Should Ocular Hemorrhage Screening be Conducted in Newborns with Acidosis?

OBJECTIVE: Ocular hemorrhages (OHs) may cause visual disturbances and incidence vary from 18 to 39% in newborns. Precipitated/instrumental delivery and perinatal asphyxia were predefined risk factors. Acidosis can interfere with coagulation and disrupt the pressure of ocular capillaries and put infants with moderate acidosis with or without hypoxic-ischemic encephalopathy at risk for OH. We aimed to evaluate the OH in neonates with fetal acidosis. STUDY DESIGN: Neonates >34 weeks are included if pH < 7.10 and BE < -12 mmol/L within the first hour. Ophthalmologic examinations for retinal (RH), vitreous, and anterior chamber (hyphema) hemorrhage were done within the third day. RH was staged according to Egge's classification. Follow-up of the patients was continued until the age of 2. Clinical characteristics of newborns were analyzed. RESULTS: Sixty-two neonates (38 ± 2.3 weeks, 2,971 ± 612 g) were included. pH = 6.91 ± 0.16, BE = - 17.2 ± 5.3 mmol/L. OH was found in 22 (36.7%) neonates (hyphema n = 2, vitreous n = 2, RH n = 21). Thirty-eight eyes with RH were staged (Stage 3: n = 15 [39.5%]; Stage 2: n =11 [28.9%]; Stage 1: n = 12 [31.6%]). Vaginal delivery (OR: 4.9, 95% CI [1.4-17.8]) and advanced resuscitation at the delivery room (OR: 8.8; 95% CI [1.9-41.7]) were found to increase the risk of RH. CONCLUSION: Approximately one-third of neonates with moderate to severe acidosis exhibited RH when examined on the third day. Contrary to previous studies that reported mild RH in otherwise healthy neonates, our findings revealed that neonates with moderate to severe acidosis predominantly presented with Stage 3 RH. While the higher incidence of RH in vaginally delivered infants is consistent with previous studies, the identification of advanced resuscitation as a risk factor is a new addition to the literature. The findings in our study highlight the importance of retinal examination in neonates with acidosis in the presence of intubation during resuscitation. KEY POINTS: · One-third of neonates with moderate to severe acidosis exhibited RH.. · Stage 3 RH was identified as the most prevalent.. · Advanced resuscitation was identified as an independent risk factor for RH..

The effect of oscillometric blood pressure measurement on pain response in preterm infants.

AIM: Preterm neonates are exposed to many painful procedures in neonatal intensive care units. This study aims to evaluate the effect of oscillometric blood pressure (BP) measurement on pain response in preterm infants. METHODS: This prospective study was performed over 4 months in a level III neonatal intensive care unit. Premature neonates whose gestational age was <34 weeks and postmenstrual age <36 weeks were included if they had no systemic diseases. BP measurement was performed on the right arm. The Premature Infant Pain Profile-Revised (PIPP-R) scores were evaluated three times before, during, and 10 min after BP measurement. RESULTS: During the 5-month period, 100 preterm neonates (53 male infants) were included in the study. Median birth weight and gestational age of the infants were 1148 (IQR: 1015-1300) g and 28 (IQR: 27-30) weeks, respectively. PIPP-R scores were found to be ≥7 in 34% of neonates. PIPP-R scores increased during BP measurement and decreased after. CONCLUSION: Our results demonstrated that oscillometric BP measurement which is generally accepted as a non-invasive tool for monitoring can produce mild pain in premature neonates of postmenstrual age <36 weeks.

Short-term outcomes of extremely low birth weight infants in a tertiary neonatal intensive care unit in Türkiye.

