The influence of EPO and hypothermia on the kidneys of rats after perinatal asphyxia

The aim of this study was to determine the effects of erythropoietin (EPO), moderate hypothermia, and a combination thereof on the kidneys of newborn rats damaged during perinatal asphyxia. An animal model of perinatal asphyxia (Wistar rats) was used in which after birth, newborn rats were divided into four groups of 15 animals each: G1, rats exposed only to asphyxia; G2, rats exposed to asphyxia and hypothermia (rectal temperature 32°C) and which received EPO (darbepoetin alpha) intraperitoneally; G3, rats exposed to asphyxia and hypothermia; G4, rats exposed to asphyxia and which received EPO. The rats were sacrificed on the 7th day of life and histopathological evaluation of kidneys was performed. Damage to the proximal tubules was significantly higher in group G1 rats than in groups G2, G3, and G4 rats (p < 0.01). Damage to the distal tubules was found only in group G1 rats. Histological changes in the proximal tubules were more prominent than in the distal tubules (p < 0.01). The immature glomeruli zone was less expressed in group G4 rats than in groups G1, G2, and G3 rats (p < 0.01). Based on these results, we conclude that EPO and hypothermia, as well as the combination thereof, have a protective effect on rats' kidneys damaged during perinatal asphyxia.

Neuroprotective effects of hypothermia and erythropoietin after perinatal asphyxia in newborn rats

OBJECTIVE

Evaluation of neuroprotective effects of hypothermia, erythropoietin and their simultaneous use after perinatal asphyxia in newborn rats.

METHOD

Hysterectomy was performed to Wistar female rats on the last day of gestation. Perinatal asphyxia was induced by submersion of uterus containing pups in saline for 15 min. After resuscitation, pups were randomized into 4 groups, 15 animals in each: G1 - asphyxia; G2 - asphyxia + hypothermia (rectal temperature 33 °C for 1 h); G3 - asphyxia + erythropoietin (Darbepoetin-α 2.5 μg, intraperitoneally) and G4 - asphyxia + erythropoietin + hypothermia. Pups were sacrificed on 7th day of life and histopathological analysis of hippocampus was performed.

RESULTS

Measure of damage to dorsal, ventral and entire hippocampus was significantly lower in groups G2, G3 and G4 than in group G1 (p ~ 0.00; respectively). Measure of damage to hippocampus in group G4 was significantly lower than in group G2 (p = 0.029).

CONCLUSIONS

This study demonstrates that simultaneous use of hypothermia and erythropoietin has more expressed neuroprotective effects than sole use of hypothermia after perinatal asphyxia in newborn rats.

Chronic inflammatory demyelinating polyradiculoneuropathy, in an 8-year-old girl, complicated by deafness and kidney fibrosis

Based on case history and clinical and electrophysiological examinations, the authors report on a case of an 8-year-old girl who was diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy. The disease was complicated by deafness and kidney fibrosis. During treatment with methylprednisolone and intravenous immunoglobulin, followed by mycophenolate mofetil, prompt improvement of neurological findings occurred. The improvement of hearing was poor. Because the pathogenesis of chronic inflammatory demyelinating polyradiculoneuropathy has still not been clear, and on the grounds of several cases of chronic inflammatory demyelinating polyradiculoneuropathy conjoined with the kidney disease described in literature (glomerulopathy, interstitial nephritis), every patient with chronic inflammatory demyelinating polyradiculoneuropathy needs to undergo the urinalyses.

