The association between fluid restriction and hyponatremia in newborns with gastroschisis.

INTRODUCTION: Newborns with gastroschisis require appropriate fluid resuscitation but are also at risk for hyponatremia that may lead to adverse outcomes. The etiology of hyponatremia in gastroschisis has not been defined. METHODS: Over a 24-month period, all newborns with gastroschisis in a free-standing pediatric hospital had sodium levels measured from serum, urine, gastric output, and the bowel bag around the eviscerated contents for the first 48 h of life. Total fluid intake and output were measured. Maintenance fluids were standardized at 120 mL/kg/day. Hyponatremia was defined as a serum sodium <132 mEq/L. A logistic regression model was created to determine independent predictors of hyponatremia. RESULTS: 28 infants were studied, and 14 patients underwent primary closure. While serum sodium was normal in all patients at birth, 9 (32%) infants developed hyponatremia at a median of 17.4 h of life. On univariate analysis, hyponatremic babies had a greater net positive fluid balance (74.9 vs 114.7 mL/kg, p = 0.001) primarily due to a decrease in total fluid output (p = 0.05). On multivariable regression, a 10 mL/kg increase in overall fluid balance was associated with an increased risk of developing hyponatremia (OR 1.84 [1.23, 3.45], p = 0.016). No differences in the sodium content of urine, gastric, or bowel bag fluid were observed, and sodium balance was equivalent between cohorts. DISCUSSION: Hyponatremia in babies with gastroschisis in the early postnatal period was associated with positive fluid balance and decreased fluid output. Prospective studies to determine the appropriate fluid resuscitation strategy in this population are warranted.

Enhanced Vancomycin Elimination in an Infant Following an Unsuccessful Gastroschisis Repair Surgery.

OBJECTIVE: To report the case of an infant who required high-dose vancomycin therapy after an unsuccessful gastroschisis repair surgery. CASE SUMMARY: An infant born at 35 weeks and 5 days of gestation underwent a gastroschisis repair on day of life 47. The repair was unsuccessful causing fluid backup and accumulation into the stomach. A replogle was placed to allow for suctioning of this fluid. During this admission, the patient received 3 courses of vancomycin. During the first course, the patient had minimal output via the replogle tube. On the infant's second and third courses of vancomycin, the infant necessitated vancomycin dosing above that of the neonatal protocol, and subsequent levels were still found to be below goal. Vancomycin was increased to a maximum of 15 mg/kg every 4 hours (90 mg/kg/d) in order to achieve serum trough levels greater than 10 mg/L. Residuals were drawn from the replogle ranging from 0.76 to 4.33 mL/kg/h during the second and third course of vancomycin. DISCUSSION: A premature male infant required up to 90 mg/kg/d of vancomycin to achieve trough levels above 10 mg/L after an unsuccessful gastroschisis repair surgery and gastric suctioning. CONCLUSION: Clinicians should be aware of the possibility for decreased vancomycin levels and the potential need for increased monitoring in postsurgical infants receiving gastric suctioning.

Low serum fatty acid levels in pregnancies with fetal gastroschisis: A prospective study.

Fetal gastroschisis is a paraumbilical abdominal wall defect with herniation of abdominal organs. The underlying cause of the disease remains unknown; however, studies suggest that nutritional factors may play a role in its development. This prospective case-control study explored the association of serum fatty acid levels of pregnant women and occurrence of gastroschisis. Gastroschisis group comprised 57 pregnant women with fetuses with gastroschisis, and the control group comprised 114 pregnant women with normal fetuses. Serum fatty acids levels were compared between the groups for the overall pregnancy at <34 weeks; ≤25 weeks, and >25 and <34 weeks; and at delivery. Total fatty acids (p = .008), unsaturated fatty acids (p = .002), and the C18:1n9/C18:00 ratio (p = .021) were lower in the gastroschisis group than in the control group during the overall pregnancy; however, the C16:00/C18:2n6 ratio (p = .018) was higher in the gastroschisis group than in the control group during the same period. Total fatty acids (p = .044) and unsaturated fatty acids (p = .024) were lower in the gastroschisis group at ≤25 weeks, and unsaturated fatty acid (p = .025) and the C18:1n9/C18:00 ratio (p = .013) were lower in the gastroschisis group than in the control group at >25 and <34 weeks. Pregnant women with fetuses with gastroschisis have low serum fatty acids levels during pregnancy. These findings suggest that fatty acids levels may be involved in the pathogenesis of fetal gastroschisis.