BACKGROUND: Advances in neonatal care have led to increased survival of extremely preterm infants. Extremely low-birth-weight (ELBW) infants, defined as infants weighing less than 1000 g at birth, constitute a significant portion of neonatal intensive care unit (NICU) patients. The aim of this study is to determine the mortality and short-term morbidities of ELBW infants and assess the risk factors related to mortality. METHODS: The medical records of ELBW neonates hospitalized in the NICU of a tertiary-level hospital between January 2017 and December 2021 were evaluated retrospectively. RESULTS: 616 ELBW (289 females and 327 males) infants were admitted to the NICU during the study period. Mean birth weight (BW) and gestational age (GA) for the total cohort were 725 ± 134 g (range 420-980 g) and 26.3 ± 2.1 weeks (range 22-31), respectively. The rate of survival to discharge was 54.5% (336/616) [33% for the infants with ≤750 g BW, 76% for the infants with 750-1000 g BW], and 45.2% of survived infants had no major neonatal morbidity at discharge. Independent risk factors for mortality of ELBW infants were asphyxia at birth, birth weight, respiratory distress syndrome, pulmonary hemorrhage, severe intraventricular hemorrhage, and meningitis. CONCLUSIONS: The incidence of mortality and morbidity was very high in ELBW infants, particularly for neonates born weighing less than 750 g in our study. We suggest that preventive and more effective treatment strategies are needed for improved outcomes in ELBW infants.

Can the triglyceride-glucose index predict insulin resistance in LGA newborns?

BACKGROUND: The aim of this study is to investigate the TyG index and TG/HDL-C ratio and their relationships with insulin resistance in LGA infants. METHODS: A prospective controlled study was conducted including 65 LGA and gestational age, gender-matched appropriate for gestational age (AGA) neonates. Serum TG, total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C), insulin and glucose levels were measured within two hours after birth, TyG index and HOMA-IR values were calculated. RESULTS: TyG index and TG/HDL- C ratio were higher in LGA neonates compared to AGA ones (p = 0.03; p = 0.00, respectively). Compared with AGA newborns, LGA newborns had higher levels of insulin and HOMA-IR (p = 0.00; p = 0.00, respectively). TyG index and TG/HDL-C ratio showed moderate correlation with HOMA-IR (r = 0.59 R2 = 0.35 p < 0.001; r = 0.5 R2 = 0.25 p < 0.001, respectively). CONCLUSiON: The results of this study show that LGA newborns have increased levels of TyG index and TG/HDL-C associated with insulin resistance.

Bevacizumab and neurodevelopmental outcomes of preterm infants with retinopathy of prematurity: should we still worry?

AIM: Bevacizumab may affect preterm infants' ongoing organogenesis with its antiangiogenic effects. We aimed to compare neurodevelopmental outcomes (NDO) of preterm infants treated for retinopathy of prematurity (ROP) with laser photocoagulation (LP), intravitreal bevacizumab (IVB) or both treatments, and to find out the effects of IVB on NDO. METHODS: Medical records of preterm infants with ROP treatment and evaluation for NDO were retrospectively collected between 1 January 2017 and 31 June 2019. Primary outcome was Bayley Scales of Infant and Toddler Development 3rd Edition (Bayley-III) scores including cognitive, language, and motor scores. Secondary outcomes were neurodevelopmental impairments (NDIs) classified as the presence of any of cerebral palsy (CP), sensorineural/mixed hearing loss, visual impairment, and developmental delay with any Bayley-III score <85. Severe NDI (sNDI) was defined as presence of any of CP with a Gross Motor Function Classification Scale of 3, 4, or 5, requirement for hearing aids or cochlear implants, bilateral visual impairment or severe developmental delay with any Bayley-III score <70. RESULTS: LP, IVB, and IVB + LP groups included 32, 12, and 10 patients, respectively. Patent ductus arteriosus treatment rates were as 68.7, 75, and 90% in groups, respectively (p<.05 between LP and IVB + LP groups). Grades 3 and 4 intraventricular hemorrhage (IVH) was lower in LP group than IVB group (9.4% vs. 33.4%, p<.05) while IVB + LP group had no grades 3 and 4 IVH. Other neonatal characteristics were similar (p > .05). CP was in 50%, 28%, and 0% of LP, IVB, and IVB + LP groups (p<.05). There was no difference in median Bayley-III cognitive, language, and motor scores between groups (p > .05). Moderate and severe developmental delays were similar between groups (p > .05) whereas IVB group had more moderate cognitive delay; and more severe cognitive, language, and motor delay. NDI rate was not different (59.3%, 50%, and 40% in groups, p > .05). sNDI was highest in IVB group but not statistically significant (31.2, 41.7, and 10% in groups, p > .05). Multiple logistic regression analysis showed that ROP treatment type and grades 3 and 4 IVH did not have any significant effect on NDO (p > .05). Odds of NDI was not effected by ROP treatment type (p > .05). CONCLUSIONS: Patients treated with bevacizumab should be carefully monitored for neurodevelopmental problems, although the frequency of grades 3 and 4 IVH in the bevacizumab group is thought to contribute to higher rates of sNDI and Bayley-III score <70.

