Neonatal frontal lobe: sonographic reference values and suggested clinical use.

BACKGROUND: Intraventricular hemorrhage (IVH) and post-hemorrhagic hydrocephalus (PHHC) remain major problems among premature infants. The need, timing and type of ventricular drainage are based on sonographic ventricular measures, without assessment of the dimensions of the frontal lobe. The aim of our study was to establish new reference values for sonographic frontal lobe cortico-ventricular thickness (FL-CVT) in a large cohort of infants. METHODS: All normal head ultrasound scans that were performed in our center during the first 4 days of life between January 2014 and December 2016 were retrospectively evaluated. RESULTS: Scans were evaluated and plotted to create a reference range for the thickness of the frontal lobe in normal infants of 24-40 weeks' gestation. The FL-CVT increased significantly during gestation. Calculating the area under the curve of the FL-CVT in 9 infants with post-hemorrhagic-hydrocephalus (PHHC) reveals a 20% mean loss of FL-CVT. The impact of increasing ventricular dilatation and of the various ventricular drainage procedures on the frontal lobe growth were described in two infants demonstrating the potential clinical value of this tool. CONCLUSIONS: Head ultrasound provides a simple, non-invasive method for measuring the thickness of the frontal lobe, which grows significantly between 24 and 40 weeks' gestation. In premature infants with PHHC, we suggest the use of the FL-CVT measure, in addition to ventricular size measures, as a direct assessment of the impact of the enlarged ventricles on the surrounding brain parenchyma. This could assist in the management of PHHC and determine the need and optimal timing for intervention.

Experience with intramuscular glucagon for infants with early neonatal hypoglycemia.

Parenteral options for treating neonatal hypoglycemia (NH) include: intramuscular (i.m.) glucagon or intravenous (i.v.) glucose 10%. So far, the role of i.m. glucagon in treating NH has not been adequately assessed. We retrospectively studied 236 neonates with NH. One hundred and twenty-one infants received oral glucose-fortified-milk-based formula (OGFM) and their blood glucose level (BGL) was maintained thereafter. Two groups of infants required intervention: (a) OGFM + i.m. glucagon (n = 77, 32.6%) and (b) OGFM + i.v. glucose bolus (n = 38, 16.1%). BGL1, BGL2 and BGL3 denote pre-treatment BGL, 2-2.5 h post-treatment and BGL within 2.5-4 h post-treatment; respectively. The two groups were compared regarding two outcome measures: Outcome no. 1: BGL2 ≥ 45 mg/dL and outcome no. 2: BGL3 ≥ 45 mg/dL. Compared to i.v. glucose, the i.m. glucagon group had significantly more infants with BGL2 ≥ 45 mg/dL (40% vs. 76%, p = 0.028), and marginal significant difference regarding BGL3 ≥ 45 mg/dL (62% vs. 77%, p = 0.08). Univariate analysis showed that i.m. glucagon, male gender, vacuum extraction, cesarean delivery and one or more NH risk factors were significantly associated with outcome measure no. 1. I.m. glucagon, small for gestational age status, cesarean delivery, BGL1 and NH risk factors were associated with outcome measure no. 2. Multi-variate analysis showed that i.m. glucagon was significantly and independently associated with BGL2 ≥ 45 mg/dL. I.m. glucagon is worth consideration as a treatment option for NH.

Optimizing Accessibility of a Hand-wash Gel to Infant's Cradle: Effect on Neonatal Conjunctivitis.

