Clinical rating scales for assessing pain in newborn infants

BACKGROUND

Six to nine per cent of all newborn infants require admission to a neonatal intensive care unit (NICU) due to either illness or prematurity. During their stay, these infants are often subjected to many painful procedures that can cause negative long-term consequences. To reduce the negative effects of pain exposure and ensure optimal and safe pain treatment, accurate assessment of pain is necessary. To achieve this, clinicians are dependent on the use of reliable, objective, and standardised clinical rating scales of pain, henceforth referred to as 'rating scales'. Numerous rating scales have been published; however, discrepancies in validity limit their overall applicability in clinical practice and research. Such limitations may lead to an over- or underestimation of pain, resulting in unnecessary sedation or inadequately treated pain, potentially jeopardising infant safety through treatment side effects, including withdrawal symptoms or prolonged discomfort. To date, the majority of rating scales have been developed to assess procedural pain, whilst fewer scales for prolonged pain are available. Premature infants further complicate matters, as they often have a reduced ability to display robust pain behaviour due to their immaturity. Research has also shown that the use of rating scales in clinical practice is suboptimal, due to both inadequate and infrequent implementation alongside inappropriate choice of scale for the specific pain, population, or setting under evaluation. Despite numerous studies investigating the burden of pain in newborn infants, little work has been done to summarise the current evidence on the appropriateness of rating scales for specific types of pain or infant conditions. This has likely been limited by the subjectivity of pain assessment and further complication of assessing such a non-verbal and immature patient population. The immense burden of neonatal pain worldwide has also led to the development of numerous rating scales in various languages, further hindering evidence summation.

OBJECTIVES

To systematically review the literature to compile and describe the development, content, and measurement properties of clinical rating scales for the assessment of pain in newborn infants.

SEARCH METHODS

An Information Specialist systematically searched CENTRAL, PubMed, Embase, and CINAHL. The latest update search is current to July 2023.

SELECTION CRITERIA

We included all study designs that involved the development or testing of a rating scale for assessing pain in newborn infants. We included preterm (born before week 37) and term (born at week 37 or beyond) infants undergoing pain assessment for any medical indication. We also included studies that included healthcare professionals.

DATA COLLECTION AND ANALYSIS

We evaluated clinical rating scales assessing pain in newborn infants using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology evaluating content validity, structural validity, internal consistency, reliability, measurement error, hypothesis testing, and cross-cultural validation. We used a modified GRADE approach to assess risk of bias, inconsistency, imprecision, and indirectness.

MAIN RESULTS

We included 79 studies involving a total of 7197 infants, 326 nurses, and 12 physicians. Twenty-seven clinical rating scales were used in 26 countries, with 14 studies evaluating preterm infants, 11 on term infants, 46 on both preterm and term infants, four solely on medical staff, and four on preterm and/or term infants plus medical staff. Following the COSMIN checklist, we found all rating scales to be of very low-certainty evidence, raising concerns regarding their validity, reliability, and applicability in this vulnerable population across diverse clinical settings.

AUTHORS' CONCLUSIONS

Clinical staff should be vigilant when applying the currently available neonatal rating scales. Further development of rating scale content and testing for structural validity are necessary and should be prioritised. Together, they determine the content and structure of rating scales, underpin further testing, including reliability, and their prioritisation will make the greatest contribution to the evidence base for rating scales to assess neonatal pain. Collaborative efforts between clinicians and methodology experts will prevent methodological pitfalls and contribute to improving the validity and reliability of pain-rating scales in neonatology.

Predictors and Outcomes of Extubation Failure in Preterm Neonates: A Systematic Review

CONTEXT

Extubation failure (EF) is common in preterm neonates and may be associated with adverse outcomes.

OBJECTIVE

To systematically review and meta-analyze the existing literature on predictors and outcomes of EF in preterm neonates.

DATA SOURCES

MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase (OvidSP), CINAHL (EBSCOHost), and Cochrane Library (Wiley) from 1995 onward. The search strategy was developed by a reference librarian.

STUDY SELECTION

Experimental or observational studies reporting on predictors and/or outcomes related to EF (defined as reintubation within 7 days) in preterm neonates less than 37 weeks were eligible. Predictors included machine learning (ML) algorithms and lung ultrasound (LUS). Main outcome of interest was association of EF with mortality and/or bronchopulmonary dysplasia (BPD).

DATA EXTRACTION

Studies identified by the search strategy were screened based on title and abstract. Data from included studies were extracted independently by 2 authors, along with adjudication of risk of bias. RevMan Web was used to conduct meta-analyses.

RESULTS

Out of 8336 studies screened, 120 were included. Neonates with lower gestational age at birth, birthweight, postmenstrual age, and weight at extubation were more likely to experience EF. Higher level of pre-extubation respiratory support, indicated by lower pre-extubation pH and higher pre-extubation mean airway pressure, fraction of inspired oxygen, and Pco2 were associated with EF risk. ML models showed variable accuracy and lower external validity. LUS may be a promising predictor, though scoring systems varied. EF was associated with higher odds of mortality and/or BPD (pooled odds ratio [OR], 4.7; 95% CI, 2.84-7.76) as well as the individual components of the composite: mortality (pooled OR, 3.87; 95% CI, 2.35-6.36) and BPD (pooled OR, 3.27; 95% CI, 2.54-4.21).

LIMITATIONS

Associations were derived from unadjusted data, precluding a definitive causal relationship between EF and predictors/outcomes.

CONCLUSIONS

Lower gestational and chronological age and higher levels of pre-extubation ventilation support were associated with EF. ML models and LUS scores require further validation in larger studies. EF was associated with mortality and/or BPD.

No More Evasion: Redefining Conflict Behaviour in Human-Horse Interactions

Euphemisms, anthropomorphisms, and equivocation are established characteristics of traditional equestrian language. 'Evasion', 'resistance', and 'disobedience' are common labels assigned to unwelcome equine behaviours, implying that the horse is at fault for not complying with the human's cues and expectations. These terms appear to overlook multiple motivations that may directly result in the horse offering unwelcome responses, which may then inadvertently be reinforced. This article revisits some of the anthropocentric inferences in these terms and explores the harmful consequences of such convenient but incorrect labels before proposing a redefinition of 'conflict behaviour' in human-horse interactions: Responses reflective of competing motivations for the horse that may exist on a continuum from subtle to overt, with frequencies that range from a singular momentary behavioural response to repetitive displays when motivational conflict is prolonged. Addressing how inadequate terms may mask pain, obscure the horse's motivation, and deflect human culpability, this commentary highlights the merits of a multidisciplinary approach to terminology across equine research. Acknowledging that variables contributing to behaviour can be biological, environmental and anthropogenic, it emphasises the need for more investigation into the relationships between equicentric motivations reflecting equine telos and problematic horse behaviours.

Using machine-learning models to predict extubation failure in neonates with bronchopulmonary dysplasia

AIM

To develop a decision-support tool for predicting extubation failure (EF) in neonates with bronchopulmonary dysplasia (BPD) using a set of machine-learning algorithms.

