Comparative Outcomes of Levetiracetam and Phenobarbital Usage in the Treatment of Neonatal Seizures: A Retrospective Analysis

OBJECTIVES AND AIM

The primary aim of this study was to conduct a comparative analysis of the safety and efficacy of levetiracetam (LEV) and phenobarbital (PB) as first-line treatments for neonatal seizure management. This study was designed to measure and compare the incidence of adverse effects and to determine the discharge and mortality rates associated with the use of these antiseizure medications (ASMs). Through this comparison, this research sought to provide insights to optimise care for neonates experiencing seizures.

MATERIALS AND METHODS

This retrospective cohort study evaluated 104 neonates treated for seizures at Zeynep Kamil Hospital from 2015 to 2020 after excluding those on non-PB/LEV antiseizure medications. Seizures were characterised using electroencephalogram (EEG) and categorised according to aetiology and frequency. Treatment efficacy was gauged by seizure cessation, as confirmed using EEG. Adverse effects and demographic data were recorded. Statistical analyses were conducted using SPSS, employing the Shapiro-Wilk, independent t-test, Mann-Whitney U test, and chi-square test, with a significance threshold of p < 0.05.

RESULTS

Overall, 104 neonates treated with first-line ASM were evaluated for efficacy; PB was administered in 68.26% of the cases, while LEV was utilised in 31.74%. The total complete response rate was 40.38%, with no significant difference between the PB and LEV groups (p = 0.309). The incidence rate ratios (IRRs) demonstrated that seizure frequency profoundly influenced treatment effectiveness, with IRRs of 2.09 for rare seizures, 3.25 for frequent seizures, and 4.01 for status epilepticus, indicating a higher treatment response rate with increasing seizure frequency. For second-line treatment, among a subset of 62 patients, PB had a slight, non-significant advantage over LEV, with an odds ratio of 1.09, suggesting a marginally better response to LEV. Adverse events were significantly more frequent in the PB group, affecting 19 of 67 neonates (28.36%), compared to only 2 of 71 neonates (2.82%) in the LEV group (p < 0.001). No significant difference was observed in the discharge rates between the two groups (PB, 67.61%; LEV, 75.76%; p = 0.674). Interestingly, the mortality rate was significantly higher in the LEV group (45.45%) than that in the PB group (22.54%; p = 0.045).

CONCLUSION

This study underscores LEV's superior safety profile over PB in neonatal seizure management, evidenced by a significantly lower rate of adverse events. PB seems to be more effective in the second-line treatment of neonatal seizures. Despite the lack of significant differences in the discharge rates, the higher mortality rate associated with LEV warrants further investigation. These findings advocate the cautious selection of antiepileptic drugs in neonatal care, with a preference for LEV based on its safety profile.

Acute Kidney Injury in Neonatal Hypoxic-Ischemic Encephalopathy Patients Treated with Therapeutic Hypothermia: Incidence and Risk Factors

Studies in infants with hypoxic-ischemic encephalopathy (HIE) due to perinatal asphyxia have generally focused on neurological outcomes. Although acute kidney injury (AKI) rate decreased in advent of therapeutic hypothermia (TH), it is still a common and important entity. In this retrospective study, we aimed to investigate the risk factors for AKI in HIE patients treated with hypothermia. Infants treated with TH due to HIE were reviewed retrospectively and infants who developed AKI and not were compared. Ninety-six patients were enrolled in the study. AKI developed in 27 (28%) patients and 4 (14.8%) of them were stage III AKI. In the AKI group, gestational age of the patients was significantly higher (p = 0.035), the 1st minute Apgar score was significantly lower (p = 0.042), and convulsions (p = 0.002), amplitude-integrated electroencephalography disorders (p = 0.025), sepsis (p = 0.017), need for inotropic therapy (p = 0.001), need of invasive mechanical ventilation (p = 0.03), and systolic dysfunction in echocardiography (p = 0.022) were significantly higher. In logistic regression tests, Apgar score at the 1st minute was found to be independent risk factor for developing AKI. AKI has the potential to worsen the neurological damage and correlates with morbidities of perinatal asphyxia. It is important to determine the incidence and risk factors for developing AKI in this delicate group of patients to prevent further renal damage.

