Variation in follow-up for children born very preterm in Europe

BACKGROUND

Children born very preterm (<32 weeks of gestation) face high risks of neurodevelopmental and health difficulties compared with children born at term. Follow-up after discharge from the neonatal intensive care unit is essential to ensure early detection and intervention, but data on policy approaches are sparse.

METHODS

We investigated the characteristics of follow-up policy and programmes in 11 European countries from 2011 to 2022 using healthcare informant questionnaires and the published/grey literature. We further explored how one aspect of follow-up, its recommended duration, may be reflected in the percent of parents reporting that their children are receiving follow-up services at 5 years of age in these countries using data from an area-based cohort of very preterm births in 2011/12 (N = 3635).

RESULTS

Between 2011/12 and 22, the number of countries with follow-up policies or programmes increased from 6 to 11. The policies and programmes were heterogeneous in eligibility criteria, duration and content. In countries that recommended longer follow-up, parent-reported follow-up rates at 5 years of age were higher, especially among the highest risk children, born <28 weeks' gestation or with birthweight <1000 g: between 42.1% and 70.1%, vs. <20% in most countries without recommendations.

CONCLUSIONS

Large variations exist in follow-up policies and programmes for children born very preterm in Europe; differences in recommended duration translate into cross-country disparities in reported follow-up at 5 years of age.

Catheter-related bloodstream infections in infants hospitalized in neonatal intensive care units: a single center study

Sepsis in neonates carries a high morbidity and mortality rate and is among the most feared complications in the neonatal intensive care unit (NICU). Catheter-related bloodstream infections (CRBSI) are a common etiology of late-onset sepsis. The aim of this study was to compare risk factors and characteristics between patients according to the type of catheter that was utilized and according to birth weight classification. The study included 51 newborns with confirmed CRBSI, which were hospitalized in our level 3 NICU between January 2017 and December 2018. The study population was stratified according to the type of venous catheter utilized (peripherally inserted central catheter, central venous catheter (CVC), and peripheral venous catheter). Infants with low birth weight and those who required prolonged parenteral nutrition were most likely to develop CRBSI in our study group. The type of venous catheter was not associated with blood culture results. Also, infants with a birth weight of < 1500 g and > 1500 g did not differ in sepsis etiology. Further research is required to assess venous catheters relative risk of causing sepsis and if the outcome can be traced back specifically to catheter type or patient characteristics.

High Healthcare Use at Age 5 Years in a European Cohort of Children Born Very Preterm

OBJECTIVES

To describe parent-reported healthcare service use at age 5 years in children born very preterm and investigate whether perinatal and social factors and the use of very preterm follow-up services are associated with high service use.

STUDY DESIGN

We used data from an area-based cohort of births at <32 weeks of gestation from 11 European countries, collected from birth records and parental questionnaires at 5 years of age. Using the published literature, we defined high use of outpatient/inpatient care (≥4 sick visits to general practitioners, pediatricians, or nurses, ≥3 emergency room visits, or ≥1 overnight hospitalization) and specialist care (≥2 different specialists or ≥3 visits). We also categorized countries as having either a high or a low rate of children using very preterm follow-up services at age 5 years.

RESULTS

Overall, 43% of children had high outpatient/inpatient care use and 48% had high specialist care use during the previous year. Perinatal factors were associated with high outpatient/inpatient and specialist care use, with a more significant association with specialist services. Associations with intermediate parental educational level and unemployment were stronger for outpatient/inpatient services. Living in a country with higher rates of very preterm follow-up service use was associated with lower use of outpatient/inpatient services.

CONCLUSIONS

Children born very preterm had high healthcare service use at age 5 years, with different patterns for outpatient/inpatient and specialist care by perinatal and social factors. Longer follow-up of children born very preterm may improve care coordination and help avoid undesirable health service use.

Hearing Impairment in Infants with Hypoxic Ischemic Encephalopathy Treated with Hypothermia

Therapeutic hypothermia acts as the standard of care for infants with moderate to severe hypoxic ischemic encephalopathy (HIE). A proportion of neonates who undergo hypothermia due to HIE have shown to develop various degrees of hearing impairment. Analyzing and identifying infants at high risk of developing hearing difficulties is fundamental for early intervention of such auditory complications. The aim was to assess clinical factors in the development of hearing impairment following therapeutic hypothermia in HIE infants. A retrospective analysis was performed on infants hospitalized in our neonatology department in Poznan University of Medical Sciences, Poland. All infants experienced moderate to severe HIE, and were treated with therapeutic hypothermia. Risk factors for hearing impairment were identified in all infants included in the study. Clinical data during hospital stay and follow-up hearing status were analyzed. A total of 87 HIE infants were included in the study. Seventy-six infants (40 male and 36 female) had otoacoustic emission (OAE) examination following birth, of which 14 (18.4%) demonstrated abnormal (positive) results. Infants with abnormal OAE results had significantly lower blood pH (6.86 ± 0.16, p = 0.001) and base excess (BE) (-22.46 ± 2.59, p = 0.006). Of the 49 infants who returned for follow-up assessment, 4 (8.2%) were diagnosed with sensorineural bilateral hearing impairment (1 infant, mild [<40 dB], 2 moderate [41-70 dB], and 1 profound [>90 dB]). The biochemical analysis following birth revealed significantly lower umbilical BE levels (-23.90 ± 4.99, p = 0.041) and higher lactate levels (160.67 ± 4.93, p = 0.019) in the infants with eventual sensorineural hearing deficit. Infants with moderate or severe HIE are at risk of delayed onset hearing loss. Diligent efforts to monitor auditory status are required, even if early screening results for hearing are insignificant. Exploring biochemical parameters, such as lactate, BE, and blood pH, can prove beneficial in identifying HIE infants at risk of developing a hearing impairment.

Biomarkers in newborns with hypoxic-ischemic encephalopathy treated with therapeutic hypothermia

PURPOSE

The aim of the presented study was to evaluate the differences between selected biochemical markers in infants with moderate or severe hypoxic-ischemic encephalopathy (HIE) and their impact on patient prognosis.

METHODS

A total of 57 cooled newborns were divided into groups according to Sarnat staging of HIE (A, moderate vs. B, severe). The differences between groups were evaluated depending on the mode of delivery, pregnancy and labor complications, gestational age at birth, birth weight, and Apgar score at 1.3 and 5 min. The differences in biochemical biomarkers of HIE (pH, base excess, serum lactate) as well as biomarkers of hepatic injury (aspartate transaminase, (AST), alanine transaminase (ALT), prothrombin time (PT), and activated partial thromboplastin time (APTT)), kidney failure (creatinine, urea), myocardial injury (troponin T (TnT)), levels of fibrinogen, and platelet counts were also examined. Univariate Kaplan-Meier method was used for survival analyses.

RESULTS

The biomarker levels in severe HIE newborns compared with moderate were as follows: pH (7.10 vs. 6.99), serum lactate (22.50 vs. 17.00 mg/dL), AST (109.50 vs. 270.55 IU/L), ALT (27.30 vs. 108.05 IU/L), PT (17.00 vs. 44.20 s), APTT (47.75 vs. 47.90 s), TnT (0.22 vs. 0.85 ng/mL), creatinine (0.68 vs. 1.15 mg/dL), urea (44.55 vs. 73.30 mg/dL), and fibrinogen (1.65 vs. 1.90 mg/dL). Survival analyses showed significantly reduced survival for severe HIE infants (75%) vs. moderate HIE (100%).

CONCLUSION

In conclusion, the severity of HIE can be evaluated based on selected markers; however, their levels do not correspond with future prognosis of newborns.

