Enterovirus Infection in Preterm Quadruplets with Clinical Presentation of Neonatal Late-Onset Sepsis: a Case Report.

This is the unusual case of concurrent late-onset sepsis caused by enteroviruses in preterm quadruplets in a neonatal ward. While viral infections are an important differential diagnosis of bacterial sepsis in the outpatient setting, the occurrence in a neonatal ward with strict prophylactic hygiene measures is unusual. In this case, transmission of enteroviruses via breast milk appears possible.

[Pregnancy and Irreversible Loss of Brain Functions - Case Report]. / Intensivtherapie bei Schwangerer mit irreversiblem Hirnfunktionsausfall.

A 29-year-old woman suffered major traumatic brain injury caused by a car accident. As diagnostic measures had revealed an early pregnancy (9th week), treatment on the intensive care unit was continued for 5 months, after unfavourable cerebral prognosis was followed by an irreversible loss of brain function in the 10th week of pregnancy. After assisted vaginal delivery of a healthy child in the 31th week of pregnancy on the critical care unit, organ procurement took place according to the presumed will of the patient. The article presents the details of the critical care therapy and discusses the supportive medical measures. Those measures served primarily to uphold the pregnancy und support the healthy development and delivery of the fetus and only in second instance the organ preservation aiming on organ donation. Necessary measures included maintenance of vital functions, hemostasis of electrolytes, nutrition, treatment of infection, prevention of adverse effects on the fetus, substitution of hormones and vitamins as well as the preparation of a planned or an unplanned delivery.

Severe Brain Damage in a Moderate Preterm Infant as Complication of Post-COVID-19 Response during Pregnancy.

Current evidence from the COVID-19 pandemic suggests that neonatal SARS-coronavirus-2 infections usually have a mild course. Data on how maternal infection during pregnancy affects fetal development are scarce. We present the unique case of a moderate preterm infant with intracranial bleeding and periventricular leukomalacia as a potential consequence of post-COVID-19 hyperinflammation during pregnancy.

Cry features of healthy neonates who passed their newborn hearing screening vs. those who did not.

OBJECTIVES: Temporal and fundamental frequency (fo) variations in infant cries provide critical insights into the maturity of vocal control and hearing performances. Earlier research has examined the use of vocalisation properties (in addition to hearing tests) to identify infants at risk of hearing impairment. The aim of this study was to determine whether such an approach could be suitable for neonates. METHODS: To investigate this, we recruited 74 healthy neonates within their first week of life as our participants, assigning them to either a group that passed the ABR-based NHS (PG, N = 36) or a group that did not, but were diagnosed as normally hearing in follow-up check at 3 months of life, a so-called false-positive group (NPG, N = 36). Spontaneously uttered cries (N = 2330) were recorded and analysed quantitatively. The duration, minimum, maximum and mean fo, as well as two variability measures (fo range, fo sigma), were calculated for each cry utterance, averaged for individual neonates, and compared between the groups. RESULTS: A multiple analysis of variance (MANOVA) revealed no significant effects. This confirms that cry features reflecting vocal control do not differ between healthy neonates with normal hearing, irrespective of the outcome of their initial NHS. CONCLUSIONS: Healthy neonates who do not pass the NHS but are normal hearing in the follow-up (false positive cases) have the same cry properties as those with normal hearing who do. This is an essential prerequisite to justify the research strategy of incorporating vocal analysis into NHS to complement ABR measures in identifying hearing-impaired newborns.

The Vocalist in the Crib: the Flexibility of Respiratory Behaviour During Crying in Healthy Neonates.

OBJECTIVE: To evaluate the flexibility of respiratory behavior during spontaneous crying using an objective analysis of temporal measures in healthy neonates. PARTICIPANTS: A total of 1,375 time intervals, comprising breath cycles related to the spontaneous crying of 72 healthy, full-term neonates (35 females) aged between two and four days, were analyzed quantitatively. METHODS: Digital recordings (44 kHz, 16 bit) of cries emitted in a spontaneous, pain-free context were obtained at the University Children's Hospital Wurzburg. The amplitude-by-time representation of PRAAT: doing phonetics by computer (38) was used for the manual segmentation of single breath-cycles involving phonation. Cursors were set in these time intervals to mark the duration of inspiratory (IPh) and expiratory phases (EPh), and double-checks were carried out using auditory analyses. A PRAAT script was used to extract temporal features automatically. The only intervals analyzed were those that contained an expiratory cry utterance embedded within preceding and subsequent inspiratory phonation (IP). Beyond the reliable identification of IPh and EPh, this approach also guaranteed inter-individual and inter-utterance homogenization with respect to inspiratory strength and an unconstructed vocal tract. RESULTS: Despite the physiological constraints of the neonatal respiratory system, a high degree of flexibility in the ratio of IPh/EPh was observed. This ratio changed hyperbolically (r = 0.71) with breath-cycle duration. Descriptive statistics for all the temporal measures are reported as reference values for future studies. CONCLUSION: The existence of respiratory exploration during the spontaneous crying of healthy neonates is supported by quantitative data. From a clinical perspective, the data demonstrate the presence of a high degree of flexibility in the respiratory behavior, particularly neonates' control capability with respect to variable cry durations. These data are discussed in relation to future clinical applications.

