Temporary pacing through umbilical venous route for neonatal heart failure due to complete atrioventricular block

We present a case of a neonate who presented with worsening heart failure due to congenital complete atrioventricular (AV) block, secondary to maternal anti Ro/SSA and anti-LA/SSB antibodies. The patient was implanted a temporary pacemaker in view of hemodynamic deterioration and subsequently was weaned off ionotropic support and referred for permanent epicardial pacemaker implantation. We report temporary pacemaker implantation in a neonate with hemodynamic instability as a stabilizing measure and discuss technical challenges for the same.

The Impact of Latent Cytomegalovirus Infection on Spontaneous Abortion History and Pregnancy Outcomes in Romanian Pregnant Women

Cytomegalovirus (CMV), a DNA virus that belongs to the Orthoherpesviridae family, infects 40-100% of people. Primary/non-primary CMV infection during pregnancy could cause fetal disabilities. After primary infection, CMV causes a latent infection and resides in cells of the myeloid compartment (CD34+, monocytes). Few studies have analyzed the impact of latent CMV infections on miscarriage history, pregnancy complications, and neonatal outcomes.

METHODS

Serum samples from 806 pregnant women (28.29 ± 4.50 years old) who came for a consultation at the Timisoara Clinical Emergency City Hospital between 2008 and 2010 were tested for anti-CMV IgM/IgG antibodies, and data about demography, obstetrical history, pregnancy complications, birth, and neonate were collected. The data were compared between the groups with and without latent CMV infection, and statistical significance was calculated.

RESULTS

We did not find a difference regarding cesarean section (OR = 0.916, p = 0.856), placental abruption (OR = 1.004, p = 1.00), pregnancy-induced hypertension rate (OR = 1.078, p = 1.00), secondary sex ratio (0.882, p = 0.857), APGAR score (p = 0.225), gestational age at birth (p = 0.434), or birth weight (p = 0.365). A borderline significant difference was found regarding the presence of miscarriage history: OR = 8.467, p = 0.051.

CONCLUSIONS

The presence of latent CMV infection does not affect the likelihood of complications in healthy women. A borderline significantly higher prevalence of miscarriage history was found in women with latent CMV infection.

Congenital and Postnatal Cytomegalovirus: Case Series and State of the Science for Neonatal Providers

Cytomegalovirus (CMV), a beta-herpes virus, is the most common viral infection in infants. Transmission may occur congenitally (cCMV) or postnatally (pCMV). Early detection and intervention are crucial in reducing morbidities, notable developmental delays, and sensorineural hearing loss. However, more than 90% of infants are asymptomatic at birth. Treatment involves intravenous ganciclovir or the oral prodrug, valganciclovir, drugs usually reserved for use with symptomatic infants because of the toxicity profile. Research currently supports standardized antenatal CMV screening and treatment of affected pregnant patients with hyperimmune globulin as well as vaccination against CMV in unaffected pregnant patients, although widespread adoption is lacking. Standardized postnatal CMV screening is a proven, cost-effective way to detect and diagnose CMV and optimize outcomes across the lifespan. This article presents a case series of cCMV and pCMV and a review of the state of science of CMV as well as promising scientific advances that are on the horizon.

Neonatal Paratesticular Scrotal Mass: A Rare Case of Atypical Neurofibromatous Neoplasm with Uncertain Biologic Potential

ABSTRACT

Atypical neurofibromatous neoplasm with uncertain biologic potential presenting as a paratesticular scrotal mass in a neonate with congenital giant melanocytic nevus is rare. Only one such case of neonatal scrotal neurofibroma has been reported earlier. We report an additional case and its management.

A rare case of severe Ebstein's anomaly and hepatoblastoma in a neonate

Primary liver tumours in neonates with single-ventricle palliation are exceedingly rare. We present the first reported case of neonatal hepatoblastoma with severe Ebstein's anomaly following Starnes procedure. The patient's postoperative course highlights the challenges and complications in simultaneous management of these diagnoses. Transition from shunted single-ventricle physiology to bidirectional cavopulmonary connection improved end-organ function, permitting more aggressive hepatic malignancy treatment.

Delayed Subaponeurotic Fluid Collection in a Neonate: A Case Report

Delayed subaponeurotic fluid collection (DSFC) is a rare cause of scalp swelling that typically presents in healthy-term babies during the second month of life. It is a benign, self-limited condition that requires only conservative management. We present a case of DSFC in a male infant who was brought to our emergency department by his parents at the age of 52 days because of concerns about a newly noticed fluctuating scalp mass. The baby was managed conservatively, and the DSFC completely resolved after three weeks. We describe and discuss the diagnostic workup conducted and the management plan implemented in line with the scientific literature and similar cases previously reported. Given its benign but rare nature, pediatricians and neurosurgeons should be more aware of DSFC as a potential entity in the differential diagnosis of fluctuant scalp swellings. Early recognition can prevent unnecessary investigations or interventions and provide reassurance to parents regarding the condition's benign course. To the best of our knowledge, this is the first reported case in Saudi Arabia, the second reported case from the Middle East, and the second from Asia.