Organ Complications of Infants with Hypoxic Ischemic Encephalopathy Before Therapeutic Hypothermia

Hypoxic ischemic encephalopathy (HIE) is a serious neurological complication that may develop in asphyxiated infants. Severity of encephalopathy may vary, and concurrent multiorgan dysfunctions are commonly observed. Analyzing the incidence of such complications according to severity of HIE, and how they correlate with each other, may shape clinical judgment and allow for early intervention. The study included a total of 57 HIE infants, in which 27/57 (47.37%) met Sarnat inclusion criteria for moderate stage II HIE (Group A) and 30/57 (52.63%) for severe stage III HIE (Group B). Both groups were assessed and compared for incidence of kidney dysfunction, liver dysfunction, coagulopathy, qualitative cardiac abnormalities, respiratory-related dysfunction, and bone marrow insufficiency/thrombocytopenia. All assessments were performed before initiation of therapeutic hypothermia. The complications were further assessed for the presence of correlations. Group B experienced significantly higher incidence of kidney dysfunction (A: 2/27 [7.4%] vs. B: 21/30 [70%], p < 0.001), liver dysfunction (A: 14/27 [51.8%] vs. B: 28/30 [93.3%], p < 0.001), and thrombocytopenia (A: 8/27 [29.6%] vs. B 21/30 [70%], p = 0.002) in our study group. Kidney dysfunction and bone marrow insufficiency showed the highest affiliation with other organ systems in both groups, correlating positively with each other as well as HIE severity, cardiac abnormalities, liver dysfunction, and infant death. A total of 8/57 (14%) infant deaths were observed, all originating from grade III severe HIE group (p = 0.003). Multiorgan dysfunction showed a significant difference between HIE severity (A: 12/27 [44.4%] vs. B: 28/30 [93.3%], p < 0.001). A positive correlation was obtained between multiorgan dysfunction, HIE severity, and infant death. Stage III HIE infants are more likely to experience abnormalities in the kidneys, liver, bone marrow as compared with stage II HIE infants. Correlations between organ complications are present, and should be taken into account during clinical assessment of HIE infants. The probability of mortality is higher in stage III HIE infants with observed multiorgan dysfunctions.

EPICE cohort: two-year neurodevelopmental outcomes after very preterm birth

OBJECTIVE

To determine whether the variation in neurodevelopmental disability rates between populations persists after adjustment for demographic, maternal and infant characteristics for an international very preterm (VPT) birth cohort using a standardised approach to neurodevelopmental assessment at 2 years of age.

DESIGN

Prospective standardised cohort study.

SETTING

15 regions in 10 European countries.

PATIENTS

VPT births: 22⁺⁰-31⁺⁶ weeks of gestation.

DATA COLLECTION

Standardised data collection tools relating to pregnancy, birth and neonatal care and developmental outcomes at 2 years corrected age using a validated parent completed questionnaire.

MAIN OUTCOME MEASURES

Crude and standardised prevalence ratios calculated to compare rates of moderate to severe neurodevelopmental impairment between regions grouped by country using fixed effects models.

RESULTS

Parent reported rates of moderate or severe neurodevelopmental impairment for the cohort were: 17.3% (ranging 10.2%-26.1% between regions grouped by country) with crude standardised prevalence ratios ranging from 0.60 to 1.53. Adjustment for population, maternal and infant factors resulted in a small reduction in the overall variation (ranging from 0.65 to 1.30).

CONCLUSION

There is wide variation in the rates of moderate to severe neurodevelopmental impairment for VPT cohorts across Europe, much of which persists following adjustment for known population, maternal and infant factors. Further work is needed to investigate whether other factors including quality of care and evidence-based practice have an effect on neurodevelopmental outcomes for these children.

Therapeutic hypothermia in asphyxiated newborns: selective head cooling vs. whole body cooling - comparison of short term outcomes

OBJECTIVES

Therapeutic hypothermia TH became broadly used in the management of the asphyxiated newborns. Although two cooling methods are used, so far the superiority of none of them has been established. The purpose of the study is to compare two cooling methods: selective head cooling (SHC) and whole body cooling (WBC) MATERIAL AND METHODS: We conducted a prospective observational study in newborns with HIE. The patients received one of methods: SHC or WBC. The eligibility criteria were similar to previous studies. Stability of cardio-respiratory parameters and short term outcomes were analyzed.

RESULTS

78 neonates with hypoxic-ischemic encephalopathy due to perinatal asphyxia were involved in this study. The SHC group consisted of 51 newborns, the WBC group consisted of 27 patients. Both study groups had similar baseline characteristics and condition at birth. There were no significant differences in hospital course, neurological status and adverse effects associated with cooling procedure between groups. Analyzing the rate of thrombocytopenia and the number of transfusions of blood components no statistically significant differences were found between the groups.

CONCLUSIONS

Results of our study indicate that two compared methods of TH despite varied target core temperature ranges do not differ significantly according to clinical course and risk of adverse events. Further observations are conducted and we look forward to the results of the long neurodevelopmental care.

Specialist health care services use in a European cohort of infants born very preterm

AIM

Children born very preterm require additional specialist care because of the health and developmental risks associated with preterm birth, but information on their health service use is sparse. We sought to describe the use of specialist services by children born very preterm in Europe.

METHOD

We analysed data from the multi-regional, population-based Effective Perinatal Intensive Care in Europe (EPICE) cohort of births before 32 weeks' gestation in 11 European countries. Perinatal data were abstracted from medical records and parents completed a questionnaire at 2 years corrected age (4322 children; 2026 females, 2296 males; median gestational age 29wks, interquartile range [IQR] 27-31wks; median birthweight 1230g, IQR 970-1511g). We compared parent-reported use of specialist services by country, perinatal risk (based on gestational age, small for gestational age, and neonatal morbidities), maternal education, and birthplace.

RESULTS

Seventy-six per cent of the children had consulted at least one specialist, ranging across countries from 53.7% to 100%. Ophthalmologists (53.4%) and physiotherapists (48.0%) were most frequently consulted, but individual specialists varied greatly by country. Perinatal risk was associated with specialist use, but the gradient differed across countries. Children with more educated mothers had higher proportions of specialist use in three countries.

INTERPRETATION

Large variations in the use of specialist services across Europe were not explained by perinatal risk and raise questions about the strengths and limits of existing models of care.

WHAT THIS PAPER ADDS

Use of specialist services by children born very preterm varied across Europe. This variation was observed for types and number of specialists consulted. Perinatal risk was associated with specialist care, but did not explain country-level differences. In some countries, mothers' educational level affected use of specialist services.

Breastfeeding outcomes in European NICUs: impact of parental visiting policies

OBJECTIVE

The documented benefits of maternal milk for very preterm infants have raised interest in hospital policies that promote breastfeeding. We investigated the hypothesis that more liberal parental policies are associated with increased breastfeeding at discharge from the neonatal unit.

DESIGN

Prospective area-based cohort study.

SETTING

Neonatal intensive care units (NICUs) in 19 regions of 11 European countries.

PATIENTS

All very preterm infants discharged alive in participating regions in 2011-2012 after spending >70% of their hospital stay in the same NICU (n=4407).

MAIN OUTCOME MEASURES

We assessed four feeding outcomes at hospital discharge: any and exclusive maternal milk feeding, independent of feeding method; any and exclusive direct breastfeeding, defined as sucking at the breast. We computed a neonatal unit Parental Presence Score (PPS) based on policies regarding parental visiting in the intensive care area (range 1-10, with higher values indicating more liberal policies), and we used multivariable multilevel modified Poisson regression analysis to assess the relation between unit PPS and outcomes.

RESULTS

Policies regarding visiting hours, duration of visits and possibility for parents to stay during medical rounds and spend the night in unit differed within and across countries. After adjustment for potential confounders, infants cared for in units with liberal parental policies (PPS≥7) were about twofold significantly more likely to be discharged with exclusive maternal milk feeding and exclusive direct breastfeeding.

CONCLUSION

Unit policies promoting parental presence and involvement in care may increase the likelihood of successful breastfeeding at discharge for very preterm infants.

Percentile charts of twin birthweight

BACKGROUND

The birthweight of multiples is naturally lower than that of singletons. Given that the incidence of twin pregnancy has risen in recent years, it seems reasonable to create standards of birthweight separately for twins. This could help in the objective assessment of small and large for gestational age twin newborns. The main goal of this study was therefore to construct and present up-to-date birthweight references.

METHODS

The present percentile charts for twins are based on a cohort retrospective study of 757 pairs of twins (767 boys and 709 girls) born between weeks 25 and 39 of gestation. Mean and standard deviation were calculated for the subsequent weeks of gestation. Percentiles were read for the subsequent gestational age. The obtained curves were smoothed with a fifth-degree polynomial function. The significance of differences between the 50th percentile values for twins and singletons was estimated using median test.