Neonatal Lymphatic Flow Disorder

OBJECTIVE

To examine and discuss patients diagnosed with acquired and congenital chylothorax in the neonatal period in the light of the literature.

METHODS

The files of newborns followed-up in the neonatal intensive care unit (NICU) and diagnosed with congenital and acquired chylothorax were reviewed retrospectively. Patients with isolated chylothorax were classified as Group 1 and those with multiple lymphatic flow disorders were classified as Group 2. Antenatal and clinical features were recorded and compared between the groups.

RESULTS

Thirteen infants were diagnosed with chylothorax; 92.3% (n = 12) of the patients were congenital. The rate of antenatal diagnosis was 61.5% (n = 8). Eight patients (61.5%) were diagnosed with hydrops fetalis. Among the cases in Group 1 and Group 2, receiving ocreotide and the incidence of sepsis (p = 0.05) were partially significant. Seven of the patients (66.6%) responded to medium chain triglycerides (MCT), and complete resolution was seen in 6 (85.7%) of the responders. Complete resolution of chylothorax fluid was observed in 7 (77.7%) of nine patients who responded to ocreotide treatment.

CONCLUSIONS

In neonatal chylothorax, the postnatal period includes a multidisciplinary approach that requires drug therapy, dietary modifications, drainage of pleural fluid, and rarely, surgery.

Ultrasonography Causes Agitation and Pain Leading to Hemodynamic Disturbance in Neonates: A Prospective Observational Study

BACKGROUND

Ultrasonography is widely used in neonatological practice and studies investigating the hemodynamic effects of various treatment protocols or clinical situations. On the other hand, pain causes changes in the cardiovascular system; so, in the case of ultrasonography leading to pain in neonates, it may cause hemodynamic alterations. In this prospective study, we evaluate whether ultrasonographic application causes pain and changes in the hemodynamic system.

METHODS

Newborns undergoing ultrasonographic examination were enrolled in the study. Vital signs, cerebral and mesenteric tissue oxygenation (StO₂) levels, and middle cerebral artery (MCA) Doppler measurements were recorded, and NPASS scores were calculated before and after ultrasonography.

RESULTS

We enrolled 39 patients in the study. After ultrasonography, Neonatal Pain, Agitation, and Sedation Scale (NPASS) scores were significantly higher (p < 0.01), and all vital signs (heart rate, respiratory rate, SpO₂, diastolic and systolic blood pressure; p = 0.03; p < 0.01, p < 0.01, p < 0.01, p = 0.02, p = 0.03, respectively) were altered. Cerebral (p = 0.008) and mesenteric (p = 0.039) StO₂ levels were significantly lower in the whole study group, MCA end-diastolic velocity decreased (p = 0.02), and the resistive index (p = 0.03) increased in patients whose NPASS score was >7 after ultrasonography.

CONCLUSIONS

This study is the first to show that ultrasonography may cause pain in newborn patients, and alters vital signs and hemodynamic parameters. Therefore, precautions should be taken to protect newborn babies from pain during ultrasound applications, as they are already exposed to many noxious stimuli. Furthermore, pain scores should be considered in studies using ultrasonography and evaluating hemodynamic parameters to increase the reliability of the studies.

Ultrasonography for Determining Endotracheal Tube Tip Position in Very Low Birth Weight Infants

OBJECTIVE

This study aims to investigate the feasibility of USG in confirming the endotracheal tube site and compare it with chest X-rays in very low birth weight infants.

METHODS

A chest X-ray and thorax ultrasonography processes are started as soon as the infant is intubated. Endotracheal tube place is evaluated with ultrasonography and noted, and with chest X-ray and time elapsed in these two processes are noted. The correlation between these two methods was calculated.

RESULTS

While endotracheal tubes are visualized with 100% success, there was a significant correlation between the measures of endotracheal tube-carina distances (r = .979, P > .001). In addition, ultrasonography was six times faster than chest X-ray interpretation (USG; 4.6 ± 1.8 min vs CXR; 29.6 ± 9.0 min, P < .001).

CONCLUSIONS

Ultrasonography is a feasible and faster method for determining endotracheal tube place in very low birth weight infants and may prevent radiation exposure in neonatal intensive care units.