The Impact of Physical and Environment Factors on Parental Presence for Oral Feeding in New Zealand Neonatal Intensive Care Units

AIM

To identify physical environmental factors influencing family involvement in feeding in New Zealand neonatal units.

BACKGROUND

Infant oral feeding development is critical for both short-term feeding skills and longer term neurodevelopmental outcomes. The neonatal environment is well-known as challenging for neuroprotection due to negative sensory exposure. The impact of environmental factors on oral feeding in New Zealand (NZ) neonatal units is currently unexplored, and knowledge of this could allow for evidence-based unit design.

METHODS

Focused ethnography at five neonatal units, a national survey of NZ neonatal professionals (n = 102), and five focus groups were carried out. Current oral feeding practice, and beliefs, experiences, and opinions of unit staff and family about these practices were explored. Data were analyzed using qualitative content analysis.

RESULTS

Units were providing the best experience to families that they could with the resources they had available. Lack of physical space, lack of privacy, limited on-site accommodation for families, and lack of coordination between maternity and neonatal services were identified as impacting on family's comfort and sense of homeliness on the unit. Unit staff used furniture, screens, and external accommodation providers to support families where they could.

CONCLUSIONS

The physical design of neonatal units in New Zealand provides barriers to family's spending time privately developing oral feeding. Solutions are proposed to increase the size of bedspaces, provide single-family rooms, create greater on-site family accommodation options, combine maternity and neonatal healthcare, and improve family comfort and therefore connection with their infant.

Echocardiography evaluation of neonatal vein of Galen aneurysmal malformation

BACKGROUND

In neonatal vein of Galen aneurysmal malformation, vein of Galen aneurysmal malformation echocardiography remains the mainstay for early detection and explains various haemodynamic changes occurring due to a large systemic arterio-venous shunt. However, there is limited evidence of echocardiography in risk stratifying neonatal vein of Galen aneurysmal malformation vein of Galen aneurysmal malformation. The objective of this study was to identify echocardiographic parameters that could be associated with major outcomes and guide timing of neuro-intervention.

METHODS

In this retrospective chart review, infants < 28 days of age with the diagnosis of vein of Galen aneurysmal malformation vein of Galen aneurysmal malformation were included. Demographic, clinical, and echocardiographic parameters were compared in neonates who survived or died with neonatal presentation. A risk algorithm model based on key echocardiographic parameters was developed to determine those who are at risk of early death.

RESULTS

Of the 19 neonates included, with median birth weight 3.1 kg (IQR 2.58-3.36), nine (47%) neonates died at median age of 5 days (IQR 4-17). All neonates showed retrograde diastolic flow at the level of descending aorta by colour Doppler on the first post-natal echocardiogram at median age of 2 days (IQR 1-5.5). An aortic antegrade-to-retrograde velocity time integral ratio of < 1.5 and supra-systemic pulmonary artery pressure had 100% positive predictive value of death (p = 0.029), whereas aortic antegrade-to-retrograde velocity time integral ratio of > 1.5 and sub-systemic pulmonary artery pressure had 100% positive predictive value of survival (p = 0.029).

CONCLUSION

Combination of aorta antegrade-to-retrograde velocity time integral ratio and degree of pulmonary hypertension on the first post-natal echocardiogram may help stratify the severity of disease and guide optimal timing for neuro-intervention for neonatal vein of Galen aneurysmal malformation.

Fluid and electrolyte management in the neonate and what can go wrong

PURPOSE OF REVIEW

This review highlights recent advances in understanding fluid and electrolyte homeostasis during the newborn period, including heightened recognition of fluid overload and acute kidney injury contributing to poor clinical outcomes. Particular attention is given towards the care of extremely preterm infants.

RECENT FINDINGS

Emerging data demonstrate (i) disproportionally large transepidermal water loss in the extremely preterm population, (ii) the relationship between postnatal weight loss (negative fluid balance) and improved outcomes, (iii) the frequency and negative effects of dysnatremias early in life, (iv) the role of sodium homeostasis in optimizing postnatal growth, and (v) the deleterious effects of fluid overload and acute kidney injury.

