Nurses' Finnegan Scoring of Newborns with Neonatal Abstinence Syndrome Not Affected by Time or Day of the Week.

OBJECTIVE: Newborns exposed to drugs in utero are at risk of developing neonatal abstinence syndrome (NAS), characterized by behavioral changes and physiologic instability. Finnegan scoring tool quantifies severity of symptoms and guides treatment. This article evaluates whether time of day and the number of shift hours affects modified Finnegan scores, and the subjective component of these scores. STUDY DESIGN: Institutional review board-approved, retrospective chart review of newborns admitted to neonatal intensive care or transitional nursery from 2011 to 2014. INCLUSION CRITERIA: > 35 weeks' gestation, known maternal substance use, positive maternal or newborn urine, or meconium drug screen, NAS treatment. RESULTS: A total of 101 charts were evaluated. Mean treatment duration was 31.8 days (standard deviation ±18.3). There was no significant relationship between observer shift hour and high scores (> 8) (p = 0.83). Highest scores occurred in the afternoon, decreased at night (p = 0.03), and throughout admission (p < 0.0001). Weekend and weekday scores were similar (p = 0.4). The objective component of the scores remained similar throughout the day (p = 0.91) and week (p = 0.52). CONCLUSION: Finnegan scores given by nurses were not influenced by shift hour. Time of day did not influence overall high scores or the proportion of objective to total Finnegan score. Inter-rater reliability was maintained regardless of time of day or day of the week.

IFN-γ and IP-10 in tracheal aspirates from premature infants: relationship with bronchopulmonary dysplasia.

BACKGROUND: Interferon-gamma (IFN-γ) and interferon-inducible protein of 10 kDa (IP-10) are potent inflammatory mediators and contribute to acute lung injury in adults. Recently, a potential role for IFN-γ and IP-10 in the pathogenesis of bronchopulmonary dysplasia (BPD) has been reported in animal models. OBJECTIVE: To study the association between IFN-γ and IP-10 in tracheal aspirate (TA) and the development of BPD in premature infants. DESIGN/METHODS: TA samples collected within 48 hr after birth from 79 mechanically ventilated premature neonates [gestational age (GA) <30 weeks (w), birth weight (BW) <1,250 g (g)] were analyzed. IFN-γ was measured in a subgroup of 38 infants by using a biochip multi-analyte immunoassay. The level of IP-10 was determined using a commercially available ELISA kit. Total protein in TA was measured by Bradford assay to correct for sampling related dilution. BPD was defined as the need of supplemental oxygen at 36 weeks postmenstrual age (PMA). RESULTS: Twenty infants (GA 26.4 ± 1.9w, BW 860 ± 201 g) survived without BPD at 36 weeks PMA and 59 infants (GA 25.5 ± 1.5w, BW 751 ± 163 g) died before 36 weeks PMA or developed BPD. The mean IFN-γ level was higher in infants who died or developed BPD (9.7 ± 2.8 vs. 3.1 ± 1.1 pg/ml, P = 0.03). Similarly, the mean IP-10 level was higher in infants who died or developed BPD (63.4 ± 17.5 pg/ml) compared to those who survived without BPD (18.5 ± 7.5 pg/ml, P = 0.02). CONCLUSIONS: Higher IFN-γ and IP-10 levels in TA samples are associated with the development of BPD or death in premature infants.

Vertically oval corneas in a child with holoprosencephaly.

Vertically oval-shaped corneas are an uncommon ophthalmic finding. The normal human cornea has an oval shape, but is wider in the horizontal dimension. The etiology of vertically oval corneas is unclear. This report presents a case of bilateral vertical oval corneas in a male infant with semilobar holoprosencephaly.

Impact of histological chorioamnionitis on tracheal aspirate cytokines in premature infants.

BACKGROUND: Histological chorioamnionitis (CHORIO) may increase inflammatory mediators in the lungs of preterm infants. OBJECTIVE: To study the impact of CHORIO on tracheal aspirate (TA) cytokines in ventilated infants. DESIGN/METHODS: TA samples collected within 48 hours after birth from 40 ventilated neonates (gestational age [GA] <30 weeks, body weight [BW] <1250 g) were analyzed. Levels of 12 cytokines (interleukin [IL]-1α, IL-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, epidermal growth factor [EGF], interferon-γ [IFN-γ], monocyte chemotactic protein-1 [MCP-1], tumor necrosis factor-α [TNF-α], vascular endothelial growth factor [VEGF]) were measured using a biochip multianalyte immunoassay (Randox Laboratories, Antrim, UK). Total protein was measured by the Bradford assay. CHORIO assessment was done by a blinded pathologist. RESULTS: Twenty-six infants (GA 26.6 ± 1.4 weeks, BW 852 ± 162 g) had no CHORIO and 14 (GA 25.1 ± 1.0 weeks, BW 776 ± 164 g) had CHORIO. IL-1α, IL-1ß, IL-8, and VEGF were significantly higher in TA of infants with CHORIO. After correction for dilution, IL-1α, IL-1ß, and IL-8 were significantly elevated. Increased TA total cell count correlated with CHORIO, VEGF, EGF, MCP-1, IL-8, and IL-6 TA levels (all p ≤ 0.02). Ventilator, oxygen supplementation, and hospital days correlated with TA IFN-γ levels (all p ≤ 0.01). CONCLUSION: CHORIO is associated with increased specific proinflammatory mediators in TA samples of preterm infants.

