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Chalfun G, Araújo Brasil AD, Paravidino VB, Soares-Lima SC, Souza Almeida Lopes MD, Santos Salú MD, Barbosa E Dos Santos PV, P da Cunha Trompiere AC, Vieira Milone LT, Rodrigues-Santos G, Genuíno de Oliveira MB, Robaina JR, Lima-Setta F, Reis MM, Ledo Alves da Cunha AJ, Prata-Barbosa A, de Magalhães-Barbosa MC. NR3C1 gene methylation and cortisol levels in preterm and healthy full-term infants in the first 3 months of life. Epigenomics 2022; 14:1545-1561. [PMID: 36861354 DOI: 10.2217/epi-2022-0444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Aim: To describe NR3C1 exon-1F methylation and cortisol levels in newborns. Materials & methods: Preterm ≤1500 g and full-term infants were included. Samples were collected at birth and at days 5, 30 and 90 (or at discharge). Results: 46 preterm and 49 full-term infants were included. Methylation was stable over time in full-term infants (p = 0.3116) but decreased in preterm infants (p = 0.0241). Preterm infants had higher cortisol levels on the fifth day, while full-term infants showed increasing levels (p = 0.0177) over time. Conclusion: Hypermethylated sites in NR3C1 at birth and higher cortisol levels on day 5 suggest that prematurity, reflecting prenatal stress, affects the epigenome. Methylation decrease over time in preterm infants suggests that postnatal factors may modify the epigenome, but their role needs to be clarified.
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Affiliation(s)
- Georgia Chalfun
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
- Department of Neonatology, Maternity School, Federal University of Rio de Janeiro (UFRJ), RJ, 22240-000, Brazil
| | - Aline de Araújo Brasil
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
| | - Vitor Barreto Paravidino
- Department of Epidemiology, Institute of Social Medicine, University of the State of Rio de Janeiro (UERJ), 20550-013, Brazil
- Department of Physical Education & Sports, Naval Academy, Brazilian Navy, Rio de Janeiro, RJ, 20021-010, Brazil
| | - Sheila Coelho Soares-Lima
- Molecular Carcinogenesis Program, Brazilian National Cancer Institute, Rio de Janeiro, RJ, 20230-130, Brazil
| | | | - Margarida Dos Santos Salú
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
| | | | | | - Leo Travassos Vieira Milone
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
| | - Gustavo Rodrigues-Santos
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
| | | | - Jaqueline Rodrigues Robaina
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
| | - Fernanda Lima-Setta
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
| | - Marcelo Martins Reis
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
| | - Antônio José Ledo Alves da Cunha
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
- Postgraduate Program in Perinatal Health, Maternity School, Federal University of Rio de Janeiro (UFRJ), RJ, 22240-000, Brazil
| | - Arnaldo Prata-Barbosa
- Department of Pediatrics, D'Or Institute for Research & Education (IDOR), Rio de Janeiro, RJ, 22281-100, Brazil
- Postgraduate Program in Perinatal Health, Maternity School, Federal University of Rio de Janeiro (UFRJ), RJ, 22240-000, Brazil
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2
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Ferber SG, Als H, McAnulty G, Klinger G, Weller A. Multi-level hypothalamic neuromodulation of self-regulation and cognition in preterm infants: Towards a control systems model. COMPREHENSIVE PSYCHONEUROENDOCRINOLOGY 2022; 9:100109. [PMID: 35755927 PMCID: PMC9216652 DOI: 10.1016/j.cpnec.2021.100109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 12/28/2021] [Indexed: 11/21/2022] Open
Abstract
Preterm infants, age-corrected for prematurity, score on average, 10 points lower on IQ tests than full-term infants tested at comparable ages. This review focuses on the potential contribution of the hypothalamus to cognitive neuro-regulatory development in preterm infants through its bidirectional neural connections with the prefrontal cortex and its neuroendocrine activity. It aims to clarify the central role of the hypothalamus in preterm high stress situations and in influencing cognitive development via its connectivity to the cerebral cortex. The review further evaluates epigenomic sensitivity to environmental inputs. Recent results suggest that an optimal range of DNA methylations (via a continuous process of decreasing levels of receptor methylations that are too high, and increasing levels that are too low) appears necessary in order to reach an adaptive level of receptor availability. Several studies have demonstrated amelioration of preterm infants' stress while in the Newborn Intensive Care Unit (NICUs) and following discharge. The authors postulate that feedback mechanisms and correction signals are the basis for a hypothalamic homeostatic modulating function, a "hypothalamic resistance response", which may account for the stress reduction brought about by in- and post-NICU early interventions and their results of promoting self-regulation and cognition.
