Assessment of splanchnic hemodynamics in neonates at risk of necrotizing enterocolitis

It has been suggested that either acute or chronic intestinal ischemia may play a primary role in the initiation of mucosol injury and subsequently the development of necrotizing enterocolitis [NEC]. Hence, this study aimed at assessment of gut blood flow in neonates at risk of developing NEC and to determine whether a disturbance in splanchnic perfusion could provide not only a pathophysiological basis for the development of NEC but also a mechanism linking a variety of seemingly disparate risk factors. Addingly, changes in splanchnic circulation with increasing postnatal age were evaluated. Duplex pulsed Doppler ultrasound was used to study changes in gut blood flow velocities during the first week of life in neonates at risk of developing NEC admitted to NICU of Obsteric and Gynecology Department, Ain Shams University Hospitals. This case-control study comprised 127 neonates [61 males and 66 females], their mean gestational age was 35.0 +/- 4.3 weeks and their mean birth weight was 2.35 +/- 0.63 kg. They were classified into 4 groups : 2 control groups [preterms [n=21] and fullterms [n=41]] and 2 patient groups recognized as being at risk of developing NEC [at risk preterms [n=30] and at risk fullterms [n=35]]. They were subjected to history taking, clinical examination, laboratory investigations relevant to the diagonosis on admission, radiological evaluation including chest and abdominal x-rays and echocardiography. Duplex pulsed Doppler ultrasound was used to determine blood flow velocities in coeliac axis [CA] and superior mesentric aretry [SMA] in all studied groups. Subjects were studied on the first, second, third, and seventh days of life. The results of the current study showed that the mean peak systolic velocities [PSVs] in the SMA were lower in the at risk groups than in the control groups on all 4 days of measurements [p<0.001]. In contrast to the SMA, PSVs of CA increased significantly in the at risk groups compared to their controls [p<0.001]. The ratio of PSV in the CA to that in the SMA, an index of relative downstream resistance in the SMA, was significantly greater in the at risk groups than in the control groups on days 1, 2 and 3 [p< 0.001]. PSVs of SMA tended to increase over the first week of life in control groups. On the other hand, the increase in PSVs of SMA was delayed in the at risk groups In conclusion, these data demonstrate that neonates at risk of developing NEC have abnormal gut blood flow velocities and splanchnic perfusion is severely compromised. Hence, alteration in the splanchnic circulation may be an important factor in the final common pathway of different risk factors of NEC and the liver could be considered as the fourth preferential organ for arterial blood supply in the compromised neonate, besides heart, brain and adrenals. Therefore, serial Doppler measurements are mandatory for early detection and prediction of NEC

Clinical significance of serum prolactin level in neonatal seizures

Researches on more economical and practical methods for the differential diagnosis of seizures are required. Prolactin is the most specific neurohormone that is elevated after seizures in adults and children. The possibility that serum prolactin could be used as an epileptic marker in neonates is attractive because an ictal EEG recording is not always available. Therefore, this study aimed at determination of the clinical usefulness of serum prolactin as a diagnostic aid in neonatal convulsions and its relation to etiology, type and duration of seizures. The present study was conducted on 35 term neonates with neonatal convulsions [patients group] recruited from the NICU of Obstetric and Gynecology Department, Ain Shams University. Their mean birth weight was 3.45 +/- 0.42 kg and their mean gestational age was 38.63 +/- 1.29 weeks. Thirty-five healthy neonates were chosen to serve as a control group. Each neonate in the patients group had at least one clinically observed seizure. Seizures were diagnosed clinically and EEG confirmation was not required. Postictal serum prolactin levels were obtained at 30 minutes, 24 hours and 72 hours [recovery level] after the seizures using ELISA technique. The ratio of 30 minutes postictal prolactin level to recovery level [prolactin ratio] was used as an indicator of postictal prolactin increase. The results of the current study showed that etiologic diagnoses included were hypoxic-ischemic encephalopathy [HIE] [40%] followed by neonatal sepsis [31.4%], intracranial hemorrhage [ICH] [14%], hypoglycemia [8.6%] and hypocalcemia [6%]. Serum prolactin level was significantly higher [P<0.01] at 30 minutes postictally in the patients with seizures than in control group and this value started to decline after 24 hours and became insignificant at 72 hours postictally. Additionally, postictal serum prolactin levels were significantly higher in tonic and clonic convulsions and in seizures due to hypoxia as compared to controls. Moreover, 24 hours postictal serum prolactin level was significantly higher than 30 minutes postictal level in both tonic and myoclonic convulsions. Postictal serum prolactin levels correlated negatively with Apgar score at 5 minutes and the mean prolactin ratio in the patients group was 2.41 +/- 1.80 denoting a marked postictal prolactin elevation. In conclusion, postictal serum prolactin levels increased significantly during the 24 hours following seizures in neonatal seizures especially with tonic and clonic types and mostly due to hypoxia. Therefore, postictal serum prolactin level may be helpful in the differentiation of seizures as well as providing important information about their etiology particularly when continuous EEG monitoring is not possible. In addition, prolactin ratios may be used to assess more accurately the phenomenon of postictal hyperprolactinemia

