The Anesthetic Modality but Not the Mode of Delivery Seem to Modulate the Methylation Status of Cyclooxygenase-2 Promoter of the Newborns.

OBJECTIVE: Cesarean section (CS) rates are high. Epidemiological data supports increased risk of inflammatory conditions in the offspring born by CS. Epigenetic alterations occurring during the perinatal period may account for this risk. Cyclooxygenase-2 (COX2) has strong implications for inflammatory diseases. The methylation of COX2 of newborn infants was compared with respect to their mode of delivery. STUDY DESIGN: Ninety healthy term infants born by vaginal delivery (VD), planned cesarean section (PCS), or emergency CS (ECS) were recruited (30 infants in each group). For obstetric anesthesia, local (LA), regional (RA), or general (GA) anesthesia were used. Carefully selected exclusion criteria were implemented to eliminate any confounders with potential epigenetic effects. Umbilical artery blood samples were collected. Demographic and clinical characteristics, folate and CRP levels, and mean methylation levels of the COX2 gene promoter were determined. RESULTS: Except the birth weight and maternal age parameters, VD, PCS, and ECS were similar. The methylation percentage of COX2 was higher in ECS (16.9 ± 5.1) than VD (14.5 ± 4.1) and PCS (14.8 ± 2.9), albeit p was 0.064. Because of the dual anesthetic modality populations (RA and GA) in PCS and ECS and the recent literature on anesthetics and epigenetics, the anesthetic modality groups were also analyzed. The methylation percentage of COX2 was significantly different between LA, RA, and GA groups (14.5 ± 4.1, 13.9 ± 2.8, and 17.0 ± 4.6, respectively, p = 0.012). CONCLUSION: When the mode of delivery is the question of debate, the anesthetic modality should be remembered as an important epigenetic modulator. KEY POINTS: · Perinatal period is a vulnerable time period for epigenetic modulations.. · The mode of delivery is influential in any potential epigenetic alterations occurring perinatally.. · The obstetric anesthetic modality should be remembered as an important epigenetic modulator..

The prevalence and diagnostic criteria of health-care associated infections in neonatal intensive care units in Turkey: A multicenter point- prevalence study.

BACKGROUND: Healthcare-acquired infections (HAIs) in the neonatal period cause substantial morbidity, mortality, and healthcare costs. Our purpose was to determine the prevalence of HAIs, antimicrobial susceptibility of causative agents, and the adaptivity of the Centres for Disease Control and Prevention (CDC) criteria in neonatal HAI diagnosis. METHODS: A HAI point prevalence survey was conducted in the neonatal intensive care units (NICUs) of 31 hospitals from different geographic regions in Turkey. RESULTS: The Point HAI prevalence was 7.6%. Ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections (CLABSI) and late onset sepsis were predominant. The point prevalence of VAP was 2.1%, and the point prevalence of CLABSI was 1.2% in our study. The most common causative agents in HAIs were Gram-negative rods (43.0%), and the most common agent was Klebsiella spp (24.6%); 81.2% of these species were extended spectrum beta-lactamase (ESBL) (+). Blood culture positivity was seen in 33.3% of samples taken from the umbilical venous catheter, whereas 0.9% of samples of peripherally inserted central catheters (PICCs) were positive. In our study, 60% of patients who had culture positivity in endotracheal aspirate or who had purulent endotracheal secretions did not have any daily FiO2 change (p = 0.67) and also 80% did not have any increase in positive end-expiratory pressure (PEEP) (p = 0.7). On the other hand, 18.1% of patients who had clinical deterioration compatible with VAP did not have endotracheal culture positivity (p = 0.005). CONCLUSIONS: Neonatal HAIs are frequent adverse events in district and regional hospitals. This at-risk population should be prioritized for HAI surveillance and prevention programs through improved infection prevention practices, and hand hygiene compliance should be conducted. CDC diagnostic criteria are not sufficient for NICUs. Future studies are warranted for the diagnosis of HAIs in NICUs.