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Key Words
- Cognitive
- Controlled process variable, (CPV)
- Corticotropin-releasing hormone, (CRH)
- Epigenetics
- Hypothalamic pituitary adrenal axis, (HPA axis)
- Hypothalamic pituitary gonadal axis, (HPG axis)
- Hypothalamic pituitary thyroid axis, (HPT axis)
- Hypothalamus
- Lateral hypothalamus, (LH)
- Magnetic resonance imaging, (MRI)
- Neuro-regulatory development
- Newborn intensive care unit, (NICU)
- Oxytocin, (OT)
- Prefrontal cortex
- Prefrontal cortex, (PFC)
- Premature infants
- Set point, (SP)
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Affiliation(s)
- Sari Goldstein Ferber
- Department of Psychology and the Leslie and Susan Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
| | - Heidelise Als
- Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gloria McAnulty
- Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gil Klinger
- Department of Neonatology, Schneider Children's Medical Center, Sackler Medical School, Tel Aviv University, Petach Tikvah, Israel
| | - Aron Weller
- Department of Psychology and the Leslie and Susan Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar Ilan University, Ramat Gan, Israel
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Volpe J. Commentary - Cerebellar underdevelopment in the very preterm infant: Important and underestimated source of cognitive deficits. J Neonatal Perinatal Med 2021; 14:451-456. [PMID: 33967062 PMCID: PMC8673497 DOI: 10.3233/npm-210774] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Affiliation(s)
- J.J. Volpe
- Department of Neurology, Harvard Medical School, Boston, MA, USA
- Department of Pediatric Newborn Medicine, Harvard Medical School, Boston, MA, USA
- Address for correspondence: Joseph J. Volpe, M.D., Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, 221 Longwood Avenue, Room 343C, Boston, MA 02115 USA. Tel.: +1 617 525 4145; E-mail:
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Shaunak M, Blair JC, Davies JH. How to interpret a single cortisol measurement. Arch Dis Child Educ Pract Ed 2020; 105:347-351. [PMID: 32859739 DOI: 10.1136/archdischild-2019-318431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 11/03/2022]
Abstract
Adrenal insufficiency can present with non-specific clinical features. Therefore, a single cortisol measurement is often included in the biochemical work-up of an unwell child. This article aims to review the diagnostic utility of a single cortisol measurement by outlining the physiological, clinical and technical factors affecting result interpretation. Clinical scenarios are used to illustrate how this test may be used in different commonly encountered situations in general paediatrics, with the aim of minimising the frequency of inconclusive results.
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Affiliation(s)
- Meera Shaunak
- Paediatric Endocrinology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Joanne C Blair
- Department of Endocrinology, Alder Hey Childrens NHS Foundation Trust, Liverpool, UK
| | - Justin Huw Davies
- Paediatric Endocrinology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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5
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Abstract
Several limitations and controversies surround the definition of hypotension; however, it remains one of the most common problems faced by neonates. Approximately 15% to 30% of neonates with hypotension fail to respond to volume and/or vasopressor or inotropes. They are considered to have refractory hypotension. Although it is thought to have multiple causes, absolute and relative adrenal insufficiency is considered as the main reason for refractory hypotension. This article focuses on the role of adrenal insufficiency in causing refractory hypotension in preterm and term infants, the different options of corticosteroids available, and their risk/benefit profiles.
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Affiliation(s)
- Neha Kumbhat
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Shahab Noori
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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6
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D’Agata AL, Roberts MB, Ashmeade T, Dutra SVO, Kane B, Groer MW. Novel method of measuring chronic stress for preterm infants: Skin cortisol. Psychoneuroendocrinology 2019; 102:204-211. [PMID: 30583244 PMCID: PMC6420357 DOI: 10.1016/j.psyneuen.2018.12.223] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Infants who begin life in the medicalized environment of the neonatal intensive care unit (NICU) do so under stressful conditions. Environmental exposures are often abrasive to vulnerable infants, while invasive and noninvasive lifesaving interventions provide additional pain and/or stress. The most commonly selected biomarker to measure stress is cortisol. The skin is the barrier between the external environment and communicates with our neurological, endocrine and immune regulatory networks. To examine if skin cortisol may be a reliable biomarker of stress, NICU stress exposure and repeated measurements of skin cortisol in very preterm infants were examined retrospectively during the first 6 weeks of life. The temporal relationship between skin cortisol and NICU stress exposure was also analyzed. MATERIALS AND METHODS Participants included 82 preterm infants born weighing less than 1500 g, admitted to a level III NICU, with a mean gestational age of 28.5 weeks. Infants were studied from birth through 6 weeks of life. NICU stress data was collected using the Neonatal Infant Stressor Scale. Skin samples were collected using d-squame tape as soon after birth as possible and every two weeks thereafter. RESULTS On average, infants experienced approximately 43 stressful events per day during the first 6 weeks of life in the NICU. Stress level and cortisol reactivity varied by gestation age. Higher stress resulted in higher cortisol for infant >28 weeks; lower stress scores were associated with higher stress for infants <28 weeks. Stress exposure during 7 days prior to cortisol sampling yielded the highest AUC for the 2 groups. A statistically significant interaction was identified between gestational age and stress exposure during the previous 7 days (p < 0.01). CONCLUSION This is the first study to demonstrate skin cortisol as a preterm infant biomarker of chronic stress exposure. For infants with appropriate skin maturation, this non-invasive sampling method provides several benefits. Importantly, this method may be less intrusive and disruptive for preterm infants.