Intracranial haemorrhage after transport of premature newborns

Intracranial hemorrhage remains an important factor of premature newborns? morbidity. Its incidence is significantly influenced by adequate perinatal care and safe neonatal transport. Risk factors for the development of intracranial hemorrhage in premature newborns after neonatal transport were analyzed in the retrospective transversal clinical study. Out of 150 study subjects, 60% (n=90/150) had intracranial hemorrhage with a statistically significant difference in relation to Apgar score, gestational age, birth weight, age at the moment of transport and the prophylactic use of surfactant. In this group, grades I/II intracranial hemorrhage were detected in 77% (n=69/90), while grades III/IV intracranial hemorrhage were diagnosed in 23% (n=21/90). A statistically significant difference was observed in relation to gestational age, birth weight, antenatal use of tocolytics and steroids, delivery mode and age in the time of transport between these groups. All patients were transferred to Intensive Care Unit, the duration of transport was less than 5 minutes in 71% 9n=107/150), whereas longer transport was recorded in 29% (n=43/150). In the group of longer transport, prophylactic surfactant was less frequently used with a higher incidence of grades III/IV intracranial hemorrhage. In order to prevent the development of intracranial hemorrhage in premature newborns, the most important measures are the antenatal use of steroids and postnatal prophylactic use of surfactant.

Etiology and Outcome of Severe Apparent Life-Threatening Events in Infants

INTRODUCTION

An apparent life-threatening event (ALTE) is defined as "an episode that is frightening to the observer and is characterized by some combination of apnea, color change, marked change of muscle tone, choking, or gagging."

OBJECTIVE

The aims of this study were to determine etiology and outcome of severe ALTE (requiring resuscitation measures) and to review diagnostic approaches in infants hospitalized after such an episode of ALTE.

METHODS

Retrospective analysis included patients hospitalized at the Intensive Care Unit, Institute of Child and Youth Healthcare of Vojvodina, after an episode of severe ALTE over a 4-year period.

RESULTS

The study included 23 infants, 18 male (78.3%), and 5 female (21.7%). The average age at presentation was 78 days (1 day to 11 months). In 8 infants (34.7%), ALTE resulted in death. The most frequent conditions after diagnostic evaluation were lower respiratory tract infections (39.1%), intracranial and extracranial hemorrhages (13.0%), and central nervous system infections (8.6%). The cause remained unknown in 8.7% of cases. Initial investigations included complete blood cell count, C-reactive protein or procalcitonin, blood gasses, lactate, electrolytes, glucose, blood culture, urinalysis, and chest x-ray.

CONCLUSIONS

Apparent life-threatening event represents a diverse disorder. Lower respiratory tract infections and neurological disorders were the most common established etiology. Prematurity and congenital heart diseases stood out as important risk factors. Diagnostic evaluation varied according to suspected cause and trigger factors.

[Acute renal failure in premature neonates]

BACKGROUND/AIM

Hemodynamic stress is the leading cause of acute renal failure (ARF) in premature neonates. Incidence of ARF in this population is between 8 and 24%. The aim of this study was to determine the frequence of presence of ARF in premature neonates, as well as its impact on their survival.

METHODS

A retrospective study of 114 premature neonates [(gestational age, GA less than 37 gestation weeks (gw)] admitted to the Intensive Care Unit (ICU) at the Pediatric Clinic, Institute of Child and Youth Healthcare of Vojvodina in 2007 was conducted. Serum creatinine, urea and bilirubine were determined on the 3rd day of life in 65 newborns who met inclusion criteria. ARF was diagnosed in 16 newborns (n = 16/65; 25%).

RESULTS

The premature neonates with ARF had significantly lower GA [<28 gw - 8/16 (50%) vs. 5/49 (10%); p < 0.05], birth weight (BW) (1265 g vs. 1615 g; p < 0.05) and systolic blood pressure (43.37 mm Hg vs. 52.7 mmHg; p < 0.05) than ones without ARF. Non-olyguric ARF was diagnosed in 62% of newborns with ARF (n = 10/16), while the rest had the olyguric type (n = 6/16; 38%). Twenty-five percent of premature neonates with ARF (n = 4/16) died in contrast to 10% of premature neonates without ARF (n = 5/49). ARF was treated conservatively in all but 3 cases when peritoneal dialysis was performed. Renal function has recovered completely in all of the survivors. In order to determine their predictivity in relation to ARF, following parameters were analyzed: GA, BW < 1500 g, presence of concomitant sepsis and intracranial hemorrhage grade III/IV. BW < 1500 g demonstrated the highest sensitivity (se 0.75), while GA < 28 gw, sepsis and intracranial hemorrhage grade III/IV showed high specificity (sp = 0.90, 0.89 0.88, respectively).