Is Nasal Septum-Tragus Length Measurement Appropriate for Endotracheal Tube Intubation Depth in Neonates? A Randomized Controlled Study.

OBJECTIVE: Endotracheal intubation is a frequent procedure performed in neonates with respiratory distress. Clinicians use different methods to estimate the intubation insertion depth, but, unfortunately, the improper insertion results are very high. In this study, we aimed to compare the two different methods (Tochen's formula = weight in kilograms + 6 cm; and nasal septum-tragus length [NTL] + 1 cm) used to determine the endotracheal tube (ETT) insertion depth. STUDY DESIGN: Infants who had intubation indications were enrolled in this study. The intubation tube was fixed using the Tochen formula (Tochen group) or the NTL + 1 cm formula (NTL group). After intubation, the chest radiograph was evaluated (above T1, proper place, and below T2). RESULTS: A total of 167 infants (22-42 weeks of gestational age) were included in the study. The proper tube placement rate in both groups was similar (32.4 vs. 30.4% for infants < 34 weeks of gestational age and 56.8 vs. 45.0% in infants > 34 weeks of gestational age). The ETT was frequently placed below T2 at a higher rate in infants with a gestational age of <34 weeks, especially in the NTL group (46% in the Tochen group and 60.7% in the NTL group). CONCLUSION: The NTL + 1 cm formula led to a higher rate of ETT placement below T2, especially in infants with a birth weight of <1,500 g. Therefore, more studies are needed to determine the optimal ETT insertion depth.

Sustained lung inflation at birth via short binasal prong in very low birth weight preterm infants: A retrospective study.

BACKGROUND AND OBJECTIVES: It is believed, that sustained lung inflation (SLI) at birth in preterm infants reduces the need for mechanical ventilation (MV) and improves respiratory outcomes. The aim of this study was to compare need for MV in preterm infants at high risk for respiratory distress syndrome (RDS) after prophylactic SLI via short binasal prongs at birth combined with early nasal continuous positive airway pressure (nCPAP) versus nCPAP alone. METHODS: Medical records of infants born at 260/7 to 296/7 weeks gestation through 2015 and 2017 were retrospectively assessed. Infants who get sustained inflations at 25 cmH2 O pressure for 15 s following delivery via binasal short prongs comprised the study group. Gestational age matched infants who was supported solely with nCPAP (6 cmH2 O PEEP) comprised the control group. Early rescue surfactant (200 mg/kg poractant alfa) was delivered using the less invasive surfactant administration technique in infants with established RDS. RESULTS: A total of 215 infants were analyzed. Fewer infants in the SLI group required MV within the first 72 h of life compared to the control group (25.7% vs 56.9%, P < 0.001). In multiple logistic regression analysis, SLI emerged as an independent factor for reduced MV need. Bronchopulmonary dysplasia (BPD) incidence including mild BPD was significantly lower in the SLI group (31.9% vs 48%, P = 0.01); however, moderate and severe BPD rates did not reach to a statistical significance (11.5% vs 20.6%, P = 0.06). CONCLUSION: Prophylactic SLI maneuver at birth for preterm infants with impending RDS reduces the need for MV with no adverse effects.

Turkish Neonatal Society guideline on prevention and management of bronchopulmonary dysplasia.

Scientific and technological advances in perinatology and neonatology have led to an increased rate of survival and decreased incidences of various neonatal morbidities. However, the incidence of bronchopulmonary dysplasia has remained almost the same for years in very-low-birth-weight preterm infants. Although bronchopulmonary dysplasia is the leading cause of chronic respiratory morbidity in small preterms, no substantial improvement has been achieved in prevention and treatment strategies to date. Currently, postnatal very-low-dose corticosteroids, caffeine, and vitamin A seem to be the drugs of choice, and stem cell therapy appears to be the most promising treatment modality for the future. In this guideline, which was prepared by the Turkish Neonatal Society, recent evidence-based recommendations for the prevention and treatment of bronchopulmonary dysplasia are summarized.