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Affiliation(s)
- Amy L. D’Agata
- College of Nursing, University of South Florida, 12912 USF Health Drive, Tampa, FL, USA,College of Nursing, University of Rhode Island, 39 Butterfield Rd., Kingston, RI, USA
| | - Mary B. Roberts
- College of Nursing, University of Rhode Island, 39 Butterfield Rd., Kingston, RI, USA,Center for Primary Care & Prevention, Care New England Medical Group, Primary Care & Specialty Services, 111 Brewster St., Pawtucket, RI, USA
| | - Terri Ashmeade
- Morsani College of Medicine, 12910 Bruce B. Downs Blvd, Tampa, FL, USA
| | | | - Bradley Kane
- College of Nursing, University of South Florida, 12912 USF Health Drive, Tampa, FL, USA
| | - Maureen W. Groer
- College of Nursing, University of South Florida, 12912 USF Health Drive, Tampa, FL, USA
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7
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Association between plasma cortisol and death or vasopressor refractory hypotension in preterm neonates: a prospective, cohort study. J Perinatol 2018; 38:672-680. [PMID: 29426854 DOI: 10.1038/s41372-018-0059-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 01/10/2018] [Accepted: 01/18/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Temporal relation between adrenal insufficiency and hypotension is poorly understood. We examined the association between basal and post-stimulation cortisol and death or vasopressor refractory hypotension in preterm neonates. STUDY DESIGN Prospective cohort study in ≤30 weeks' and/or <1,250 g weight. Primary outcome-composite of death or vasopressor refractory hypotension by day 14 of life. Plasma cortisol levels were measured at 24-36 h (T1), 72-84 h (T2) and 10 days (T3), and post-stimulation cortisol at T1 and later at T2 and T3 if the adrenal response was inadequate earlier. RESULTS Basal cortisol (µg/dl) at 24-36 h was significantly higher in the outcome group (37.2 ± 21.1 vs. 22.04 ± 14.6; mean difference (MD) (95% confidence interval (CI)): -15.1 (-23.6, -6.6); p = 0.005). High basal cortisol at 24-36 h (odds ratio (OR) (95% CI): 1.044 (1.009, 1.079); p = 0.01) and need for ventilation (OR (95% CI): 9.7 (1.2, 81.2); p = 0.04) independently increased the risk of death or vasopressor refractory hypotension. CONCLUSION Preterm neonates who died or developed vasopressor refractory hypotension by day 14 had significantly elevated basal cortisol at 24-36 h of life.
