Gastrointestinal perforations in neonatal period: experience over 10 years.

AIM: This report describes our experience concerning gastrointestinal perforation due to necrotizing enterocolitis during a 10-year period. METHOD: The cases of 27 gastrointestinal perforations, which were treated in our hospital, were retrospectively reviewed. RESULTS: All patients were neonates and infants up to the age of 2 months. The study population consisted of 16 boys (59.3%) and 11 girls (40.7%). Twenty-one neonates (77.8%) were preterm, and the median gestational age was 28 weeks. Twenty-four cases (88.9%) of perforation underwent laparotomy. The overall mortality was 63%. Seventy-six percent of the preterm neonates and only 16.7% of the full-term neonates died. CONCLUSIONS: Gastrointestinal perforation is still connected with a high mortality rate, with necrotizing enterocolitis being the main cause of death. The neonates who did not undergo surgery all died.

Quantitative ultrasound measurements in premature infants at 1 year of age: the effects of antenatal administered corticosteroids.

The aim of this study was to evaluate the effects of antenatally administered glucocorticoids on bone status of preterm infants at 1 year corrected age. The study population consisted of 32 preterm infants with a gestational age of 24-34 weeks. The infants were divided into two groups according to antenatal exposure to corticosteroids. Quantitative ultrasound (QUS) assessment of bone was performed in the study infants at the corrected age of 1 year. Blood levels of carboxy-terminal propeptide of type I procollagen (PICP) and carboxy-terminal telopeptide of type I collagen (ICTP) were measured at birth and at 1 year corrected age. Levels of PICP and ICTP were significantly lower at birth in corticosteroid-exposed neonates (P < 0.05). At corrected age of 12 months ICTP levels remained significantly lower in corticosteroid-exposed infants, but we found no significant difference in levels of the bone-formation marker PICP between corticosteroid-exposed and nonexposed infants. In the majority of participant preterm infants bone speed of sound (SOS) was within age-adjusted normal values of full-term infants. There was no significant difference in bone SOS between exposed and nonexposed infants at corrected age of 12 months. There was no correlation between SOS and levels of bone markers. The results of our study indicate that, despite the suppression of fetal bone turnover at birth in corticosteroid-exposed infants, antenatal glucocorticoid treatment seems to have no long-term impact on bone status of preterm infants assessed by QUS complementary to measurement of bone-turnover markers at 1 year corrected age.

Circulating concentrations of α- and ß-chemokines in neonatal sepsis.

BACKGROUND: Despite advances in neonatal care, sepsis remains a threat, in particular for premature neonates, due to immature immunologic defense. Deficient chemotaxis, an essential process in the host response to pathogens, may contribute to this vulnerability. In this study we investigated chemokine expression in septic premature and term neonates. METHODS: Seventy-one neonates with signs and symptoms suggestive of systemic infection, requiring full sepsis evaluation and treatment, formed the study group; 58 neonates without sepsis served as the control group. Serum concentrations of two α-chemokines (GRO-α and ENA-78) and two ß-chemokines (RANTES and MIP-1α) were measured at day 0 and day 3-5 of infection in the study group, and on the day of inclusion in the study in the control group. RESULTS: During infection, serum levels of GRO-α in the study group were higher and serum levels of RANTES were lower as compared to those of the control group (p<0.001 and p<0.001, respectively). Furthermore, levels of GRO-α were higher and levels of RANTES were lower on day 0 as compared to levels on day 3-5 (p<0.001 and p<0.001, respectively). Chemokine serum concentrations on day 3-5 in the study group did not differ significantly as compared to those of the control group. Term and preterm infants seemed to respond similarly regarding chemokine expression. No significant differences were found in serum levels of MIP-1α and ENA-78. CONCLUSIONS: Our findings suggest up-regulation of GRO-α and down-regulation of RANTES at the onset of a septic episode, similar to the response pattern observed in septic adults. Both term and preterm neonates appear to have the potential to elicit a chemotactic response to infection.

Outcome of toxoplasmosis acquired during pregnancy following treatment in both pregnancy and early infancy.

OBJECTIVES: Congenital toxoplasmosis is associated with clinical dilemmas as untreated infants may have a guarded prognosis and as treatment may induce severe side effects. The aim of this study was to investigate the outcome of infants born to mothers with toxoplasmosis acquired during pregnancy, following administration of appropriate regimens both during pregnancy and early infancy. STUDY DESIGN: All 35 infants, born to mothers with toxoplasmosis acquired during pregnancy, and referred to the major Neonatal Department in Crete, Greece, during the 7-year period 1997-2003 were included. All neonates were evaluated soon after birth and on a regular follow-up. RESULTS: Almost all mothers received spiramycin from diagnosis through labor and 2 received pyrimethamine and sulfadiazine. At birth, infants had IgG antibody titers ranging from 1/1,350 to 1/109,350. All infants initially received pyrimethamine, sulfadiazine and folinic acid but in only 4 cases treatment was continued beyond the second month of life. Transient neutropenia was commonly observed. A follow-up period of 1.2-8.2 years did not reveal any remarkable sequelae. CONCLUSIONS: Our findings suggest that effective treatment both during pregnancy and early infancy is safe and may contribute to a good outcome of infants born to mothers with toxoplasmosis acquired during pregnancy.