SUMMARY

As clinicians care for an increasing number of preterm infants, understanding progress in approaches to fluid and electrolyte management and avoidance of fluid overload states will improve the care and outcomes of this vulnerable population. Further translational and clinical studies are needed to address remaining knowledge gaps and improve current approaches to fluid and electrolyte management.

Tissue-Tracking Mitral Annular Displacement in Neonates: A Novel Index of Left Ventricular Systolic Function

OBJECTIVES

To assess the feasibility, accuracy, and reproducibility of tissue-tracking mitral annular displacement (TMAD) compared with other measures of left ventricular systolic function in healthy preterm and term neonates in the transitional period.

METHODS

This was a prospective observational study. Two echocardiograms were performed at 24 and 48 hours of life. TMAD, shortening fraction (SF), ejection fraction (EF), s', and global longitudinal strain (GLS) were measured offline. Accuracy to detect impaired GLS was tested by ROC curve analysis. DeLong test was used to compare AUCs. Intra and interobserver reproducibility of the off-line analysis was calculated.

RESULTS

Mean ± SD gestational age and weight were 34.2 ± 3.8 weeks and 2162 ± 833 g, respectively. TMAD was feasible in 168/180 scans (93%). At 24 hours the AUC (95% CI) of SF, EF, s', and TMAD (%) was 0.51 (0.36-0.67), 0.68 (0.54-0.82), 0.63 (0.49-0.77), and 0.89 (0.79-0.99) respectively. At 48 hours the AUC (95% CI) of SF, EF, s', and TMAD (%) was 0.64 (0.51-0.77), 0.59 (0.37-0.80), 0.70 (0.54-0.86), and 0.96 (0.91-1.00), respectively. The AUC of TMAD was superior to the AUC of SF, EF, s', at both timepoints (P < .02). Intraclass correlation coefficients (95% CI) of intra and interobserver reproducibility of TMAD were 0.97 (0.95-0.99) and 0.94 (0.88-0.97), respectively.

CONCLUSION

TMAD showed improved accuracy and optimal reproducibility in neonates in the first 48 hours of life.

Recent Advances in Kidney Replacement Therapy in Infants: A Review

Kidney replacement therapy (KRT) is used to treat children and adults with acute kidney injury (AKI), fluid overload, kidney failure, inborn errors of metabolism, and severe electrolyte abnormalities. Peritoneal dialysis and extracorporeal hemodialysis/filtration can be performed for different durations (intermittent, prolonged intermittent, and continuous) through either adaptation of adult devices or use of infant-specific devices. Each of these modalities have advantages and disadvantages, and often multiple modalities are used depending on the scenario and patient-specific needs. Traditionally, these therapies have been challenging to deliver in infants due the lack of infant-specific devices, small patient size, required extracorporeal volumes, and the risk of hemodynamic stability during the initiation of KRT. In this review, we discuss challenges, recent advancements, and optimal approaches to provide KRT in hospitalized infants, including a discussion of peritoneal dialysis and extracorporeal therapies. We discuss each specific KRT modality, review newer infant-specific devices, and highlight the benefits and limitations of each modality. We also discuss the ethical implications for the care of infants who need KRT and areas for future research.

Accurate Neonatal Face Detection for Improved Pain Classification in the Challenging NICU Setting

There is a tendency for object detection systems using off-the-shelf algorithms to fail when deployed in complex scenes. The present work describes a case for detecting facial expression in post-surgical neonates (newborns) as a modality for predicting and classifying severe pain in the Neonatal Intensive Care Unit (NICU). Our initial testing showed that both an off-the-shelf face detector and a machine learning algorithm trained on adult faces failed to detect facial expression of neonates in the NICU. We improved accuracy in this complex scene by training a state-of-the-art "You-Only-Look-Once" (YOLO) face detection model using the USF-MNPAD-I dataset of neonate faces. At run-time our trained YOLO model showed a difference of 8.6% mean Average Precision (mAP) and 21.2% Area under the ROC Curve (AUC) for automatic classification of neonatal pain compared with manual pain scoring by NICU nurses. Given the challenges, time and effort associated with collecting ground truth from the faces of post-surgical neonates, here we share the weights from training our YOLO model with these facial expression data. These weights can facilitate the further development of accurate strategies for detecting facial expression, which can be used to predict the time to pain onset in combination with other sensory modalities (body movements, crying frequency, vital signs). Reliable predictions of time to pain onset in turn create a therapeutic window of time wherein NICU nurses and providers can implement safe and effective strategies to mitigate severe pain in this vulnerable patient population.

