Predicting resolution of hypoglycemia with and without dextrose infusion in newborn infant of gestational diabetic mothers.

Introduction: Neonatal hypoglycemia (NH) may lead to significant neurological impairment if left untreated. Infants of gestational diabetic mothers (IGDM) are at increased risk of early NH and need to be screened. However, it is challenging to predict management with or without intravenous dextrose once hypoglycemia is identified. We evaluated the association between hypoglycemia risk scores at 1-hour of life and the need for intravenous dextrose for hypoglycemia resolution in IGDM. Methods: This was a retrospective cohort study of IGDM born at a gestational age ≥35 weeks from January 2015 to December 2017. NH was the disease of interest. The outcomes were the association of hypoglycemia risk score (HRS) with and without intravenous dextrose for hypoglycemia resolution. Each infant's hypoglycemia risk score (HRS) was calculated using data extracted from the maternal and neonatal electronic medical records. Resolution of hypoglycemia with and without intravenous dextrose was compared between the low HRS (0-1) group and the high HRS (2-5) group. Results: Sixty-five infants were included in the study with a mean gestational age of 38.2 ± 1 weeks for low HRS and 38.0 ± 2 weeks for high HRS. While more children with high HRS were delivered by cesarean section (p = 0.04), hypoglycemia resolved more frequently without intravenous dextrose in infants with low HRS (p = 0.03). Conclusion: IGDM is at increased risk of NH. The resolution of hypoglycemia without dextrose infusion is frequently associated with low HRS at 1-hour of life. Early identification using HRS of IGDM whose hypoglycemia will resolve with or without intravenous dextrose may help clinicians triage newborns to either stay in the nursery or transfer for more invasive care.

Transcutaneous CO2 versus end-tidal CO2 in neonates and infants undergoing surgery: a prospective study.

Aim: End-tidal CO2 (EtCO2) is the standard in operative care along with pulse oximetry for ventilation assessment. It is known to be less accurate in the infant population than in adults. Many neonatal intensive care units (NICU) have converted to utilizing transcutaneous CO2 (tcPCO2) monitoring. This study aimed to compare perioperative EtCO2 to tcPCO2 in the pediatric perioperative population specifically below 10 kg, which encompasses neonates and some infants. Methods: After IRB approval and parental written informed consent, we enrolled neonates and infants weighing less than 10 kg, who were scheduled for elective surgery with endotracheal tube under general anesthesia. PCO2 was monitored with EtCO2 and with tcPCO2. Venous blood gas (PvCO2) samples were drawn at the end of the anesthetic. We calculated a mean difference of EtCO2 minus PvCO2 (Delta EtCO2), and tcPCO2 minus PvCO2 (Delta tcPCO2) from end-of-case measurements. The mean differences in the NICU and non-NICU patients were compared by t-tests and Bland-Altman analysis. Results: Median age was 10.9 weeks, and median weight was 4.4 kg. NICU (n=6) and non-NICU (n=14) patients did not differ in PvCO2. Relative to the PvCO2, the Delta EtCO2 was much greater in the NICU compared to the non-NICU patients (-28.1 versus -9.8, t=3.912, 18 df, P=0.001). Delta tcPCO2 was close to zero in both groups. Although both measures obtained simultaneously in the same patients agreed moderately with each other (r =0.444, 18 df, P=0.05), Bland-Altman plots indicated that the mean difference (bias) in EtCO2 measurements differed significantly from zero (P<0.05). Conclusions: EtCO2 underestimates PvCO2 values in neonates and infants under general anesthesia. TcPCO2 closely approximates venous blood gas values, in both the NICU and non-NICU samples. We, therefore, conclude that tcPCO2 is a more accurate measure of operative PvCO2 in infants, especially in NICU patients.

The Oro-Helical Length Accurately Predicts Endotracheal Tube Insertion Depth in Neonates.

We evaluated the reliability of the oro-helical length in predicting the ideal endotracheal tube depth in neonates and found the oro-helical length was a consistently more reliable and better predictor of the ideal endotracheal tube depth on chest radiograph than the 7-8-9 rule, especially in infants weighing ≤1500 g.

Epidemiological trends among preterm infants with apnea. A twelve-year database review.