Methicillin-resistant Staphylococcus aureus osteomyelitis and septic arthritis in neonates: diagnosis and management.

Acute osteomyelitis (AO) in neonates, although rare, represents a diagnostic and therapeutic challenge. A high index of suspicion is necessary to make an early diagnosis, and the observation of clinical signs is crucial. The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) is an emerging problem in pediatrics. In neonates, MRSA infections can cause a wide spectrum of diseases including bone and joint infections. We report two cases of AO in full-term neonates, with no risk factors, due to MRSA.

Levels of bone collagen markers in preterm infants: relation to antenatal glucocorticoid treatment.

Although the beneficial effects of antenatally administered glucocorticoids are well documented, data on the potential of adverse consequences are limited. The objective of this study was to determine the effects of antenatally administered glucocorticoids on biochemical markers of bone metabolism of 55 preterm infants with a gestational age of 24-34 weeks who were enrolled in the study. Neonates were divided into two groups according to antenatal exposure to corticosteroids. There were no significant differences between the groups in clinical characteristics and anthropometric variables. We studied blood levels of osteocalcin (OC), carboxy-terminal propeptide of type I procollagen (PICP), and carboxy-terminal telopeptide of type I collagen (ICTP) at the time of delivery, on postnatal day 10, and at 2 and 4 months of life. Comparing the groups, we found statistically significant reduction in PICP levels at birth in corticosteroid-exposed neonates (P < 0.05). The levels of bone markers increased progressively on the first days of life. There were no significant differences between groups in bone markers at 10 days or at 2 and 4 months of life. We found no significant difference for bone markers between groups of infants exposed to single or repeated maternal corticosteroid treatments. In summary, antenatal glucocorticoid treatments are suggested to have a negative impact on fetal bone formation as reflected by low PICP levels at birth. However, this negative effect on bone markers seems to be a temporary effect that subsides on the first days of life and afterward.

Significance of hypocarbia in the development of periventricular leukomalacia in preterm infants.

BACKGROUND: Despite rapid advances in the management of preterm infants, periventricular leukomalacia (PVL) remains a considerable problem in neonatal intensive care. The aim of this study was to determine whether hypocarbia is associated with the development of PVL in mechanically ventilated, preterm infants and to emphasize the importance of avoiding this disturbance. METHODS: The authors evaluated 52 mechanically ventilated infants with a gestational age of <34 weeks, who exhibited hypocarbia in the first three postnatal days (lowest carbon dioxide tension being <25 mmHg). These infants were then compared with 52 infants in a control group not exhibiting hypocarbia, matched for birthweight and gestational age. A diagnosis of PVL was made on the basis of the results of cranial ultrasonography. Confounding factors potentially associated with the development of PVL were controlled in logistic regression analyses. RESULTS: Of the 52 mechanically ventilated preterm infants with hypocarbia, 10 (19.2%) developed cystic PVL, and six (11.5%) developed periventricular echodensity. Of the 52 infants in the control group only two (3.8%) developed cystic PVL, and one (1.9%) infant developed periventricular echodensity. The authors observed no significant differences in other prenatal and perinatal risk factors between the two groups. CONCLUSION: Hypocarbia in mechanically ventilated preterm infants during the first days of life is suggested as being an independent predictor of PVL, predisposing these infants to subsequent neurodevelopmental delay.

Feeding difficulties in a neonate with primary cricopharyngeal achalasia treated by cricopharyngeal myotomy.

Primary cricopharyngeal achalasia resulting from failure of relaxation of the cricopharyngeus muscle is a rare but significant cause of dysphagia in newborns. Symptoms may be nonspecific. Although surgical management with cricopharyngeal myotomy has been employed successfully for the treatment of this disorder, swallowing difficulties may persist postoperatively, probably due to association with other esophageal abnormalities. Alternative methods of feeding may be required to ensure adequate nutrient intake. We report the case of a full-term, 2-day-old neonate with this rare clinical condition, treated by myotomy, in whom swallowing difficulties persisted for several weeks after surgery. Satisfactory nutrition was maintained postoperatively with the support of a nasogastric feeding tube until improvement in feeding intolerance. Complete symptomatic relief was attained at the age of 5 months.