Perioperative and Long-Term Outcomes in Infants Undergoing a Tracheostomy from a Neonatal Intensive Care Unit

OBJECTIVE

The purpose of this study was to identify risk factors for perioperative complications and long-term morbidity in infants from the neonatal intensive care unit (NICU) presenting for a tracheostomy.

METHODS

This single-center retrospective cohort study included infants in the NICU presenting for a tracheostomy from August 2011 to December 2019. Primary outcomes were categorized as either a perioperative complication or long-term morbidity. A severe perioperative complication was defined as having either (1) an intraoperative cardiopulmonary arrest, (2) an intraoperative death, (3) a postoperative cardiopulmonary arrest within 30 days of the procedure, or (4) a postoperative death within 30 days of the procedure. Long-term morbidities included (1) the need for gastrostomy tube placement within the tracheostomy hospitalization and (2) the need for diuretic therapy, pulmonary hypertensive therapy, oxygen, or mechanical ventilation at 12 and 24 months following the tracheostomy.

RESULTS

One-hundred eighty-three children underwent a tracheostomy. The mean age at tracheostomy was 16.9 weeks while the mean post-conceptual age at tracheostomy was 49.7 weeks. The incidence of severe perioperative complications was 4.4% (n = 8) with the number of pulmonary hypertension medication classes preoperatively (OR: 3.64, 95% CI: (1.44-8.94), p = 0.005) as a significant risk factor. Approximately 81% of children additionally had a gastrostomy tube placed at the time of the tracheostomy, and 62% were ventilator-dependent 2 years following their tracheostomy.

CONCLUSION

Our study provides critical perioperative complications and long-term morbidity data to neonatologists, pediatricians, surgeons, anesthesiologists, and families in the expected course of infants from the NICU presenting for a tracheostomy.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1945-1954, 2024.

Neonatal hemophagocytic lymphohistiocytosis: A meta-analysis of 205 cases

BACKGROUND

Neonatal hemophagocytic lymphohistiocytosis (nHLH), defined as HLH that presents in the first month of life, is clinically devastating. There have been few large descriptive studies of nHLH.

OBJECTIVES

The objective of this study was to perform a meta-analysis of published cases of nHLH.

METHODS

A comprehensive literature database search was performed. Cases of HLH were eligible for inclusion if clinical analysis was performed at age ≤30 days. Up to 70 variables were extracted from each case.

RESULTS

A total of 544 studies were assessed for eligibility, and 205 cases of nHLH from 142 articles were included. The median age of symptom onset was day of life 3 (interquartile range [IQR]: 0-11, n = 141). Median age at diagnosis was day of life 15 (IQR: 6-27, n = 87). Causes of HLH included familial HLH (48%, n = 99/205), infection (26%, n = 53/205), unknown (17%, n = 35/205), macrophage activation syndrome/rheumatologic (2.9%, n = 4/205), primary immune deficiency (2.0%, n = 5/205), inborn errors of metabolism (2.4%, n = 5/205), and malignancy (2.0%, n = 4/205). Fever was absent in 19% (n = 28/147) of all neonates and 39% (n = 15/38) of preterm neonates. Bicytopenia was absent in 26% (n = 47/183) of patients. Central nervous system (CNS) manifestations were reported in 63% of cases (n = 64/102). Liver injury (68%, n = 91/134) and/or liver failure (24%, n = 32/134) were common. Flow cytometry was performed in 22% (n = 45/205) of cases. Many patients (63%, n = 121/193) died within the period of reporting. Discernable values for HLH diagnostic criteria were reported between 30% and 83% of the time.

CONCLUSIONS

Evaluation of nHLH requires rapid testing for a wide range of differential diagnoses. HLH diagnostic criteria such as fever and bicytopenia may not occur as frequently in the neonatal population as in older pediatric populations. Neurologic and hepatic manifestations frequently occur in the neonatal population. Current reports of nHLH suggest a high mortality rate. Future publications containing data on nHLH should improve reporting quality by reporting all clinically relevant data.

Preliminary exploration of the health and behavior around the time of transportation of beef × dairy calves and Holstein bull calves 3 days of age or younger in the western United States