BACKGROUND: In our recent study in 2015, we showed a significant relationship between increased rate of clinical neonatal conjunctivitis (CNC) and performance of eye red reflex examination. Our study aim was to assess whether improved accessibility of staff to disinfectant gel (via attaching the gel bottle to infant's cradle) will increase the caring staff compliance with hand hygiene and decrease the rate of CNC. METHODS: Our intervention included attaching bottles of alcohol-based gel to newborns' cradles to ensure full availability and accessibility of hand-wash disinfectant. We included all newborn infants who were born beyond 35 weeks' gestation and stayed in the well-baby nursery. We compared 2 periods: pre-intervention period (n = 9380) versus an intervention period (n = 8087). Three variables were recorded: (1) rate of CNC: number of conjunctival swabs sampled per 1000 newborns whenever an eye discharge was noted, (2) rate of bacterial conjunctivitis: number of positive swabs per 1000 newborns and (3) percentage of positive swabs out of all sampled swabs. RESULTS: Compared with pre-intervention period, the rate of CNC dropped significantly during the intervention period: 28.6/1000 versus 21.3/1000, respectively, P < 0.01. However, the number of positive bacterial swabs per 1000 newborns (3.2 vs. 2.5) and the percentage of positive bacterial swabs of all sent samples (11.6% vs. 10.8%) were not different between the 2 periods. The majority of pathogens in swabs were Gram-negative sp. without difference between study periods (77.4% vs. 80%), respectively. Univariate analysis showed significant association between rate of CNC and longer length of stay >5 days (P < 0.001) and vaginal delivery. Logistic stepwise regression analysis showed that 4 variables were significantly and independently associated with higher rate of clinical conjunctivitis. These include birth during pre-intervention period [P = 0.018, odds ratio (OR) = 1.27, 95% confidence interval (CI): 1.04-1.54], length of stay 4-5 days (P < 0.001, OR = 2.23, CI: 1.63-3.06), length of stay >7 days (P < 0.001, OR = 6.51, CI: 4.24-10.02), vaginal delivery (P = 0.004, OR = 1.6, CI: 1.17-2.2) and male gender (P = 0.006, OR = 1.31, CI: 1.08-1.59). CONCLUSIONS: Accessibility of a disinfectant gel within each newborn's cradle raised hygiene awareness among the caring staff and contributed to the reduction of CNC rate in the newborn nursery.

Less is More: Modern Neonatology.

Iatrogenesis is more common in neonatal intensive care units (NICUs) because the infants are vulnerable and exposed to prolonged intensive care. Sixty percent of extremely low-birth-weight infants are exposed to iatrogenesis. The risk factors for iatrogenesis in NICUs include prematurity, mechanical or non-invasive ventilation, central lines, and prolonged length of stay. This led to the notion that "less is more." In the delivery room delayed cord clamping is recommended for term and preterm infants, and suction for the airways in newborns with meconium-stained fluid is not performed anymore. As a symbol for a less aggressive attitude we use the term neonatal stabilization rather than resuscitation. Lower levels of oxygen saturations are accepted as normal during the first 10 minutes of life, and if respiratory assistance is needed, we no longer use 100% oxygen but 0.21-0.3 FiO2, depending on gestational age and the level of oxygen saturation. We try to avoid endotracheal ventilation by using non-invasive respiratory support and administering continuous positive airway pressure early on, starting in the delivery room. If surfactant is needed, non-invasive methods of surfactant administration are utilized. Use of central lines is shortened, and early feeding of human milk is the routine. Permissive hypercapnia is allowed, and continuous non-invasive monitoring not only of the O2 but also of CO2 is warranted. "Kangaroo care" and Newborn Individualized Developmental Care and Assessment Program (NIDCAP) together with a calm atmosphere with parental involvement are encouraged. Whether "less is more," or not enough, is to be seen in future studies.

Hyperthyroxinemia at birth: a cause of idiopathic neonatal hyperbilirubinemia?