RESULTS

In both sexes, a continuous observable trend occurs of a significantly lower average birthweight for twins. Differences increase with increasing gestational age and are greater in girls. The estimated 50th percentile for twins was greater than the estimated 10th percentile for singletons. This supports the notion of discordant growth as a physiological adaptation that promotes maturity.

CONCLUSIONS

Percentile charts for singletons are not applicable for twins. This indicates the importance of applying separate percentile charts for twins, enabling objective evaluation of their health status and identifying deviations from normality.

Severe bronchopulmonary dysplasia - incidence and predictive factors in a prospective, multicenter study in very preterm infants with respiratory distress syndrome

BACKGROUND

Severe bronchopulmonary dysplasia (BPD) remains a major complication of prematurity and can have significant impact on long-term pulmonary sequelae and adverse neurodevelopmental outcomes.

OBJECTIVE

To assess the incidence and evaluate the predictive factors for severe BPD in very preterm infants with respiratory distress syndrome.

METHODS

Of the 846 premature infants born at ≤32-week gestation who developed respiratory distress syndrome (RDS), 707 infants with known oxygen dependency at 36 weeks gestational age were included in the analysis of BPD incidence. With univariate and multiple logistic regression models we evaluated the risk factors for the development of severe BPD and calculated odds ratios (ORs).

RESULTS

The overall incidence of BPD was 45.2%. Severe BPD accounted for 6%, with morbidity pertaining mainly to infants <29-week gestation (incidence 10%). The risk factors for severe BPD included male gender (OR 3.02 95%CI 1.30-7.46), intubation in the delivery room (OR 2.57, 95%CI 1.00-7.18), and invasive ventilation >7 days (OR 7.05, 95%CI 2.63-22.4). The protective factors were early continuous positive airway pressure (CPAP) in the univariate analysis and receiving surfactant <15 min after birth in the multivariate model.

CONCLUSIONS

Mechanical ventilation >7 days is the most prevalent risk factor for severe BPD. CPAP initiated in the delivery room and early surfactant are key preventive measures.

Ranibizumab after laser photocoagulation failure in retinopathy of prematurity (ROP) treatment

The purpose of this study was to investigate the anatomical and functional outcomes of the two-stage treatment of severe retinopathy of prematurity (ROP) using laser photocoagulation and intravitreal ranibizumab injection. The medical records of 53 eyes of 28 infants treated by conventional laser photocoagulation with deferred intravitreal 0.25 mg/0.025 mL ranibizumab injection were analysed. All patients had at least 11 months of follow-up. In the analysed group, the mean gestational age at birth was 25 weeks and mean birthweight was 790 g. The mean time of laser photocoagulation was 34 weeks of postmenstrual age (PMA). Ranibizumab injection was performed on average at 37 weeks of PMA. The mean time between interventions was 19 days. Retinal detachment occurred in 12 eyes (22.6%), in three children bilaterally. Visual responses were obtained in 23 of 28 treated children. Our results indicate that ranibizumab injection can be taken into consideration in the selected cases of laser photocoagulation failure. The unsatisfactory results of this study elicited a change in the ROP treatment protocol in our medical centre. The study gives an insight into anatomical and functional outcomes of ROP treatment in the Central and Eastern European population.

Role of endothelial nitric oxide synthase and endothelin-1 polymorphism genes with the pathogenesis of intraventricular hemorrhage in preterm infants

In the pathogenesis of neonatal intraventricular hemorrhage (IVH) in preterm infants, an important role is played by changes in venous and arterial cerebral flows. It has been shown that the ability of autoregulation of cerebral flows in response to variations in arterial blood pressure in preterm infants is impaired. This impaired autoregulation causes an increased risk of germinal matrix rupture and IVH occurrence. We examined three polymorphisms of genes, related to regulation of blood flow, for an association with IVH in 100 preterm infants born from singleton pregnancy, before 32 + 0 weeks of gestation, exposed to antenatal steroids therapy, and without congenital abnormalities. These polymorphisms include: eNOS (894G > T and −786T > C) and EDN1 (5665G > T ) gene. We found that infants with genotype GT eNOS 894G > T have 3.4-fold higher risk developing of IVH born before 28 + 6 weeks of gestation. Our investigation did not confirm any significant prevalence for IVH development according to eNOS −786T > C genes polymorphism. Our novel investigations in EDN1 5665G > T polymorphism did not show any link between alleles or genotypes and IVH. Future investigations of polymorphisms in blood-flow associated genes may provide valuable insight into the pathogenetic mechanisms underlying the development of IVH.

The role of FV 1691G>A, FII 20210G>A mutations and MTHFR 677C>T; 1298A>C and 103G>T FXIII gene polymorphisms in pathogenesis of intraventricular hemorrhage in infants born before 32 weeks of gestation

BACKGROUND

Congenital thrombophilia is associated with an increased intraventricular hemorrhage (IVH) risk among newborns, but it may also play a protective role. The role of genetic polymorphisms involved in the coagulation pathway of IVH pathogenesis is probably a consequence of an increased risk of thrombosis in the fine blood vessels in the germinal matrix region.

MATERIAL AND METHODS

The aim of this study was to evaluate the possible relationship between Factor V (FV) 1691G>A, Factor II (FII) 20210G>A mutations and methylenetetrahydrofolate reductase (MTHFR) 677C>T; 1298A>C and Factor XIII (FXIII) 103G>T gene polymorphisms and the occurrence of IVH in 100 infants born from 24 + 0 to 32 + 0 weeks of gestation, born from singleton pregnancy, before 32 + 0 weeks of gestation, exposed to antenatal steroid therapy, and without congenital abnormalities.

RESULTS

IVH developed 45 (45%) infants, including 15 (33.33%) diagnosed with IVH stage I, 20 (42.22%) with stage II, 8 (17.77%) with stage III, and 3 (6.66%) with stage IV. Analysis showed a prevalence 4.5 times higher of IVH stages II to IV in infants with the genotype CC (OR 4511 (1147-17.75); p = 0.026) of MTHFR 1298A>C gene polymorphism. Our investigation did not confirm any significant prevalence of IVH development in other studied mutations/polymorphisms.

CONCLUSIONS

This study confirmed that the MTHFR 1298A>C polymorphism is associated with the risk of IVH. IVH is a significant problem for preterm infants. In addition to little progress in preventing IVH in preterm babies, substantial research that is focused on understanding the etiology, mechanism, and risk factors for IVH is imperative. In the era of personalized medicine, identification of genetic risk factors creates opportunities to generate preventative strategies.

Intraventricular hemorrhage in neonates born from 23 to 26 weeks of gestation: Retrospective analysis of risk factors

BACKGROUND

The study aim was to determine the incidence and analyze risk factors of IVH stage 3 and 4 in infants born before 26 weeks of gestation.

OBJECTIVES

A retrospective analysis of 110 preterm babies (23-26 weeks of gestation) hospitalized from 2009 to 2014 at the Department of Neonatology of Poznan University of Medical Sciences was performed.

MATERIAL AND METHODS

In the study group there were 29 (26.4%) children in the 23rd-24th weeks of pregnancy and 81 (73.6%) in the 25th-26th weeks of gestation.

RESULTS

Among IVH stage 3 and 4 in neonates without prenatal steroids therapy, OR was 1.616 (1.059- 2.456; p = 0.022) for children born in the 23rd-24th week of gestation and 1.677 (1.001-2.809; p = 0.047) for children born in the 25th-26th week of pregnancy. An analysis of various risk factors revealed the chance of the appearance IVH stage 3 and 4 among neonates born in the 23th-24th and 25th-26th week of gestation rising only among those children who were treated for hypotension with catecholamines (OR 2.031 (0.269-24.21), p = 0.033 and OR 1.989 (0.224-16.55), p = 0.024).

CONCLUSIONS

The lower the gestational age, the more frequent the risk of IVH stage 3 and 4. The use of appropriate prophylaxis of perinatal patients (steroids in all pregnant women at risk of preterm birth, limiting the indications for the use of catecholamines for hypotension treatment) reduces the incidence of severe IVH.