Sirtuin1 in tracheal aspirate leukocytes: possible role in the development of bronchopulmonary dysplasia in premature infants.

OBJECTIVE: To study the association between Sirtuin1 (Sirt1), a class III histone deacetylator, in tracheal aspirate (TA) leukocytes and the development of bronchopulmonary dysplasia (BPD) in premature infants and modulation of Sirt1 with dexamethasone (Dex) use. DESIGN/METHODS: Serial TA samples were collected on days 1, 3, 5 and 7 from ventilated premature neonates. Sirt1 was localized by immunocytochemistry and quantified on a scale of 0-4 by blinded observers. BPD was defined as the need of supplemental oxygen at 36 weeks postmenstrual age (PMA). RESULTS: A total of 130 TA samples were collected from 51 infants (mean ± SD: GA 25.5 ± 1.4 w, BW 762 ± 174 g). Eleven infants survived without BPD and 40 infants died before 36 weeks PMA or developed BPD. Sirt1 was localized in the cytoplasm and nuclei of mononuclear (MONO) as well as polymorphonuclear cells. Sirt1 was significantly more localized in the nuclei of MONO cells in infants without BPD compared to infants who developed BPD or died before 36 weeks PMA. Twenty six infants received Dex. There was no significant change in Sirt1 localization with steroid therapy. CONCLUSIONS: Lower Sirt1 in TA leukocytes is associated with the development of BPD or death in premature infants. Dex use had no effect on Sirt1.

Twice-weekly fluconazole prophylaxis in premature infants: association with cholestasis.

BACKGROUND: Fluconazole prophylaxis is effective in preventing invasive candidiasis in extremely low-birthweight (ELBW) infants. The authors previously reported an increased incidence of cholestasis with fluconazole prophylaxis in ELBW infants, which led to fluconazole prophylaxis being changed to a less frequent dosing (LFD) schedule of twice a week at their institution. The purpose of the present study was therefore to evaluate the effectiveness and safety of LFD fluconazole prophylaxis in preventing invasive candidiasis in ELBW infants. METHODS: ELBW infants who received the LFD regimen of fluconazole (twice a week for up to 6 weeks) were compared with infants who received the frequent dosing (FD) schedule (every 72 h for first 2 weeks, every 48 h for next 2 weeks and every 24 h for the final 2 weeks). The two groups were compared for baseline demographics, risk factors for candidiasis, the rate of invasive fungal infection and the incidence and severity of cholestasis. RESULTS: There was no significant difference in the incidence of invasive candidiasis in infants who received the LFD (2/104, 2%) compared to FD (0/140, 0%; P= 0.4) fluconazole prophylaxis. The severity of cholestasis was lower and a trend towards decreased incidence of cholestasis was observed on the LFD schedule. CONCLUSION: The LFD regimen of fluconazole prophylaxis is effective in preventing invasive fungal infection in ELBW infants. The severity of cholestasis was decreased with the LFD schedule.

Intractable neonatal seizures: an unusual presentation of congenital hypothyroidism.

Congenital hypothyroidism is the most common treatable cause of mental retardation. We report an unusual case of congenital hypothyroidism presenting as intractable seizures in an infant delivered to a mother known to have autoimmune hypothyroidism and who was noncompliant with therapy. To our knowledge, this rare presentation of congenital hypothyroidism has not been reported previously.

Azithromycin suppresses activation of nuclear factor-kappa B and synthesis of pro-inflammatory cytokines in tracheal aspirate cells from premature infants.

Nuclear factor-kappaB (NF-kappaB) plays a central role in regulating key proinflammatory mediators. The activation of NF-kappaB is increased in tracheal aspirate (TA) cells from premature infants developing bronchopulmonary dysplasia (BPD). We studied the effect of azithromycin (AZM) on the suppression of NF-kappaB activation and the synthesis of pro-inflammatory cytokines IL-6 and IL-8 by TA cells obtained from premature infants. Tracheal aspirate cells were stimulated with tumor necrosis factor-alpha (TNF-alpha) and incubated with AZM. The nuclear NF-kappaB-DNA binding activity, the levels of inhibitory kappaB-alpha (IkappaB-alpha) in the cytoplasmic fraction and IL-6 and IL-8 release in the cell culture media were measured. Stimulation of TA cells by TNF-alpha increased the activation of NF-kappaB, which was suppressed by the addition of AZM. Increased activation of NF-kappaB was also associated with increased levels of pro-inflammatory cytokines (IL-6 and IL-8). AZM significantly reduced the IL-6 and IL-8 production to the levels similar to control. TNF-alpha stimulation also increased the degradation of IkappaB-alpha, which was restored with the addition of AZM. Our data suggest that AZM therapy may be an effective alternative to steroids in reducing lung inflammation and prevention of BPD in ventilated premature infants.