Utilizing Infant Cry Acoustics to Determine Gestational Age.

OBJECTIVES/HYPOTHESIS: The date of last menstruation period and ultrasonography are the most commonly used methods to determine gestational age (GA). However, if these data are not clear, some scoring systems performed after birth can be used. New Ballard Score (NBS) is a commonly used method in estimation of GA. Cry sound may reflect the developmental integrity of the infant. The aim of this study was to evaluate the connection between the infants' GA and some acoustic parameters of the infant cry. STUDY DESIGN: A prospective single-blind study was carried out. METHODS: In this prospective study, medically stable infants without any congenital craniofacial anomalies were evaluated. During routine blood sampling, cry sounds were recorded and acoustic analysis was performed. Step-by-step multiple linear regression analysis was performed. RESULTS: The data of 116 infants (57 female, 59 male) with the known GA (34.6 ± 3.8 weeks) were evaluated and with Apgar score of higher than 5. The real GA was significantly and well correlated with the estimated GA according to the NBS, F0, Int, Jitt, and latency parameters. The obtained stepwise linear regression analysis model was formulized as GA=(31.169) - (0.020 × F0)+(0.286 × GA according to NBS) - (0.003 × Latency)+(0.108 × Int) - (0.367 × Jitt). The real GA could be determined with a ratio of 91.7% using this model. CONCLUSIONS: We have determined that after addition of F0, Int, Jitt, and latency to NBS, the power of GA estimation would be increased. This simple formula can be used to determine GA in clinical practice but validity of such prediction formulas needs to be further tested.

The effect of lactational mastitis on the macronutrient content of breast milk.

AIMS: Mastitis in lactating mothers reduces milk production and alters the cellular composition of milk. Changes occurring in the mammary gland during the inflammatory response are believed to increase the permeability of the blood-milk barrier. This study examined the effect of mastitis during lactation on the macronutrient content of breast milk. METHODS: The study was conducted at Zekai Tahir Burak Maternity Teaching Hospital. Transitional breast milk samples were obtained from term lactating mothers with or without mastitis. Milk protein, fat, carbohydrate, and energy levels were measured using a mid-infrared human milk analyzer. RESULTS: The study recruited 30 term lactating mothers: 15 mothers diagnosed with mastitis and 15 healthy mothers. The characteristics of the mothers in both groups were similar. Fat, carbohydrate, and energy levels were statistically lower in the milk samples of mothers with mastitis compared with the mothers without mastitis. CONCLUSION: Lactational mastitis was associated with lower breast milk fat, carbohydrate, and energy levels. The local inflammatory response induced by cytokines and increased blood-milk barrier permeability might account for the changes in the fat, carbohydrate, and energy levels of human milk.

Effect of dopamine infusion on thyroid hormone tests and prolactin levels in very low birth weight infants.

OBJECTIVE: To evaluate the effect of dopamine on thyroid hormone tests and prolactin (PRL) and to assess requirement for L-thyroxin (LT4). METHODS: The infants (n = 102) were divided into three groups (Group 1; received no dopamine, Group 2 received ≤25 mg/kg cumulative dose and Group 3; received >25 mg/kg cumulative dose). Blood samples were taken at 6-8 days (timepoint 1), 13-15 days (timepoint 2), and 4-6 weeks of life (timepoint 3). RESULTS: Respiratory distress syndrome was higher in group 2 and 3. Patnet ductus arteriosus was higher in group 3 than in groups 1 and 2. Duration and cumulative dose in group 3 were higher than group 2. There was no difference between thyroid hormones that were taken after stopping infusion at timepoint 3 among all groups. No therapy with LT4 was needed. PRL levels were higher at timepoint 1 in group 1 than compared to group 2 and 3 (p < 0.05), and no difference between group 2 and 3 (p > 0.05). This difference was disappeared at following timepoints. CONCLUSIONS: The release of TSH, FT3, FT4 and PRL were not inhibited and prophylactic thyroid hormone treatment was not required in VLBW infants receiving dopamine infusions.