Lipofuscin; a new lipid peroxidation marker among jaundiced neonates with oxygen free radical induced diseases

This study was an attempt to investigate the lipid peroxidation represented by lipofuscin in correlation to some serum antioxidants levels such as vitamins A and E, ceruloplasmin and bilirubin in jaundiced neonates suffering from oxygen free radical induced diseases [ORD] in comparison to a control group. This case-control study was conducted in the NICU, Gynecology and Obstetric Department, Ain Shams University Hospitals in the period from December 1999 to January 2002. This study included 107 jaundiced neonates diagnosed as necrotizing enterocolitis, chronic lung disease, hypoxic-ischemic encephalopathy and neonatal sepsis [ORD Patients group]. They were classified into two subgroups: subgroup I, [51 term and preterm babies] with non pathological level of bilirubin i.e not needing interference and subgroup II, [56 newlyborn term and preterm infants] with pathological level of bilirubin i.e needing interference. One hundred and seven apparently healthy neonates were enrolled in this study as a control group. The results of this study revealed that the mean serum levels of vitamins A and E, ceruloplasmin, and hemoglobin were highly significantly decreased while, the mean serum lipofuscin and bilirubin levels were highly significantly increased in the ORD patients group compared to controls [p

Early onset neonatal sepsis, rule out viral infection

This cross-sectional prospective study was an attempt to define the frequency of viral infections in early onset neonatal sepsis. It was conducted on 260 septic neonates with different diagnoses who had been admitted to Neonatal Intensive Care Unit, affiliated to Obstetric and Gynecology Department, Ain Shams University Hospitals throughout one year from November 2001 to October 2002. Their mean gestational age was 35.9 +/- 3.7 weeks, their mean birth weight was 2.4 +/- 1.08 kg and their mean postnatal age was 12.35 +/- 10.34 days. They included 148 males and 112 females. The results of this study revealed that 49 out of 260 septic neonates [19%] were diagnosed as virus infected using different cell cultures. Seven viruses were identified by indirect fluorescent antibody tests [IFA] which were in order of frequency; cytomegalovirus [5%], respiratory syncytial virus [3.4%], Echo-11 [3.1%], Echo-14 [2.7%], Coxsackie B5 [2.7%], mumps [1.2%] and parainfluenza type 3 [0.8%]. Most of virus infected cases presented with low Apgar score, low or very low birth weight, prematurity, jaundice, peticheal rash, in addition to signs of sepsis. Meanwhile, respiratory viruses [respiratory syncytial virus, parainfluenza virus] were the major pathogens among respiratory distressed infants, enteroviruses, cytomegalovirus and mumps were implicated in neonates with multiple congenital malformations. Cytomegalovirus was the most prevalent single virus isolated. Thirteen cases out of 260 septic neonates proved to be CMV positive. 77% were congenitally acquired, while 23% were postnatally acquired. These neonates presented with various clinical presentations, the most common were prematurity [85%], very low birth weight [62%], jaundice [54%] and hepatosplenomegaly [46%], meanwhile congenital malformations were recorded in 23% of cases [microcephaly, congenital hernia and congenital cataract]. Mortality rate was 46%. It is concluded from this study that viral infection is significantly implicated in the etiopathogenesis of neonatal sepsis. So, this study should raise the awareness of the neonatologists for the diagnosis and anticipation of the potential implications of virus infection on the subsequent growth and development of the newborn infants.