CONCLUSION

Acute renal failure frequently occurs in population of premature neonates and requires meticulous fluid and electrolyte balance, especially in the case of low birth weight and extreme immaturity.

[Morbidity and mortality of premature neonates after introduction of national in vitro fertilisation programme--our experience]

INTRODUCTION

Infertility occurs in approximately 10% of couples and in vitro fertilisation (IVF) is its most efficient treatment method. The National IVF Programme started in October 1st, 2006.

OBJECTIVE

Examination of morbidity and mortality of premature neonates conceived by IVF after initiation of the National IVF Programme.

METHODS

Retrospective analysis of history charts of IVF premature neonates treated at the Neonatal Intensive Care Unit (NICU) of the Institute of Child and Youth Healthcare of Vojvodina, Novi Sad, Serbia, from March 1st, 2007 to March 1st, 2008.

RESULTS

Of 189 treated premature neonates, 25 (13.23%) were IVF conceived, with mean gestational age (GA) of 29.46 +/- 3.28 gestational weeks (GW), one-minute Apgar score 5.44 +/- 2.45, five-minute Apgar score 7.16 +/- 1.92 and birth weight (BW) 1299 +/- 484.35 g; from singleton 12 (48%), twin 10 (40%), and trigeminal 3 (12%) gestations. The largest number of neonates were of GA between 29 and 31.9 GW (12; 48%) and BW between 1500 and 2499 g (9; 36%). All of them were treated due to respiratory distress syndrome, complicated in 2 (8%) with air leak syndromes and in 4 (16%) with pulmonary haemorrhage. Congenital anomalies were detected in 2 (8%) and intracranial haemorrhage developed subsequently in 21 (84%) neonates. Lethal outcome occurred in 7 (28%) neonates, in all cases in lower gestation groups (<29 GW). Variable analysis showed significantly higher incidence of chorioamnionitis (p = 0.0004) and lower GA (p approximately 0.00), BW (p approximately 0.00), one-minute Apgar score (p = 0.0007) as well as significant difference in prophylactic surfactant application (p approximately 0.00) and mean arterial pressure on admission (p = 0.002).

CONCLUSION

Morbidity and mortality of IVF premature neonates does not differ significantly from that of other premature neonates treated at NICU. Prematurity and low BW are important factors in pathology of these neonates and final outcome is influenced by perinatal asphyxia, risk of systemic infection, prophylactic surfactant application and arterial hypotension.

Newborns from in vitro fertilization conceived pregnancies

Infertility, defined as 'unsuccessful conception after 1 year of unprotected intercourse', is an increasing problem in many countries. Demographic data in Serbia continue to show negative trend of depopulation. One-third of married couples in Serbia are childless and half of them cannot have offspring due to health problems. Analysis of morbidity and mortality of premature newborns IVT (in vitro fertilization) conceived and treated in two Department of Intensive Care, in Novi Sad and Belgrade, Serbia during 2 years. Significant number of IVF conceived newborns are treated at NICUs. Prematurity, low birth weight, perinatal asphyxia, systemic infection, as well as proper initial stabilization, especially prevention and early treatment of systemic hypotension are important factors contributing to morbidity of these patients.

[Pain indicators in newborns]

DEFINITION OF PAIN: The International Association for the Study of Pain has defined pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage." The interpretation of pain is subjective. Each person forms an internal construct of pain through encountered injury. PAIN AND NEWBORN: The issue of pain perception in newborns, its management and prevention has been neglected for decades. The inability of "self-report" of painful experience has contributed significantly to misunderstanding of the importance of this problem and inadequate treatment. The main characteristic of this 'critical window of brain development' period is rapid enlargement of brain volume and its great plasticity. Harmful short-term and long-term consequences can arise as a consequence of disturbance of the sophisticated balance between newborn and its surrounding. NEONATAL PAIN INDICATORS: As a response to a present painful stimulus, the newborn adapts to this acute stress with changes in endocrine, vegetative, immune and behavioral area. An ideal pain indicator in neonatal period does not exist. There are several different groups of them, namely contextual and developmental indicators (gestational age, contributed illness, medication, for example), physiological (heart rate, vagal tone, breathing rate, blood pressure, oxygen saturation, transcutaneous partial pressures of oxygen and carbon-dioxide, intracranial pressure, palm sweating) and behavioral ones (face expression, movements of limbs, cry), several neonatal pain scales were constructed on the basis of these indicators.