METHODS

A dataset of 284 BPD neonates on mechanical ventilation was used to develop predictive models via machine-learning algorithms, including extreme gradient boosting (XGBoost), random forest, support vector machine, naïve Bayes, logistic regression, and k-nearest neighbor. The top three models were assessed by the area under the receiver operating characteristic curve (AUC), and their performance was tested by decision curve analysis (DCA). Confusion matrix was used to show the high performance of the best model. The importance matrix plot and SHapley Additive exPlanations values were calculated to evaluate the feature importance and visualize the results. The nomogram and clinical impact curves were used to validate the final model.

RESULTS

According to the AUC values and DCA results, the XGboost model performed best (AUC = 0.873, sensitivity = 0.896, specificity = 0.838). The nomogram and clinical impact curve verified that the XGBoost model possessed a significant predictive value. The following were predictive factors for EF: pO2, hemoglobin, mechanical ventilation (MV) rate, pH, Apgar score at 5 min, FiO2, C-reactive protein, Apgar score at 1 min, red blood cell count, PIP, gestational age, highest FiO2 at the first 24 h, heart rate, birth weight, pCO2. Further, pO2, hemoglobin, and MV rate were the three most important factors for predicting EF.

CONCLUSIONS

The present study indicated that the XGBoost model was significant in predicting EF in BPD neonates with mechanical ventilation, which is helpful in determining the right extubation time among neonates with BPD to reduce the occurrence of complications.

Implementation of an Extubation Readiness Guideline for Preterm Infants

BACKGROUND

Intubated preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV neonatal intensive care unit (NICU) faced a high number of ventilator days. Based on 6 weeks of electronic health record (EHR) chart audits of extubations in this NICU in 2021, 44% of preterm infants 32 6 / 7 weeks or less of gestation were intubated for more than 28 days, with an average of 23 days on a ventilator. This NICU lacked a standardized extubation guideline providing criteria to drive extubation eligibility.

PURPOSE

The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of an extubation readiness guideline in preterm infants 32 6 / 7 weeks or less of gestation in a mid-Atlantic level IV NICU.

METHODS

This project occurred over a 17-week period in 2021. Implementation included a multidisciplinary committee formation, identification of champions, NICU staff education, completion of a guideline checklist by bedside nursing (for eligible patients), clinician reminders, and chart audits for collection of pre-/postimplementation data. Staff education completion, guideline use and compliance, demographic patient data, ventilator days, time to first extubation, and need for reintubation were tracked.

RESULTS

Postimplementation data indicated decreased need for intubation for more than 28 days, ventilator days, and days to first extubation attempt.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Results suggested that implementation of the evidence-based guideline was effective in decreasing average total ventilator days for preterm infants 32 6 / 7 weeks or less of gestation.

Peri-extubation settings in preterm neonates: a systematic review and meta-analysis

OBJECTIVE

To systematically review: 1) peri-extubation settings; and 2) association between peri-extubation settings and outcomes in preterm neonates.

STUDY DESIGN

In this systematic review, studies were eligible if they reported patient-data on peri-extubation settings (objective 1) and/or evaluated peri-extubation levels in relation to clinical outcomes (objective 2). Data were meta-analyzed when appropriate using random-effects model.

RESULTS

Of 9681 titles, 376 full-texts were reviewed and 101 included. The pooled means of peri-extubation settings were summarized. For objective 2, three experimental studies were identified comparing post-extubation CPAP levels. Meta-analyses revealed lower odds for treatment failure [pooled OR 0.46 (95% CI 0.27-0.76); 3 studies, 255 participants] but not for re-intubation [pooled OR 0.66 (0.22-1.97); 3 studies, 255 participants] with higher vs. lower CPAP.

CONCLUSIONS

Summary of peri-extubation settings may guide clinicians in their own practices. Higher CPAP levels may reduce extubation failure, but more data on peri-extubation settings that optimize outcomes are needed.

Acute kidney injury in birth asphyxiated patients: A cross sectional study at Bahawal Victoria Hospital

BACKGROUND

The presence of perinatal asphyxia and its severity appear to correlate with increasing incidence of Acute kidney injury (AKI). The objective of this study is to determine the frequency of AKI and its outcome in birth asphyxia.

METHODS

This cross-sectional study was carried out in the Department of Pediatric Medicine from March 2019 to September 2019. A total of 111 newborns with birth asphyxia of gestational age 37-41 weeks were included. Neonates born to mothers having hypertension and diabetes mellitus, patients with congenital kidney anomalies like polycystic kidney disease and renal agenesis, and mothers taking nephrotoxic drugs or any other known cause of AKI like hypovolemic shock were excluded. Urine output (UOP) and final outcome of the patient were also noted. AKI was noted.

RESULTS

The mean gestational age was 38.29 ± 1.07 weeks. The mean weight of neonates was 3.08 ± 0.31 kg. The frequency of AKI in birth asphyxia was 20 (18.02%) neonates. Complete recovery in AKI patients was seen in 07 (35.0%) and death in 13 (65.0%) patients.

CONCLUSION

This study has shown that the frequency of AKI in birth asphyxia was found in 18.02% neonates with complete recovery seen in 35.0% and death in 65.0% patients.

Massive subgaleal hematoma: a potentially fatal rare entity-a case-based review

BACKGROUND

Massive subgaleal hematoma is defined as profuse bleeding in the subgaleal layer of the scalp, causing excessive accumulation of hematoma, thus progressively increasing the size of head circumference. If not immediately diagnosed and managed carefully, continuous bleeding will lead to hematoma enlargement, impairing the functions of surrounding organ(s) and general homeostasis. In severe cases, subgaleal hematoma could lead to severe morbidity or even death.

CASE REPORT

We describe the case of an 11-year-old girl with a history of microcephaly and intellectual disability, presented with massive soft tissue swelling on more than half of her cranial circumference, accompanied with intermittent fever, anemia, and leukocytosis. The initial cerebral CT scan identified a mixed density extracranial lesion with multilobulated cystic appearance. The initial effort to aspirate the mass by a needle failed, and the patient was initially diagnosed with Pott's puffy tumor. Intraoperative findings confirmed the presence of massive subgaleal hematoma, and complete removal of the hematoma was achieved. The post-surgical period was uneventful, and the patient was discharged without any complications.

CONCLUSION

Massive subgaleal hematoma should be considered in cases where children's head circumference increases rapidly, with or without a clear history of trauma and the presence of any possible risk factors. Missed diagnosis and inappropriate therapy could lead to unfavorable outcome. Hence, it is important for any clinicians to be familiar with this entity, so timely diagnosis and treatment can be made.

Minimally Invasive Fetal Surgery and the Next Frontier

Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.

Trial of Erythropoietin for Hypoxic-Ischemic Encephalopathy in Newborns

BACKGROUND

Neonatal hypoxic-ischemic encephalopathy is an important cause of death as well as long-term disability in survivors. Erythropoietin has been hypothesized to have neuroprotective effects in infants with hypoxic-ischemic encephalopathy, but its effects on neurodevelopmental outcomes when given in conjunction with therapeutic hypothermia are unknown.