BACKGROUND: Some neonates develop idiopathic hyperbilirubinemia (INHB) requiring phototherapy, yet with no identifiable causes. We searched for an association between abnormal thyroid levels after birth and INHB. METHODS: Of 5188 neonates, 1681 (32.4%) were excluded due to one or more risk factors for hyperbilirubinemia. Total thyroxine (TT4) and thyroid stimulating hormone values were sampled routinely at 40-48 hours of age and measured in the National Newborn Screening Program. RESULTS: Of the 3507 neonates without known causes for hyperbilirubinemia, 61 (1.7%) developed INHB and received phototherapy. Univariate analyses found no significant association between mode of delivery and INHB (vacuum-delivered neonates were a priori excluded). Nonetheless, in cesarean-delivered (CD) neonates, two variables had significant association with INHB: TT4 ≥ 13 µg/dL and birth at 38-38.6 weeks. In vaginally delivered (VD) born neonates, INHB was associated with weight loss > 7.5% up to 48 hours of age. Multivariate logistic regression analysis showed a strong effect of mode of delivery on possible significant association with INHB. In CD neonates, such variables included: TT4 ≥ 13 µg/dL [P = 0.025, odds ratio (OR) 5.49, 95% confidence interval (CI) 1.23-24.4] and birth at 38-38.6 weeks (P = 0.023, OR 3.44, 95% CI 1.19-9.97). In VD neonates, weight loss > 7.5% (P = 0.019, OR 2.1, 95% CI 1.13-3.83) and 1-min Apgar score < 9 (P < 0.001, OR 3.8, 95% CI 1.83-7.9), but not TT4, showed such an association. CONCLUSIONS: INHB was significantly associated with birth on 38-38.6 week and TT4 (≥ 13 µg/dL) in CD neonates, and with a weight loss > 7.5% in VD neonates. We herein highlight some acknowledged risk factors for neonatal hyperbilirubinemia, and thus minimize the rate of INHB.

Standards of admission capillary blood glucose levels in cesarean born neonates.

BACKGROUND: Neonatal hypoglycemia (NH) and cutoffs remain undefined. Our center screens all cesarean-delivered (CD) neonates for NH. We sought to define standards of admission capillary blood glucose levels (ACBGLs) in CD neonates who were at the lowest risk for hypoglycemia. METHODS: Of 4947 neonates, 519 met all 14 inclusion criteria. These highly-selected neonates were apparently the healthiest, least-stressed, earliest to be admitted to nursery and at lowest-risk for hypoglycemia. For each CD, cord blood gases and glucose were determined and each infant was screened for blood glucose at nursery admission. RESULTS: Sampling age was 41.6±15.3 minutes, a mean ACBGL of 52.3±10.7 mg/dL, and percentiles as follows: 1st percentile, 29.2; 3rd, 33.6; 5th, 35.0; 10th, 39.0; 25th, 46.0; 50th, 51.0; 75th, 58.0; 90th, 67.0; 95th, 71.0; 97th, 73.0, and 99th, 84.4. ACBGL rose significantly with increasing gestational age (P=0.004), increasing cord blood glucose (P<0.001), decreasing cord blood pH (P<0.001) and decreasing sampling age (P=0.027). CONCLUSIONS: Setting uniform ACBGL cutoffs for NH definition is unachievable due to the enormous heterogeneity among newborns. Hence, we provide group-based ACBGL standards in CD neonates. We propose setting ACBGL cutoffs for use in CD neonates: 1) hypoglycemia: ACBGL <5th percentile (<35 mg/dL); and 2) interventional hypoglycemia: ACBGL <1st percentile (<30 mg/dL).

Hypothyroxinemia and Risk for Transient Tachypnea of Newborn.

Transient tachypnea of newborn is associated with hypothyroxinemia in animals via decreased stimulation of beta-adrenergic receptors and Na-K-ATPase activity. In 26 549 term neonates, serum total thyroxine <14 ug/dL, male sex, and elective cesarean delivery were significantly associated with greater risk for transient tachypnea of newborn.

Erythromycin Prophylaxis for Neonatal Conjunctivitis: Ointment Versus Drops.