Early Hemodynamic Effects of Mydriatic Eye Drops in Preterm Infants

OBJECTIVE

 Mydriatic eye drops used for retinopathy of prematurity (ROP) examination can cause systemic effects, and there are case reports of serious adverse effects in the literature. In this prospective study, we aimed to evaluate the early hemodynamic effects of mydriatic eye drops to understand the possible mechanisms of adverse effects.

STUDY DESIGN

 Between December 2018 and March 2019, preterm babies less than 32 gestational weeks and who underwent ophthalmologic examination in our unit were included. The vital signs (heart rate, respiratory rate, oxygen saturation [SpO2], and blood pressure values), cerebral and mesenteric tissue saturation by near-infrared spectroscopy (NIRS), and left ventricular functions of infants were recorded before and after applying mydriatic eye drops (2.5% phenylephrine and 0.5% tropicamide). The data were compared statistically. Strict adherence to prevent systemic absorption of the eye drops was applied.

RESULTS

 Thirty-two mydriasis procedures were evaluated in 26 patients. The mean gestational age was 28.5 ± 1.7 weeks, and the mean birth weight was 943 ± 233 g. There were no significant differences in terms of vital signs of infants including heart rate, blood pressure, and oxygen saturation [SpO2] levels before and after eye-drop application. In addition, NIRS values showed no significant differences between before and after measurements. No significant differences were detected at echocardiographic evaluation performed before and after mydriatic administration. No adverse reaction was observed in the study population during the study.

CONCLUSION

 This is the first study that evaluated the early hemodynamic effects of mydriatic eye drops used for ROP screening by vital signs, NIRS, and echocardiographic evaluation. Mydriatic eye drops have no significant effect on early hemodynamic parameters including vital signs, NIRS, and echocardiographic findings in preterm infants. We suggest that a cautious approach for avoiding the systemic absorption of these agents may prevent the possible early systemic effects in this high-risk population.

KEY POINTS

· Mydriatic eye drops are commonly used for pupil dilatation before retinopathy of prematurity examination, and there are reports of serious adverse events caused by these drops.. · Due to the adverse events of eye drops, hemodynamic effects of these agents were investigated by clinical findings, near-infrared spectroscopy, and echocardiography.. · No significant early hemodynamic effect was observed so avoiding systemic effects may be prevented with precautions..

Inflammation Markers in Infants of Mothers with Gestational Diabetes

AimPentraxin-3, high sensitive CRP (HsCRP) and adropin were investigated in cord blood of infants of mothers with gestational diabetes mellitus (IDM) to evaluate the exposure of fetus to inflammation and whether there is any correlation with clinical findings.MethodsForty IDM and forty three infants whose mother did not have diabetes were included in this prospective study. Adropin, pentraxin-3 and HsCRP levels were measured in the cord blood samples. Echocardiographic measurements were performed in the first three days of life.ResultsAdropin and pentraxine-3 levels were significantly lower and HsCRP levels were significantly higher in IDM group. Echocardiographic measurements of myocardial hypertrophy were negatively correlated with adropin.ConclusionAlterations in these markers in IDM supports the hypothesis of in utero fetal exposure to inflammation caused by gestational diabetes mellitus. Potentially, cord blood adropin might be used as a predictor for complications of diabetes.

Factors Associated with the Transition Time to Full Enteral Feeding in Newborns with Hypoxic Ischemic Encephalopathy

BACKGROUND

We aimed to assess the factors associated with the transition time to full enteral feeding (FEF) in newborns with hypoxic ischemic encephalopathy (HIE) undergoing therapeutic hypothermia.

METHODS

We obtained data retrospectively from medical records of the neonates diagnosed with HIE and treated by therapeutic hypothermia to evaluate the factors associated with transition time to FEF.

RESULTS

Sixty-one neonates were included in the study. The median gestational age (GA) and birth weight were 39 (37-40) weeks and 3245 (2715-3575) grams, respectively. APGAR scores at the first and fifth minutes were 3 (1-5) and 6 (4-7), respectively. Fifty-seven (93.4%) of the newborns were diagnosed as having moderate HIE, and 4 (6.6%) of them had severe HIE. Transition time to FEF was found to be negatively correlated with gestational week (r, P: -0.280, 0.029) and birth weight (r, P: -0.315, 0.013); and positively correlated with lactate (r, P: 0.295, 0.044), BUN (r, P: 0.285, 0.026) and creatinine levels (r,P: 0.345, 0.007); duration of invasive (r, P: 0.565, 0.0001) and non-invasive mechanical ventilation (r, P: 0.261, 0.042), use of antibiotics (r, P: 0.556, 0.0001) and inotropic agents (r, P: 0.524, 0.0001) and hospitalization (r, P: 0.654, 0.0001).