METHODS

In a multicenter, double-blind, randomized, placebo-controlled trial, we assigned 501 infants born at 36 weeks or more of gestation with moderate or severe hypoxic-ischemic encephalopathy to receive erythropoietin or placebo, in conjunction with standard therapeutic hypothermia. Erythropoietin (1000 U per kilogram of body weight) or saline placebo was administered intravenously within 26 hours after birth, as well as at 2, 3, 4, and 7 days of age. The primary outcome was death or neurodevelopmental impairment at 22 to 36 months of age. Neurodevelopmental impairment was defined as cerebral palsy, a Gross Motor Function Classification System level of at least 1 (on a scale of 0 [normal] to 5 [most impaired]), or a cognitive score of less than 90 (which corresponds to 0.67 SD below the mean, with higher scores indicating better performance) on the Bayley Scales of Infant and Toddler Development, third edition.

RESULTS

Of 500 infants in the modified intention-to-treat analysis, 257 received erythropoietin and 243 received placebo. The incidence of death or neurodevelopmental impairment was 52.5% in the erythropoietin group and 49.5% in the placebo group (relative risk, 1.03; 95% confidence interval [CI], 0.86 to 1.24; P = 0.74). The mean number of serious adverse events per child was higher in the erythropoietin group than in the placebo group (0.86 vs. 0.67; relative risk, 1.26; 95% CI, 1.01 to 1.57).

CONCLUSIONS

The administration of erythropoietin to newborns undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy did not result in a lower risk of death or neurodevelopmental impairment than placebo and was associated with a higher rate of serious adverse events. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT02811263.).

Hypothermia cannot ameliorate renal fibrosis after asphyxia in the newborn piglet

BACKGROUND

The effects of therapeutic hypothermia (TH) on renal function are not widely reported, especially in longer term animal models. The hypothesis of this study was that TH of the kidneys of hypoxic-ischemic newborn piglets would reduce pathological renal fibrosis.

METHODS

Twenty-five newborn piglets obtained within 24 h of birth were classified into a control group (n = 5), an hypoxic insult with normothermia (HI-NT) group (n = 12), and an hypoxic insult with TH (HI-TH) group (33.5 °C ± 0.5 °C for 24 h; n = 8). Five days after the insult, all piglets were sacrificed under deep anesthesia by isoflurane inhalation. The kidneys were perfused with phosphate-buffered paraformaldehyde and immersed in formalin buffer. Territory fibrosis was studied and scored in the renal medulla using Azan staining.

RESULTS

Fibrosis area scores (means ± standard deviations) based on Azan staining were 1.00 ± 0.46 in the control group, 2.85 ± 0.93 in the HI-NT group, and 3.58 ± 1.14 in the HI-TH group. The fibrosis area of the HI-NT and HI-TH groups was larger than that of the control. The HI-NT and HI-TH groups were not statistically different.

CONCLUSIONS

Renal fibrosis is affected by perinatal asphyxia and cannot be prevented by TH, based on histopathological findings.

Long-Term Pulmonary Damage From SARS-CoV-2 in an Infant With Brief Unexplained Resolved Events: A Case Report

A brief unexplained resolved event (BRUE) is an event observed in a child under 1 year of age in which the observer witnesses a sudden, brief but resolved episode of change in skin color, lack of breathing, weakness or poor responsiveness. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease-2019 (COVID-19). We report the case of a previously healthy, full-term infant infected with SARS-CoV-2 when he was 8 months old. Previous to this event, both his grandfather and great-uncle had died of severe pneumonia and his mother had developed respiratory symptoms and fever. Over the following month he was seen five times in the emergency room and was hospitalized twice for recurrent BRUE. At the first hospital admission, after the second emergency room visit, he twice tested positive for COVID-19 after nasopharyngeal swab tests. During his second hospital admission, after the fifth emergency room visit, chest computed tomography revealed typical SARS-CoV-2 pneumonia. During a follow-up examination 6 months later, mild respiratory distress required administration of inhaled oxygen (0.5 L/min) and chest computed tomography disclosed a slight improvement in pulmonary involvement. The clinical manifestation of pulmonary complications from COVID-19 infection was unusual. This is the first report of an infant at high-risk for BRUE, which was the only manifestation of long-term lung involvement due to SARS-CoV-2 pneumonia.

Predictors and outcomes of extubation failure in extremely preterm infants

AIM

To determine predictors and outcomes of extubation failure in extremely preterm (EP) infants born <28 weeks' gestational age (GA).

METHODS

Retrospective clinical audit across two tertiary-level neonatal intensive care units in Melbourne, Australia. Two-hundred and four EP infants who survived to their first extubation from mechanical ventilation. Extubation failure (re-intubation) within 7 days after the first extubation.

RESULTS

Lower GA (odds ratio [OR] 0.71, 95% confidence interval (CI), 0.61-0.89, P < 0.001) and higher pre-extubation measured mean airway pressure (MAP) on the mechanical ventilator (OR 1.9 [95% CI 1.41-2.51], P < 0.001) predicted extubation failure. The area under a receiver operating characteristic curve for GA and MAP was 0.77 (95% CI 0.70-0.82). After adjustment for GA, infants who experienced extubation failure had higher rates of bronchopulmonary dysplasia (P < 0.001), post-natal systemic corticosteroid treatment (P < 0.001), airway trauma (P < 0.003), longer durations of treatment with mechanical ventilation (P < 0.001), non-invasive respiratory support (P < 0.001), supplemental oxygen therapy (P = 0.05) and longer hospitalisation (P = 0.025).

CONCLUSIONS

Lower GA and higher pre-extubation measured MAP were predictive of extubation failure within 7 days in extremely preterm infants. Extubation failure was associated with increased morbidity and extended periods of respiratory support and hospitalisation.

The use and reporting of neonatal pain scales: a systematic review of randomized trials

ABSTRACT

The burden of pain in newborn infants has been investigated in numerous studies, but little is known about the appropriateness of the use of pain scales according to the specific type of pain or infant condition. This systematic review aimed to evaluate the reporting of neonatal pain scales in randomized trials. A systematic search up to March 2019 was performed in Embase, PubMed, PsycINFO, CINAHL, Cochrane Library, Scopus, and Luxid. Randomized and quasirandomized trials reporting neonatal pain scales were included. Screening of the studies for inclusion, data extraction, and quality assessment was performed independently by 2 researchers. Of 3718 trials found, 352 with 29,137 infants and 22 published pain scales were included. Most studies (92%) concerned procedural pain, where the most frequently used pain scales were the Premature Infant Pain Profile or Premature Infant Pain Profile-Revised (48%), followed by the Neonatal Infant Pain Scale (23%). Although the Neonatal Infant Pain Scale is validated only for acute pain, it was also the second most used scale for ongoing and postoperative pain (21%). Only in a third of the trials, blinding for those performing the pain assessment was described. In 55 studies (16%), pain scales that were used lacked validation for the specific neonatal population or type of pain. Six validated pain scales were used in 90% of all trials, although not always in the correct population or type of pain. Depending on the type of pain and population of infants included in a study, appropriate scales should be selected. The inappropriate use raises serious concerns about research ethics and use of resources.