[Rare Differential Diagnosis of a Neonatal Bacterial Sepsis: The Neonatal Viral Myocarditis]. / Seltene Differentialdiagnose einer neonatalen bakteriellen Sepsis: Die neonatale Virusmyokarditis.

The neonatal bacterial infection is a potentially life-threatening condition that justifies intravenous antibiotic therapy. However, clinical symptoms are often unspecific. Particularly in the absence of a response to antibiotic therapy, various differential diagnoses can be considered. We report the clinical presentation, the diagnostic steps, the therapy as well as the long-term progression of a preterm infant who acquired a perinatal enterovirus infection including viral myocarditis. The case underlines the clinical relevance of enterovirus infections in newborns. The current literature, however, describes only single aspects and lacks, in particular, accurate data on both epidemiology and morbidity.

[Unusual Case of a a Severely Injured Toddler - Pre- and Early Hospital Treatment and Happy End Despite Obstacles]. / Ungewöhnlicher Fall eines schweren Polytraumas beim Kleinkind ­ Happy End trotz Fallstricken.

A 16-month-old boy suffers a massive trauma (open dislocated pelvic fracture and decollement with haemorrhagic shock) due to a traffic accident. We present the characteristics and obstacles in the prehospital and early hospital emergency care of this severe and rare trauma in a pediatric patient with an emphasis on medical-operational tactics.

[A Rare Cause of Perinatal Postrenal Failure with Megalourethra]. / Seltene Ursache eines Perinatalen Postrenalen Nierenversagens mit Megalourethra.

We present a case of a premature infant with a presumed obstructive uropathy found to be a megalourethra leading to a perinatal postrenal failure. A megalourethra - an uncommon cause of urethral dilatation - is a congenital, non-obstructive anomaly of the penile erectile tissue. We think that a distal stenosis resulted in dysplasia of the penile tissue and an aspect of a megalourethra. Further diagnostic workup included urinary tract sonograms, a voiding cystourethrogram and MAG3 scintigrafy. Initially the patient was managed with supportive care such as a suprapubic urinary catheter, followed by surgical intervention (Bengt Johanson).

Successful treatment of severe arterial hypotension and anuria in a preterm infant with renal tubular dysgenesis- a case report.

BACKGROUND: Oligohydramnios sequence can be caused by renal tubular dysgenesis (RTD), a rare condition resulting in pulmonary and renal morbidity. Besides typical features of Potter-sequence, the infants present with severe arterial hypotension and anuria as main symptoms. Establishing an adequate arterial blood pressure and sufficient renal perfusion is crucial for the survival of these infants. CASE PRESENTATION: We describe a male preterm infant of 34 + 0 weeks of gestation. Prenatally oligohydramnios of unknown cause was detected. After uneventful delivery and good adaptation the infant developed respiratory distress due to a spontaneous right-sided pneumothorax and required thoracocentesis and placement of a chest tube; he showed no major respiratory concerns thereafter and needed only minimal ventilatory support. Echocardiography revealed no abnormalities, especially no pulmonary hypertension. However, he suffered from severe arterial hypotension and anuria refractory to catecholamine therapy (dobutamine, epinephrine and noradrenaline). After 36 h of life, vasopressin therapy was initiated resulting in an almost immediate stabilization of arterial blood pressure and subsequent onset of diuresis. Therapy with vasopressin was necessary for three weeks to maintain adequate arterial blood pressure levels and diuresis. Sepsis and adrenal insufficiency were ruled out as inflammation markers, microbiological tests and cortisol level were normal. At two weeks of age, our patient developed electrolyte disturbances which were successfully treated with fludrocortisone. He did not need renal replacement therapy. Genetic analyses revealed a novel compound hyterozygous mutation of RTD. Now 17 months of age, the patient is in clinically stable condition with treatment of fludrocortisone and sodium bicarbonate. He suffers from stage 2 chronic kidney disease; blood pressure, motor and cognitive development are normal. CONCLUSIONS: RTD is a rare cause of oligohydramnios sequence. Next to pulmonary hypoplasia, severe arterial hypotension is responsible for poor survival. We present the only second surviving infant with RTD, who did not require renal replacement therapy during the neonatal period. It can be speculated whether the use of vasopressin prevents renal replacement therapy as vasopressin increases urinary output by improving renal blood flow.

