A Neonatal Patient Diagnosed with a COL4A1 Mutation Presenting with Hemorrhagic Infarction and Severe Jaundice.

We report a patient diagnosed with a COL4A1 mutation in the early postnatal period. Patients with early postnatal jaundice, intracranial lesions that are negative for TORCH syndrome, and recurrent hemolytic anemia should be suspected of having a COL4A1/COL4A2 gene mutation.

The prenatal causes of slight lateral ventricular enlargement in infants treated in a neonatal intensive care unit.

OBJECTIVE: The aim of this study was to determine the prenatal causes of slight lateral ventricular enlargement in infants treated in a neonatal intensive care unit. METHODS: We examined 318 infants with a gestational age of at least 28 weeks who were treated in a neonatal intensive care unit. We investigated the relationships between slight lateral ventricular enlargement and prenatal factors. Also, we investigated the relationships between the laterality of lateral ventricular enlargement and arm growth to verify our proposed mechanism of lateral ventricular enlargement. RESULTS: Slight lateral ventricular enlargement was observed in 97 (30.5%) infants. Slight lateral ventricular enlargement was related to gestational age (p < .001), maternal anemia (p = .025), diabetes mellitus (p = .048), threatened premature labor (p = .027), and premature rupture of the membrane (p = .049). In 97 infants with ventricular enlargement, the numbers of infants with left-side dominant, equivalent, and right-side dominant laterality were 60 (61.9%), 27 (27.8%), and 10 (10.3%), respectively. Maternal anemia and diabetes mellitus were related to left-side dominant ventricular enlargement. Threatened premature labor and premature rupture of the membrane were related to right-side dominance. The laterality of lateral ventricular enlargement was not relate to that of the arm growth. CONCLUSIONS: We propose that the main cause of slight lateral ventricular enlargement may not be malnutrition but instead may be hypoxic stress in utero.

The efficacy of routine brain MRI for term neonates admitted to neonatal intensive care unit.

OBJECTIVE: The efficacy of routine brain MRI for term infants admitted to a neonatal intensive care unit (NICU) has not been well studied. This study aimed to investigate the types and frequencies of abnormal findings on routine brain MRI and the predictors of abnormality for term infants in an NICU setting. METHODS: We examined the results of routine brain MRI of 239 term infants who were hospitalized in the NICU. Data on the perinatal factors were also collected, and the association with MRI abnormalities was assessed. RESULTS: Of the 239 MRI scans, we found abnormal findings in 52 (21.8%) patients. Intracranial hemorrhage accounted for 74% of the abnormal findings, including subdural, intraparenchymal, cerebellar, and subependymal hemorrhages. Twenty-six percent of these were ischemic lesions, including cerebral infarction, white matter abnormal intensities, and cystic periventricular leukomalacia (PVL). Five (2.1%) MRI scans required detailed examination or were known to be associated with a poor neurological prognosis. No patient needed treatment for the findings. An Apgar score ≤7 points at 5 min was identified as a perinatal factor significantly associated with abnormal MRI findings (adjusted OR = 3.034, 95% CI: 1.107-8.315, p = .031). CONCLUSION: The efficacy of routine brain MRI for term infants admitted to the NICU was limited. Routine brain MRI is not recommended for this population.

The prenatal causes of slight lateral ventricular enlargement in healthy infants.

OBJECTIVE: The aim of this study was to determine the prenatal causes of slight lateral ventricular enlargement in healthy infants. METHODS: We examined 1089 healthy infants who weighed at least 2000 g and were born at a gestational age of at least 36 weeks. We assessed the presence of ventricular enlargement when an apparent space was observed in the frontal horn or body of the lateral ventricle of the brain by a transfontanel ultrasound scan. We investigated the relationships between slight lateral ventricular enlargement and various prenatal factors. RESULTS: Slight lateral ventricular enlargement was observed in 497 (45.6%) infants. Slight lateral ventricular enlargement was related to maternal anemia (p = .004; odds ratio = 1.630; 95% CI: 1.168-2.276), threatened premature labor (p = .010; odds ratio = 1.441; 95% CI: 1.093-1.900), and diabetes mellitus (p = .022; odds ratio = 2.020; 95% CI: 1.109-3.682) using multiple logistic regression analysis. The birth weight of the infants with slight lateral ventricular enlargement was heavier than that of those without ventricular enlargement at 36-40 weeks of gestation. Forty infants with ventricular enlargement had head circumferences greater than the 90th percentile, while only one infant without ventricular enlargement did (p < .001). In addition, 22 infants with ventricular enlargement had head circumferences less than the 10th percentile, while only 4 infants without ventricular enlargement did (p < .001). In 497 infants with ventricular enlargement, the numbers of infants with left side dominant, equivalent, and right side dominant ventricular enlargement were 289 (58.1%), 110 (22.1), and 98 (19.7%), respectively. CONCLUSIONS: Slight lateral ventricular enlargement could be caused by several pathological conditions in utero, including brain atrophy, ventricular enlargement, the influence of blood flow in the brain, and various pathological changes in different brain regions.