NEUTROPHIL GELATINASE-ASSOCIATED LIPOCALIN AS AN EARLY BIOMARKER OF ACUTE KIDNEY INJURY IN NEWBORNS

The aim of the study was to determine the incidence, risk factors and efficiency of the neutrophil gelatinase-associated lipocalin (NGAL) biomarker in early diagnosis of acute kidney injury (AKI) in newborns. The study was designed as a prospective, clinical, epidemiological investigation conducted in the period of three years, which included 50 newborns with AKI hospitalized in the Neonatal Intensive Care Unit, University Children’s Hospital in Skopje. The estimated prevalence of AKI was 6.4%, while the prevalence according to RIFLE classification was 8.7%. Perinatal asphyxia was a common predisposing factor associated to kidney injury. The mortality rate was 32% and was significantly higher in the group of newborns with congenital heart diseases. There was a significant difference between NGAL values and creatinine values on the day of admission. There was a significant difference in NGAL values between newborns with AKI and lethal outcome and newborns without lethal outcome (p<0.001). In conclusion, AKI is a life-threatening condition. It is an independent contributor to mortality. Urinary NGAL is an early predictive biomarker of AKI in critically ill newborns.

Unusual fetal ascites and spontaneous bladder rupture in a female fetus: a case report

BACKGROUND

Fetal bladder rupture causing urinary ascites is uncommon. It is generally related to invasive fetal medicine procedures or obstructive disorders such as in posterior urethral valves in male fetuses. An exceptional case of spontaneous bladder rupture in a female fetus occurred in a pregnant woman treated with high doses of opiates in an intensive care unit. This unusual obstetric situation leads to discussion of the possible causes of fetal bladder rupture, its management, and the pediatric prognosis.

CASE PRESENTATION

We report the case of a 30-year-old nulliparous black woman with a history of mesenteric cystic lymphangioma and multiple bowel resections leading to chronic malabsorption. During her pregnancy, our patient presented with an occlusive syndrome and major bilateral renal dilation. Urinary derivation resulted in iatrogenic bilateral ureteral perforation. Our patient thus presented with major uroperitoneum, bilateral pleural effusion and acute renal failure, treated by thoracic drainage and bilateral nephrostomy. Postoperative pain required treatment with level III analgesics. In this context, 5 days after morphine treatment introduction an enlarged fetal bladder was observed, followed 3 days later by voluminous fetal ascites. The diagnosis of spontaneous bladder rupture was suspected. After multidisciplinary discussion, expectant management was decided. At 31 weeks and 4 days gestation, our patient went into spontaneous labor with a subsequent vaginal delivery. The infant required resuscitation and paracentesis of ascites at birth. Her neonatal course was favorable with a simple urethral bladder drainage. Cystography at day 9 was normal. At 2 years of follow-up, the mother and the child have a normal course.

CONCLUSIONS

An iatrogenic origin of megacystis in a female fetus must be evoked in the event of maternal administration of high doses of opiates in the second part of her pregnancy. In our case, the megacystis was followed by spontaneous bladder rupture at 30 weeks of gestation, with a favorable maternal fetal issue.

Clinical Characteristics and Outcomes of Patients Admitted with Brief Resolved Unexplained Events to a Tertiary Care Pediatric Intensive Care Unit

The aim of this study was to determine outcomes of patients admitted to a tertiary care pediatric intensive care unit (PICU) with brief, resolved, unexplained event (BRUE), and to review the diagnostic and treatment options utilized for such patients. A retrospective data analysis was conducted for infants and children who were admitted to the PICU at a tertiary hospital with a diagnosis of BRUE over a period of three years (2015-2017). The study included 30 infants, 15 males, and 15 females. All patients survived to hospital discharge. The most frequent presenting symptoms and signs were apnea (73.3%), cyanosis (60.0%), and cough (20.0%). The most frequent reported affected systems were respiratory (33.3%), gastrointestinal (20%), and infection-related illness (20.0%). We conclude that the careful history taking, complete physical examination, and the appropriate workup for patients with BRUE play an integral role in optimum health service and utilization of critical care beds. Survival to hospital discharge with no serious in-hospital events warrants the adaptation of evidence-based medicine guidelines to stratify such patients based on the risk of recurrence or a serious underlying condition. Prospective multicenter studies are recommended to explore the effectiveness of such guidelines implementation on outcomes and diagnostic testing in such patients to optimize the utilization of the limited critical care beds.

Trends and Causes of Neonatal Mortality in Serbia, 1997-2016

Background

Regardless of the notable reduction in infant deaths worldwide over the last 30 years, the proportion of neonatal mortality in total child mortality is increasing.

Aims

To perform a trend analysis of neonatal mortality in Serbia.

Study Design

Descriptive observational study.

Methods

Joinpoint regression was used to analyze neonatal mortality data for the years 1997 to 2016 that were obtained from the Statistical Office of Serbia.

Results

The trend in the neonatal mortality rate decreased significantly by -5.6% (95% CI: -6.5 to -4.6) per year from 1997 to 2007, and by -2.6% (95% CI: -3.7 to -1.5) per year from 2007 to 2016. The neonatal mortality rate for certain conditions originating in the perinatal period decreased by -6.2% (95% CI: -7.5 to -4.9) per year during the years from 1997 to 2006, and by -1.9% (95% CI: -3.1 to -0.7) per year from 2006 to 2016. Among these conditions, disorders related to short gestation and low birth weight, not elsewhere classified, showed an upward trend by 8.5% (95% CI: 6.2 to 10.8) per year during the entire study period. From 1997 to 2016, a significant decrease in the neonatal mortality rate was detected in cases of congenital malformations, deformations, and chromosomal abnormalities, by -5.0% (95% CI: -6.1 to -4.0) per year. The neonatal mortality rate for cases of symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified, decreased by -8.1% (95% CI: -11.0 to -5.2) yearly.

Conclusion

The neonatal mortality rate in Serbia decreased between 1997 and 2016, excluding deaths due to short gestation and low birth weight. Therefore, prevention of short gestation and low birth weight should be the highest public priority.

Non-additive effects of adjunct erythropoietin therapy with therapeutic hypothermia after global cerebral ischaemia in near-term fetal sheep

KEY POINTS

Recombinant human erythropoietin (rEpo) is neuroprotective in immature animals, but it is unclear whether the combination of high-dose rEpo therapy with therapeutic hypothermia can further improve outcomes. Hypothermia and rEpo independently improved neuronal survival, with greater improvement with hypothermia, and similarly reduced numbers of caspase-3 positive cells and reactive microglia after 7 days recovery. Hypothermia, but not rEpo, was associated with markedly improved EEG power, whereas both interventions improved recovery of EEG frequency. There was no significant improvement in any outcome after combined rEpo and hypothermia compared with hypothermia alone, and of concern, the combination was associated with increased numbers of cortical caspase-3-positive cells compared with ischaemia-hypothermia. These data suggest that the mechanisms of neuroprotection with hypothermia and rEpo overlap and, thus, high-dose rEpo infusion does not appear to be an effective adjunct therapy for therapeutic hypothermia.