[Maternal serum alpha fetoprotein and free ß-hCG of second trimester for screening of fetal gastroschisis and omphalocele].

OBJECTIVE: To assess the detection of maternal serum alpha fetoprotein (MSAFP) and free beta-HCG levels of second trimester for screening of fetal gastroschisis and omphalocele. METHODS: Clinical data of 622 639 pregnant women from 5 prenatal screening centers in Hangzhou during October 2007 and September 2016 were analyzed retrospectively. Thirty cases of gastroschisis and 30 cases of omphalocele diagnosed by ultrasonography and postmortem findings were enrolled in the study and 116 cases of pregnant women with normal fetal development during the same period were selected as control group. The cut-off value and area under ROC curve (AUC) of MSAFP and free ß-hCG for diagnosis of fetal gastroschisis and omphalocel were analyzed. RESULTS: MSAFP levels of women with fetal gastroschisis and omphalocele were 4.41 (0.88-11.69) MOM and 2.31 (0.72-23.20) MOM, which were significantly higher than that of control group[0.98 (0.41-2.26) MOM, all P<0.01]. Free ß-hCG level of women with fetal gastroschisis was 1.25 (0.35-19.94) MOM, which was significantly higher than that of control group[0.86 (0.17-6.11) MOM, P<0.05). But there were no significant difference in free ß-hCG between fetal omphalocele group[1.03(0.21-8.95)]and control group (P>0.05). The AUCs of MSAFP for diagnosis of gastroschisis and omphalocele were 0.897 (95% CI:0.822-0.972) and 0.852(95% CI:0.762-0.942), respectively (all P<0.01). Taking 1.655 MOM as the cut-off value of MSAFP for abdominal wall defects (gastroschisis and omphalocele), the sensitivity was 68.30%, specificity was 99.60% and Youden index was 0.649. CONCLUSIONS: MSAFP of second trimester is a better biomarker than free ß-hCG in screening abdominal wall defects.

Zonulin: A Potential Marker of Intestine Injury in Newborns.

INTRODUCTION: Zonulin (ZO), a new diagnostic biomarker of intestinal permeability, was tested in newborns presenting symptoms of infection and/or inflammation of the gut or being at risk of intestinal pathology. MATERIAL AND METHODS: Serum ZO was assessed in 81 newborns diagnosed with sepsis, necrotizing enterocolitis (NEC), rotavirus infection, and gastroschisis, also in extremely low gestational age babies, and in controls (healthy newborns). ZO concentration was compared to C-reactive protein (CRP) and procalcitonin (PCT) values, leucocyte and platelet count, basic demographic data, and the value of the Neonatal Therapeutic Intervention Scoring System (NTISS). RESULTS: Median values of ZO were markedly higher in groups with rotavirus infection and gastroschisis (36.0 (1-3Q: 26.0-43.2) and 20.3 (1-3Q: 17.7-28.2) ng/ml, resp.) versus controls (3.5 (1-3Q: 2.7-4.8) ng/ml). Its concentration in the NEC group was twice as high as in controls but did not reach statistical significance. ZO levels were not related to NTISS, CRP, and PCT. CONCLUSIONS: Zonulin is a promising biomarker of intestinal condition, markedly elevated in rotavirus infections. Its role in defining the severity of necrotizing enterocolitis and the risk for perforation is not well described and needs further evaluation. An increase in zonulin may not be parallel to the release of inflammatory markers, and low CRP should not exclude an injury to neonatal intestine.

Maternal Antibodies to Chlamydia trachomatis and Risk of Gastroschisis.

