 12.0. Serum CRP levels were analyzed in 10 clinical case-control studies (652 infants with pneumonia and 845 healthy controls); significant differences in serum CRP levels were observed between infants with pneumonia and the healthy controls (SMD=4.41, 95% CI: 3.34-5.47, P<0.001). Ethnicity-stratified subgroup analysis detected that high levels of serum CRP may be the main risk factor for infant pneumonia in Asian, African and Caucasian populations (all P<0.05). Serum CRP levels were statistically higher in infants with pneumonia than in healthy infants, and thus serum levels of CRP may have independent diagnostic value for pneumonia in children.

Acute Neonatal Respiratory Failure

Acute respiratory failure requiring assisted ventilation is one of the most common reasons for admission to the neonatal intensive care unit. Respiratory failure is the inability to maintain either normal delivery of oxygen to the tissues or normal removal of carbon dioxide from the tissues. It occurs when there is an imbalance between the respiratory workload and ventilatory strength and endurance. Definitions are somewhat arbitrary but suggested laboratory criteria for respiratory failure include two or more of the following: PaCO₂ > 60 mmHg, PaO₂ < 50 mmHg or O₂ saturation <80 % with an FiO₂ of 1.0 and pH < 7.25 (Wen et al. 2004).