Severe neonatal subgaleal hemorrhage as the first presentation of hemophilia A

Introduction. Subgaleal hemorrhage is a rare but potentially fatal birth trauma. It is caused by rupture of the emissary veins (connections between the dural sinuses and scalp veins), followed by the accumulation of blood between the epicranial aponeurosis and the periosteum. Usually, it is associated with instrumental delivery (vacuum extraction, forceps delivery), but it may also occur spontaneously, suggesting the possibility of congenital bleeding disorder. Case Outline. A full term male neonate was born at 40 weeks gestation by spontaneous vaginal delivery, with birth weight of 3,700 g. The Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. At the age of 23 hours, the baby became pale and lethargic. Large fluctuant swelling on his head was noted. He developed severe anemia and hypovolemia as a result of massive subgaleal hemorrhage. After successful treatment, the baby fully recovered. Follow-up and further evaluation revealed hemophilia A as a result of a de novo mutation. Conclusion. This case illustrates that subgaleal hemorrhage may be the first presentation of hemophilia A. Infants without obvious risk factors for developing subgaleal hemorrhage should be evaluated for congenital bleeding disorder. Successful outcome in affected infants requires early diagnosis, careful monitoring and prompt treatment.

The use of peritoneal dialysis in newborns

Introduction. Acute renal failure is a common complication in critically ill newborn infants. The therapy of acute renal failure is conservative and etiological. Patients not responding to this kind of therapy require peritoneal dialysis. Material and methods. This retrospective study included 6 newborn infants undergoing peritoneal dialysis during the period from January 2004 to June 2006, at the Nephrology Department of the Institute of Child and Youth Health Care in Novi Sad. All patients presented with complications of acute renal failure including hypercalemia and uremic encephalopathy. Results. Complete restoration of kidney function was evident in four patients on peritoneal dialysis. Three patients are still alive, but in one patient acute renal failure progressed to chronic renal failure. One patient died in the third month of life due to multiple organ dysfunction, after just two days of dialysis. Several complications were reported: intra-abdominal hemorrhage, dialysate leakage, peritonitis and dialysis catheter obstruction. Discussion. Periotoneal dialysis catheter placement is a great problem due to the size of the newborn. If it is estimated that it will be a long-lasting dialysis, Tenckhoff catheter is recommended. In very low birth weight newborn infants, in poor overall condition, general anesthesia is too risky, and acute peritoneal dialysis catheter should be placed (i.v. cannula, venous catheter). Conclusion. Peritoneal dialysis is the method of choice in newborns with acute renal failure, and it is used in the treatment of neonatal asphyxia till the restoration of kidney function is achieved. .

TRAP (Twin Reversed Arterial Perfusion) sequence

TRAP (Twin Reversed Arterial Perfusion) sequence is a rare malformation that occurs in monozygotic twin pregnancies. Twin weight ratio in our case was 76% (body weight of pump twin was 1800 g, acardiac twin 1370 g), but in spite of that the pump twin had a mild clinical picture with premature birth, fetal hydrops (mild pleural effusion; hypoproteinemia; on the 3rd day of life the baby was without edema and the level of his serum proteins were in referral ranges) and mild myocardial hypertrophy of left ventricle (echocardiography performed on the 28th day of life was normal).

Chronic renal failure as a complication of hemorrhagic fever with renal syndrome in 17 years’ old boy

Hemorrhagic fever with renal syndrome (HFRS) is an acute infective multisystemic disease that commonly presents with fever, hemorrhage and acute renal failure. A 17-year-old boy presented with thrombocytopenia, profuse subconjunctival hemorrhage and anuric renal failure with fluid overload. The patient required continuous ambulatory peritoneal dialysis. He developed diuresis but did not recover renal function during reconvalescent period. Hantaan, Puumala, Seoul, Belgrade virus infection with haemorrhagic fever with renal syndrome was confirmed by serologic test.