Evaluation of radiologic evidence of metabolic bone disease in very low birth weight infants at fourth week of life.

AIM: The aim of this study is to determine the incidence of metabolic bone disease (MBD) and assess the risk factors for development radiologic evidence of MBD. METHODS: Preterm infants with gestational age ≤32 weeks and birth weight ≤1500 g were included in this prospective study. Metabolic bone disease was defined as hypophosphatemia (phosphorus levels <4 mg/dl), ALP levels >450 U/L, or radiologic findings of MBD at four weeks of age. RESULTS: The study included 254 infants (gestational age: 29 (27-30) weeks, birth weight: 1130 g (960-1300)). Metabolic bone disease was diagnosed in 96 patients (37%); 48 infants had only radiologic evidence of MBD, 24 infants had only biochemical diagnosis of MBD, and 24 infants had both radiologic evidence of MBD and biochemical diagnosis of MBD. CONCLUSIONS: Our results showed that radiologic evidence of MBD existed in some infants with normal biochemical results. That finding may guide further development of screening programs for MBD.

Incidence and risk factors of postnatal growth restriction in preterm infants.

AIM: Preterm infants are often significantly underweight at the time of hospital discharge. Growth impairment during early infancy can have permanent detrimental effects. We aimed to evaluate the incidence and risk factors of postnatal growth restriction (PNGR) in preterm infants. METHODS: This prospective study included 124 preterm infants in neonatal intensive care unit between January 2015 and June 2016. RESULTS: Of 140 preterm infants screened, postnatal growth retardation was detected in 46 babies (37%). Low gestational age was independent risk factors for PNGR. CONCLUSION: Clinicians should be aware of the presence of this morbidity when caring for preterm infants and to provide optimal enteral nutrition.

Increased ADMA levels are associated with poor pulmonary outcome in preterm neonates.

BACKGROUND: Nitric oxide (NO), synthesized from the amino acid L-arginine by the action of NO synthases (NOS), is a pulmonary vasodilator. Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of NOS. Preterm infants have higher plasma ADMA concentrations than term infants which could cause inhibition of NO synthesis and deterioration in pulmonary functions. We aimed to investigate the relationship between serum ADMA and L-arginine levels of preterm infants and respiratory distress syndrome (RDS), requirement of surfactant treatment, duration of mechanical ventilation, oxygen treatment, and development of bronchopulmonary dysplasia (BPD). METHODS: A prospective cohort study was conducted including 80 preterm infants born with gestational age (GA) ≤ 32 weeks and birth weight (BW) ≤ 1500 g. Blood samples were obtained from all infants immediately after birth, and at postnatal 28th day of age. The relationship of first-day serum ADMA and L-arginine levels and surfactant requirement, duration of mechanical ventilation, oxygen treatment was investigated. Serum ADMA and L-arginine levels at 1st and 28th days were compared at patients with and without BPD. The role of serum ADMA levels at postnatal 28th day of age to predict the requirement of oxygen at postmenstrual 36 weeks of age was also investigated. RESULTS: Eighty preterm infants (42 male, 38 female) were enrolled in the study. Mean BW and GA for the total cohort was 1144.81 ± 220.44 g and 28.3 ± 1.8 weeks, respectively. Sixty-one infants were diagnosed as RDS and 44 infants treated with surfactant. The first-day ADMA levels were significantly higher in infants with surfactant requirement (1.14 ± 0.23 versus 0.86 ± 0.37, p < 0.01). First-day L-arginine levels were lower in infants with surfactant requirement compared to infants without surfactant requirement (22.32 ± 2.33 versus 23.75 ± 2.42, p > 0.05) but not significantly. Serum ADMA and L-arginine concentrations at first day were not different among infants with and without BPD (p > 0.05). ADMA concentrations at 28th day was significantly higher in infants with BPD (1.00 ± 0.25 versus 0.81 ± 0.25, p < 0.05). The cutoff level of 0.875 µmol/L for ADMA at 28th day offered the best predictive value for oxygen requirement at postnatal 36 weeks of age with a sensitivity of 88% and a specificity of 54%. Conclusion: Serum ADMA and L-arginine levels are related to pulmonary morbidities in newborn. The results of this study show that increased ADMA levels are associated with poor pulmonary outcomes in preterm infants.