ABSTRACT

Therapeutic hypothermia for hypoxic-ischaemic encephalopathy (HIE) provides incomplete neuroprotection. Recombinant human erythropoietin (rEpo) is neuroprotective in immature animals, but it is unclear whether adjunct rEpo therapy with therapeutic hypothermia can further improve outcomes. Near-term fetal sheep received sham-ischaemia (n = 9) or global cerebral ischaemia for 30 min (ischaemia-vehicle, n = 8), followed by intravenous infusion of rEpo (ischaemia-Epo, n = 8; 5000 U/kg loading dose, then 833.3 U/kg/h), cerebral hypothermia (ischaemia-hypothermia, n = 8), or rEpo plus hypothermia (ischaemia-Epo-hypothermia, n = 8), from 3 to 72 h post ischaemia. Fetal brains were collected 7 days after cerebral ischaemia. Cerebral ischaemia was associated with severe neuronal loss and microglial induction in the parasagittal cortex and subcortical regions. Hypothermia reduced overall neuronal loss, cortical caspase-3 and reactive microglia in the striatum and cortex, with greater recovery of electroencephalographic (EEG) power and spectral edge (SEF) from 48 h onwards. rEpo independently improved neuronal survival in the parasagittal cortex, hippocampal CA4 and thalamus, and reduced cortical caspase-3 and activated microglia in striatal and cortical areas, with greater SEF from 120 h onwards. However, ischaemia-Epo-hypothermia did not further improve outcomes compared with ischaemia-hypothermia and was associated with increased numbers of cortical caspase-3-positive cells. These findings suggest that although delayed, prolonged treatment with both hypothermia and rEpo are independently neuroprotective, they have overlapping anti-inflammatory and anti-apoptotic mechanisms, such that the delayed, high-dose rEpo infusion for 3 days did not materially augment neuroprotection with therapeutic hypothermia.

Protocolized Versus Nonprotocolized Weaning to Reduce the Duration of Invasive Mechanical Weaning in Neonates: A Systematic Review of All Types of Studies

Mechanical ventilation is one of the most commonly used treatments in neonatology. Prolonged mechanical ventilation is associated with deleterious outcomes. To reduce the ventilation duration, weaning protocols have been developed to achieve extubation in adult and pediatric care in a safe and uniform manner. We performed a systematic review to obtain all available evidence on the effect of protocolized versus nonprotocolized weaning on the duration of invasive mechanical ventilation in critically ill neonates. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Web of Science, and the International Clinical Trial Registry Platform were searched until January 2018. Quantitative and qualitative studies involving neonates that investigated or described protocolized versus nonprotocolized weaning were included. Primary outcome was the difference in weaning duration. A total of 2099 potentially relevant articles were retrieved. Three studies met the inclusion criteria. Of 2 of these, the separate neonatal data could not be obtained. Only one retrospective study was included for this review. This reported a decrease in the mean weaning time from 18 to 5 and 6 days, respectively. There is no robust evidence in the literature to support or disprove the use of a weaning protocol in critically ill neonates.

Pain Assessment Practices in the Pediatric Intensive Care Unit

PURPOSE

Pain assessment is the first step in managing pain; however, this can be challenging, particularly in settings such as the Pediatric Intensive Care Unit (PICU). This paper reports the current pain assessment practices from a study that was conducted describing the prevalence of pain, pain assessment, painful procedures, interventions, and characteristics of critically-ill children. Specifically, this paper addresses the child's communicative ability, pain scales, and characteristics of pain.

DESIGN AND METHODS

The primary study was a cross-sectional, multi-site, descriptive design. Data from a 24-hour time period were collected from medical records and bedside nurses.

RESULTS

Data were collected from the records of 220 children across 15 PICUs. The average number of pain assessments per child was 11.5 (SD 5.8, range 1-28). Seven behavioral scales and five self-report scales were used. There were times when no scale was used, "assume pain present" was recorded, or a sedation scale was documented. Twelve pain scales, including the target population, scoring, psychometric properties, and clinical utility are described.

CONCLUSIONS

Results of this study indicate that a wide range of pain assessment tools are used, including behavioral scales for children unable to self-report.

IMPLICATIONS

Foremost, the appropriate assessment method needs to be chosen for each child to manage pain. Knowledge of the criteria for the use of each pain assessment scale will help the clinician select the appropriate scale to use for each child. The practice of "assume pain present," as well as standardization of pain scales, and clinical support tools needs further investigation.

Prematurity alters skin conductance and behavioural scoring after acute stress in term-equivalent age infants

AIM

The primary objective was to assess the effect of prematurity at term-equivalent age on skin conductance and behavioural responses to acute stress. The secondary objective was to explore the reliability of skin conductance in detecting neonatal discomfort in preterm and full-term populations.

METHODS

Very preterm infants at term-equivalent age and healthy full-term neonates, 34 infants in each group, underwent the hip dysplasia screening test. The acute pain in newborn infants (APN) scale was scored before and 15, 45 and 90 seconds after stimulus. Skin conductance was measured in the 30-second time-lap before and after stimulus.

RESULTS

The APN score was lower in preterm infants after intervention (term: 5.4 ± 2.8 vs. preterm: 3.9 ± 2.2; p = 0.03). Peaks-per-second, a skin conductance parameter, exhibited lower basal values in preterm infants than in term infants, with similar rise induced by stressful challenge. Peaks-per-second values were correlated to the 15-second APN score in both groups (term: r = 0.55, p < 0.001; preterm: r = 0.43, p = 0.01).

CONCLUSION

Preterm birth changed skin conductance signal and behavioural response to stress at term-equivalent age. The skin conductance device may be an objective tool for a continuous monitoring of acute neonatal stress.

Neuroprotection from acute brain injury in preterm infants

Infants born at ≤32+6 weeks gestation are at higher risk for intracranial ischemic and hemorrhagic injuries, which often occur in the first 72 hours postbirth. Antenatal strategies to reduce the incidence of acute brain injuries include administering maternal corticosteroids and prompt antibiotic treatment for chorioamnionitis. Perinatal strategies include delivery within a tertiary centre, delayed cord clamping, and preventing hypothermia. Postnatal strategies include empiric treatment with antibiotics when chorioamnionitis is suspected, the cautious use of inotropes, the avoidance of blood PCO2 fluctuation, and neutral head positioning. Clinicians should be aware of the policies and procedures that, especially when combined, can provide neuroprotection for preterm infants.

Risk of Severe Intraventricular Hemorrhage in the First Week of Life in Preterm Infants Transported Before 72 Hours of Age

OBJECTIVES

Evaluate the risk of severe intraventricular hemorrhage, in the first week of life, in preterm infants undergoing early interhospital transport.