BACKGROUND: Gastroschisis, a birth defect of the abdominal wall, is increasing in prevalence. The largest increase in prevalence has been observed among young mothers (<20 years). The prevalence of Chlamydia trachomatis (CT) infection is highest among young women and has also been increasing over time. The objective was to investigate the association between immunoglobulin G antibodies to Chlamydia trachomatis (CT) (anti-CT) and Chlamydial heat shock protein 60 (anti-CHP60) during pregnancy, and risk of gastroschisis among offspring. METHODS: We conducted a nested case-control study of 292 gastroschisis cases identified from the Congenital Malformations Register and 826 live born controls matched on age and birth year within the Finnish Maternity Cohort. Early pregnancy serum samples were used to categorize women by seropositivity to anti-CT and anti-CHP60. Women seronegative for anti-CT and anti-CHP60 served as the reference. We used conditional logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Effect measure modification by maternal age (<25 years, ≥25 years) was also assessed. RESULTS: Seropositivity to anti-CT (17.8% of cases vs. 16.0% of controls) or anti-CHP60 (23.6% of cases vs. 22.0% of controls) was not associated with gastroschisis. Although, the OR for seropositivity to anti-CT alone was slightly elevated (OR, 1.19; 95% CI, 0.73-1.94), specifically among young mothers (<25 years) (OR, 1.65; 95% CI, 0.81-3.37), the results were imprecise. CONCLUSION: Chlamydia infection, as measured by immunoglobulin G antibodies to CT and CHP60, is not associated with gastroschisis, however, our assays were not able to distinguish recent infection.Birth Defects Research 109:543-549, 2017.© 2017 Wiley Periodicals, Inc.

Intestinal ischemia secondary to volvulus of gastroschisis within a silo: detection, confirmation and reversal of near infra-red spectroscopy detected O2 saturation.

A neonate with gastroschisis had silo placement and near-infrared spectroscopy (NIRS) monitoring of intestinal haemoglobin oxygen saturation (RSO2). An ischemic loop of bowel demonstrated decreased RSO2, with reversal of clinical ischemia and RSO2 postoperatively. This demonstrates possible advantage of monitoring intestinal RSO2 in neonates at risk of ischemia, and response to intervention.

Differential diagnosis of abdominal wall defects - omphalocele versus gastroschisis.

A newborn with abdominal wall defect is one of the most dramatic cases in neonatology, but also a challenge for pediatric surgeons. This article describes the fundamental concepts of two major abdominal wall defects - gastroschisis and omphalocele - including options and principles of prenatal and postnatal care. Although these birth defects of the abdominal wall are always grouped together, they are two separate and distinct entities, with many differences in terms of pathology and associated anomalies; this explains the different therapeutic approach and results. For a correct management of the newborn with this anomaly, it is essential to understand the similarities and differences between gastroschisis and omphalocele. This article emphasises the similarities between these two parietal defects, highlighting the differences as well.

C-reactive protein (CRP) levels in babies with gastroschisis managed with preformed silos.

BACKGROUND/PURPOSE: The purpose of this study was to assess the degree of elevation of serum C-reactive protein (CRP) levels in infants with gastroschisis managed by placement of a preformed silo and subsequent nonoperative closure. METHODS: CRP measurements were collected prospectively in infants with gastroschisis undergoing preformed silo placement until defect closure. Infants requiring operative closure or surgical silo placement were excluded as were any infants with confirmed sepsis during the closure period. RESULTS: Data were available for 43 infants. Median CRP at birth was 8 mg/L (range 6 to 55) rising to 42 mg/L (range 35 to 68) at the time of closure. CONCLUSIONS: Elevation of serum CRP levels is to be expected in infants with gastroschisis managed with a preformed silo in the absence of infection. This data may be used to prevent unnecessary use of antibiotics in this group of patients.

Does administering albumin to postoperative gastroschisis patients improve outcome?

OBJECTIVES: Newborns who undergo surgery for gastroschisis correction may present with oliguria, anasarca, prolonged postoperative ileus, and infection. New postoperative therapeutic procedures were tested with the objective of improving postoperative outcome. PATIENTS AND METHODS: One hundred thirty-six newborns participated in one of two phases. Newborns in the first phase received infusions of large volumes of crystalloid solution and integral enteral formula, and newborns in the second phase received crystalloid solutions in smaller volumes, with albumin solution infusion when necessary and the late introduction of a semi-elemental diet. The studied variables were serum sodium and albumin levels, the need for albumin solution expansion, the occurrence of anasarca, the length of time on parenteral nutrition, the length of time before initiating an enteral diet and reaching a full enteral diet, orotracheal intubation time, length of hospitalization, and survival rates. RESULTS: Serum sodium levels were higher in newborns in the second phase. There was a correlation between low serum sodium levels and orotracheal intubation time; additionally, low serum albumin levels correlated with the length of time before the initiation of an oral diet and the time until a full enteral diet was reached. However, the discharge weights of newborns in the second phase were higher than in the first phase. The other studied variables, including survival rates (83.4% and 92.0%, respectively), were similar for both phases. CONCLUSIONS: The administration of an albumin solution to newborns in the early postoperative period following gastroschisis repair increased their low serum sodium levels but did not improve the final outcome. The introduction of a semi-elemental diet promoted an increase in body weight at the time of discharge.