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Travers S, Martinerie L, Boileau P, Lombès M, Pussard E. Alterations of adrenal steroidomic profiles in preterm infants at birth. Arch Dis Child Fetal Neonatal Ed 2018; 103:F143-F151. [PMID: 28747362 DOI: 10.1136/archdischild-2016-312457] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 05/22/2017] [Accepted: 05/22/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Preterm infants have relative adrenal and kidney immaturity. Recently, we linked their urine sodium loss to a hypoaldosteronism at variance with an appropriate stimulation of the renin-angiotensin system. To investigate this defective aldosterone secretion, we analyse the biosynthesis pathways of adrenal steroids in neonates according to gestational age (GA). DESIGN Multicentre study (Premaldo) including 152 neonates classified into three groups: group 1 (very preterm (VPT)): <33 gestational weeks (GW); group 2 (preterm (PT)): 33-36 GW and group 3 (term (T)): ≥GW. METHOD Steroidomic profiles of mineralocorticoids, glucocorticoids and adrenal androgens were established from umbilical cord at birth (n=152) and peripheral blood at day 3 (n=70) using a recently developed liquid chromatography mass spectrometry method (LC-MS/MS). The enzymatic activity of each biosynthesis step was estimated by the product-to-substrate ratio. RESULTS At birth, VPT infants exhibit a global defect in adrenal steroid synthesis pathways leading to lower levels of aldosterone, cortisol and androstenedione than in term infants. This defect was strongly related to GA. On day 3, steroid precursors (progesterone, 11-deoxycorticosterone (DOC), 17-hydroxyprogesterone(17-OH-P) and 11-deoxycortisol (S)) were higher in VPT and negatively correlated with GA. Despite of precursors' accumulation, aldosterone and cortisol were similar in the three groups. At birth and day 3, a low cortisol/11-deoxycortisol ratio was found in preterm infants, suggesting an 11-beta-hydroxylase activity (CYP11B1) deficiency. CONCLUSIONS At birth, VPT infants exhibit a global deficit in mineralocorticoids, glucocorticoids and adrenal androgens that attenuates on day 3 of life. Steroid profiling using LC-MS/MS provides evidence for a partial defect in 11-hydroxylase along with prematurity.
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Affiliation(s)
- Simon Travers
- Inserm, U1185, Le Kremlin-Bicêtre, France.,Fac Med Paris-Sud, Univ, Paris-Sud, Université Paris Saclay, Le Kremlin-Bicêtre, France.,Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpital de Bicêtre, Hôpitaux Universitaires Paris Sud, Assistance Publique'Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Laetitia Martinerie
- Inserm, U1185, Le Kremlin-Bicêtre, France.,Service d'Endocrinologie Pédiatrique, Hôpital Robert Debré, Assistance Publique Hôpitaux de Paris, Paris, France.,PremUp Foundation, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Pascal Boileau
- PremUp Foundation, Paris, France.,Service de Réanimation Néonatale, CH Poissy St'Germain en'Laye, Poissy, France.,EA 7285, UFR des Sciences de la Santé, Simone Veil, Université Versailles St-Quentin en Yvelines, Montigny le Bretonneux, France
| | - Marc Lombès
- Inserm, U1185, Le Kremlin-Bicêtre, France.,Fac Med Paris-Sud, Univ, Paris-Sud, Université Paris Saclay, Le Kremlin-Bicêtre, France.,PremUp Foundation, Paris, France.,Service d'Endocrinologie et Maladies de la Reproduction, Hôpital de Bicêtre, Hôpitaux Universitaires Paris Sud, Assistance Publique'Hêpitaux de Paris, Le Kremlin Bicêtre, France.,Institut Biomédical de Bicêtre, Le Kremlin-Bicêtre, France
| | - Eric Pussard
- Inserm, U1185, Le Kremlin-Bicêtre, France.,Fac Med Paris-Sud, Univ, Paris-Sud, Université Paris Saclay, Le Kremlin-Bicêtre, France.,Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpital de Bicêtre, Hôpitaux Universitaires Paris Sud, Assistance Publique'Hôpitaux de Paris, Le Kremlin Bicêtre, France.,Institut Biomédical de Bicêtre, Le Kremlin-Bicêtre, France
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9
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Late-onset Circulatory Collapse and Continuous Positive Airway Pressure are Useful Predictors of Treatment-requiring Retinopathy of Prematurity: A 9-year Retrospective Analysis. Sci Rep 2017. [PMID: 28634380 PMCID: PMC5478650 DOI: 10.1038/s41598-017-04269-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Visual loss caused by retinopathy of prematurity (ROP) will be prevented if treatment-requiring ROP (TR-ROP) can be predicted. In this retrospective study including 418 infants with ≤32 weeks of gestational age (GA) and/or ≤1500 grams of birthweight, we attempted to identify useful predictors. We also examined the efficiency of significant predictors compared with existing predictive models, ROPScore and CHOP model. Multivariable logistic regression analyses supported the following factors were useful for predicting TR-ROP from all infants and infants with any ROP: GA (odds ratio [OR], 0.47 and 0.48), history of late-onset circulatory collapse (LCC) (OR, 2.76 and 2.44) and use of continuous positive airway pressure (CPAP) at 35 weeks of postmenstrual age (OR, 3.78 and 4.50). The comparison of areas under receiver operating characteristic curves indicated the combination of LCC, CPAP and ROPScore was better than ROPScore to predict TR-ROP from all infants and infants with any ROP (P = 0.007 and 0.02) and the combination of LCC, CPAP and CHOP model was also better than CHOP model to predict TR-ROP from all infants and infants with any ROP (P = 0.01 and 0.02). Our results suggested infants with a history of LCC and a long CPAP support have a high incidence of TR-ROP.