Double Peripheral Venous and Arterial Cannulation for Extracorporeal Membrane Oxygenation in Combined Septic and Cardiogenic Shock.

BACKGROUND The use of venoarterial extracorporeal membrane oxygenation (va-ECMO) via peripheral cannulation for septic shock is limited by blood flow and increased afterload for the left ventricle. CASE REPORT A 15-year-old girl with acute myelogenous leukemia, suffering from severe septic and cardiogenic shock, was treated by venoarterial extracorporeal membrane oxygenation (va-ECMO). Sufficient extracorporeal blood flow matching the required oxygen demand could only be achieved by peripheral cannulation of both femoral arteries. Venous drainage was performed with a bicaval cannula inserted via the left V. femoralis. To accomplish left ventricular unloading, an additional drainage cannula was placed in the left atrium via percutaneous atrioseptostomy (va-va-ECMO). Cardiac function recovered and the girl was weaned from the ECMO on day 6. Successful allogenic stem cell transplantation took place 2 months later. CONCLUSIONS In patients with vasoplegic septic shock and impaired cardiac contractility, double peripheral venoarterial extracorporeal membrane oxygenation (va-va-ECMO) with transseptal left atrial venting can by a lifesaving option.

Severe Respiratory Distress in a Neonate due to Bilateral Dacryocystoceles.

Nasal passage contributes up to 50% of total resistance in normal breathing especially in neonates who are obligatory nose breathers. Any further increase in airway resistance may lead to severe respiratory distress. Dacryocystoceles are a rare cause of nasal obstruction in neonates. We present the case of a full-term 3-day-old female infant with progressive respiratory distress due to bilateral dacryocystoceles.

Does rapid enteral feeding increase intestinal morbidity in very low birth weight infants? A retrospective analysis.

PURPOSE: To investigate the association of a standardized rapid enteral feeding strategy (established in 2011 in our unit) with intestinal morbidity in very low birth weight (VLBW) infants. METHODS: A total of 301 inborn VLBW infants were included in this single-centre retrospective cohort study. We compared the incidence of intestinal morbidity (defined as necrotizing enterocolitis or intestinal perforation) in slowly enterally fed infants in 2008-2010 (10 ml/kg/day increase of milk feeds) to a corresponding cohort of rapidly enterally fed infants in 2011-2013 (20 ml/kg/day increase of milk feeds). Univariate and multivariable logistic and linear regression analyses, respectively, were performed to control for confounding variables. RESULTS: Both groups were similar regarding baseline demographic and perinatal characteristics. In univariate modeling, intestinal morbidity did not significantly differ between the two groups (p = 0.25), neither did all-cause mortality nor incidence of late onset sepsis in multivariable modeling. In contrast, length of hospital stay (HS) and duration of parenteral nutrition (PEN) were significantly shorter in the rapid group (HS: -8.35 days, p = 0.012 and PEN: -7.13 days, p < 0.001). CONCLUSIONS: Implementation of a more rapid enteral feeding regime is safe in VLBW infants and may significantly shorten length of HS and PEN in this cohort.

Occipital plagiocephaly: unilateral lambdoid synostosis versus positional plagiocephaly.

OBJECTIVE: We defined parameters that could differentiate between positional and synostotic plagiocephaly and defined a diagnostic chart for decision making. DESIGN: Prospective study. SETTING: We examined 411 children with non-syndromic skull abnormalities between January 2011 and December 2012. PARTICIPANTS: A total of 8 infants under 1 year of age with proven unilateral non-syndromic lambdoid synostosis (LS) and 261 children with positional deformity were examined to outline the specific clinical features of both diagnoses. After clinical examination, an ultrasound revealed either a closed suture suggestive of LS or a patent lambdoid suture suggestive of positional deformity. For patients with synostosis, plain radiographs, MR imaging and follow-up examinations were performed. In cases of open sutures, only follow-ups were completed. MAIN OUTCOME MEASURE: Clinical, imaging, genesis and treatment differences between positional plagiocephaly and LS. RESULTS: In all 8 cases of unilateral LS and 258 cases of positional plagiocephaly, the diagnosis was established by clinical examination alone. In three cases of positional plagiocephaly, diagnosis was determined after an additional ultrasonography. MR imaging revealed a unilateral tonsillar herniation in five of the eight children with LS and hydrocephalus in one child. CONCLUSIONS: We have suggested a list of clinical features that specify the underlying cause of posterior plagiocephaly. An additional ultrasound scanning confirmed the diagnosis without any risks of ionising radiation or sedation as in a CT scan.

[Should opioids be routinely used for the induction of general anaesthesia for caesarean section?]. / Leser fragen - Experten antworten - Rapid-Sequence-Induction bei Sectio caesarea: Sollte standardmäßig ein Opioid gegeben werden?