Clinical findings and effect of sodium hydrogen carbonate in patients with glutathione synthetase deficiency.

BACKGROUND: Glutathione synthetase (GS) deficiency is a rare inborn error of glutathione (GSH) metabolism manifested by severe metabolic acidosis, hemolytic anemia, neurological problems and massive excretion of pyroglutamic acid (5-oxoproline) in the urine. The disorder has mild, moderate, and severe clinical variants. We aimed to report clinical and laboratory findings of four patients, effect of sodium hydrogen carbonate treatment and long-term follow up of three patients. METHODS: Urine organic acid analysis was performed with gas chromatography-mass spectrometry. Molecular genetic analysis was performed in three patients, mutation was found in two of them. Enzyme analysis was performed in one patient. Clinical and laboratory findings of four patients were evaluated. RESULTS: One patient died at 4 months old, one patient's growth and development are normal, two patients have developed intellectual disability and seizures in the long term follow up period. Three patients benefited from sodium hydrogen carbonate treatment. CONCLUSIONS: The clinical picture varies from patient to patient, so it is difficult to predict the prognosis and the effectiveness of treatment protocols. We reported long term follow up of four patients and demonstrated that sodium hydrogen carbonate is effective for treatment of chronic metabolic acidosis in GS deficieny.

A case series of neonatal arrhythmias.

OBJECTIVE: Neonatal arrhythmias (NAs) are defined as abnormal heart rates in the neonatal period. They may occur as a result of various cardiovascular, systemic and metabolic problems. METHODS: A retrospective chart review was performed on newborns who were diagnosed with NA during hospitalization in a neonatal intensive care unit (NICU), or who were admitted to the NICU because of an arrhythmia diagnosis in two NICUs in Turkey from May 2011 to June 2013. RESULTS: Seventeen neonates with arrhythmias were identified. The incidence of NA was 0.4% and 0.3% in the two NICUs, and was 0.37% in the study population as a whole. Mean gestational age was 37 (29-40) weeks. Nine of the infants (53%) were diagnosed with fetal arrhythmia (FA) during the last week of gestation. The distribution of NA types was as follows: six (35%) supraventricular tachycardia (SVT), six (35%) premature atrial contractions (PACs), two (11%) premature ventricular contractions (PVCs), two (11%) multiple arrhythmias such as SVT + PAC and AV block + PVC, and one (5%) AV block. Wolff-Parkinson-White syndrome was present in one patient. An association of NA with congenital heart malformations was identified in five cases. CONCLUSIONS: Cardiac arrhythmias are important causes of infant morbidity, and an occasional cause of infant mortality if undiagnosed and untreated. It is important for the physician to be aware of the etiology, development and natural history of arrhythmias in the fetal and neonatal period.

Risk of retinopathy of prematurity in small for gestational age premature infants.

OBJECTIVE: To evaluate the incidence, risk factors and severity of retinopathy of prematurity in neonatal intensive care unit and to evaluate its relationship with gestational age. METHODS: Cohort study of neonates with gestational age ≤ 32 weeks or birthweight ≤ 1500 g. RESULTS: Of the 495 neonates screened, 43 (8.7%) infants were small for gestational age; the frequency of severe retinopathy of prematurity was 5.8%. Sepsis and being small for gestational age were independent risk factors for severe retinopathy of prematurity. CONCLUSIONS: Clinicians should be aware of the presence of presence of retinopathy of prematurity when caring for protein small for gestational age infants.