Synchronized nasal intermittent positive pressure ventilation (SNIPPV) decreases work of breathing (WOB) in premature infants with respiratory distress syndrome (RDS) compared to nasal continuous positive airway pressure (NCPAP).

Synchronized nasal intermittent positive pressure ventilation (SNIPPV) is non-invasive respiratory support that delivers ventilator breaths via the nasal prongs. We hypothesized that SNIPPV is more effective than nasal continuous positive airway pressure (NCPAP) in premature neonates due to decreased work of breathing (WOB). Fifteen infants (BW: 1,367 +/- 325 g, GA: 29.5 +/- 2.4 weeks) were studied on (a) NCPAP at 5 cmH(2)O (NCPAP5) and (b) three increasing SNIPPV settings achieved by NCPAP5 with additional delivered peak inspiratory pressures (PIP) of 10, 12, and 14 cmH(2)O. Tidal volumes and transpulmonary pressures were estimated via calibrated respiratory inductance plethysmography (RIP) and esophageal pressures, respectively. Inspiratory (WOB(insp)), resistive (RWOB), and elastic (WOB(E)) components of WOB were calculated using standard methods. Compared to NCPAP5, (a) WOB(insp) and RWOB were significantly lower with SNIPPV12, and were similarly lower with SNIPPV14 and (b) WOB(E) was significantly lower only with SNIPPV14. WOB components did not differ significantly for the three SNIPPV settings. Tidal volume, respiratory rate (RR), minute ventilation, compliance, and phase angle were similar for all four measurements. In conclusion, compared to NCPAP, the addition of ventilator-delivered PIP during SNIPPV decreases WOB in premature infants.

Work of breathing during nasal continuous positive airway pressure in preterm infants: a comparison of bubble vs variable-flow devices.

OBJECTIVE: To compare work of breathing and breathing asynchrony during bubble nasal continuous positive airway pressure (NCPAP) vs variable-flow (VF)-NCPAP in premature infants. STUDY DESIGN: We studied 18 premature infants of birth weight <1500 g who required NCPAP for mild respiratory distress. Each infant was studied on bubble and VF-NCPAP at 8, 6, 4, and 0 cm H2O. Tidal volumes were obtained by calibrated respiratory inductance plethysmography. Esophageal pressure estimated intrapleural pressure. Inspiratory and resistive work of breathing were calculated from pressure-volume data. Breathing asynchrony was assessed with phase angle. The results at all NCPAP levels were referenced to VF-NCPAP values at 8 cm H2O. RESULTS: Provision of NCPAP with either device decreased inspiratory work of breathing, tidal volume, and minute ventilation relative to NCPAP of 0 cm H2O. Bubble NCPAP did not decrease resistive work of breathing relative to 0 cm H2O. Resistive work of breathing (p=0.01), respiratory rate (p<0.03), and phase angle (p=0.002) were all greater with bubble compared to VF-NCPAP. CONCLUSION: The more labored and asynchronous breathing seen with bubble NCPAP may lead to higher failure rates over the long term than with VF-NCPAP.

Changes in lung volume and work of breathing: A comparison of two variable-flow nasal continuous positive airway pressure devices in very low birth weight infants.

Variable flow nasal continuous positive airway pressure (VF-NCPAP) recruits lung volume more effectively and reduces work of breathing (WOB) compared to constant-flow NCPAP (CF-NCPAP) in very low birth weight (VLBW) infants. Because different VF-NCPAP devices have somewhat different flow patterns, whether different VF-NCPAP devices function similarly is unknown. We compared two VF-NCPAP devices: the Infant Flow trade mark (EME, Ltd.) and the Arabella(R) (Hamilton Medical) to assess whether lung volume recruitment and WOB were similar in VLBW infants requiring NCPAP. Eighteen infants <1,500 g were studied on both NCPAP devices applied in random order. All infants required NCPAP for mild respiratory distress. Calibrated DC-coupled respiratory inductance plethysmography (RIP) was used to assess lung volume changes. NCPAP was first increased to 8 cmH(2)O to allow comparable recruitment in all infants, and then was slowly decreased to 6, 4, and 0 cmH(2)O, with data collection at each level. Mean birth weight (+/-SD) was 1,107 +/- 218 g, gestational age was 27.9 +/- 2.0 weeks, weight at study was 1,092 +/- 222 g, and age at study was 4.6 +/- 4.3 days. There were no differences in lung volume recruitment overall or at any NCPAP level (P = 0.943). No differences were found in either inspiratory WOB (P = 0.468) or in resistive WOB (P = 0.610) between devices. Compliance, tidal volume, respiratory rate, and minute ventilation were also similar. Despite differences in flow characteristics between the two VF-NCPAP devices we studied, lung volume recruitment and WOB were similar.