OBJECTIVES: This study sought to characterize trends in the diagnosis of apnea, associated comorbidities and complications, and 30-day readmission rates in preterm singleton infants. SUBJECTS AND METHODS: The study design was a retrospective, longitudinal, observational study. 2003-2014 New York State Statewide Planning and Research Cooperative System and New York City Vital Statistics databases were merged identifying preterm live singleton births. Hospitalizations of preterm newborns with and without apnea were compared; multivariable logistic regression and log-linear Poisson regression models applied. RESULTS: Of 1,384,013 singleton births, 7.5% were identified as preterm. While relative risk of preterm birth rates declined (RR = 0.987, 95% CI = 0.982-0.991), the diagnosis of apnea increased significantly (RR = 1.069, 95% CI = 1.049-1.089). Multivariable analysis identified two apnea predictors, gastric reflux (OR = 3.19, 95% CI = 2.80-3.63) and early gestational age (OR = 0.83 for 1 week GA increase, 95% CI = 0.82-0.84). Preterm newborns with apnea were more likely to be readmitted within the first 30 days and total charges were 5.4 times higher. CONCLUSIONS: While the preterm birth rate has declined the rate of diagnosis of apnea with associated comorbidities and complications has increased. Given the additional findings of higher 30-day readmission rates and charges, more multidisciplinary research appears warranted to identify ways to optimize the quality of high risk newborn care.

One Less Painful Procedure: Using Umbilical Cord Blood as Alternative Source to Admission Complete Blood Count.

Objective This study aims to evaluate the use of umbilical cord blood as an alternative to the admission complete blood count (CBC) in the well-appearing late preterm neonates admitted to the neonatal intensive care unit. Study Design Paired umbilical cord and admission blood CBC samples from well late preterm infants were compared using a two-sample t-test or analysis of variance with an unequal variance for differences in the hemoglobin, platelet counts, white blood cell, and absolute neutrophil counts. Results A total of 100 infants were enrolled in the study. The study included 46 females, 5 Asian, 9 Black, 35 Hispanic, 51 White, with a mean gestational age of 35.3 ± 1 weeks (range: 34-36.5 weeks), and a mean birth weight of 2,347 ± 491 g (range: 1,840-4,260 g). Around 80% were appropriate for gestational age, 5% were large for gestational age, and 15% were small for gestational age. The median difference between the cord and admission blood samples were hemoglobin: 1.1 g/dL, platelet: 7.50 × 103 cells/µL, white blood cell count: 2.3 × 103 cells/µL, and absolute neutrophil count: 0.6 × 103 cells/µL. Conclusion The cord and admission blood testing were not statistically or clinically different when compared. In well late preterm infants, the NICU admission blood CBC may be replaced with an umbilical cord blood CBC.

Perinatal isolated atrial flutter associated with maternal cocaine and opiate use in a late preterm infant.

Atrial flutter is a serious form of neonatal tachyarrhythmia. Maternal drug use of cocaine and/or opiate is associated with central and autonomic nervous signs in fetuses and newborn infants. The fetal cardiovascular effects of cocaine and opiate exposure are not well characterized. We present the case of isolated atrial flutter in a late preterm infant who has been perinatally exposed to cocaine and opiate.

Serial head ultrasound studies in preterm infants: how many normal studies does one infant need to exclude significant abnormalities?

OBJECTIVE: We hypothesized that preterm infants with two normal head ultrasound (HUS) screening studies > or = 7 days apart would have subsequently normal follow-up studies. POPULATION: We reviewed reports of all HUS studies performed in preterm infants < or = 32 weeks gestation admitted to our nursery between January 1998 and July 2000. SETTING: Regional perinatal referral center. DESIGN: A normal HUS screening study was defined as either no findings; or grade I intraventricular hemorrhage (IVH) (Papile classification), germinal matrix irregularity or cyst, or normal but unequal ventricular size. An abnormal study was defined as any with IVH > or = grade II, periventricular leukomalacia (PVL), ventriculomegaly (VM), or periventricular echogenicity (PVE). RESULTS: Of 98 infants, 92 infants (94%) who had two normal HUS studies > or = 7 days apart had normal repeat studies subsequently, and six (6%) were abnormal. Four of the six abnormal infants were <25 weeks gestation at birth. One infant (27 weeks) became abnormal after culture-positive bacterial sepsis and necrotizing enterocolitis with bowel perforation requiring surgery. The remaining infant (29 weeks) had a question of PVE, and a normal repeat study. The positive predictive value for having a normal HUS after two previously normal studies > or = 7 days apart was 94% with a specificity of 86%. CONCLUSION: Stable premature infants > or = 25 weeks gestation without intervening deterioration may not need repeat screening HUSs after having had two normal studies > or = 7 days apart. Unstable or extremely premature infants <25 weeks gestation may be subject to late severe IVH, VM, and PVL, and therefore need a repeat study before hospital discharge, even if two initial studies > or = 7 days apart were normal.