Cytomegalovirus load among Egyptian newborn infants admitted to the neonatal intensive care unit: new perspective

CMV transmission is very hazardous to neonates whether due to its severe congenital form or the latent effects of this virus. The aim of the study was to assess CMV load among Egyptian newborn infants admitted to the NICU, to clarify the risk factors for CMV transmission and to set clinical criteria for suspicion of this viral infection among such neonates. This cross-sectional prospective study included 260 neonates admitted to the NICU of the Gynecology and Obstetric hospital, Ain Shams University. Each enrolled case was subjected to detailed history taking laying stress on the socioeconomic st and ard, maternal diseases such as infection, fever, premature - rupture of membranes and past history of any abortion, neonatal deaths or affected newborns. APGAR score at 1 and 5 minutes, their birth weights and skull circumferences were assessed. Thorough clinical examination including assessment of gestational age was done together with regular follow up of the clinical course of the neonates during their NICU admission for a mean postnatal age of 12.35 +/- 10.34 days. In addition to the routine laboratory investigations and the sepsis screen, peripheral blood samples and nasopharyngeal secretions were taken from all the studied neonates on their first and fifth day of life for viral isolation using human fibroblasts cell line culture. Indirect Fluorescent Antibody [IFA] test was carried out for the identification of isolated CMV virus. The present study revealed positive viral culture in 49 cases, 13 of which were confirmed CMV by IFA. Ten of the CMV positive cases were detected in the first day sample [prenatally acquired] and the other three were detected in the fifth day sample which denotes either perinatal or community acquired infection. In all, 84.6% of the CMV positive cases were delivered prematurelv and 61.5% were IDM. Clinical examination showed that 53.9% of them had MCA, 53.9% had jaundice, 46.2% had rash and 38.5% had enlarged lymph nodes, 30.8% were hypothermic, 23.1% had poor peripheral perfusion, 7.7% were pale and 7.7% were cyanosed. Systemic examination revealed that 46.2% had HSM and 23.1% had abdominal distension. As regards the neurological manifestations, 30.8% had hyporeflexia while 15.4% had hyperreflexia, 38.5% were hypotonic while 15.4% were hypertonic and 15.4% suffered from tonic convulsions. A cardiac murmur was heard in 15.4% and inguinal hernia was detected in 7.7%. In conclusion, CMV acquisition especially the congenital form represent a significant problem among newborn Egyptian infants who may be asymptomatic or present with various manifestations ranging from mild to fetal illness. Thus increasing awareness of this viral infection, its ways of transmission, risk factors for neonatal acquisition and its mode of presentation are m and atory to prevent its neonatal as well as the delayed hazards

Neonatal neutrpenia associated with pregnancy induced hypertension and cord blood granulocyte colony stimulating factor

Neutropenia is frequently observed in neonates born to mothers with pregnancy induced hypertension [PIH]. Though transient, it may be a leading cause of early neonatal sepsis. Hence, prophylactic exogenous hematopoietic factors are currently tried. However. Causes of this neonatal neutronenia [NN] and its relation to the endogenous production of these factors are still obscure, therefore we aimed to study granulocyte colony stimulating factor [G-CSF] among other determinants of NN in this population. The present study included 92 neonates; 52 born to normotensive mothers and 40 neonates with maternal PIH. Gestational age [GA] and birth weight [BW] were assessed with clinical evaluation of all studied neonates at birth and after 72 hours to rule out infection. Cord blood absolute neutrophil count [ANC] and levels Of G-CSF [as measured by ELISA] were studied. Neonates born to mothers with PIH had significantly [P<0.05] lower ANC than control newborns. ANC was significantly [P<0.01] lower in neonates with GA <32 weeks as compared to those >32 weeks. Values of ANC were significantly positively correlated with BW [P<0.05]. Neonatal neutropenia [ANC <1.5 x 10[9]/ L] was observed in 35% of infants born to mothers with PIH being moderate to severe [ANC< 1x10[9] / L] in 25%. Of these neonates with moderate to severe NN, 90% were of low BW and 60% were preterms of GA less than 32 weeks. Mean value of cord blood G-CSF [126.3 +/- 99.6 pg/L] was significantly [P<0.001] lower in all babies of mothers with PIH than control [283.9 +/- 221.7 pg/L]. A significant positive correlation was noted between ANC and G-CSF [P<0.05] in FT neonates. Neonates whose GA<32 weeks showed significantly increased frequency of moderate to severe neutropenia [66.7%] compared to other GA groups [13.3% and 12.5% in those born after 37 weeks and those born between 33 and 36 weeks, respectively] [p<0.05]. The least reported mean cord blood G-CSF in this study [79.3 +/- 31.14 pg /L] was encountered in neonates whose GA<32 weeks and who exhibited NN that approached severity [mean ANC: 0.59 +/- 0.21 x 10 [9]/L]. Early neutropenia may be noted in neonates born to mothers with PIH. It may be related to reduced serum G-CSF especially in LBW and in those with increased degree of prematurity. This population may be suitable c and idates for recombinant human G-CSF [rh G-CSF] therapy