In the western United States, it is common practice for dairy and beef × dairy calves to be sold and shipped within the first few days of life, making transportation one of the first challenges that a calf will experience. To date, no published research has examined the effects of calf transport within the western United States. The objectives of this observational study were to describe the health status of calves leaving the source dairy, characterize transportation conditions and calf behavior during transportation, and determine if age at transportation and transportation duration are associated with dehydration, blood glucose and lactate, and behavior. An observational study was performed on 2 source dairies in the western United States. Initial enrollment consisted of dairy bull calves and beef × dairy calves (n = 126 total) across 16 transport cohorts which were sold and transported to separate calf-raising facilities approximately 80 km from the source dairy. Health exams and measurements were performed on all study participants 2 to 3 h before transport and ≤2 h after transport. Two researchers performed health exams using the Wisconsin calf health score, which included clinical respiratory scores, lung ultrasound, and fecal, navel, and joint scores. Hydration status was assessed using skin tent duration. Blood samples were collected and immediately analyzed for blood glucose and lactate using glucose and lactate meters. Accelerometers were attached at the source dairy on ≤10 calves in each of the 16 transport groups to record movement and behavior during transport (n = 90 had accelerometers attached). Results showed that about half of calves (49%) were identified with at least one health abnormality before transport. Researchers found an association between age and dehydration status in which calves <24 h of age were more likely to be dehydrated compared with calves 1 d of age. Additionally over half of the calves (56%) were identified as dehydrated after transport. To the authors' knowledge, this is the first observational study that investigates the effects of transportation on dairy bull and beef × dairy calf health and welfare in the western United States. Our findings support the need for improved management and decision making before transporting calves to reduce the negative effects of transport.

Tadalafil in Neonates and Infants With Pulmonary Hypertension Secondary to Bronchopulmonary Dysplasia

OBJECTIVES

The primary outcome of this study was to describe the dosing regimen of tadalafil in neonates and infants diagnosed with pulmonary hypertension (PH) secondary to bronchopulmonary dysplasia (BPD). Secondary outcomes included tolerability, efficacy, adverse events, discontinuation of therapy, and changes in echocardiography.

METHODS

This was a single-center, retrospective review of neonates and infants <1 year of age at initiation of tadalafil for PH secondary to BPD from January 2010 to November 2021. Data collected from the electronic medical record included patient demographics, tadalafil dosing, oxygen support, mechanical ventilation, concomitant PH medications, adverse events, and echocardiography information.

RESULTS

Forty-two patients-4 neonates and 38 infants-met the inclusion criteria. The postnatal and post-menstrual age (median, IQR) at diagnosis were 121 (35.5-153.5) days and 42.6 (40.6-47.6) weeks, respectively. The initial and highest tadalafil doses (median, range) were 1 (0.25-2) and 1 (0.5-2) mg/kg/day. Only 1 patient experienced pulmonary overcirculation and required tadalafil to be discontinued. Over half (57.1%) of the patients in this study discontinued tadalafil therapy owing to improvements in pulmonary artery pressures.

CONCLUSIONS

Tadalafil 1 mg/kg/day was the most commonly used dose regimen in neonates and infants. Tadalafil at this dose of 1 mg/kg/day appears well tolerated in neonates and infants with PH secondary to BPD and correlates with improvements in pulmonary artery pressures. Further studies evaluating tadalafil in comparison to other phosphodiesterase-5 inhibitors in neonates with PH secondary to BPD are warranted.

Group B Streptococcus Brain Abscess in a Neonate with Bilateral Otorrhea

Introduction  Group B streptococcus (GBS) is the leading cause of bacterial sepsis and meningitis in neonates worldwide, but brain abscess secondary to GBS is extremely rare. While temporal brain abscesses have been described as a sequelae of otogenic infections in children and adults, such a presentation has not been described in neonates. Case Description  An 8-day-old female infant presented with a fever and irritability along with bilateral purulent otorrhea. Maternal GBS screening was negative, but the delivery was complicated by chorioamnionitis. Workup revealed neutrophilic pleocytosis in the cerebrospinal fluid and culture of the ear drainage was positive for GBS. Magnetic resonance imaging showed a circular lesion with rim enhancement within the left temporal lobe concerning for an abscess. The infant was treated with 14 days of intravenous vancomycin, cefepime, and metronidazole followed by 10 weeks of intravenous ampicillin. The hospital course was complicated by seizures and obstructive hydrocephalus requiring multiple neurosurgical interventions. Conclusion  Brain abscess can occur as a sequela of GBS meningitis in neonates, but they are rare. Otogenic infections require prompt evaluation and treatment as they can progress to serious central nervous infections in neonates.

Auriculocondylar syndrome 2 caused by a novel PLCB4 variant in a male Chinese neonate: A case report and review of the literature

BACKGROUND

Auriculocondylar syndrome (ARCND) is a rare congenital craniofacial developmental malformation syndrome of the first and second pharyngeal arches with external ear malformation at the junction between the lobe and helix, micromaxillary malformation, and mandibular condylar hypoplasia. Four subtypes of ARCND have been described so far, that is, ARCND1 (OMIM # 602483), ARCND2 (ARCND2A, OMIM # 614669; ARCND2B, OMIM # 620458), ARCND3 (OMIM # 615706), and ARCND4 (OMIM # 620457).