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10
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Giarraputo J, DeLoach J, Padbury J, Uzun A, Marsit C, Hawes K, Lester B. Medical morbidities and DNA methylation of NR3C1 in preterm infants. Pediatr Res 2017; 81:68-74. [PMID: 27653086 PMCID: PMC5313510 DOI: 10.1038/pr.2016.185] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 08/08/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Although there are no accepted "normal" levels of circulating cortisol in preterm infants, critically ill preterm infants show lower cortisol levels than healthy preterm infants. The regulation of cortisol reactivity by epigenetic changes in glucocorticoid receptor gene (NR3C1) expression has been demonstrated. This study aims to examine the relationship between medical morbidities in preterm infants and DNA methylation of NR3C1. METHODS Pyrosequencing was used to determine DNA methylation in CpG sites 1-4 of promoter region 1F of NR3C1. Cluster analysis placed 67 preterm infants born <1,500 g into groups based on medical morbidities. The DNA methylation pattern was compared across groups. RESULTS Cluster analysis identified a high medical risk cluster and a low medical risk cluster. A Mann-Whitney U-test showed lower methylation at CpG1 for infants in the high-risk group (M = 0.336, SE = 0.084) than infants in the low-risk group (M = 0.617, SE = 0.109, P = 0.032). The false discovery rate was low (q = 0.025). Cohen's D effect size was moderate (0.525). CONCLUSION Decreased DNA methylation of CpG1 of NR3C1 in high-risk infants may allow for increased binding of transcription factors involved in the stress response, repair and regulation of NR3C1. This may ensure healthy growth in high-risk preterm infants over increasing cortisol levels.
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Affiliation(s)
- James Giarraputo
- Department of Neuroscience, Brown University, Providence, Rhode Island
- Warren Alpert Medical School of Brown University, Center for the Study of Children at Risk, Providence, Rhode Island
| | - Jordan DeLoach
- Warren Alpert Medical School of Brown University, Center for the Study of Children at Risk, Providence, Rhode Island
- Department of Sociology, Brown University, Providence, Rhode Island
| | - James Padbury
- Warren Alpert Medical School of Brown University, Departments of Pediatrics, Providence, Rhode Island
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, Rhode Island
| | - Alper Uzun
- Warren Alpert Medical School of Brown University, Departments of Pediatrics, Providence, Rhode Island
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, Rhode Island
| | - Carmen Marsit
- Department of Pharmacology and Toxicology and Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Katheleen Hawes
- Warren Alpert Medical School of Brown University, Center for the Study of Children at Risk, Providence, Rhode Island
- Warren Alpert Medical School of Brown University, Departments of Pediatrics, Providence, Rhode Island
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, Rhode Island
| | - Barry Lester
- Warren Alpert Medical School of Brown University, Center for the Study of Children at Risk, Providence, Rhode Island
- Warren Alpert Medical School of Brown University, Departments of Pediatrics, Providence, Rhode Island
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, Rhode Island
- Warren Alpert Medical School of Brown University, Departments of Psychiatry and Human Behavior, Providence, Rhode Island
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11
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Ng PC. Adrenocortical insufficiency and refractory hypotension in preterm infants. Arch Dis Child Fetal Neonatal Ed 2016; 101:F571-F576. [PMID: 27601464 DOI: 10.1136/archdischild-2016-311289] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/18/2016] [Accepted: 08/19/2016] [Indexed: 11/04/2022]
Abstract
Preterm, very low birthweight (VLBW) infants are prone to life-threatening hypotension secondary to hypothalamic-pituitary-adrenal axis immaturity, resulting in adrenocortical insufficiency. Clinical presentations of inotrope-resistant refractory hypotension are usually evident, but interpretation of serum cortisol may pose much difficulty to front-line neonatologists. This review examines the salient pathophysiology of adrenocortical insufficiency in the immediate postnatal period, characterises its endocrinological abnormalities, and describes the typical and variant clinical presentations. Based on existing evidence, a practical scheme is proposed for logical interpretation of circulating cortisol levels and management of inotrope-resistant refractory hypotension in VLBW infants.