The changing pattern of perinatal mortality and causes of death in central Anatolian region of Turkey.

In this study, the perinatal mortality is presented in 2009 compared to 1998. Changing patterns of the perinatal mortality rate (PNMR), the stillbirth rate (SBR), early neonatal mortality rate (ENMR) and the causes of the perinatal mortality in Zekai Tahir Burak Women's Health Education and Research Hospital (ZTBH) were described. This is the largest maternity hospital of Ankara in the central Anatolian region of Turkey. The total deliveries were 22,777 and 18,567 in 1998 and 2009, respectively. PNMR was 27.7 per 1000, and SBR was 23.7 per 1000 total births. ENMR was 4 per 1000 in 1998. PNMR is 20.7 per 1000, and SBR was 16.3 per 1000 and ENMR was 4.6 per 1000 total births in 2009. It is important to know the causes of mortality. In this study, the causes of perinatal deaths were classified according to the Wigglesworth classification. Antepartum stillbirth (62.3%) was the most frequent cause in 1998. Perinatal asphyxia is the majority (46.6%) of the perinatal deaths in 2009. This study shows that even prenatal care is getting better, obstetric care as well as close follow-up throughout the intrapartum period and diminishing the preterm delivery rate is also important for preventing and reducing perinatal mortality.

Isolated macrodystrophia lipomatosa of the foot in a neonate: a case report.

Macrodystrophia lipomatosa characterized by enlargement of one or more fingers or toes with predominantly fibroadipose tissue can be part of an overgrowth syndrome such as Proteus syndrome (Biesecker, 2006) or CLOVES syndrome (Sapp et al., 2007; Alomari, 2009) or found as an isolated abnormality in an otherwise normal patient. It maybe present at birth or occur in early infancy with a progressive course. Here, we report a case of macrodystrophia lipomatosa (MDL) diagnosed in the neonatal period in a baby who had no other apparent problems on follow-up.

Total antioxidant capacity and total oxidant status after surfactant treatment in preterm infants with respiratory distress syndrome.

BACKGROUND: Oxidative damage is important in the pathogenesis of respiratory distress syndrome (RDS). However, data on the effect of surfactant therapy on oxidative stress in vivo are limited. We aimed to evaluate the oxidant/antioxidant status in preterm infants with RDS via measurement of total antioxidant capacity (TAC) and total oxidant status (TOS), to determine the effect of surfactant on oxidant/antioxidant balance and to assess the association between TAC, TOS and clinical outcomes of the patients. METHODS: Sixty-nine infants with RDS were included. Blood samples for determining TAC and TOS were collected before and 48 h after surfactant treatment. TAC and TOS levels were analysed in serum. Patients were followed up until discharge or death. RESULTS: Post-surfactant TAC levels were significantly higher than pre-surfactant TAC levels (P = 0.029). TAC/TOS ratio significantly increased after surfactant treatment (P = 0.018). Infants <28 weeks of gestational age had lower levels of baseline TAC than those ≥28 weeks of gestational age (P = 0.020), whereas TOS levels were similar. Baseline TAC/TOS ratio was lower in infants who died in the study period than those who survived (P = 0.023). After controlling gestational age, baseline TAC levels were significantly and inversely correlated with the duration of total respiratory support (r = -0.343; P = 0.009) and hospitalization (r = -0.341; P = 0.009). TAC or TOS levels were not associated with the development of bronchopulmonary dysplasia or other complications as determined during the investigation period. CONCLUSIONS: Oxidant-antioxidant balance shifts in favour of the antioxidant system after surfactant treatment. Lower TAC/TOS ratio in preterm infants may be associated with increased mortality.

Serum amyloid-A levels in neonatal necrotizing enterocolitis.