Does administering albumin to postoperative gastroschisis patients improve outcome?

OBJECTIVES: Newborns who undergo surgery for gastroschisis correction may present with oliguria, anasarca, prolonged postoperative ileus, and infection. New postoperative therapeutic procedures were tested with the objective of improving postoperative outcome. PATIENTS AND METHODS: One hundred thirty-six newborns participated in one of two phases. Newborns in the first phase received infusions of large volumes of crystalloid solution and integral enteral formula, and newborns in the second phase received crystalloid solutions in smaller volumes, with albumin solution infusion when necessary and the late introduction of a semi-elemental diet. The studied variables were serum sodium and albumin levels, the need for albumin solution expansion, the occurrence of anasarca, the length of time on parenteral nutrition, the length of time before initiating an enteral diet and reaching a full enteral diet, orotracheal intubation time, length of hospitalization, and survival rates. RESULTS: Serum sodium levels were higher in newborns in the second phase. There was a correlation between low serum sodium levels and orotracheal intubation time; additionally, low serum albumin levels correlated with the length of time before the initiation of an oral diet and the time until a full enteral diet was reached. However, the discharge weights of newborns in the second phase were higher than in the first phase. The other studied variables, including survival rates (83.4 percent and 92.0 percent, respectively), were similar for both phases. CONCLUSIONS: The administration of an albumin solution to newborns in the early postoperative period following gastroschisis repair increased their low serum sodium levels but did not improve the final outcome. The introduction of a semi-elemental diet promoted an increase in body weight at the time of discharge.

Early high C-reactive protein in infants with open abdominal wall defects does not predict sepsis or adverse outcome.

AIM: To study CRP values and relate it to outcome in infants with antenatal diagnosis of gastroschisis, exomphalos and other surgical conditions. METHODS: Over five years, infants admitted to our neonatal unit with gastroschisis, exomphalos and other surgical diagnoses were identified. Serum CRP measurements in first 5 days were studied. Group one included 33 gastroschisis patients, group two, 18 exomphalos patients, and group three, 38 patients with other surgical diagnoses. Outcome measures included TPN days, time to full feeds and duration of hospitalization. RESULTS: Infants with gastroschisis were more premature (36.9 vs 38.1 weeks) with lower birth weights (2515 vs 3078 g), than infants with exomphalos. CRP values on admission in gastroschisis group were significantly higher than exomphalos and other diagnoses groups (33.7 +/- 6.4 vs 8.8 +/- 6.0 vs 5.7 +/- 2.0, respectively, p < 0.05). All blood cultures were sterile. There was no relationship between high CRP and death or adverse outcome (TPN days, time to full feeds or duration of hospitalization) in the gastroschisis group. CONCLUSION: Infants with gastroschisis exhibit high early CRP, which may not indicate sepsis or adverse outcome. This increase can complicate the assessment of these infants. Clinicians should be aware of this finding as it could inform management decisions in this group.

Bacteremic infection with Pediococcus: vancomycin-resistant opportunist.

Pediococci are recently recognized Gram-positive human pathogens, resistant to vancomycin and generally susceptible to penicillin. Infection in adults has been seen in patients with chronic underlying conditions as well as those with previous abdominal surgery. Two previous infants with congenital gastrointestinal malformations requiring surgical correction have been reported with sepsis attributable to Pediococcus sp. We report a third infant born with gastroschisis who developed Pediococcus bacteremia and meningitis 3 months after surgery, and speculate regarding the role of probiotics in the pathogenesis of this infection.