The significance of polymorphisms in genes encoding Il-1β, Il-6, TNFα, and Il-1RN in the pathogenesis of intraventricular hemorrhage in preterm infants

INTRODUCTION

Intraventricular hemorrhage (IVH) is a significant morbidity seen in very low birth weight infants. Genes related to inflammation may be risk factors for IVH.

MATERIAL AND METHODS

We examined five polymorphisms for an association with IVH in 100 preterm infants born from singleton pregnancy, before 32 + 0 weeks of gestation, exposed to antenatal steroid therapy, and without congenital abnormalities. These polymorphisms include interleukin-1β 3953 C>T, interleukin-6 -174G>C and -596G>A, tumor necrosis factor -308 G>A, and 86 bp variable number tandem repeat polymorphism of interleukin-1 receptor antagonist (Il -1RN 86 bp VNTR).

RESULTS

In our study population, 45 (45%) infants developed IVH, including 15 (33.33%) with stage 1, 19 (42.22%) with stage 2, 8 (17.77%) with stage 3, and 3 (6.66%) with stage 4. In contrast to the previously published data, the prevalence of IVH did not vary between infants with different IL-6 and TNFα alleles and genotypes. Our novel investigations in Il-1 +3953 C>T and Il-1RN 86 bp VNTR polymorphism did not show any significant link between those alleles or genotypes and IVH.

CONCLUSIONS

IVH is a significant problem for preterm infants. In addition to little progress in preventing IVH in preterm babies, substantial research that are focused on understanding the etiology, mechanism and risk factors for IVH are imperative. In the era of personalized medicine, identification of genetic risk factors creates opportunities to generate preventative strategies. Further studies should be performed to confirm the role of genetic factors in etiology and pathogenesis of IVH.

Intraventricular hemorrhage in neonates born before 32 weeks of gestation-retrospective analysis of risk factors

INTRODUCTION

Intraventricular hemorrhage (IVH) affects 15-20 % of babies born before 32 weeks of pregnancy. A lot of risk factors of developing IVH are known. The making appropriate recommendations for dealing with infant born less than 32 weeks of gestation aimed at reducing the incidence of IVH is still needed. The study aim was to determine the incidence and analyze risk factors of IVH stage 3 and 4 in infants born before 32 + 0 weeks of pregnancy.

METHODS

The retrospective analysis of 267 preterm babies (24 to 32 weeks of gestation) hospitalized in 2011-2013 at Department of Neonatology, Poznan University of Medical Sciences was performed. The diagnosis of IVH was confirmed by ultrasound scans according to Papille criteria. Stage 3 and 4 of IVH was confirmed in 14 (25 %) newborns from 23 to 24 weeks of gestation; 21 (37.5 %) from 25 to 26 weeks of gestation; 11 (19.6 %) from 27 to 28 weeks of gestation; 9 (16.1 %) from 29 to 30 weeks of gestation; and 1 (1.8 %) from 31 to 32 weeks of gestation.

RESULT

The incidence of IVH stage 3 and 4 was higher in children: with less use of AST (OR 1.27; 0.62-2.61), born out of third-level hospitals (OR 2.25; 1.23-4.08), born with asphyxia (OR 3.46; 1.8-6.64), with acidosis treated with NaHCO3 (OR 6.67; 3.78-11.75), those who in the first days of life were treated for hypotension (OR 9.92; 5.12-19.21).

CONCLUSION

No or uncompleted antenatal steroid therapy increased probability for development of severe intraventricular hemorrhage. Antenatal steroids therapy should be promoted among women at risk of a premature delivery. Hypotension therapy with catecholamines and acidosis with sodium hydrogen carbonate should be carefully considered. The use of appropriate prophylaxis of perinatal (antenatal steroids therapy women at risk of preterm birth, limiting the indications for the use of catecholamines for hypotension treatment and sodium hydrogen carbonate for acidosis therapy, limitation of preterm deliveries outside tertiary referral centeres) significantly reduces the incidence of intraventricular hemorrhage stage 3 and 4. The significance of intraventricular hemorrhage creates a need to carry out periodical analysis, at regional level, concerning its incidence, causes and effects to improve local treatment outcomes by identifying further courses of action.

Use of evidence based practices to improve survival without severe morbidity for very preterm infants: results from the EPICE population based cohort

OBJECTIVES

 To evaluate the implementation of four high evidence practices for the care of very preterm infants to assess their use and impact in routine clinical practice and whether they constitute a driver for reducing mortality and neonatal morbidity.

DESIGN

 Prospective multinational population based observational study.

SETTING

 19 regions from 11 European countries covering 850 000 annual births participating in the EPICE (Effective Perinatal Intensive Care in Europe for very preterm births) project.

PARTICIPANTS

 7336 infants born between 24+0 and 31+6 weeks' gestation in 2011/12 without serious congenital anomalies and surviving to neonatal admission.

MAIN OUTCOME MEASURES

 Combined use of four evidence based practices for infants born before 28 weeks' gestation using an "all or none" approach: delivery in a maternity unit with appropriate level of neonatal care; administration of antenatal corticosteroids; prevention of hypothermia (temperature on admission to neonatal unit ≥36°C); surfactant used within two hours of birth or early nasal continuous positive airway pressure. Infant outcomes were in-hospital mortality, severe neonatal morbidity at discharge, and a composite measure of death or severe morbidity, or both. We modelled associations using risk ratios, with propensity score weighting to account for potential confounding bias. Analyses were adjusted for clustering within delivery hospital.

RESULTS

 Only 58.3% (n=4275) of infants received all evidence based practices for which they were eligible. Infants with low gestational age, growth restriction, low Apgar scores, and who were born on the day of maternal admission to hospital were less likely to receive evidence based care. After adjustment, evidence based care was associated with lower in-hospital mortality (risk ratio 0.72, 95% confidence interval 0.60 to 0.87) and in-hospital mortality or severe morbidity, or both (0.82, 0.73 to 0.92), corresponding to an estimated 18% decrease in all deaths without an increase in severe morbidity if these interventions had been provided to all infants.

CONCLUSIONS

 More comprehensive use of evidence based practices in perinatal medicine could result in considerable gains for very preterm infants, in terms of increased survival without severe morbidity.

Role of selected cytokines in the etiopathogenesis of intraventricular hemorrhage in preterm newborns

Proinflammatory cytokines are essential mediators and indicators of an inflammatory process occurring in the body. Their physiological role is to stimulate the immune response, yet their excessive propagation and interaction with cells outside the immune system may be linked to the risk of organ damage. This is specifically important in the case of immature tissues of fetuses and prematurely born infants. Analysis of the concentrations of specific cytokines in different compartments makes it possible to assess the risk of premature birth, preterm rupture of the membranes, and to determine an existing intrauterine infection. The purpose of this paper is to summarize the existing research concerning the relationships between the concentrations of specific proinflammatory cytokines in different compartments (maternal blood serum, amniotic fluid, umbilical cord blood, arterial and venous blood, and cerebrospinal fluid of the newborn) and the risk of intraventricular hemorrhage (IVH) and the degree of its severity. The paper takes also into account the assessment of the usefulness of cytokines as biomarkers for IVH and its complications (posthemorrhagic hydrocephalus, white matter injury).

The incidence of severe intraventricular hemorrhage based on retrospective analysis of 35939 full-term newborns-report of two cases and review of literature

INTRODUCTION

Intraventricular hemorrhage (IVH) is mostly documented in premature infants, and the younger the gestational age, the more often it occurs. IVH is very rarely reported in full-term neonates.

CASE REPORT

Retrospective analysis was performed in 35939 full-term neonates, who were born in the Clinical Hospital of Gynecology and Obstetrics at the University of Medical Sciences in Poznań. Clinical data were retrieved from their medical records. We report a case series of 2 term newborns, who developed severe IVH grade 3 and 4 with no evidence of asphyxia, neuroinfection, TORCH infections, coagulation disorders and trombocytopenia, metabolic disorders, arteriovenous malformations, and selected genetic abnormalities (factor V Leiden 1601G > A polymorphism and MTHFR 677C > T; 1298A > C polymorphisms). IVH in both cases was complicated by posthemorrhagic hydrocephalus treated with decompressive lumbar punctures and next ventriculoperitoneal shunt placement.