METHODS

This study reports a case of ARCND2 resulting from a novel pathogenic variant in the PLCB4 gene, and summarizes PLCB4 gene mutation sites and phenotypes of ARCND2.

RESULTS

The proband, a 5-day-old male neonate, was referred to our hospital for respiratory distress. Micrognathia, microstomia, distinctive question mark ears, as well as mandibular condyle hypoplasia were identified. Trio-based whole-exome sequencing identified a novel missense variant of NM_001377142.1:c.1928C>T (NP_001364071.1:p.Ser643Phe) in the PLCB4 gene, which was predicted to impair the local structural stability with a result that the protein function might be affected. From a review of the literature, only 36 patients with PLCB4 gene mutations were retrieved.

CONCLUSION

As with other studies examining familial cases of ARCND2, incomplete penetrance and variable expressivity were observed within different families' heterozygous mutations in PLCB4 gene. Although, motor and intellectual development are in the normal range in the vast majority of patients with ARCND2, long-term follow-up and assessment are still required.

Ketorolac Dosing and Outcomes in Neonates Following Congenital Heart Surgery: A Retrospective Analysis

BACKGROUND

Pain management is essential for postoperative surgery. Given the association of opioids with adverse outcomes, interest in the use of nonopioid analgesics, such as ketorolac, has increased. Published data on use in neonates are limited.

OBJECTIVES

To describe ketorolac dosing and safety and efficacy outcomes in the first 48 hours postcardiac surgery in neonates.

DESIGN

We performed a single-center retrospective cohort study of neonates (ages < 28 d) who received ketorolac following cardiac surgery from November 2020 to July 2023 (inclusive). The primary safety outcome was a clinically significant decline in renal function, as defined by the composite of an increase in serum creatinine by greater than or equal to 0.3 mg/dL from baseline within 96 hours of ketorolac initiation and urine output less than or equal to 0.5 mL/kg/hr for 6 hours. The secondary safety outcome was clinically significant bleeding, defined as the composite of major bleeding by the International Society on Thrombosis and Hemostasis pediatric criteria and severe/fatal bleeding by the criteria of Nellis et al (2019). Efficacy was measured by opioid utilization based on a standardized pain score-driven analgesia protocol.

INTERVENTIONS

Ketorolac was administered at 0.5 mg/kg every 6 hours as per an institutional clinical management algorithm.

MEASUREMENTS AND MAIN RESULTS

Thirty-nine patients met the eligibility criteria. The median ketorolac dose was 0.5 mg/kg/dose, and median (interquartile range [IQR]) duration of therapy was 48 hours (6-48 hr). No patients experienced a significant decline in renal function, and there were no clinically significant bleeding events. The median (IQR) IV morphine milligram equivalents (MMEs)/kg/d of opioid administration was 0.2 MME/kg/d (0.1-0.25 MME/kg/d) at the time of ketorolac initiation and 0.1 MME/kg/d (0.1-0.2 MME/kg/d) at 48 hours post-ketorolac initiation.

CONCLUSIONS

If validated prospectively, these findings suggest that a ketorolac regimen of 0.5 mg/kg/dose every 6 hours in neonates postcardiac surgery may be safe with regard to renal function and bleeding risk. Additional randomized studies would be needed to determine efficacy with regard to opioid-sparing capacity.

Neonatal X-linked myotubular myopathy with a de novo mutation: A case report and literature review

X-linked myotubular myopathy (XLMTM) is a rare congenital myopathy. In February 2021, a male neonate was admitted to the West China Second University Hospital, Sichuan University, with clinical manifestations of hypotonia, accompanied by distinctive facial features, and requiring continuous ventilatory support. He was born prematurely at 36+2 weeks gestation and developed respiratory distress postnatally, followed by difficulty in weaning from mechanical ventilation. Additional clinical features included hypotonia of the limbs, swallowing dysfunction, and specific facial characteristics (elongated limbs, narrow face, high-arched palate, wrist drop, empty scrotum, elongated fingers/toes). Genetic testing confirmed the diagnosis of XLMTM. Whole-exome sequencing analysis of the family revealed no mutations in the father, paternal grandfather, or paternal grandmother, while the mother had a heterozygous mutation. The pathogenic mutation was identified as MTM1 gene (OMIM: 300415), chromosome position chrX-150649714, with a nucleotide change of c.868-2A>C. The patient exhibited typical facial features. Genetic testing is crucial for accurate diagnosis of XLMTM in infants presenting with abnormal muscle tone and distinctive facial features.