Fetal echogenic bowel in association with Zellweger syndrome.

Increased echogenicity of fetal bowel in the second trimester obstetrical ultrasound has been described in association with several pathologic conditions, such as growth restriction, aneuploidy, cystic fibrosis, congenital infections, and gastrointestinal malformations. Zellweger syndrome (ZS) is the prototype of peroxisomal disorders characterized by craniofacial dysmorphism and severe neurologic abnormalities. We report two cases with fetal echogenic bowel (FEB) but no associated anomalies and normal fetal growth. After birth, clinical and laboratory findings led to diagnosis of ZS. Association of FEB with neurometabolic disorders is limited to a few case reports in the medical literature. To the best of our knowledge, this is the first report of ZS associated with FEB.

Remifentanil analgesia during laser treatment for retinopathy of prematurity: a practical approach in neonatal intensive care unit.

BACKGROUND: Retinopathy of prematurity (ROP) is a significant cause of childhood blindness. AIM: The aim of this study is to determine the feasibility of remifentanil analgesia during laser treatment of ROP performed in the neonatal intensive care unit (NICU). PATIENTS AND METHODS: Remifentanil was infused continuously during the procedure starting with a dose of 0.2 µg/kg/min and increased gradually to 0.6 µg/kg/min to provide an adequate level of analgesia. RESULTS: We enrolled 64 infants. Remifentanil was infused continuously at a mean rate of 0.4 ± 0.1 µg/kg/min. No major adverse effects were observed except in two patients with reversible bradycardia and hypotension. Premature infant pain profile (PIPP) scores revealed no pain. Patients with bronchopulmonary dysplasia had similar remifentanil dosage, intubation duration, and extubation time. CONCLUSIONS: Remifentanil analgesia for ROP treatment performed in the NICU by pediatricians is a safe and effective modality. This modality offers a practical solution in hospitals without readily available pediatric anesthetists.

Body temperature changes of newborns under fluorescent versus LED phototherapy.

OBJECTIVE: To determine changes in body temperature (BT) of hyperbilirubinemic newborns under conventional phototherapy with fluorescent lamps and light emitting diodes (LED) at different irradiances. METHODS: Otherwise healthy newborn infants >34 wk gestational age (GA) hospitalized for indirect hyperbilirubinemia, requiring phototherapy in the first 10 d of life were enrolled. Infants who received conventional phototherapy with fluorescent lamps (10-15 µW/cm(2)/nm irradiance) were defined as group 1, LED phototherapy of 26-60 µW/cm(2)/nm irradiance as group 2, and LED phototherapy of 60-120 µW/cm(2)/nm irradiance as group 3. Primary outcome measure was mean BT which was defined as arithmetical mean of axillary BT measured at 2 h intervals during the first day of phototherapy. RESULTS: Thirty patients were enroled in each group. Mean birth weight and GA of the total cohort was 2800 ± 530 g and 36.6 ± 2 wk, respectively. Baseline demographic variables and serum total bilirubin levels were similar among groups. Mean BT was 36.7 ± 0.1 °C in group 1, 36.6 ± 0.2 °C in group 2, 37.7 ± 0.2 °C in group 3. Mean BT was higher in group 3 compared to group 1 (p < 0.001) and group 2 (p < 0.001). Group 1 and group 2 had similar mean BT measurements (p = 0.09). During phototherapy all the patients in group 3 had at least one BT measurement ≥ 37.5 °C and 77 % had BT ≥ 38 °C. Only one patient in group 2 had BT ≥ 37.5 °C which was also ≥ 38 °C. During phototherapy all BT measurements were <37.5 °C in group 1. CONCLUSIONS: LED phototherapy of ≥ 60 µW/cm(2)/nm intensity significantly increases BT in hyperbilirubinemic newborns.