CONCLUSIONS

In conclusion, several factors influence the predisposition for severe IVH in term neonates. Perinatal period complicated by fetal distress, birth trauma, and severe asphyxia should be taken into account. However, it is possible that etiopathogenesis cannot be defined clearly as in our cases. Cranial ultrasounds in a specific group of term newborns (taking into account risk factors for IVH) should be widely recommended.

PRACTICAL ASPECTS OF THERAPEUTIC HYPOTHERMIA IN NEONATES WITH HYPOXIC ISCHEMIC ENCEPHALOPATHY--QUESTIONS AND ANSWERS. PART I. PROVIDING NEWBORN CARE BEFORE AND DURING TRANSFER TO THE REFERENCE CENTER

The first decade of the 21st century saw the worldwide spread of therapeutic hypothermia as a beneficial therapeutic procedure in neonates with hypoxic-ischemic encephalopathy. New guidelines for the resuscitation of newborns confirm that therapeutic hypothermia should be the standard method of treatment offered to neonates with acute perinatal hypoxia. The quality of care which an asphyxiated newborn receives during and immediately after resuscitation, as well as the mode of preparation for transport, can have a significant impact on improving the outcome, but it can also result in the deterioration of neonates treated with hypothermia. Since to a considerable degree the therapeutic effect depends on the time of beginning the cooling procedure, there is no reason to unnecessarily delay treatment. For this purpose, neonatologists or pediatricians from referring hospitals who do not have the equipment for hypothermia can and even should begin the cooling process while waiting for the arrival of the neonatal transport team. In that short period a number of concerns arise regarding the optimal methods of child care and preparation for transport to the hypothermia center. The authors discuss the possibility of initiating cooling before transportation using simple, so called low-tech cooling methods, the possible risks associated with the incidence of hyperthermia, difficulties in the interpretation of the eligibility criteria, supportive therapy, and the problems connected with the communication process between the medical team and the parents. The aspects that have been analyzed should be helpful for professionals in neonatal wards, outside hypothermia centers.

[Heliox augmented mechanical ventilation in the treatment of premature infants with respiratory distress syndrome]

OBJECTIVE

The aim of the study was to assess the influence of mechanical ventilation with helium-oxygen mixture (heliox) on basic vital signs, oxygenation, acid-base balance and respiratory mechanics in newborns with respiratory distress syndrome (RDS), previously treated with surfactant.

MATERIAL AND METHODS

The study was carried out in preterm newborns with respiratory failure requiring mechanical ventilation due to RDS, requiring Fi02>0.4 after a single dose of surfactant. Patients were ventilated using PC-SIMV Parameters of mechanical ventilation, respiratory function, oxygenation, acid-base balance and vital signs were recorded at baseline, one hour during and one hour after heliox ventilation.

RESULTS

Ten newborns with RDS were enrolled in the study Mechanical ventilation with heliox did not affect vital signs and patient general condition remained stable during and after ventilation with heliox. Mechanical ventilation with heliox was associated with a statistically significant increase in tidal volume (mean 5.48 vs. 6.55 ml/kg). There were no significant changes in minute ventilation and peak expiratory flow rate. Mechanical ventilation with heliox allowed the use of significantly lower fractions of inspired oxygen (mean 0.55 vs. 0.35), with a significant decrease in the oxygenation index (mean 8.77 vs. 5.02) and alveolar-arterial oxygen tension difference (mean 263.81 vs. 113.28 mm Hg). After ventilation with this gas mixture was stopped, the patients required higher Fi02, 01 and AaD02 levels increased.

CONCLUSIONS

Mechanical ventilation with heliox was safe, improved oxygenation and caused an increase in tidai, volume in newborns with RDS previously treated with surfactant.

Disordered eating attitudes during pregnancy in mothers of newborns requiring Neonatal Intensive Care Unit admission: a case control study

OBJECTIVE

The aim of the study was to assess disordered eating attitudes and other related factors in mothers of newborns requiring Neonatal Intensive Care Unit (NICU) admission compared to those of mothers who delivered healthy infants.

METHODS

An anonymous self-report study conducted among 199 mothers of newborns hospitalized in NICU, and a control group of 127 mothers of healthy newborns. Eating Attitudes Test-26 (EAT-26) and a survey regarding other perinatal health issues were used.

RESULTS

Women in the study group (SG) gained significantly less weight during pregnancy when compared to control group (CG; p = 0.001). There were fewer women with appropriate pre-gestational BMI in the SG (p = 0.052). Women who feared weight-gain during pregnancy were younger (p < 0.001) and had higher EAT-26 scores (p < 0.001). Women with EAT-26 scores >20 smoked significantly more often during their last pregnancy in the SG (p = 0.010). Cesarean section was more frequent in the SG (p = 0.017).

CONCLUSIONS

Disordered eating attitudes in gestation may significantly influence the pregnancy outcomes and newborns' health. Hence, it is vital for perinatal counseling and obstetrical care to focus on these issues to facilitate early diagnosis and intervention.

The impact of assisted reproductive technologies on the genome and epigenome of the newborn

The question of genetic alterations resulting from assisted reproductive technologies (ART) in humans is examined within the organization of the human genome. Increased rates of birth defects have been reported among children conceived using ART; however, questions remain and controversy exists regarding how "infertility" predisposes to birth defects. ART has been shown to be associated with an increased number of chromosomal alterations especially in the X chromosome. There is increased risk for embryonal tumors among ART conceived children, as well as, imprinting disorders (Beckwith-Wiedemann and Angelman Syndromes). Genetic studies of children conceived using ART reveal a larger (genome-wide) scale of methylation defects that encompass hundreds of genes. Genes involved in carcinogenesis and developmental pathways appear altered and may impact on later development of chronic illness, although these data are very preliminary. ART may create novel mutations by different chromosomal and molecular mechanisms; however, these techniques also enable propagation of pre-existing mutations that are associated with impaired fertility. While older maternal age is often associated with female infertility and chromosomal aneuploidy, sperm from older men have more new gene mutations. The prevalence of birth defects is increased when ART is used for conception. These data are summarized by large meta-analyses or from multi-year national registries. Whether the increased number of birth defects is due to ART procedures themselves or are a consequence of the impaired fertility of the parents is discussed. Long-term evaluation of children conceived using ART and/or ovarian hyper-stimulation is needed to determine whether alterations during embryonic development may increase the prevalence of chronic diseases in adulthood.

Late-onset bloodstream infections of Very-Low-Birth-Weight infants: data from the Polish Neonatology Surveillance Network in 2009-2011

Background

Late-Onset Bloodstream Infections (LO-BSI) continue to be one of the most important complications associated with hospitalization of infants born with very low birth weight (VLBW). The aims of this study were to assess the epidemiology of LO-BSI together with the risk factors and the distribution of causative pathogens at six Polish neonatal intensive care units that participated in the Polish Neonatology Surveillance Network from January 1, 2009 to December 31, 2011.

Methods

The surveillance covered 1,695 infants whose birth weights were <1501 grams (VLBW) in whom LO-BSI was diagnosed >72 hours after delivery. Case LO-BSI patients were defined according to NeoKISS.

Results

Four hundred twenty seven episodes of LO-BSI were diagnosed with a frequency of 25.3% and an incidence density of 6.7/1000 patient-days (pds). Results of our multivariate analysis demonstrated that surgical procedures and lower gestational age were significantly associated with the risk of LO-BSI. Intravascular catheters were used in infants with LO-BSI significantly more frequently and/or for longer duration: Central venous cathters (CVC) (OR 1.29) and Peripheral venous catheters (PVC) (OR 2.8), as well as, the total duration of total parenteral nutrition (13 vs. 29 days; OR 1.81). Occurrence of LO-BSI was significantly associated with increased the length of mechanical ventilation (MV) (OR 2.65) or the continuous positive airway pressure (CPAP) (OR 2.51), as well as, the duration of antibiotic use (OR 2.98). The occurrence of more than one infection was observed frequently (OR 9.2) with VLBW with LO-BSI. Microorganisms isolated in infants with LO-BSI were dominated by Gram-positive cocci, and predominantly by coagulase-negative staphylococci (62.5%).