Oral intake of bovine lactoferrin alleviates intestinal injury induced by perinatal hypoxia and hypothermia in newborn rats

Introduction/Objectives. To investigate whether oral administration of lactoferrin attenuates intestinal injury induced by perinatal hypoxia and hypothermia. Methods. Newborn Wistar rat pups were exposed to perinatal asphyxia, followed by global hypothermia. The pups were distributed into two groups: lactoferrin group (LG) ? pups that received lactoferrin orally for seven days (20 mg/day), control group (CG) ? pups that received normal saline orally during first seven days of life. After seven days macroscopic examination of the bowels and pathohistological analyses of tissue samples have been performed. Results. The incidence of macroscopic injuries was significantly lower in LG group compared to CG. The incidence of pathological findings, as well as the values of injury scores used to assess the intensity and extent of intestinal injury at microscopic level were significantly lower in LG group. Conclusions. Lactoferrin attenuates perinatal hypoxia/hypothermia-induced intestinal injury in newborn rats.

Herpes simplex and Ebstein Barr virus encephalitis complicated with Klüver-Bucy syndrome

A case of sixteen-year-old boy with initial herpes simplex virus (HSV) and Epstein-Barr virus (EBV) encephalitis is reported. Herpesviruses are often found in cerebrospinal fluid (CSF) along with EBV. After eradication of HSV in CSF in this case, a positive polymerase chain reaction (PCR) to EBV in CSF remained along with a severe clinical picture (segmental myoclonus and Klüver-Bucy syndrome) and worsening of brain magnetic resonance imaging (MRI) findings. Neurological and psychological improvement occurred after treatment with intravenous immunoglobulin.

A multisystem inflammatory syndrome in children associated with COVID-19 in a 11-years-old girl

Introduction. Multisystem inflammatory syndrome in children (MIS-C) is a post-viral, life-threatening, inflammatory state with multisystem involvement that typically manifests 3?4 weeks after SARS-CoV-2 infection. In this article, we present the first case of MIS-C at the Institute for Child and Youth Health Care of Vojvodina at the beginning of the COVID-19 pandemic. Case outline. A previously healthy 11-year-old girl got sick two days before admission to the hospital with a fever, headache, vomiting, abdominal pain, and fatigue. She was tested positive for COVID-19 by a nasopharyngeal PCR swab with positive IgM and IgG antibodies. In the further course, the illness presented with prolonged fever, laboratory evidence of inflammation, multiorgan involvement such as respiratory, gastrointestinal, cardiovascular, and dermatologic. Based on CDC and WHO criteria, the diagnosis of MIS-C was made and IVIG and methylprednisolone were introduced with favorable clinical course. Conclusion. Every prolonged and unusual febrile state, especially if it is accompanied by gastrointestinal symptoms, in a school-age child, should be investigated in the direction of recent COVID-19 infection or exposure. In a case of a positive COVID-19 history or history of exposure, the MIS-C diagnosis should be considered.

Sudden death in children

Introduction/Objective. Sudden death in children may occur as a result of many diseases and accidents, while the cause often remains unknown. There are different terms in the literature that represent the causes of sudden death in children. The aim of our study was to determine the most common cause of sudden death in children admitted to the Clinic of Pediatrics. Methods. The retrospective study was conducted in the period from January 1, 1995 to December 31, 2015 and included 49 patients, aged from 10 days to 17 years, in whom death occurred in the Emergency Department and in the first 48 hours of hospitalization. Results. In 23 patients (47%) the cause of death was infection, in 10 patients (20%) heart failure, four patients (8%) died due to status epilepticus, the same number of patients (8%) died due to aspiration of a foreign body, while the rest of the patients died due to diabetic ketoacidosis (2%), rickets (2%), carbon monoxide poisoning (2%), hemolytic anemia (2%), suicide by hanging (2%), drowning (2%), sudden infant death syndrome (2%), and sudden unexpected death in epilepsy (2%). Most of the patients in our study were infants (43%). Conclusion. Our study shows that infants are at the highest risk of sudden death, while the most frequent causes of death are infections and cardiovascular diseases.