Incidence of encephalopathy and comorbidity in infants with perinatal asphyxia: a comparative prospective cohort study

Background

Programs that aim to improve the detection hypoxic-ischemic encephalopathy (HIE) should establish which neonates suffering from perinatal asphyxia need to be monitored within the first 6 h of life.

Method

An observational prospective cohort study of infants with gestational age ≥35 weeks, and above 1,800g, were included according to their arterial cord pH value (ApH): ≤7.00 vs. 7.01-7.10. Data was collected including obstetrical history, as well as neonatal comorbidities, including the presence of HIE, that happened within 6 h of life. A standardized neurological exam was performed at discharge.

Results

There were 9,537 births; 176 infants with ApH 7.01-7.10 and 117 infants with ApH ≤7.00. All 9 cases with moderate-to-severe HIE occurred among infants with ApH ≤7.00. The incidence of global and moderate-severe HIE was 3/1,000 and 1/1,000 births, respectively. Outcome at discharge (abnormal exam or death) showed an OR 12.03 (95% CI 1.53, 94.96) in infants with ApH ≤7.00 compared to ApH 7.01-7.10 cohort. Ventilation support was 5.1 times (95% CI 2.87, 9.03) more likely to be needed by those with cord ApH ≤7.00 compared to those with ApH 7.01-7.10, as well as hypoglycemia (37% vs. 25%; p = 0.026). In 55%, hypoglycemia occurred despite oral and/or intravenous glucose administration had been already initiated.

Conclusions

Cord pH 7.00 might be a safe pH cut-off point when developing protocols to monitor infants born with acidemia in order to identify infants with moderate or severe HIE early on. There is non-negligible comorbidity in the ApH ≤7.00 cohort, but also in the 7.01-7.10 cohort.

Investigating Father or Partner Involvement in Family Integrated Care in Neonatal Units: Protocol for a Prospective, Multicenter, Multiphase Study

BACKGROUND

Neonatal unit (NU) admissions for premature babies can last for months, which can significantly impact parental mental health (MH) with symptoms of depression, stress, and anxiety. Literature suggests fathers experience comparable MH symptoms to mothers. Family integrated care (FICare) is a culture where parents are collaborators and partners in caring for their hospitalized newborns. FICare improves infant outcomes and maternal MH. Similar reports on fathers are limited.

OBJECTIVE

The primary aim of this study is to investigate the impact of supporting father or partner engagement in FICare of preterm infants on their MH up to 6 weeks postdischarge. The secondary aim is to investigate the impact on maternal MH.

METHODS

This is a 2-phase study: phase 1 to gather baseline information and phase 2 to assess the impact of enhanced father or partner engagement in FICare on their MH, involving 2 NUs (tertiary and level 2). Enhanced FICare will be developed and introduced (eg, information booklet, workbook, classes, and a father peer-support group) alongside standard FICare practices. Father or partner MH will be assessed with semistructured qualitative interviews and validated questionnaires: Generalized Anxiety Disorder Assessment, Patient Health Questionnaire, and Parental Stressor Scale: Neonatal Intensive Care Unit from NU admission to 6 weeks postdischarge. Mothers will be assessed by focus groups and the same questionnaires. Descriptive statistics and appropriate comparative tests, such as the 2-tailed t test, will be used to analyze and compare phase 1 and 2 data. Qualitative data will be coded line by line with the use of NVivo (Lumivero) and thematically analyzed. Simultaneously, systematic reviews (SRs) of fathers' experiences of FICare and their MH outcomes will be conducted. The study was approved by the National Research Ethics Committee (22/EM/0140) in August 2022. A parent advisory group was formed to advise on the study methodology, materials, involvement of participant parents, and dissemination of study findings.

RESULTS

A recent SR demonstrated that data saturation is likely to be achieved by interviewing 9 to 17 participants. We will study a maximum of 20 parents of infants born at less than 33 weeks' gestation in each phase. As of October 2023, the study was ongoing. The SR studies are registered with the PROSPERO database (324275 and 306760). The projected end date for data collection is July 2024; data analysis will be conducted in November 2024 and publication will occur in 2025.

CONCLUSIONS

The study aims to demonstrate the feasibility of using a father or partner-sensitive FICare model for parents of premature babies with a positive impact on their MH. It will demonstrate the feasibility of providing FICare to extremely premature babies receiving intensive care. This study may support the development of inclusive FICare guidelines for nonbirthing parents and their extremely premature infants.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06022991; https://classic.clinicaltrials.gov/ct2/show/NCT06022991.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53160.

Nursing experiences and knowledge of paediatric delirium: Analysing knowledge-practice gaps

BACKGROUND

Delirium commonly occurs in paediatric patients with acute critical illness and negatively affects clinical outcomes. Variations in delirium knowledge levels and its management have been noted among nurses.