Conclusions

Independent risk factor for LO-BSI in VLBV infants are: low gestational age and requirement for surgery. The incidence rates of LO-BSI especially CVC-BSI were higher in the Polish NICUs surveillance than those of other national networks, similar to the central- and peripheral utilization ratio.

Necrotising enterocolitis in preterm infants: epidemiology and antibiotic consumption in the Polish neonatology network neonatal intensive care units in 2009

The aim of this study was to describe the epidemiology of necrotising enterocolitis (NEC), antibiotic consumption and the usefulness of microbiological tests in very low birth weight (VLBW) Polish newborns.

METHODS

Prospective surveillance was performed in the year 2009 by local infection control teams. The study covered 910 infants hospitalized in six Polish neonatal intensive care units. Two kinds of indicators were used for the description of antibiotic usage: the duration of treatment (days of treatment, DOTs) and the defined daily dose (DDD).

RESULTS

NEC incidence was 8.7% and fatality rate was 19%. Chorioamnionitis, late gestational age and low birth weight were identified as risk factors for NEC. Catheterization, mechanical ventilation and other selected procedures were used considerably longer in newborns with NEC than in the remaining neonates. Total usage of antibiotics reached 2.9 DDDs or 1.437 days; the average use of drugs per case of NEC amounted to 0.47 DDD or 23.2 DOTs. The level of antibiotic usage was analysed with correlation to microbiological tests performed and it was non-significantly greater in the group of children with NEC in whom the tests were performed.

CONCLUSIONS

A high risk of developing NEC is closely associated with VLBW and with inflammation of the amnion during labour. We observed no relationship between the consumption of antibiotics in neonates with NEC and positive results of microbiological testing indicating sepsis accompanying NEC or gut colonization with pathogens.

Heliox for mechanically ventilated newborns with bronchopulmonary dysplasia

OBJECTIVE

We assessed the safety and studied the influence of short-term helium-oxygen (heliox) mechanical ventilation (MV) on respiratory function, gas exchange and oxygenation in infants with bronchopulmonary dysplasia (BPD) or at high risk for BPD.

DESIGN

A pilot, time-series study.

SETTING

Neonatal intensive care unit.

PATIENTS

Infants with severe BPD who required MV.

INTERVENTIONS

MV with helium-oxygen and air-oxygen mixtures.

MAIN OUTCOME MEASURES

Respiratory parameters, acid-base balance, oxygenation and vital signs were recorded at five time points: initially during MV with air-oxygen, after 15 and 60 min of helium-oxygen MV, and 15 and 60 min after return to air-oxygen MV.

RESULTS

15 infants with BPD were enrolled. Helium-oxygen MV was well tolerated and was associated with a statistically significant increase in tidal volume, dynamic compliance and peak expiratory flow rate. An improvement in oxygenation and a decrease in fraction of inspired oxygen was also observed. During helium-oxygen MV there was a significant decrease in the oxygenation index and alveolar-arterial oxygen tension difference. The PaO2/fraction of inspired oxygen (FiO2) ratio increased significantly during helium-oxygen ventilation. A decrease in PaCO2 and an increase in pH were also observed during helium-oxygen administration, however this was not statistically significant. After ventilation with helium-oxygen was discontinued, the infants' respiratory function and oxygenation deteriorated and supplemental oxygen requirements increased accordingly.

CONCLUSIONS

Helium-oxygen MV is safe and resulted in improvement of respiratory function and oxygenation in infants with severe BPD requiring MV.

Comparison of cerebral tissue oxygenation values in full term and preterm newborns by the simultaneous use of two near-infrared spectroscopy devices: an absolute and a relative trending oximeter

The aim of this study is to compare a two-wavelength light emitting diode-based tissue oximeter (INVOS), which is designed to show trends in tissue oxygenation, with a four-wavelength laser-based oximeter (FORE-SIGHT), designed to deliver absolute values of tissue oxygenation. Simultaneous values of cerebral tissue oxygenation (StO2) are measured using both devices in 15 term and 15 preterm clinically stable newborns on the first and third day of life. Values are recorded simultaneously in two periods between which oximeter sensor positions are switched to the contralateral side. Agreement between StO2 values before and after the change of sensor position is analyzed. We find that mean cerebral StO2 values are similar between devices for term and preterm babies, but INVOS shows StO2 values spread over a wider range, with wider standard deviations than shown by the FORE-SIGHT. There is relatively good agreement with a bias up to 3.5% and limits of agreement up to 11.8%. Measurements from each side of the forehead show better repeatability for the FORE-SIGHT monitor. We conclude that performance of the two devices is probably acceptable for clinical purposes. Both performed sufficiently well, but the use of FORE-SIGHT may be associated with tighter range and better repeatability of data.

[Epidemiology of infections in very low birth weight infants. Polish Neonatology Network research]

AIM OF STUDY

1. prospective record of infections; 2. prevention of nosocomial infections by providing current data about infections, which are significant for making therapeutic decisions.

MATERIAL AND METHODS

Recorded infections: early-onset sepsis (congenital), late-onset sepsis (acquired in hospital), necrotising enterocolitis (NEC), pneumonia. Infections were diagnosed and qualified on the basis of definitions of infections based on the National Nosocomial Infections Surveillance (NNIS) criteria, developed by CDC, USA, including modifications of German Neo-KISS programme. Infection control was realised as a part of common research project of "Polish Neonatology Network", appointed by the decision of the Minister of Science and Higher Education no. 669/E-215/BWSN- 0180/2008 dated 20.05.2008 r. The study was conducted by 6 Polish neonatology units, Microbiology Chair of Jagiellonian University Collegium Medicum and Institute of Theoretical and Applied Computer Science. Infants with birth weight lower than 1500 g were qualified for the study.

RESULTS

Between 1.01.2009 and 31.12.2009, 910 patients were registered, i.e. 19.1% of VLBW infants born in that period. The conducted analysis showed significant differences between centres in gestational age, birth weight, hospitalisation, use of invasive procedures, antibiotics and parenteral feeding. Cumulative morbidity rate was 68.5% total. Blood infection (sepsis) was the most commonly observed type of infection: 268 cases - 43.1% of all recorded forms of infection. Pneumonia was diagnosed in 242 cases, 38.8% total. NEC constituted 12.7% studied infections (79 cases). Apart from NEC, the risk of other forms of infection differed between centres. Dominant etiologic factor of all infections were Gram-positive cocci, which constituted 565 isolated microorganisms. Among them coagulase-negative staphylococci (CNS) were the most common (41.7%), while Staphylococcus aureus was fourth most frequent etiologic factor of infections (6.3% total).

CONCLUSIONS

1. Introduction of unified definition and criteria for diagnosing infections and the use of morbidity rates enables comparative analysis of epidemiology of infections in neonatal intensive care units. 2. Due to significant differences observed between prophylactic and therapeutic procedures in various units, it is essential to propose Polish recommendations regarding control over etiology of infections and use of invasive procedures, such as intravenous catheters and ventilation. 3. It is essential to undertake action leading to fully rational antibiotic therapy, because overuse of antibiotics leads to bacterial resistance and increases incidence of infections.

Infections reported in newborns with very low birth weight who required surgical treatment. Data from the Polish Neonatology Surveillance Network

AIM

To determine the risk of various forms of infections appearing in very low birth weight newborns (VLBW) during the period of 30 days after surgical treatment in hospitals which have perinatal care departments with neonatal intensive care units that form the Polish Neonatology Surveillance Network (PNSN).

MATERIAL AND METHODS

Continuous prospective monitoring of infections was carried out from January 1st to December 31st 2009 in six neonatal intensive care units which form the Polish Neonatal Surveillance Network. (PNSN). 910 newborns with very low birth weight (VLBW) were included in the study programme. 91 (10%) of this group underwent 118 surgical interventions. 12 newborns needed two or more surgeries. The most common procedure was the closure of persistent ductus artesiosus (PDA) and photocoagulation of vascular damage in the eye fundus.