The spinal anaesthesia, epidural anaesthesia or combinations of these techniques (combined spinal epidural anaesthesia) so far remain the gold standard to facilitate caesarean section. For some reasons such as refusal by the patients, medical reasons or emergency caesarean section, a general anaesthesia can be necessary. In patients with preeclampsia hypertension during endotracheal intubation has to be avoided. Here the application of an opioid is possible or even necessary to lessen increases of the heart rate and blood pressure. To lessen cardiovascular response, short acting Remifentanil has advantages, e.g. the fast clearance rate in newborns. However, the risk for the newborn from respiratory depression has to be considered and experienced staff to care for the newborn should be present after childbirth. Therefore, an interdisciplinary approach seems to be vital to cope with adverse effects that may arise due to the more frequent use of opioids in conjunction with general anaesthesia for caesarean section.

Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a "poor man's epidural".

BACKGROUND: The epidural route is still considered the gold standard for labour analgesia, although it is not without serious consequences when incorrect placement goes unrecognized, e.g. in case of intravascular, intrathecal and subdural placements. Until now there has not been a viable alternative to epidural analgesia especially in view of the neonatal outcome and the need for respiratory support when long-acting opioids are used via the parenteral route. Pethidine and meptazinol are far from ideal having been described as providing rather sedation than analgesia, affecting the cardiotocograph (CTG), causing fetal acidosis and having active metabolites with prolonged half-lives especially in the neonate. Despite these obvious shortcomings, intramuscular and intravenously administered pethidine and comparable substances are still frequently used in delivery units. Since the end of the 90 ths remifentanil administered in a patient-controlled mode (PCA) had been reported as a useful alternative for labour analgesia in those women who either don't want, can't have or don't need epidural analgesia. DISCUSSION: In view of the need for conversion to central neuraxial blocks and the analgesic effect remifentanil has been demonstrated to be superior to pethidine. Despite being less effective in terms of the resulting pain scores, clinical studies suggest that the satisfaction with analgesia may be comparable to that obtained with epidural analgesia. Owing to this fact, remifentanil has gained a place in modern labour analgesia in many institutions. However, the fact that remifentanil may cause harm should not be forgotten when the use of this potent mu-agonist is considered for the use in labouring women. In the setting of one-to-one midwifery care, appropriate monitoring and providing that enough experience exists with this potent opioid and the treatment of potential complications, remifentanil PCA is a useful option in addition to epidural analgesia and other central neuraxial blocks. Already described serious consequences should remind us not refer to remifentanil PCA as a "poor man's epidural" and to safely administer remifentanil with an appropriate indication. SUMMARY: Therefore, the authors conclude that economic considerations and potential cost-savings in conjunction with remifentanil PCA may not be appropriate main endpoints when studying this valuable method for labour analgesia.

Myocardial response in preterm fetal sheep exposed to systemic endotoxinaemia.

Exposure of the fetus to antenatal inflammation can occur from chorioamnionitis, which may progress to a fetal inflammatory response syndrome (FIRS) and to fetal sepsis. We tested whether the fetal myocardium responded to systemic Gram-negative endotoxinaemia. We hypothesized that the myocardium would respond to inflammation by changes in hypoxia-inducible factor-α (HIF-1α), inducible NO-synthase (iNOS), Toll-like receptors 2 and 4 (TLR2 and TLR4), IL-6, and phosphorylated signal transducer and activator of transcription-3 (pSTAT3). To model systemic endotoxinaemia, fetal sheep were exposed to Gram-negative endotoxin or saline i.v. 3 d before preterm delivery at 113 d of gestation (term = 147 d). All endotoxin-exposed animals developed cardiac dysfunction within these 72 h. Cardiac mRNA and protein levels of HIF-1α and TLR2 and TLR4 mRNA increased, whereas STAT3 phosphorylation decreased significantly. IL-6 and iNOS mRNA remained unchanged. Fetal systemic endotoxinaemia induced myocardial inflammation by activating TLR2 and 4. The following cardiac dysfunction seems not to be mediated via cardiac iNOS.

[Anaesthesia and breast-feeding: should breast-feeding be discouraged?]. / Leser fragen - Experten antworten - Stillen nach Narkosen: Ist eine Stillpause obligat?

Until a few years ago an interruption of breast-feeding for 12 or even 24 hours was recommended for breast-feeding mothers after anaesthesia, this is no longer valid. If it is the mother's wish, if she is sufficiently awake and physically able, there is no reason not to start breast-feeding a mature and healthy baby immediately after recovery from a general or regional anaesthesia. Even breast-feeding after a Caesarean delivery with administration of the common anaesthetics in the usual (single) doses is no longer considered to be a problem since the amount of the substance taken up from colostrum is vanishingly small in comparison to the amount that is transferred by transplacental routes. Neither the pharmacological properties of the drugs used in association with anaesthesia nor clinical experience justify an interruption of breast-feeding.