DESIGN

Retrospective cohort study.

SETTING

Tertiary neonatal centers of the Trent Perinatal Network in the United Kingdom.

PATIENTS

Preterm infants less than 32 weeks gestation, who were either born within and remained at the tertiary neonatal center (inborn), or were transferred (transported) between centers in the first 72 hours of life.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Multivariable logistic regression models adjusting for key confounders were used to calculate odds ratios for intraventricular hemorrhage with 95% CIs for comparison of inborn and transported infants. Cranial ultrasound findings on day 7 of life. Secondary analyses were performed for antenatal steroid course and gestational age subgroups. A total of 1,047 preterm infants were included in the main analysis. Transported infants (n = 391) had a significantly higher risk of severe (grade III/IV) intraventricular hemorrhage compared with inborns (n = 656) (9.7% vs 5.8%; adjusted odds ratio, 1.69; 95% CI, 1.04-2.76), especially for infants born at less than 28 weeks gestation (adjusted odds ratio, 1.83; 95% CI, 1.03-3.21). Transported infants were less likely to receive a full antenatal steroid course (47.8% vs 64.3%; p < 0.001). A full antenatal steroid course significantly decreased the risk of severe intraventricular hemorrhage irrespective of transport status (odds ratio, 0.33; 95% CI, 0.2-0.55). However, transported infants less than 28 weeks gestation remained significantly more likely to develop a severe intraventricular hemorrhage despite a full antenatal steroid course (adjusted odds ratio, 2.84; 95% CI, 1.08-7.47).

CONCLUSIONS

Preterm infants transported in the first 72 hours of life have an increased risk of early-life severe intraventricular hemorrhage even when maternal antenatal steroids are given. The additional burden of postnatal transport could be an important component in the pathway to severe intraventricular hemorrhage. As timely in-utero transfer is not always possible, we need to focus research on improving the transport pathway to reduce this additional risk.

A case for expanding carrier testing to include actionable X-linked disorders

A research study utilizing whole-genome sequence analysis for preconception carrier screening provided a genome-first detection of a severe de novo Factor VIII mutation in a woman with implications for pregnancy management and life-saving interventions of her newborn son, and a challenge to the existing paradigm regarding carrier testing.

Comparing N-PASS and NIPS: Improving Pain Measurement in the Neonate

BACKGROUND

Proper assessment of pain is essential to allow for safe and compassionate care of infants in the neonatal intensive care unit (NICU). The Neonatal Infant Pain Scale (NIPS) used in an urban level IV NICU addresses acute pain but may not adequately measure chronic neonatal pain.

PURPOSE

The purpose of this quality improvement study was to improve acute and chronic pain measurements for neonates in an NICU through implementation of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS).

METHODS/SEARCH STRATEGY

An evidence search for a comprehensive tool to assess neonatal pain in the setting of a 45-bed level IV NICU was completed. The N-PASS was found to be inclusive of measuring acute and chronic neonatal pain. Participants for a quality improvement study, including NICU nurses and providers, were educated on the N-PASS. Nurses documented in the N-PASS and the NIPS during routine pain assessments for NICU infants for comparison. Participants completed a survey assessing knowledge of the N-PASS.

FINDINGS/RESULTS

When compared, the N-PASS generated 98% of pain scores greater than the NIPS. Surveys demonstrated an increase in staff knowledge for the N-PASS.

IMPLICATIONS FOR PRACTICE

Implementation of a multidimensional pain tool that measures acute and chronic pain is essential for proper pain assessment. Providers can manage neonatal pain when accurate documentation is available.

IMPLICATIONS FOR RESEARCH

Further research evaluating guided management of acute and chronic pain scores on the N-PASS would aid hospital policies on therapies for neonatal pain.

Chronic inflammatory demyelinating polyneuropathy: evaluation of the vestibular system with cervical and ocular vestibular evoked myogenic potentials

PURPOSE

To investigate the possibility of vestibular damage in a group of patients suffering from chronic inflammatory demyelinating polyneuropathy (CIDP) using a diagnostic protocol including the caloric test, C-VEMPs and O-VEMPs.

METHODS

Twenty patients suffering from CIDP (mean age 58.5 years, range 33-80 years; 4 women and 16 men) were investigated. To assess any eventual audio-vestibular involvement, all patients of the study underwent pure tone audiometry, Fitzgerald-Hallpike caloric vestibular test, C-VEMPs and O-VEMPs.

RESULTS

In 11 patients with CIDP values of both O-VEMPs and C-VEMPs were either absent or abnormal. An absent trace at O-VEMPs testing occurred in 36% of these pathological patients, whereas an increase of n10 latency and amplitude was present in the other 64% .

CONCLUSIONS

A specific diagnostic protocol including the caloric test, C-VEMPS, O-VEMPS, could be useful when employed for identifying vestibular damage in CIDP patients.

Oral glucose efficacy on neonate's pain responses at the NICU: A quasi experimental trial of two clinical procedures

AIM

This research was undertaken with the purpose of testing two research hypotheses regarding the efficacy of 10% oral glucose solution on procedural pain associated with venepuncture and nasopharyngeal suctioning within three neonatal intensive care units (NICU). The hypotheses were formulated from previous conclusions reached by other researchers highlighting the efficacy of sucrose solutions on neonates' pain responses during minor painful procedures.

METHOD

A quasi-experimental trial utilising a time series design with one group was used. Data from a total of 90 neonates included 60 neonates who underwent a venepuncture and 30 neonates who underwent a nasopharyngeal suctioning procedure for clinical purposes. The neonate's pain response for each procedure was scored using the Neonatal Pain Assessment Scale (NPAS) on two separate occasions over three time periods. The pre-procedural score (T₀) when the neonate received no sucrose, the inter-procedural score (T₁) when the neonate was given 2ml of 10% glucose solution two minutes before the procedure (intervention group) or where oral glucose was withheld (control group) and the post-procedural score (T₂) being at the end of the procedure.

RESULTS

The results showed the mean NPAS scores in response to venepuncture or nasopharyngeal suctioning were significantly lower in the intervention group than the control group.

CONCLUSION

This showed that oral glucose (10%) had a positive effect on the pain response during venepuncture and nasopharyngeal suctioning procedures.