RESULTS

In the period of 30 days after surgery the following were diagnosed: in 3 newborns - necrotizing enterocolitis (NEC), in 22 newborns - sepsis (BSI) and in 54 newborns - pneumonia (PNEU). Symptoms of BSI and PNEU were on average observed on the 10th day after surgical intervention, while in the case of NEC on the 17th day. The highest incidence of infection (148.4%) was observed after PDA closure and in connection with introducing a drain into the pleural cavity through the intercostal space. The incidence of PN EU (37.3%) was twice as high as the incidence of BSI (18.6%). Surgical procedure was a factor significantly increasing the risk of infection and morbidity (RR 2.1, P<001) In our investigations there was no case of the local infection of a surgical site. 11 newborns died (mortality was 12.1%). The most common bacterial strains found in our investigation were coagulase-negative Staphylococcus and Escherichia Coli.

CONCLUSIONS

Taking into consideration the fact that surgical procedure in VLBW-newborns significantly increases the risk of pneumonia and to a minor degree the risk of NEC and BSI, further detailed investigation in the field of perisurgical epidemiology is needed in order to elaborate a more deeply oriented and more effective strategy of infection prevention in the group of VLBW newborns.

[The use of therapeutic whole body cooling in treating hypoxic-ischemic encephalopathy in the newborn--the first case in Poland]

Hypoxic-ischemic encephalopathy (ENN) concerns neonates born after 35 completed weeks of gestation. The incidence rate has been shown to be 1-6/1000 births and can lead to significant permanent neurological damage, cerebral palsy and even death. Until the whole body cooling and selective brain cooling methods have been accepted, the treatment of children with ENN was only symptomatic. The article describes the first case of ENN neonatal treatment with the whole body hypothermia in Poland, which took place at the Department of Neonatology Poznań University of Medical Sciences. Currently both methods--whole body hypothermia and selective brain cooling--offer a chance for a normal neurological development and a better life for children born with ENN. Both methods are accessible in a few centers in Poland.

[The first application of therapeutic hypothermia in Poland--selective head cooling (Cool-Cap) with whole-body moderate hypothermia in a newborn with features of hypoxic ischemic encephalopathy]

The authors present the first application of therapeutic hypothermia in a newborn in Poland. The female newborn, born with severe asphyxia, was transported to a referral perinatal center where the method of brain cooling was possible. Severe hypoxic ischemic encephalopathy was confirmed by an integrated EEG. During the cooling procedure (which lasted 72 hours), no important side effects were noticed. The neurodevelopmental outcome of the baby assessed during the first 2 years of her life is normal.

[Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy]

Hypoxia-ischemia in the perinatal period is a serious condition affecting infants, which can result in death and cerebral palsy and associated disabilities. There has been significant research progress in hypoxic-ischemic encephalopathy over the last 2 decades. Many new molecular mechanisms of asphyxia have been identified. Despite all these advances, therapeutic interventions in HIE remain to be limited. Recently it has been revealed that mild therapeutic hypothermia is the only modality shown to improve neurologic outcome. The authors present a summary of pathogenesis of HIE, animal studies of cooling for hypoxic and ischemic models, and first publications on human therapeutic hypothermia trials. The diagnosis of encephalopathy in full-term neonates and enrollment criteria for hypothermia are also discussed. The current data from randomized control trials of hypothermia as neuroprotection for full and near-term infants are presented along with the results of meta-analyses of these trials. Finally the status of ongoing neonatal hypothermia trials as well as status of therapeutic hypothermia in Poland is summarized.

[Antibiotic consumption and its costs of purchase in Polish neonatology networks units]

AIM

The study presents the results of the analysis of antibiotic consumption and its direct costs in selected neonatal units.

MATERIAL AND METHODS

Data were collected retrospectively (the year 2007) in five hospitals, during the pilot phase of the Polish Neonatal Network . Antibiotic consumption was assessed using the Defined Daily Dose (DDD). The costs were assessed as the costs of purchase of one DDD.

RESULTS

The study included 11 922 children hospitalized in the period from 1.01 to 31.12.2007. In this group, 731 infants have birth weight < 1500 grams (from 2.2% to 64.2% in individual units, median--7.3%). The mean consumption of antibacterial drugs was 48.52 DDD/1 000 person-days (P-D) of stay among the entire study population (median--42,52), and varied from 23.13 to 85.82 DDD/1,000 P-D. However, this difference has not been statistically significant. The most commonly used group of antibiotics were beta-lactams--in four out of five units the percentage of its usage ranged from 48.71% to 74.67%. Next group were aminoglicosides--in one unit its usage reached 56.97% and in other ranged from 5.01% to 22.53%. Glycopeptides and macrolides were also used in every unit of the studied group. The usage of glycopeptides ranged from 1.7% to 10.81% and of macrolides from 1.32% to 15.71%. Different kinds of antibiotics were used occasionally. The differences of costs of purchase of one DDD between hospitals were greater and varied from 17,64 PLN/ DDD to 84,58 PLN/ DDD (average costs). A considerable range of costs index values was also noted for different groups of antibiotics. The costs of purchase of one DDD of beta-lactams varied from 19.54 PLN/ DDD to 68.35 PLN/ DDD; for aminoglicosides the cost varied from 4.61 PLN/ DDD to 122.9 PLN/ DDD, for glycopeptides--from 31.40 PLN/ DDD to 283.13 PLN/ DDD and in case of macrolides: from 12.05 PLN/ DDD to 90.77 PLN/ DDD. This differentiation of the cost of purchasing a single defined daily dose, taking into account the specific groups of antibiotics, did not have the characteristics of statistical significance.

CONCLUSIONS

As expected, the antibiotic regimens in the studied wards were similar. This is due to a homogeneous population of hospitalized patients. However, the differences of costs of purchase of antibiotics observed in the study, indicate the considerable variety of the treatment patterns in Polish neonatology units and the need to develop and implement recommendations of effective pharmacotherapy for patients in intensive neonatal care units and the implementation of a unified model of infections surveillance.

[Nonimmune hydrops fetalis associated with congenital small bowel atresia--a case study]

Nonimmune hydrops fetalis is observed with the frequency of 1:3000 cases diagnosed pre- and postnatally. In the following paper the authors analyzed the course of pregnancy complicated by fetal ascites and polyhydramnios with the appearance of colonic ileus and they presented the postnatal condition of the baby The preliminary diagnosis was confirmed after birth and the newborn was operated in the second day of his life. The congenital small bowel atresia was qualified as a III B type (Grossfeld qualification), which is called the "pagoda" syndrome [3]. The colonic atresia is located then around the superior mesenteric vessels, which leads to colonic necrosis (Figure 1).

[Obstetric consequences of uncontrolled gestational diabetes--a case study]

This paper presents a case of a pregnant woman who was admitted to the obstetrics and gynecology department because of a new onset of uncontrolled diabetes in 27 weeks gestation. The maternal and fetal diabetic complications suggested a chronic character of the disease which must have been undiagnosed before pregnancy. Many of the co-existing infections caused a life-threatening ketoacidosis. Fortunately with the adequate treatment it was possible to ensure appropriate birth weight of the newborn baby despite the ultrasound markers for LGA (Large For Gestational Age) observed during pregnancy. Intensive insulin therapy was obligatorily continued by the mother after the delivery.

[Are in-utero interventions justified? Perspective of neonatologists. Part III. Twin to Twin Transfusion Syndrome and Congenital Heart Defects]

INTRODUCTION

TTTS complicates from 10 to 15% of monochorionic diamniotic pregnancies. Expectant management is associated with 80 - 100% mortality First in-utero intervention in the fetus with CHD was performed in 1991. However only recently have they attained wider acceptance of cardiologists and perinatologists.

OBJECTIVE

Our main objective was to analyze the studies evaluating prenatal interventions in pregnancies complicated by TTTS or CHD, and to determine whether given the available data, those interventions are justified.

METHODS

Pubmed and Cochrane database were searched for all studies related to in-utero interventions in fetuses with TTTS or CHD. Emphasis was placed on randomized controlled trials.