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Affiliation(s)
- Pak Cheung Ng
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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12
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Khashana A, Saarela T, Ramet M, Hallman M. Cortisol intermediates and hydrocortisone responsiveness in critical neonatal disease. J Matern Fetal Neonatal Med 2016; 30:1721-1725. [DOI: 10.1080/14767058.2016.1223032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Abdelmoneim Khashana
- PEDEGO Research Center, and Medical Research Center Oulu, University of Oulu, Oulu, Finland,
- Department of Pediatrics and Neonatology, Suez Canal University Hospital, Ismailia, Egypt
| | - Timo Saarela
- PEDEGO Research Center, and Medical Research Center Oulu, University of Oulu, Oulu, Finland,
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland, and
| | - Mika Ramet
- PEDEGO Research Center, and Medical Research Center Oulu, University of Oulu, Oulu, Finland,
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland, and
| | - Mikko Hallman
- PEDEGO Research Center, and Medical Research Center Oulu, University of Oulu, Oulu, Finland,
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland, and
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13
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Khashana A, Ojaniemi M, Leskinen M, Saarela T, Hallman M. Term neonates with infection and shock display high cortisol precursors despite low levels of normal cortisol. Acta Paediatr 2016; 105:154-8. [PMID: 26537554 DOI: 10.1111/apa.13257] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/01/2015] [Accepted: 10/29/2015] [Indexed: 01/08/2023]
Abstract
AIM Neonatal therapy-resistant septic shock is a common problem in middle and low-income countries. We investigated whether newborn infants with infection and therapy-resistant hypotension showed evidence of abnormal levels of cortisol or cortisol precursors. METHODS A total of 60 term or near term neonates with evidence of infection were enrolled after informed consent. Of these, 30 had an infection and refractory shock and 30 had an infection without shock. There were no detectable differences between the groups in the length of gestation, birth weight or gender distribution. Serum was obtained during days four and 14 after birth. Cortisol and cortisol precursor concentrations were analysed using liquid chromatography-tandem mass spectrometry. RESULTS The cortisol concentrations were low considering the expected responses to stress and they did not differ between the groups. The infants with infection and shock had higher serum dehydroepiandrosterone (DHEA) levels than those without shock (319.0 ± 110.3 μg/dL, versus 22.3 ± 18.3 μg/dL; p < 0.0001) and they also had higher 17-hydroxy-pregnenolone, pregnenolone and progesterone concentrations. There were no detectable differences in the levels of 17-hydroxy-progesterone, 11-deoxy-cortisol, cortisol or cortisone. CONCLUSION Septic newborn infants with therapy-resistant hypotension had very high DHEA levels, suggesting that 3-beta-hydroxysteroid dehydrogenase activity limited the rate of cortisol synthesis.
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Affiliation(s)
- Abdelmoneim Khashana
- PEDEGO Research Center and Medical Research Center Oulu; University of Oulu; Oulu Finland
- Department of Paediatrics and Neonatology; Suez Canal University Hospital; Ismailia Egypt
| | - Marja Ojaniemi
- PEDEGO Research Center and Medical Research Center Oulu; University of Oulu; Oulu Finland
- Department of Children and Adolescents; Oulu University Hospital; Oulu Finland
| | - Markku Leskinen
- Department of Children and Adolescents; Oulu University Hospital; Oulu Finland
| | - Timo Saarela
- Department of Children and Adolescents; Oulu University Hospital; Oulu Finland
| | - Mikko Hallman
- PEDEGO Research Center and Medical Research Center Oulu; University of Oulu; Oulu Finland
- Department of Children and Adolescents; Oulu University Hospital; Oulu Finland
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14
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Lester BM, Marsit CJ, Giarraputo J, Hawes K, LaGasse LL, Padbury JF. Neurobehavior related to epigenetic differences in preterm infants. Epigenomics 2015; 7:1123-36. [PMID: 26585459 PMCID: PMC5551936 DOI: 10.2217/epi.15.63] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
UNLABELLED Preterm birth is associated with medical problems affecting the neuroendocrine system, altering cortisol levels resulting in negative effects on newborn neurobehavior. Newborn neurobehavior is regulated by DNA methylation of NR3C1 and HSD11B2. AIM Determine if methylation of HSD11B2 and NR3C1 is associated with neurobehavioral profiles in preterm infants. PATIENTS & METHODS Neurobehavior was measured before discharge from the hospital in 67 preterm infants. Cheek swabs were collected for DNA extraction. RESULTS Infants with the high-risk neurobehavioral profile showed more methylation than infants with the low-risk neurobehavioral profile at CpG3 for NR3C1 and less methylation of CpG3 for HSD11B2. Infants with these profiles were more likely to have increased methylation of NR3C1 and decreased methylation of HSD11B2 at these CpG sites. CONCLUSION Preterm birth is associated with epigenetic differences in genes that regulate cortisol levels related to high-risk neurobehavioral profiles.