We aimed to evaluate serum levels of serum amyloid-A (SAA) both in the diagnosis and monitoring the treatment response of necrotizing enterocolitis (NEC). Forty-five preterm neonates were enrolled in the study, including 15 infants with NEC, 15 with sepsis, and 15 healthy preterm infants. Pre- and posttreatment serum SAA levels were measured. Among patients with NEC, 11 had stage 1 and 4 had stage 2 disease according to the modified Bell's staging criteria. Baseline SAA levels of the infants with NEC were significantly higher than controls (P=0.013) and were significantly lower than those with sepsis (P=0.004). When infants with stage 1 and stage 2 NEC were analyzed separately, baseline SAA levels of the infants with stage 2 NEC were significantly higher than controls (P=0.027) than those with stage 1 NEC (P=0.018), but similar to those with sepsis. There was a trend that baseline SAA levels were also correlated with the Bell stage (r=0.501, P=0.057). Posttreatment SAA levels significantly decreased in infants with sepsis (P=0.002). Pre- and posttreatment SAA levels were similar in patients with stage 1 and 2 NEC. In conclusion, SAA rises in early stages of NEC and may aid in diagnosis as a serum marker.

C-reactive protein and interleukin-6 responses for differentiating fungal and bacterial aetiology in late-onset neonatal sepsis.

Fungal infections are increasingly frequent causes of neonatal sepsis (NS). This study examined the predictive value of the combined evaluation of the C-reactive protein (CRP) and interleukin-6 (IL-6) responses for differentiating fungal and bacterial aetiologies in patients with NS. From January to September 2007, neonates who were diagnosed with NS and had their CRP and IL-6 levels measured were selected. Based on their blood culture results, the neonates were divided into two groups: group of fungal sepsis (FS) and group of bacterial sepsis (BS). FS included 14 Candida albicans and one non-albicans Candida isolates and BS included five Klebsiella pneumoniae, three Pseudomonas aeruginosa, three Enterococcus faecalis, two coagulase-negative Staphylococcus species, one Enterococcus faecium and one Acinetobacter species. Significant differences were observed in the CRP (FS vs. BS: 28.10 ± 11.03 vs. 11.39 ± 2.94 mg l(-1), P = 0.026) and IL-6 (FS vs. BS: 38.60 ± 24.24 vs. 392.82 ± 102.46 ng l(-1), P = 0.000) levels between groups. The combined evaluation of the CRP and IL-6 responses better predicted the causative micro-organism in NS.

Dealing with pandemic influenza A during postpartum and early neonatal period in a busy family-centered neonatal intensive care unit.

Although most infections with the current pandemic H1N1 virus have been self-limited, the risk of influenza complications is higher in some subpopulations. Pregnant women had an increased risk of influenza complications in two past epidemics (1918-1919 and 1957-1958). Since neonates do not have a well-developed immune system, they are also vulnerable to viral infections and its complications. This article reports the interventions and health care planning strategies for pandemic influenza A, and its seasonal results in a tertiary perinatal care center with annually 20,000 deliveries.

Phrenic nerve injury due to thoracentesis for TPN effusion in a preterm newborn: consecutive two unusual complications.

Central venous catheters ara commonly used in neonatal intensive care units as routes of parenteral nutrition. Pleural effusions caused by extravasation of parenteral alimentation fluid are a rare complication of central venous catheters in the newborn. Diaphragmatic paralysis due to phrenic nerve injury is a rare respiratory condition which may be life-threatening in infants.

Enterocutaneous fistula secondary to purpura fulminans in a preterm infant.

Enterocutaneous fistula in newborns and preterms is a well-recognized complication after necrotizing enterocolitis and abdominal surgical procedures/percutaneous interventions. However, to our knowledge, enterocutaneous fistula associated with purpura fulminans has not been reported before. Herein we report a preterm infant with purpura fulminans who developed cutaneous necrotic lesions on anterior abdominal wall. Adherence of necrotic abdominal skin to the adjacent intestinal wall resulted in enterocutaneous fistula. The patient was treated conservatively with bowel rest and antibiotics. The fistula was surgically closed 2 months later.