RESULTS

Meta-analysis published in Cochrane database concludes that laser photocoagulation of communicating vessels improves outcome in all stages of TTTS. Additional studies are required to elucidate the role of amnioreduction. For interventions in fetuses with CHD published data is limited to the case series. Potentially selected patients with CHD would benefit from in-utero intervention, but additional studies are required.

CONCLUSIONS

Prenatal interventions in TTTS improve the outcome. Further studies are required to define their role in patients with CHD. For all procedures selection criteria and indications for interventions need to be clarified. More precise prenatal diagnosis and improvements in the area of fetal monitoring during the procedure might positively impact survival Preterm birth and premature rapture of membranes remain significant adverse outcomes. Complications associated with prematurity might counteract the positive effect of fetal intervention. Most cases of in-utero interventions should only be performed in specialized centers as a part of a clinical trial protocol.

[Are in-utero interventions justified? - perspective of neonatologists. - Part II. Spina bifida, obstructive uropathy, pleural effusion]

INTRODUCTION

Spina bifida, obstructive uropathy and congenital pleural effusion (PE) belong to the group of congenital defects in which attempts of in-utero treatment were undertaken.

OBJECTIVE

Main objective of our study was to search for scientific evidence that would justify offering, and performing, in utero interventions in fetuses with spina bifida, obstructive uropathy and PE.

METHODS

Using Pubmed as the main source, all publications relevant to the subject of in-utero interventions in fetuses with spina bifida, obstructive uropathy and PE were sought and carefully reviewed. An extra effort was made to identify all randomized controlled trials and meta-analyses.

RESULTS

Up to date, none of the aforementioned in-utero interventions was evaluated in the randomized controlled trial. Two ongoing studies, one for patients with spina bifida, and one for patients with obstructive uropathy are still actively recruiting the subjects. As suggested by the results of meta-analysis, vesico-amniotic shunt might be recommended for selected group of fetuses with obstructive uropathy. For fetuses with unilateral or bilateral PE, in-utero drainage seems to improve the outcome only in cases complicated by hydrops fetalis. However only case series are available.

CONCLUSIONS

Because of insufficient scientific evidence, offering in utero intervention to women with pregnancy complicated by spina bifida, obstructive uropathy and fetal PE on the routine basis is not justified. Until more data, preferably from randomized controlled trials are available, these procedures should only be performed in specialized centers as a part of carefully designed clinical trial.

[Are in-utero interventions justified?--perspective of neonatologists. Part I. Congenital diaphragmatic hernia (CDH)]

INTRODUCTION

In-utero interventions are often perceived by parents as the only hope for their unborn child. Because it is neonatologists who have to deal with a sick newborn and sometimes unrealistic optimism of the parents after delivery we have taken on the task of reviewing the current knowledge concerning fetal surgeries from the neonatologist's perspective. In the first of three parts we have analyzed the data for in-utero interventions for CDH.

OBJECTIVE

Our main objective was to evaluate available data and to ascertain whether performing fetal surgeries for CDH is justified.

METHODS

Review of available literature on the subject of in-utero interventions in the fetuses with CDH was performed. Pubmed and Cochrane library were searched for relevant publications, in particular for randomized controlled trials.

RESULTS

In randomized controlled trial (RCT), the in-utero intervention did not improve the outcome. The results of uncontrolled clinical trials suggest that it may be beneficial in cases with severe lung hypoplasia. The RCT testing the efficacy of the procedure performed later in pregnancy in moderately severe cases in currently under way

CONCLUSIONS

In-utero interventions might improve survival in a carefully selected group of patients with CDH. However the evidence to support this claim is not strong, and until more data is available, in-utero interventions for CDH should only be performed in specialized centers as part of controlled clinical trial.

Use of heliox in the management of neonates with meconium aspiration syndrome

BACKGROUND

Helium-oxygen mixture (heliox) ventilation has been known as an alternative treatment in patients with airway obstruction. Because of the physical properties of heliox, mechanical ventilation with this gas mixture may offer advantages in the management of respiratory failure associated with meconium aspiration syndrome (MAS).

OBJECTIVES

The purpose of this pilot study was to assess the effect of short-term mechanical ventilation with heliox in newborns with MAS on vital signs, oxygenation, acid-base balance and respiratory function parameters.

METHODS

The study was carried out in newborns with respiratory failure requiring mechanical ventilation due to MAS. Eight patients were ventilated using pressure-controlled synchronized intermittent mandatory ventilation. Parameters of respiratory function, oxygenation, acid-base balance and vital signs were recorded at baseline, then twice during 1 h of heliox ventilation and finally twice during 1 h after switching back to air-oxygen ventilation.

RESULTS

Mechanical ventilation with heliox did not affect vital signs and the infants' clinical condition remained stable during the study. Heliox ventilation was associated with a nonsignificant increase in tidal volume, minute ventilation and peak expiratory flow rate values. Mechanical ventilation with heliox allowed the use of significantly lower FiO(2), with a significant decrease in alveolar-arterial oxygen tension difference and a decrease in the oxygenation index which was not statistically significant. There was also a significant increase in the PaO(2)/FiO(2) ratio during heliox ventilation.

CONCLUSIONS

Ventilation with a helium and oxygen mixture had a positive effect on the selected parameters of oxygenation, while its effects on other respiratory parameters were relatively small.

Rates of bronchopulmonary dysplasia in very preterm neonates in Europe: results from the MOSAIC cohort

BACKGROUND

A considerable local variability in the rate of bronchopulmonary dysplasia (BPD) has been recorded previously.

OBJECTIVES

The objectives of the present study were to describe regional differences in the rate of BPD in very preterm neonates from a European population-based cohort and to further delineate risk factors.

METHODS

4,185 survivors to 36 weeks' postmenstrual age of 4,984 live-born infants born at 24+0-31+6 weeks' gestation in 2003 (the MOSAIC cohort) in 10 European regions were enrolled using predefined structured questionnaires.

RESULTS

Overall median gestational age of preterms without BPD was 30 weeks (range 23-31), median birth weight 1,320 g (range 490-3,150) compared with 27 weeks (23-31) and 900 g (370-2,460) in those with BPD. The region-specific crude rate of BPD ranged from 10.2% (Italian region) to 24.8% (UK Northern region). Maternal hypertension, immaturity, male gender, small for gestational age, Apgar <7 and region of care were associated with an increased incidence of BPD on multivariate analysis.

CONCLUSION

A wide variability of BPD between European regions may be explained by different local practices; the strongest association however was with degree of immaturity.

When you smoke your baby smokes: advancing maternal and child health through an academic alliance to improve health of mothers and their infants

The detrimental effect of tobacco exposure prior to conception and during pregnancy has been receiving much worldwide attention. Maternal smoking during pregnancy is associated with early-onset wheezing, increased respiratory illnesses, and a 2-fold increased risk for Sudden Infant Death Syndrome (SIDS). Adverse effects on the infant include altered infant behaviors such as an increased occurrence of infant colic or Attention Deficit Disorders (ADD). Studies have shown that a significant number of smoking woman "quit" smoking during pregnancy. However, a majority of women, 67% by 3 months and up to 90% by 6 month, resume smoking following delivery. An infant's birth related hospitalization is a "teachable moment" to address parental smoking, and to advocate for reducing fetal exposure to tobacco smoke. Academic alliance focused on well designed educative program can further increase rate of smoking free pregnant women and decrease smoking relapse rates significantly.

[Nicotine in infancy--QUIT for kids]

Environmental tobacco smoke (ETS) during pregnancy as well as during postnatal period has been shown to be potentially responsible for variety of diseases, including premature delivery, upper and lower respiratory illnesses, asthma or behavioral disturbances (colic, attention deficient disorders). It is estimated that up to 70 to 80% of children are exposed to ETS, and most often they are forced to inhale air contaminated by tobacco smoke in public places such as kindergartens, schools, play grounds, but also cars and in other forms of transportation. Nevertheless one of the most significant sources of nicotine and other toxicants of tobacco smoke is breast milk from the smoking mother, or even among mothers exposed to ETS. Lack of individual educational approach focused on prevention of ETS exposure by infants lead our academic collaboration and establishment of "The QUIT for kids" program.