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Affiliation(s)
- Barry M Lester
- Brown Center for the Study of Children at Risk, Providence, RI, USA
- Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
| | - Carmen J Marsit
- Departments of Pharmacology & Toxicology & Community & Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - James Giarraputo
- Brown Center for the Study of Children at Risk, Providence, RI, USA
- Department of Neuroscience, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Katheleen Hawes
- Brown Center for the Study of Children at Risk, Providence, RI, USA
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
| | - Linda L LaGasse
- Brown Center for the Study of Children at Risk, Providence, RI, USA
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
| | - James F Padbury
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
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15
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Affiliation(s)
- Hye Rim Chung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
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16
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Chung HR. Adrenal and thyroid function in the fetus and preterm infant. KOREAN JOURNAL OF PEDIATRICS 2014; 57:425-33. [PMID: 25379042 PMCID: PMC4219944 DOI: 10.3345/kjp.2014.57.10.425] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/14/2014] [Indexed: 02/04/2023]
Abstract
Adrenal and thyroid hormones are essential for the regulation of intrauterine homeostasis, and for the timely differentiation and maturation of fetal organs. These hormones play complex roles during fetal life, and are believed to underlie the cellular communication that coordinates maternal-fetal interactions. They serve to modulate the functional adaptation for extrauterine life during the perinatal period. The pathophysiology of systemic vasopressor-resistant hypotension is associated with low levels of circulating cortisol, a result of immaturity of hypothalamic-pituitary-adrenal axis in preterm infants under stress. Over the past few decades, studies in preterm infants have shown abnormal clinical findings that suggest adrenal or thyroid dysfunction, yet the criteria used to diagnose adrenal insufficiency in preterm infants continue to be arbitrary. In addition, although hypothyroidism is frequently observed in extremely low gestational age infants, the benefits of thyroid hormone replacement therapy remain controversial. Screening methods for congenital hypothyroidism or congenital adrenal hyperplasia in the preterm neonate are inconclusive. Thus, further understanding of fetal and perinatal adrenal and thyroid function will provide an insight into the management of adrenal and thyroid function in the preterm infant.
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Affiliation(s)
- Hye Rim Chung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
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17
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Mitchell AJ, Yates CC, Williams DK, Chang JY, Hall RW. Does daily kangaroo care provide sustained pain and stress relief in preterm infants? J Neonatal Perinatal Med 2014; 6:45-52. [PMID: 24246458 DOI: 10.3233/npm-1364212] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES 1. Determine whether stress in preterm infants, measured with salivary cortisol, decreases after five days of Kangaroo Care (KC) compared to five days of Standard Care (SC). 2. To determine whether kangaroo care provides sustainable pain relief beyond the period of skin-to-skin holding. STUDY DESIGN Preterm infants (n = 38) born at 27-30 weeks gestational age were randomized to either the KC or the SC group and received the allocated intervention starting on day of life (DOL) five and continuing for five days. Salivary cortisol was collected on DOL five and again on DOL ten. Differences were analyzed using repeated measures ANOVA and t tests. Pain during nasal suctioning over five days was assessed using the Premature Infant Pain Profile (PIPP). RESULT 1. Adequate saliva samples for salivary cortisol were collected for 13 KC infants and 11 SC infants. There was no main effect of group (p = 0.49), but there was a significant main effect of age (DOL five versus DOL ten), with salivary cortisol levels decreasing in both groups (p = 0.02). 2. Pain scores for both groups (n = 38) indicted mild to moderate pain during suctioning, with no significant difference in pain scores between groups. CONCLUSION 1. KC did not affect salivary cortisol levels in preterm neonates, but levels in both the KC and SC groups decreased over time from DOL five to ten. Salivary cortisol may vary with age of infant. 2. Infants experience pain during routine suctioning and may require pain management.