Neurobehavioral radiation mitigation to standard brain cancer therapy regimens by Mn(III) n-butoxyethylpyridylporphyrin-based redox modifier

Combinations of radiotherapy (RT) and chemotherapy have shown efficacy toward brain tumors. However, therapy-induced oxidative stress can damage normal brain tissue, resulting in both progressive neurocognitive loss and diminished quality of life. We have recently shown that MnTnBuOE-2-PyP(5+) (Mn(III)meso-tetrakis(N-n-butoxyethylpyridinium -2-yl)porphyrin) rescued RT-induced white matter damage in cranially-irradiated mice. Radiotherapy is not used in isolation for treatment of brain tumors; temozolomide is the standard-of-care for adult glioblastoma, whereas cisplatin is often used for treatment of pediatric brain tumors. Therefore, we evaluated the brain radiation mitigation ability of MnTnBuOE-2-PyP(5+) after either temozolomide or cisplatin was used singly or in combination with 10 Gy RT. MnTnBuOE-2-PyP(5+) accumulated in brains at low nanomolar levels. Histological and neurobehavioral testing showed a drastic decrease (1) of axon density in the corpus callosum and (2) rotorod and running wheel performance in the RT only treatment group, respectively. MnTnBuOE-2-PyP(5+) completely rescued this phenotype in irradiated animals. In the temozolomide groups, temozolomide/ RT treatment resulted in further decreased rotorod responses over RT alone. Again, MnTnBuOE-2-PyP(5+) treatment rescued the negative effects of both temozolomide ± RT on rotorod performance. While the cisplatin-treated groups did not give similar results as the temozolomide groups, inclusion of MnTnBuOE-2-PyP(5+) did not negatively affect rotorod performance. Additionally, MnTnBuOE-2-PyP(5+) sensitized glioblastomas to either RT ± temozolomide in flank tumor models. Mice treated with both MnTnBuOE-2-PyP(5+) and radio-/chemo-therapy herein demonstrated brain radiation mitigation. MnTnBuOE-2-PyP(5+) may well serve as a normal tissue radio-/chemo-mitigator adjuvant therapy to standard brain cancer treatment regimens. Environ. Mol. Mutagen. 57:372-381, 2016. © 2016 Wiley Periodicals, Inc.

Bridging Translation by Improving Preclinical Study Design in AKI

Despite extensive research, no therapeutic interventions have been shown to prevent AKI, accelerate recovery of AKI, or reduce progression of AKI to CKD in patients. This failure in translation has led investigators to speculate that the animal models being used do not predict therapeutic responses in humans. Although this issue continues to be debated, an important concern that has not been addressed is whether improvements in preclinical study design can be identified that might also increase the likelihood of translating basic AKI research into clinical practice using the current models. In this review, we have taken an evidence-based approach to identify common weaknesses in study design and reporting in preclinical AKI research that may contribute to the poor translatability of the findings. We focused on use of N-acetylcysteine or sodium bicarbonate for the prevention of contrast-induced AKI and use of erythropoietin for the prevention of AKI, two therapeutic approaches that have been extensively studied in clinical trials. On the basis of our findings, we identified five areas for improvement in preclinical study design and reporting. These suggested and preliminary guidelines may help improve the quality of preclinical research for AKI drug development.

Treatment of pediatric chronic inflammatory demyelinating polyneuropathy: Challenges, controversies and questions

Pediatric chronic inflammatory demyelinating polyneuropathy (CIDP) is an uncommon acquired disorder of unknown cause, presumed to have an immunological basis. We report 20 patients seen at Children's Hospital Los Angeles over a period of 10 years. The outcome of our patients was favorable in a vast majority with good response to various treatments instituted. However, residual neurologic deficit was common. The choice of treatment modality was empirical and selected by the treating neurologist. Intravenous immunoglobulin (IVIG) and corticosteroids were most commonly utilized for treatment. Plasmapheresis, mycophenolate mofetil, rituximab, cyclophosphamide, azathioprine, and abatacept were added if the patients were refractory to IVIG or became corticosteroid dependent. The spectrum of disease severity ranged from a single monophasic episode, to multiphasic with infrequent relapses with good response to IVIG, to progressive disease refractory to multiple therapies.

Effect of Marine Collagen Peptides on Physiological and Neurobehavioral Development of Male Rats with Perinatal Asphyxia

Asphyxia during delivery produces long-term deficits in brain development. We investigated the neuroprotective effects of marine collagen peptides (MCPs), isolated from Chum Salmon skin by enzymatic hydrolysis, on male rats with perinatal asphyxia (PA). PA was performed by immersing rat fetuses with uterine horns removed from ready-to-deliver rats into a water bath for 15 min. Caesarean-delivered pups were used as controls. PA rats were intragastrically administered with 0.33 g/kg, 1.0 g/kg and 3.0 g/kg body weight MCPs from postnatal day 0 (PND 0) till the age of 90-days. Behavioral tests were carried out at PND21, PND 28 and PND 90. The results indicated that MCPs facilitated early body weight gain of the PA pups, however had little effects on early physiological development. Behavioral tests revealed that MCPs facilitated long-term learning and memory of the pups with PA through reducing oxidative damage and acetylcholinesterase (AChE) activity in the brain, and increasing hippocampus phosphorylated cAMP-response element binding protein (p-CREB) and brain derived neurotrophic factor (BDNF) expression.

Should we assess pain in newborn infants using a scoring system or just a detection method?

Newborn infants' pain should be scored indirectly using dedicated pain scales. Unfortunately, while some scales for prolonged pain have given good results, a gold standard to assess acute pain does not exist. Acute pain scales still have weak points, most are complex and are scarcely used in neonatal departments. Moreover, carefully scoring pain in clinical practice seems redundant, because any avoidable pain is a concern. This suggests that researchers must find new ways to assess acute pain. A possible approach is to settle for pain detection instead of pain scoring in selected cases. Here, we describe a two-point method that illustrates this approach.

CONCLUSION

For everyday practice, detecting pain is more useful than scoring it; acute pain scales should be reserved for research, for those clinical settings where the personnel has received a careful training and where overcrowding and hurry are absent.

Ovine fetal renal development impacted by multiple fetuses and uterine space restriction

Intrauterine growth restriction (IUGR) from uteroplacental dysfunction causes impaired nephrogenesis and ultimately hypertension, but it is unknown whether IUGR caused by insufficient space for placental development seen in uterine anomalies and/or multifetal gestation exerts the same effects. Fetal renal development and metabolism were studied in an ovine space-restriction model by combining unilateral horn surgical ligation and/or multifetal gestation. Reduced placental attachment sites and placental weight per fetus defined space-restricted (USR) v. control nonrestricted (NSR) fetuses. Space-restricted fetuses exhibited evidence for decreased plasma volume, with higher hematocrit and plasma albumin at gestational day (GD) 120, followed by lower blood pO2, and higher osmolarity and creatinine at GD130, P < 0.05 for all. By combining treatments, fetal kidney weight relative to fetal weight was inversely related to both fetal weight and plasma creatinine levels, P < 0.05 for both. At GD130, space-restricted fetal kidney weights, cortical depths and glomerular generations were decreased, P < 0.05 for all. Space-restricted kidneys underwent an adaptive response by prolonging active nephrogenesis and increasing maculae densa number, P < 0.05 for both. The major renal adaptations in space-restricted IUGR fetuses included immaturity in both development and endocrine function, with evidence for impaired renal excretory function.