BACKGROUND: Due to a shortage of individualized erythromycin ointment (IEO), we switched to shared erythromycin drops (SED). Following this change, nurses claimed observing more cases of eye discharge. OBJECTIVES: To test whether switching from IEO to SED affected the rate of neonatal conjunctivitis (NC). METHODS: The study group included 14,916 neonates > 35 weeks of gestation, further divided into two birth periods of 12 months each: 1 January 2013 to 31 December 2013 (IEO) and 1 February 2014 to 31 January 2015 (SED). We compared the two birth periods with regard to three variables: clinical NC (number of conjunctival swabs/1000 neonates), bacterial NC (number of culture-positive swabs/1000 neonates), and bacterial growth percentage (number of culture-positive swabs/100 samples). RESULTS: Compared to 2012-2013, the period 2014-2015 included fewer cesarean deliveries and shorter length of stay (LOS). Clinical NC, bacterial NC and bacterial-growth percentage were not different between the two periods. Variables that were independently significantly associated with increased clinical NC included male gender (OR 1.48, CI 1.21-1.81) and LOS (OR 1.24, CI 1.18-1.29). LOS was associated with bacterial NC (OR 1.19, CI 1.11-1.28). Coagulase-negative staphylococci, Escherichia coli and Pseudomonas aeruginosa were the prevalent pathogens, though without difference between periods. CONCLUSIONS: Rates of clinical NC, bacterial NC and bacterial-growth percentage were not different between the study periods. Switching from IEO to SED had no effect on the NC rate.

Performing red reflex eye examinations increases the rate of neonatal conjunctivitis.

AIM: Red reflex eye examinations often require opening the eyelids, risking infection. We evaluated links between this procedure and neonatal conjunctivitis. METHODS: We divided 18 872 neonates of more than 35 weeks of gestation into two birth periods, 2008-2009 and 2010-2011, before and after red reflex examinations were carried out by our facility. The rates of clinical conjunctivitis, bacterial conjunctivitis and bacterial growth percentage were compared between the two periods. RESULTS: The 2010-2011 period included more Caesarean deliveries and longer lengths of stay (LOS) than the 2008-2009 period. The clinical conjunctivitis rate increased significantly during 2010-2011 (p = 0.029), but the bacterial conjunctivitis and bacterial growth percentages did not differ between the two periods. Variables that were independently and significantly associated with clinical conjunctivitis included being born in 2010-2011, with an odds ratio (OR) of 1.22, male gender (OR 1.31) and LOS (OR 1.19). Bacterial conjunctivitis was associated with vaginal delivery (OR 3.65), males delivered by Caesarean (OR 2.68) and LOS (OR 1.37). CONCLUSION: Clinical conjunctivitis was significantly associated with the later study period, male gender and LOS. Conjunctival swab sampling increased significantly following the implementation of red reflex examinations, but without changes in the bacterial conjunctivitis rate and the bacterial growth percentage.

[The effect of maternal medications, hypertension/pre-eclamptic toxemia and diabetes mellitus on neonatal hearing screening].

BACKGROUND: The effects of maternal medications and disease on neonatal hearing screening have scarcely been investigated. OBJECTIVE: To verify the effect of maternal medications and disease during gestation on the results of the first otoacoustic emissions (OAE) test. METHODS: We recorded perinatal and hearing screening data, medications during pregnancy and Labor (119 kinds of medication), hypertension/pre-eclamptic toxemia (HTN/PET) and diabetes mellitus (DM). RESULTS: Of the 2306 infants studied, 214 (9.3%) failed the first OAE test. Vaginal delivery (VD) and cesarean delivery (CD) infants were analyzed separately. Multivariate logistic regression analysis showed: Independently significant variables associated with failed first OAE in VD infants included: Birth weight (BW) >4000g [OR 2.2 (1.1-4.3) p=0.026]; decreasing age at first OAE [OR 0.31 (0.17-0.6) p<0.001] and maternal DM [OR 2.2 (1.0-4.84) p=0.049]. The findings for CD infants were: male gender [OR 1.91 (1.24-2.96) p=0.004); decreasing age at first OAE [OR 0.34 (0.21-0.55) p<0.001]; maternal HTN/PET [OR 2.3 (1.22-4.3) p=0.01 and small-for-gestational-age (SGA) status [OR 2.9 (1.1-7.56) p=0.03]. CONCLUSION: Increased failure on first OAE occurs in VD infants with BW >4,000g, early first OAE and DM; and in CD infants with male gender, early first OAE, HTN/PET and SGA status. It is yet to be determined whether postponing of first OAE beyond 48 hours of age will allow the reduction of false positive results on first OAE.

Impact of gestational age on neonatal hearing screening in vaginally-born late-preterm and early-term infants.