The prognosis of infants with neonatal respiratory inhibition syndrome.

Objective: The goal of this study was to investigate the prognosis of infants with neonatal respiratory inhibition syndrome (NRIS).Methods: Infants with a gestational age of at least 36 weeks and a birth weight of at least 2000 g who were born at Nara Prefecture General Medical Center, in Nara, Japan, between March 2013 and June 2016 were screened for NRIS using our established method. NRIS was defined as severe hypoxemia caused by respiratory inhibition immediately after crying (RIAC) or gastroesophageal reflux (RIGER) or as a respiratory pause during feeding (feeding hypoxemia), accompanied clinically by central cyanosis and a decrease in SpO2 to less than 70%. All infants were monitored using pulse oximetry immediately after birth. Diagnosis of RIAC, feeding hypoxemia, and RIGER are based on observation by both parents and medical staff as well as on on-screen computer analysis using specific software. All infants were examined at a one-month check-up. Parents of the infants who experienced one or more episodes of NRIS accompanied by a decrease in SpO2 to less than 70% for more than approximately 60 s received a questionnaire by mail about their child's development. We conducted a logistic regression analysis with developmental problems as the dependent variable.Results: NRIS was observed in 362 (28.5%) infants; 216 (17.0%) infants showed RIAC, 254 (20.0%) infants showed feeding hypoxemia, and 54 (4.2%) infants showed RIGER. Although all infants were monitored in the maternity ward nursery, 184 (85.2%) infants with RIAC and 111 (43.7%) infants with feeding hypoxemia were overlooked. All infants with NRIS were found to have successfully recovered at one month after birth. Sixty-two cases were examined in the follow-up study by the mailed questionnaire. The median age of the subjects at time of study was 22 months. Fourteen cases (22.6%) exhibited developmental problems including delayed speech development, stereotyped interests and behaviors, sensory disturbance, hyperactivity, delayed motor development, and short stature. Developmental problems tended to relate to shorter gestational age (odds ratio, 0.622; p = .068; 95% CI, 0.373-1.036), smaller birth weight (odds ratio, 0.998; p = .069; 95% CI, 0.997-1.000), and maximum duration of SpO2 to less than 70% by RIAC (odds ratio, 1.009; p = .086; 95% CI, 0.999-1.020). All cases had experienced severe hypoxemia accompanied by a decrease in SpO2 to less than 60%. Seven cases had experienced prolonged hypoxemia accompanied by a decrease in SpO2 to less than 70% for at least 2 min. Among the subjects, 19 infants were examined closely, and their natural course of NRIS was observed in the neonatal intensive care unit. No cases demonstrated abnormal findings with blood examinations, chest-abdominal X-ray, echocardiogram, laryngoendoscopy, hearing loss screening, or mass screening. Only one case had a small intracranial hemorrhage as evidenced in a magnetic resonance imaging of the head.Conclusions: The infants with severe NRIS tended to have developmental problems. Spreading knowledge about NRIS worldwide is thought to be very important.

A simple and feasible antimicrobial stewardship program in a neonatal intensive care unit of a Japanese community hospital.

BACKGROUND: Although tertiary hospitals have successfully introduced ASPs by antimicrobial stewardship teams, lots of community hospitals without pediatric infectious disease specialists have difficulty implementing ASP. We present a successful implementation of simple and feasible NICU antimicrobial stewardship program in a Japanese community hospital. METHOD: We developed a protocol of antimicrobial treatment in our NICU department and have implemented the protocol from September 2017. The protocol consists of start and stop of criteria antimicrobial treatment, weekend report of blood culture result from microbiology department and stopping ordering antimicrobials beforehand for the next day. We compared days of therapy (DOT) during the post-implementation period (September 2017 to August 2018) with that of pre-implementation period (March 2013 to August 2017). RESULT: In pre- and post-ASP implementation periods, 913 and 194 patients were analyzed. DOT was 175.1 and 41.6/1000 patient-days, respectively (p < 0.001) with 76.2% reduction. The percentage of neonates who had any antimicrobials and the percentage of prolonged antimicrobial treatments among neonates who had any antimicrobials decreased significantly (55.3% vs 20.6%, p < 0.001 and 65.0% vs 32.5%, p < 0.001). The protocol compliance rates were also significantly different (55.4% vs 95.4%; p < 0.001). The methicillin-resistant rate of S.aureus rates were significantly reduced in post-ASP period (31.1% vs 12.9%; p = 0.002). CONCLUSION: This ASP program was easily implemented in a NICU department of a community hospital and significantly reduced antimicrobial prescription. This kind of simple protocol may be successfully scaled-up in resource limited community hospitals without no pediatric infectious disease specialists or antimicrobial stewardship team.