The cooling tube: A novel small animal model of systemic hypothermia in awake Syrian Golden Hamsters (mesocricetus auratus)

Hypothermia is increasingly used as a therapeutic strategy in a diversity of clinical scenarios. Its impact on mammalian physiology, particularly on the microcirculatory changes of critical organ systems, are, however, incompletely understood. Close examination of the literature reveals a marked paucity of small animal models of rapid systemic hypothermia. All published models introduce important microvascular confounders by investigating either local cooling processes or using anaesthetised animals. Here we present the first rapid systemic hypothermia model in an awake hamster. We developed a waterstream cooled copper tube system for standardized systemic temperature control. With this novel system core body temperature (Tc) in 14 awake animals could be precisely stabilised at temperatures of 30°C and 18°C (7 animals, respectively) within 10-20 min. Rewarming was achieved over 10-15 min. Tolerance of the procedure was excellent. Hamsters did not show any behavioural changes in the mild hypothermia group. In the deep hypothermia group 6 of 7 animals regained normal behaviour within 2-11 hs. As hypothermia was induced in dorsal skinfold chamber bearing animals this model seems suitable for investigation of microcirculatory purposes.Advantages over previously established experimental hypothermia models are significant. Amongst these, the possibility of visualization of microcirculation, the lack of microcirculation confounding factors such as anaesthetic drugs, the ability for precise Tc control and rapid induction of hypothermia are prominent.

The effect of erythropoietin on the severity of retinopathy of prematurity

AIMS

Exogenous human erythropoietin (EPO) artificially synthesised through recombinant DNA technology (rHuEPO) is currently used as a substitute for blood transfusion in preterm and low birth weight neonates. The objective of this study is to determine whether the use of rHuEPO is associated with an increased severity of retinopathy of prematurity (ROP) in preterm neonates.

METHOD

This retrospective review studies neonates who were admitted to a tertiary perinatal unit and screened for ROP during the 10-year period from January 2003 to December 2012.

RESULTS

: During the 10-year period, 688 preterm neonates underwent ROP screening, with 198 identified as having ROP. The incidence of stage 1 ROP was 51.5% (102/198), followed by 35.9% (71/198) for stage 2, and 12.6% (25/198) for stage 3 and greater. Plus disease was seen in 14 neonates (7.1%). Treatment (laser photocoagulation) was administered in 64% of neonates (16/25) with stage 3 of the disease and above because of progression to threshold ROP. Twenty-six (13%) of the neonates received rHuEPO treatment. There were no statistically significant differences in birth weight (910.4 vs 885 g; P=0.71), gestational age (26.5 vs 25.8 weeks; P=0.09), and duration of ventilation (512 vs 501.4 h; P=0.92) between neonates who did not receive rHuEPO compared with those who were treated with rHuEPO. Multivariate regression analysis showed that the use of EPO was associated with increased severity of ROP.

CONCLUSIONS

EPO therapy appears to increase the risk of development and worsening of ROP.

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.

Maternal ventilation and sedation for H1N1 influenza resulting in fetal bladder rupture and urinary ascites

Urinary ascites in a newborn infant is unusual and most commonly results from bladder perforation following umbilical arterial catheterisation or obstructive uropathy. The following report describes a case of fetal bladder rupture with urinary ascites in a mother ventilated and sedated with narcotics and benzodiazepines for H1N1 influenza. This was associated with a unique biochemical profile of hyponatraemia and elevated serum urea and creatinine characteristic of urinary autodialysis in the neonate.

Childhood chronic inflammatory demyelinating polyneuroradiculopathy--three cases and a review of the literature

BACKGROUND

Chronic inflammatory demyelinating polyneuroradiculopathy (CIDP) is an autoimmune disease of the peripheral nervous system, causing demyelination and even axonal degeneration. In children, abnormal gait as a first sign of muscle weakness is a frequent reason to seek medical attention. Diagnosis is made on the basis of clinical characteristics, electromyography and nerve conduction studies, and elevated protein in cerebrospinal fluid.

AIMS

We present three new cases of CIDP. The literature was reviewed in order to obtain more information on presentation, outcome and treatment strategies world-wide.

RESULTS

The course of disease can be relapsing-remitting or chronic-progressive. From case series it is known that first-line immunotherapy (intravenously administered immunoglobulin, corticosteroids or plasmapheresis) is initially of benefit in most children with CIDP. There is little evidence, however, on second-line therapies as azathioprine, cyclosporine A, mycophenolate mofetil, methothrexate, cyclophosphamide and IFN alpha. Although the outcome of children with CIDP is generally regarded to be good, disease related disability can be severe.

CONCLUSION

Childhood CIDP is rare. In general and in comparison to adults, children tend to have a more acute progressive onset, with more severe symptoms. Showing a higher tendency towards a relapsing-remitting course, children often show a better and faster improvement after therapy, and a more favorable outcome. Swift recognition of CIDP and empiric start of treatment are considered important to avoid potentially irreversible axonal damage and associated disability. Response to first-line therapies is usually favorable, however recommendations regarding the choice of second-line therapy can only be made on the basis of current practice described in case reports. Safety and efficacy data are insufficient. The cases described show that trial and error are often involved in finding an optimal treatment strategy, especially in those patients refractory to first-line treatment or with a prolonged course. Clinical experience with immunomodulatory treatment is paramount when treating children with CIDP.

The implementation of neonatal peritoneal dialysis in a clinical setting

OBJECTIVE

To investigate etiology, outcome and complications related to neonatal peritoneal dialysis (PD).

METHODS

Neonates treated with PD in our neonatal intensive care unit during 2007-2010 were analyzed retrospectively.

RESULTS

Among 4036 hospitalized neonates; 20 neonates (0.5%) who underwent 21 cycles of PD [7 preterm, 13 term; 13 female, 7 male] were included. The mean birth weight was 2930.2 ± 720.6 g (1120-4570), mean gestational age was 37.5 ± 3.5 weeks (27-41). The etiologic disorders included inborn errors of metabolism (propionic acidemia, methylmalonic acidemia, citrullinemia, glutaric aciduria type 2, maple syrup urine disease, 10), or acute renal failure secondary to perinatal asphyxia (4), sepsis (2), prematurity (2), hypoplastic left heart syndrome (1), kernicterus (1). The complications included peritonitis (2), early leakage (4), hemorrhage (1), catheter removal (3) and occlusion (2). The mortality rate was 50%. The gestational ages and birth weights of surviving neonates were higher (p < 0.05). Among surviving neonates, chronic renal failure (1), severe (4) and moderate neuromotor impairment (2) developed within 4-43 months.

CONCLUSION

PD, although invasive, is an effective therapy in neonates. The complexity and invasiveness of the procedure is probably responsible for high rate of complications and mortality. If appropriate catheter selection and technique in the placement should be done, PD might improve outcome.

Palliative care for the newborn in the United Kingdom

Palliative care for the newborn is a developing area. There are more than 2000 estimated neonatal deaths each year in the UK from causes likely to benefit from palliative care. There is an increasing recognition that while the goals of care may be different for dying newborns, they deserve the same high standard of care as those babies who go on to survive. Recent neonatal palliative care guidance is available from the British Association for Perinatal Medicine (BAPM), the General Medical Council (GMC), and ACT (the U.K. association for children's palliative care). We attempt to answer the question: 'What does the provision of good neonatal palliative care look like?' by examining the factors important in the provision of such care.

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.