BACKGROUND: Late-preterm and early-term (LP-ET) infants, defined herein as 35(0)-37(6) weeks' gestation, often fail on 1st otoacoustic emissions (OAE) test. HYPOTHESIS: LP-ET infants fail more than term infants (38(0)-42 weeks' gestation) on the 1st OAE test. Aim : To evaluate the effect of gestational age on the 1st OAE test. METHODS: We studied 1,572 vaginally-delivered (VD) infants ≥35 weeks' gestation (1.1.2011-30.9.2011). Perinatal and neonatal variables and results of OAE tests were recorded. RESULTS: LP-ET infants, compared to full-term infants, had a significantly 2-fold higher need for repeated hearing tests: 80.2 versus 43.3 tests/1,000 neonates, respectively (p = 0.026). Univariate analysis showed that late prematurity and age at 1st OAE were significantly associated with failure on 1st OAE. At age 24-42 h, failure on 1st OAE was 2-fold higher in the LP-ET infants than in full-term infants: 9.4 versus 4.7% (p = 0.02). Risk for failure on 1st OAE was age-dependent: 9-fold higher when 1st OAE was performed at 24-42 h of age (5.3%) versus 0.6% after age 42 h. Multivariate analysis showed that variables that were independently significantly associated with failure on 1st OAE included late prematurity (OR 2.0 (1.1-3.7)) and age at 1st OAE (OR 9.2 (1.2-70.7)). CONCLUSIONS: Compared to term infants, VD LP-ET infants had 2-fold higher rates of failure on 1st OAE (up to 42 h of life) and needed repeated hearing tests. Failure rates after 42 h become negligible in both groups. In VD LP-ET infants, 1st OAE is better performed after 42 h of age.

Triplet pregnancies--a three-decade perspective: do we fare better?

OBJECTIVES: To evaluate the impact of advances in perinatal and neonatal care in the past three decades on the outcome of triplet pregnancies. STUDY DESIGN: We compared the outcome of 29 sets of triplets born in our medical center during 1978-1987 with 34 sets of triplets born in the same medical center during 2001-2011. Data were extracted from maternal and neonatal medical records. RESULTS: There were no significant differences in mortality or morbidity in any of the studied outcome measures between the two epochs. Of the 34 women with triplet pregnancies in the present cohort only 28 (82%) took all three born babies home, not different from the 86% found in the early cohort. The overall take-home baby rate was 93% (95/102) in the present cohort, not different than the 86% (74/86) in the early cohort. CONCLUSIONS: Despite technological advances in perinatal and neonatal care, there was no significant improvement in the outcome of triplet pregnancies during the past three decades.

Delayed first otoacoustic emissions test decreases failure on neonatal hearing screening after caesarean delivery.

AIM: Caesarean delivery (CD) was associated with a 3.2-fold higher failure on 1st otoacoustic emissions (OAE) hearing test. We aimed to verify whether postponing 1st OAE beyond 48 h in CD infants decreases hearing screening failure. METHODS: We compared two groups of CD infants as to failure on 1st OAE test: early-1st OAE (n = 560): 1st OAE at 12- to 48-h-olds and late-1st OAE (n = 566): 1st OAE at 48- to 132-h-olds. RESULTS: Compared with early-1st OAE group, the failure rate among late-1st OAE infants was significantly sixfold lower (20.5% vs. 3.4%), with sixfold lower need for repeated tests: 205 vs. 34 tests/1000 CD neonates (p < 0.001). The failure rate decreased with increasing age in both groups (p < 0.001). Univariate analysis: timing of 1st OAE (late vs. early) was significantly associated with failure on 1st OAE. Multivariable analysis: late (48-132 h) 1st OAE test was associated with a 7.7-fold lower risk for failure of 1st OAE, OR (95% CI): 0.13 (0.08-0.21). CONCLUSION: Among CD infants, the risk for failure in late-1st OAE group (>48 h) was 7.7-fold lower, with a sixfold lower need for repeated hearing tests. Delaying 1st OAE in CD infants beyond 48 h of age (preferably between 48 and 132 h) decreases neonatal OAE screening failure.