Elevated C-reactive protein in umbilical cord blood: Neonatal case review.

BACKGROUND: C-reactive protein (CRP) has limited placental transportability. Relying on CRP level in umbilical cord blood alone is an inaccurate way to predict early onset neonatal sepsis, and we retrospectively reviewed the clinical courses of neonates with elevated CRP in umbilical cord blood. METHODS: This study was a retrospective case review of neonates with elevated CRP in umbilical cord blood (>0.5 mg/dL) in the Nara Prefecture General Medical Center, Nara, Japan between February 2013 and August 2017. We investigated the association of maternal and neonatal factors with neonatal clinical course. Then, we compared the cases of neonates with and without elevated CRP in umbilical cord blood. RESULTS: The subjects consisted of a total of 22 neonates with elevated CRP in umbilical cord blood and 344 neonates without elevated CRP in umbilical cord blood. Of the 22 neonates with elevated CRP, 18 had some symptoms of sepsis at birth, but the symptoms of 85% of the symptomatic patients resolved ≤24 h after birth. Two neonates with elevated CRP in umbilical cord blood had bacteremia, and they had poor prognoses. Elevated CRP in umbilical cord blood was associated with length of antimicrobials (P = 0.021), immature/total neutrophil ratio (P = 0.017), and pathological chorioamnionitis (CAM; P = 0.028) on multivariable logistic regression analysis. CONCLUSION: Elevated CRP in umbilical cord blood was associated with pathological CAM. Most symptoms of sepsis resolved <24 h after birth.

Prenatal predictors of neonatal intensive care unit admission due to respiratory distress.

BACKGROUND: Admission to the neonatal intensive care unit (NICU) due to respiratory distress is determined according to subjective clinician judgement. We investigated prenatal factors predictive of NICU admission in neonates with respiratory distress. METHODS: This case-control study was conducted at Nara Prefecture General Medical Center, Nara, Japan, from February 2013 to April 2017 and included neonates with birthweight ≥2,000 g, ≥36 weeks of gestational age, who required oxygen due to respiratory distress at birth. The cases consisted of neonates admitted to the NICU, and the control group consisted of neonates who did not require NICU admission. Perinatal factors between the groups were compared, and multivariate logistic regression analysis carried out to evaluate predictive factors. RESULTS: The NICU group consisted of 94 neonates, and the control group, 417 neonates during the period reviewed. On multivariate analysis, maternal anemia (OR, 2.97; 95%CI: 1.42-6.21), infertility treatment (OR, 2.79; 95%CI: 1.36-5.71), threatened preterm labor (OR, 2.16; 95%CI: 1.10-4.23), premature rupture of membranes (OR, 5.30, 95%CI: 2.52-11.17), fibroids (OR, 6.06; 95%CI: 1.57-23.41), history of uterine surgery (OR, 3.53, 95%CI: 1.13-11.06), abruptio placentae (OR, 10.21; 95%CI: 1.83-57.17), intrauterine growth restriction (OR, 6.69; 95%CI: 1.96-22.85), and having twins (OR, 0.23; 95%CI: 0.09-0.58) were significant prenatal predictors of NICU admission. CONCLUSION: Factors that potentially predict NICU admission were identified. Clinicians may wish to consider these factors when treating neonates with respiratory distress.

Efficacy of routine catheter tip culture in a neonatal intensive care unit.

BACKGROUND: Routine catheter tip cultures are not recommended because some cases of colonization, such as with Staphylococcus aureus, can lead to subsequent bacteremia. To evaluate the safety of colonization without antimicrobial treatment, as well as the effectiveness of routine catheter tip cultures in the neonatal intensive care unit (NICU), we performed a retrospective data analysis in a Japanese community hospital. METHODS: We reviewed all peripherally inserted central venous catheter tip culture results from the NICU ward between April 2012 and June 2017 and noted outcome (i.e. antimicrobial treatment or subsequent infection). We then performed a cost analysis for routine catheter tip culturing on patients who were symptom free during the study period. RESULTS: Of the 93 positive cases in 80 patients from 1,051 catheter tip cultures, seven patients had suspected infection and were treated with antimicrobials. The other 73 symptom-free, positive patients had no subsequent or exacerbated symptoms indicative of an infection, and did not have antimicrobial treatment. The total cost for catheter tip culturing during the study period was ¥548 731. After excluding patients with symptoms of infection at the time of culture, the efficacy of routine catheter tip cultures on symptom-free patients was estimated to be zero. CONCLUSION: Symptom-free colonization did not affect clinician management in this study, and all colonized patients without suspected infection were safely managed without antimicrobials. Furthermore, routine catheter tip culturing was not cost-effective; therefore, this practice may be no longer recommended in the NICU.