CONCLUSION

Clinicians should be more careful while starting to feed babies undergoing therapeutic hypothermia with higher lactate levels and impaired renal functions, and should be encouraged to feed clinically stable neonates with HIE as soon as possible, as the transition time to FEF could be related with better clinical outcomes.

Determination of Accurate Position of Umbilical Venous Catheters in Premature Infants

OBJECTIVE

The aim of the study is to determine the most accurate length and position of umbilical venous catheter (UVC).

STUDY DESIGN

This prospective study included premature infants who were admitted to the neonatal intensive care unit with inserted UVC between January 1, 2014 and December 31, 2015. The length of UVC was calculated according to the Shukla formula [(3 × birth weight + 9)/2 + 1] and the catheter was inserted under sterile conditions. After the insertion, umbilical catheter was first evaluated through chest X-ray and then with echocardiography to confirm its position. Catheters seen on the chest X-ray at the level of T9-T10 vertebrae were classified as "accurate position," those seen above T9 vertebra as "high position," and the catheters identified below T10 vertebra were classified as "low position."

RESULTS

A total of 68 infants smaller than 36 weeks of gestation were included in the study. In echocardiographic evaluation, 80% of the cases identified as in the "accurate position," 100% of the cases classified as in a "high position," and 33% of the cases defined as in a "low position" on the chest X-rays were found to be intracardiac. In our study, length of the catheter calculated according to the Shukla formula was intracardiac in 88.2% of premature infants.

CONCLUSION

Radiography alone is not sufficient for the determination of adequate position of umbilical catheter, especially in premature infants. Specialists practicing in neonatal intensive care units could improve themselves and evaluate UVC with echocardiography, making this a routine part of clinical practice. Echocardiography-guided fixation of the catheter will reduce the complications related to catheter malposition.

KEY POINTS

· Shukla formula is commonly used to calculate the adequate length of UVC.. · Chest X-ray is the most widely used modality for locating the tip of UVC.. · Echocardiography can be conveniently used for the determination of adequate position of UVC..

Effects of COVID-19 pandemic on breastfeeding rates in a neonatal intensive care unit

OBJECTIVES

To find out if the expressed breast milk delivery rate to neonatal intensive care unit (NICU) for babies who were hospitalized for any reason other than COVID-19, and exclusive breastfeeding (EB) rates between discharge date and 30th day of life of those babies were affected by COVID-19 pandemic.

METHODS

Babies who were hospitalized before the date first coronavirus case was detected in our country were included as control group (CG). The study group was divided into two groups; study group 1 (SG1): the mothers whose babies were hospitalized in the period when mother were asked not to bring breast milk to NICU, study group 2 (SG2): the mothers whose babies were hospitalized after the date we started to use the informed consent form for feeding options. The breast milk delivery rates to NICU during hospitalization and EB rates between discharge and 30th day of life were compared between groups.

RESULTS

Among 154 mother-baby dyads (CG, n=50; SG1, n=46; SG2, n=58), the percentage of breast milk delivery to NICU was 100%, 79% for CG, SG2, respectively (p<0.001). The EB rate between discharge and 30th day of life did not change between groups (CG:90%, SG1:89%, SG2:75.9; p=0.075).

CONCLUSIONS

If the mothers are informed about the importance of breast milk, the EB rates are not affected by the COVID-19 pandemic in short term, even if the mothers are obligatorily separated from their babies. The breast milk intake rate of the babies was lowest while our NICU protocol was uncertain, and after we prepared a protocol this rate increased.

Ertapenem for the treatment of urinary tract infections caused by extended-spectrum β-lactamase-producing bacteria in children

BACKGROUND

Urinary tract infections (UTIs) are a problem frequently encountered by paediatric healthcare providers. Recent data suggest that extended-spectrum β-lactamase (ESBL)-producing bacteria are an emerging cause of UTIs in non-hospitalized patients. We report our experience of ertapenem use in 50 patients with complicated UTIs, mainly pyelonephritis, caused by ESBL-producing organisms.