Effects of phototherapy using different light sources on oxidant and antioxidant status of neonates with jaundice.

BACKGROUND/AIM: Neonates have limited antioxidant protective capacity. It has recently been demonstrated that phototherapy used for treatment of neonatal jaundice produces oxidative stress. Various phototherapy devices using different light sources are available for phototherapy. We aimed to investigate the effects of phototherapy applied with different light sources on the global oxidant/antioxidant status in neonates. METHODS: Term and late-preterm (≥35 weeks) newborn infants hospitalized to receive phototherapy for non-hemolytic jaundice in the 2-9 days of life were enrolled. Infants who received conventional phototherapy with fluorescent lamps were defined as group 1, intensive light emitting diode (LED) phototherapy as group 2, and fiberoptic phototherapy as group 3. The serum total antioxidant capacity (TAC) and total oxidant status (TOS) were measured before and 24 h after phototherapy. Oxidative stress index (OSI) was calculated. RESULTS: Twenty nine patients were included in each group. At the beginning of phototherapy serum TAC, TOS and OSI levels were similar in all groups. After phototherapy serum TAC decreased significantly in all three groups (p < 0.001). Total oxidant status increased significantly in group 1 (p < 0.001) and group 2 (p = 0.001) whereas a statistically insignificant increase was observed in group 3 (p = 0.057). After phototherapy OSI increased significantly in group 1 (p < 0.001), group 2 (p = 0.001), and group 3 (p = 0.038). CONCLUSION: As indicated by increased OSI, oxidant/antioxidant balance is disturbed in favor of oxidants after blue fluorescent light, LED and fiberoptic phototherapy.

The effect of galactagogue herbal tea on oxidant and anti-oxidant status of human milk.

OBJECTIVE: Human milk (HM) has antioxidant constituents which protect newborns against oxidative damage. We aimed to evaluate whether maternal consumption of herbal tea containing fenugreek had any effects on global oxidant and antioxidant capacity of HM. METHODS: Volunteer mothers 18-35 years of age without any antenatal or perinatal risk factors were randomly assigned to receive galactagogue herbal tea (Humana still-tee®, Herford, Deutschland) 3 cups/d or same amount of water as placebo. The total antioxidant capacity (TAC), total oxidant status (TOS) and the oxidative stress index (OSI) of breast milk samples taken in the 1st day and 7-10 d were compared between groups. RESULTS: Herbal tea (n = 40) and placebo (n = 40) groups had similar TAC, TOS and OSI values in the 1st day samples. TAC, TOS and OSI values in the breast milk samples taken on 7-10th day were also similar. OSI increased significantly in 7-10 day samples compared to 1st day in each group, while TAC and TOS levels did not differ. CONCLUSION: Galactagogue herbal tea containing fenugreek has no detectable effect on global oxidant and antioxidant status of HM. OSI increases in course of lactation compared to colostrums irrespective of galactagogue use.

Erythema annulare centrifugum as the presenting sign of Pseudomonas aeruginosa sepsis in a newborn.

We report a case of erythema annulare centrifugum (EAC) with neonatal onset. The patient presented on the fourth day of life with erythematous papules that enlarged centrifugally to form annular or policyclic plaques on anterior surface of trunk and legs without signs of systemic toxicity. Subsequently, she developed sepsis and disseminated intravascular coagulation and died on the sixth day of life. Blood culture grew Pseudomonas aeruginosa. The coexistence of P. aeruginosa sepsis with the clinical appearance of erythema annulare centrifugum strongly suggests a pathogenetic effect of the microorganism on the skin eruption. To the best of our knowledge, this is the first report of EAC with P. aeruginosa sepsis in a newborn.

An unusual localization of the umbilicus in a neonate.

We report the case of a male neonate with a low-set umbilicus. Physical examination revealed an appropriately grown term infant with no unusual findings, except ectopically placed umbilical cord at the level of the bladder in the hypogastric zone. The infant underwent detailed investigations that revealed no associated malformation. To the best of our knowledge, this is the first case with very distinct localization of the umbilicus without any congenital abnormalities.