AIMS

This study investigated nurses' experiences and knowledge levels regarding paediatric delirium. Additionally, we aimed to assess the gap between knowledge levels and practical experiences with paediatric delirium.

STUDY DESIGN

This cross-sectional descriptive study conveniently sampled paediatric nurses from a university hospital in South Korea between September 2022 and March 2023. Nursing experiences with paediatric delirium and delirium knowledge levels were measured using structured survey questionnaires. Delirium knowledge was scored 0 to 47, and higher scores indicated higher levels of delirium-related knowledge. Data were analysed using descriptive statistics and presented as mean, standard deviation, frequency and percentage.

RESULTS

A total of 127 paediatric nurses participated in this study; 40.2% had experience with 1-5 delirium cases in the previous year, and 86.6% (n = 110) had never used assessment tools for paediatric delirium assessment. The mean total delirium knowledge score was 34.45 ± 5.4; the mean scores of knowledge regarding aetiology, signs and symptoms and nursing management of delirium were 8.93 ± 1.31, 13.24 ± 2.81 and 12.3 ± 2.7, respectively. Interventions associated with a lower level of delirium-related knowledge and a lower performance rate included avoiding restraint use and maintaining hydration and electrolyte levels. Interventions associated with a higher level of delirium-related knowledge but a lower rate of performance comprised providing orientation, offering emotional support, allowing participants to stay with family members and administering medications to manage delirium.

CONCLUSIONS

Although nurses working in paediatric units exhibited high rate of delirium nursing care, there was the gap between their delirium-related knowledge and practice. Nurses need to be aware of the insufficient part of delirium care, and paediatric delirium education should be reinforced.

RELEVANCE TO CLINICAL PRACTICE

Preventing, assessing and systematically managing paediatric delirium is crucial, and considering the study results, delirium education among nurses is needed.

The association between plasma IgG N-glycosylation and neonatal hypoxic-ischemic encephalopathy: a case-control study

Introduction

Hypoxic-ischemic encephalopathy (HIE) is one of severe neonatal brain injuries, resulting from inflammation and the immune response after perinatal hypoxia and ischemia. IgG N-glycosylation plays a crucial role in various inflammatory diseases through mediating the balance between anti-inflammatory and pro-inflammatory responses. This study aimed to explore the effect of IgG N-glycosylation on the development of HIE.

Methods

This case-control study included 53 HIE patients and 57 control neonates. An ultrahigh-performance liquid chromatography (UPLC) method was used to determine the features of the plasma IgG N-glycans, by which 24 initial glycan peaks (GPs) were quantified. Multivariate logistic regression was used to examine the association between initial glycans and HIE, by which the significant parameters were used to develop a diagnostic model. Though receiver operating characteristic (ROC) curves, area under the curve (AUC) and 95% confidence interval (CI) were calculated to assess the performance of the diagnostic model.

Results

There were significant differences in 11 initial glycans between the patient and control groups. The levels of fucosylated and galactosylated glycans were significantly lower in HIE patients than in control individuals, while sialylated glycans were higher in HIE patients (p < 0.05). A prediction model was developed using three initial IgG N-glycans and fetal distress, low birth weight, and globulin. The ROC analysis showed that this model was able to discriminate between HIE patients and healthy individuals [AUC = 0.798, 95% CI: (0.716-0.880)].

Discussion

IgG N-glycosylation may play a role in the pathogenesis of HIE. Plasma IgG N-glycans are potential noninvasive biomarkers for screening individuals at high risk of HIE.

Multiple Congenital Granular Cell Epulis Involving Different Parts of the Oral Cavity: A Case Report

Congenital granular cell epulis (CGCE) is a rare disease, particularly when it affects multiple oral and maxillofacial regions. We present the case of a female neonate with 4 asymptomatic masses attached to the maxillary and mandibular gingiva as well as the tongue. Due to the size of the masses causing feeding and respiratory difficulties, lesion removal was performed under general anesthesia. Histopathological analysis revealed tightly arranged polygonal cells with abundant granular eosinophilic cytoplasm. Immunohistochemically, the cells were negative for Smur100 (S-100), neuron-specific enolase (NSE), cluster of differentiation (CD) 68, and Sry-related HMG box (SOX)-10, and positive for alpha-1-antitrypsin (AAT) and vimentin. The diagnosis of multiple CGCEs was established through clinical examinations, histomorphometrical, and immunohistochemical analyses. In conclusion, CGCE should be considered in the differential diagnosis of intraoral lesions in neonates.