METHODS

Fifty patients aged <16 y who had a complicated UTI caused by ESBL-producing organisms and who were treated with ertapenem at our hospital from 1 January 2009 to 31 December 2009, were included in the study.

RESULTS

There were 20 (40%) males and 30 (60%) females with a mean ± standard deviation age of 38.6 ± 36.9 months (range 6-156 months). Twenty-eight patients had no urological abnormality. In 40 patients ertapenem was initiated after results of microbiological cultures became available. Ertapenem was initiated empirically for 10 patients known to be colonized with ESBL-producing bacteria. Urine cultures were negative at 3.3 ± 0.7 days (range 2-5 days) after starting ertapenem treatment. The mean duration of ertapenem treatment was 7.8 ± 1.2 days (range 7-14 days). No laboratory or clinical side effects were observed.

CONCLUSIONS

Ertapenem is promising for the culture-guided treatment of ESBL-producing Gram-negative complicated UTIs. Well-designed prospective studies are needed to define the role of ertapenem in treating complicated paediatric UTIs, especially upper UTIs.

Bloodstream infections in a medical-surgical intensive care unit: incidence, aetiology, antimicrobial resistance patterns of Gram-positive and Gram-negative bacteria

In the present study, the incidence and antimicrobial resistance patterns of the microorganisms that caused bloodstream infections (BSIs) in a medical-surgical intensive care unit during the years 2005-2007 were determined. The mean BSI incidence density was 6.56 per 1000 patient-days. The incidence density increased linearly during the study period (from 3.57 to 9.60 per 1000 patient-days). Staphylococcus aureus was most frequently isolated (47.3%), followed by Enterococcus spp. (10.8%) and Candida spp. (10.1%). There was a high rate of resistance to several of the prescribed antimicrobials among the bacteria isolated from patients with BSIs.

Amiodarone induces apoptosis of human and rat alveolar epithelial cells in vitro

The antiarrhythmic amiodarone (AM) and its metabolite desethylamiodarone (Des) are known to cause AM-induced pulmonary toxicity, but the mechanisms underlying this disorder remain unclear. We hypothesized that AM might cause AM-induced pulmonary toxicity in part through the induction of apoptosis or necrosis in alveolar epithelial cells (AECs). Two models of type II pneumocytes, the human AEC-derived A549 cell line and primary AECs isolated from adult Wistar rats, were incubated with AM or Des for 20 h. Apoptotic cells were determined by morphological assessment of nuclear fragmentation with propidium iodide on ethanol-fixed cells. Necrotic cells were quantitated by loss of dye exclusion. Both AM and Des caused dose-dependent necrosis starting at 2.5 and 0.1 microg/ml, respectively, in primary rat AECs and at 10 and 5 microg/ml in subconfluent A549 cells (P < 0.05 and P < 0.01, respectively). AM and Des also induced dose-dependent apoptosis beginning at 2.5 microg/ml in the primary AECs (P < 0.05 for both compounds) and at 10 and 5 microg/ml, respectively, in the A549 cell line (P < 0.01). The two compounds also caused significant net cell loss (up to 80% over 20 h of incubation) by either cell type at drug concentrations near or below the therapeutic serum concentration for AM. The cell loss was not due to detachment but was blocked by the broad-spectrum caspase inhibitor Z-Val-Ala-Asp-fluoromethylketone. Furthermore, the angiotensin-converting enzyme inhibitor captopril (500 ng/ml) and the angiotensin-receptor antagonist saralasin (50 microg/ml) significantly inhibited both the induction of apoptosis and net cell loss in response to AM. These results are consistent with recent work from this laboratory demonstrating potent inhibition of apoptosis in human AECs by captopril (Uhal BD, Gidea C, Bargout R, Bifero A, Ibarra-Sunga O, Papp M, Flynn K, and Filippatos G. Am J Physiol Lung Cell Mol Physiol 275: L1013-L1017, 1998). They also suggested that the accumulation of AM and/or its primary metabolite Des in lung tissue may induce cytotoxicity of AECs that might be inhibitable by angiotensin-converting enzyme inhibitors or other antagonists of the renin-angiotensin system.