Peroneal nerve palsy: a complication of umbilical artery catheterization in the full-term newborn of a mother with diabetes.

Umbilical artery catheters are an essential aid in the treatment of newborn infants who have cardiopulmonary disease. However, it is well-known that umbilical artery catheterization is associated with complications. The most frequent visible problem in an umbilical line is blanching or cyanosis of part or all of a distal extremity or the buttock area resulting from either vasospasm or a thrombotic or embolic incidence. Ischemic necrosis of the gluteal region is a rare complication of umbilical artery catheterization. We report the case of a full-term infant of an insulin-dependent diabetic mother with poor blood glucose control who developed a left peroneal nerve palsy after ischemic necrosis of the gluteal region after umbilical artery catheterization. The infant was born weighing 5050 g. The mother of the infant had preexisting diabetes mellitus that was treated with insulin from the age of 14 years. The metabolic control of the mother had been unstable both before and during the pregnancy. The neonate developed respiratory distress syndrome soon after birth and was immediately transferred to the neonatal intensive care unit. Mechanical ventilation via endotracheal tube was quickly considered necessary after rapid pulmonary deterioration. Her blood glucose levels were 13 mg/dL. A 3.5-gauge umbilical catheter was inserted into the left umbilical artery for blood sampling without difficulty when the infant required 100% oxygen to maintain satisfactory arterial oxygen pressure. Femoral pulses and circulation in the lower limbs were normal immediately before and after catheterization. A radiograph, which was taken immediately, showed the tip of the catheter to be at a level between the fourth and fifth sacral vertebrae. The catheter was removed immediately. Circulation and femoral pulses were normal and no blanching of the skin was observed. Another catheter was repositioned and the tip was confirmed radiologically to be in the thoracic aorta between the sixth and seventh thoracic vertebrae. The catheter was continuously flushed with heparinized solution. Three days after umbilical arterial catheterization, bruising was observed over the left gluteal region. The catheter was immediately removed despite its correct position. Over the next few days, the bruised skin and underlying tissues became necrotic. The area affected was 3 x 4 cm in diameter, with central necrosis surrounded by a rim of dark, red skin, which, in turn, was sharply demarcated from normal skin by a narrow, pale zone. Surgical excision of the gluteal necrosis was performed, but a deep ulcer 3 cm in diameter was left. The gluteal ulcer required 1 month to heal completely with extensive scar tissue formation. Throughout this period, the infant showed active movements in all of her limbs. At 4 weeks of age deterioration of all movement below the left knee with a dropping foot was observed. Severe peroneal nerve palsy was confirmed through nerve conduction studies, and there was electromyographic evidence of degeneration of the muscles supplied by the peroneal branch of the sciatic nerve. A Doppler study, which was also conducted, revealed no vascular damage. Treatment with physiotherapy and night-splinting of the left ankle was instituted. Repeated examination and nerve conduction tests at 3 months showed slow improvement with the left peroneal nerve remaining nonexcitable. At the time of this writing, the infant is 6 months old, and muscular strength below the left knee is still weak and atrophic changes in the form of muscle-wasting are already present. The rest of her motor development is normal. In our case, gangrene of the buttocks and sciatic nerve palsy followed displacement of the tip of the catheter into the inferior gluteal artery, a main branch of the internal iliac artery supplying the gluteus maximus, the overlying skin, and the sciatic nerve. The gangrenous changes were probably caused by vascular occlusion resulting from catheter-induced vasospasm of the inferior gluteal artery. Sciatic nerve palsy associated with umbilical artery catheterization has been postulated to be caused by vascular occlusion of the inferior gluteal artery. Infants of diabetic mothers may exhibit changes in coagulation factors and be at increased risk of thrombotic complications in utero and postnatally. In addition, maternal diabetes mellitus is associated with an increased incidence of congenital abnormalities, the incidence of which is 3 to 5 times higher than that among nondiabetic mothers. Although no particular or specific abnormalities have been associated with maternal disabilities, abnormalities of the cardiovascular system, including the development of umbilical vessels, frequently occur. This complication of umbilical artery catheterization has not been widely reported. We describe the first case that refers to gluteal gangrene and peroneal nerve palsy after umbilical artery catheterization of a newborn infant of a diabetic mother with poor blood glucose control. It should be noted that there were no contributing factors except that of the displacement of the catheter into the inferior gluteal artery. We speculate that the displacement of the tip of the catheter, with no difficulty in the present case, was associated with the maldevelopment of normal branching patterns of arteries after exposure of the fetus to hyperglycemia. In conclusion, umbilical artery catheterization is possibly associated with vascular occlusion, particularly in infants of diabetic mothers. Frequent inspection after the procedure has been performed is of the utmost importance especially in these neonates who often suffer from cardiopulmonary disease and require catheterization of their umbilical artery.