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Affiliation(s)
- A J Mitchell
- College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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18
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Timing is everything: evidence for a role of corticolimbic endocannabinoids in modulating hypothalamic-pituitary-adrenal axis activity across developmental periods. Neuroscience 2011; 204:17-30. [PMID: 22015924 DOI: 10.1016/j.neuroscience.2011.10.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 10/04/2011] [Accepted: 10/05/2011] [Indexed: 02/05/2023]
Abstract
Growing evidence suggests that the endocannabinoid system is vital to ensuring normative maturation of the brain into adulthood. Endocannabinoid signaling contributes to guiding pro-neurogenic processes in early life and the development of neurotransmitter systems. Moreover, there is extensive evidence that recruitment of the endocannabinoid system is crucial in the regulation of neuroendocrine responses to stress via the hypothalamic-pituitary-adrenal (HPA) axis, and contributes to subsequent psychopathological consequences associated with emotionality and anxiety. These stress-induced physiological and behavioural sequelae are regulated by neural structures within the corticolimbic circuit, including the amygdala, hypothalamus, hippocampus, and prefrontal cortex. Based on evidence demonstrating endocannabinoid system involvement in both development and stress-induced changes in HPA axis function, it is reasonable to suggest that endocannabinoid signaling is an important mediator of interactions between stress responsivity and maturational stage. In this review, we discuss the ontogeny of the endocannabinoid system in the central nervous system, clinical and rodent models demonstrating short- and long-term effects of stress exposure, regulation of HPA axis responsivity by endocannabinoid signaling, as well as pharmacological and stress models indicating involvement of the endocannabinoid system in early post-natal and adolescent development on stress reactivity of the HPA, the corticolimbic system, and behaviour.
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Hyman SJ, Novoa Y, Holzman I. Perinatal endocrinology: common endocrine disorders in the sick and premature newborn. Pediatr Clin North Am 2011; 58:1083-98, ix. [PMID: 21981950 DOI: 10.1016/j.pcl.2011.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Endocrine disorders are common in infants in the neonatal ICU. They often are associated with prematurity, low birth weight or very low birth weight, and small size for gestational age. They also frequently occur in infants who are critically ill or stressed. This article describes the most common conditions and current knowledge regarding management.
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Affiliation(s)
- Sharon J Hyman
- Division of Pediatric Endocrinology and Diabetes, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1616, New York, NY 10029, USA.
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20
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Ng PC, Wong SPS, Chan IHS, Lam HS, Lee CH, Lam CWK. A prospective longitudinal study to estimate the "adjusted cortisol percentile" in preterm infants. Pediatr Res 2011; 69:511-6. [PMID: 21364494 DOI: 10.1203/pdr.0b013e31821764b1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The normal range of serum cortisol concentrations and the appropriate levels of circulating cortisol in different clinical situations in preterm infants are not well defined. This study aimed to evaluate the impact of perinatal factors on circulating cortisol levels in preterm infants and to create a quantitative model that could estimate the "adjusted cortisol percentile." Serial serum cortisol concentrations were measured in 209 infants ≤ 32 wk gestation on d 1, 4, 7, 14, and 21 of life. Seven perinatal factors or conditions that could affect circulating cortisol level were identified. Serum cortisol levels were higher on d 4 (p = 0.007) and d 7 (p = 0.007) but lower on d 21 (p = 0.001) compared with d 1. Serum cortisol was also higher in infants on nasal continuous positive airway pressure (p = 0.003); requiring a second vasopressor (p < 0.001); with intraventricular hemorrhage (≥ grade 3; p < 0.001); with histologic chorioamnionitis (p = 0.007); with severe lung disease (p = 0.046); and with decreasing GA (p < 0.001). A mathematical equation was proposed based on factors derived in this preliminary study for estimating the adjusted cortisol percentile. Frontline neonatologists could now access the equation on our Web site (http://www.sta.cuhk.edu.hk/pswong/ACortP.html) to calculate the adjusted cortisol percentile, which could potentially improve the interpretation of circulating cortisol in different clinical situations.
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Affiliation(s)
- Pak C Ng
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories, Hong Kong.
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21
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Abstract
The hypothalamic-pituitary-adrenal (HPA) axis is essential for maintaining homeostasis in the fetus and newborn. A proportion of extremely preterm infants suffer from transient adrenocortical insufficiency of prematurity. Although these infants have suboptimal adrenocortical response to stress in the first week of life, the HPA axis adapts rapidly, and most exhibit an adequate response by day 14. An attenuated cortisol response in preterm infants might be protective against intracranial bleeding. Severe hypoxic-ischemic encephalopathy is a potent stimulus to the HPA axis. Chronic intrauterine hypoxemia can up-regulate the setpoint of the HPA axis and augments adrenal steroidogenic production, resulting in sustained elevation of circulating cortisol levels.
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22
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Joung KH, Cho SC. The effect of sucrose on infants during a painful procedure. KOREAN JOURNAL OF PEDIATRICS 2010; 53:790-4. [PMID: 21189976 PMCID: PMC3004494 DOI: 10.3345/kjp.2010.53.8.790] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Revised: 05/28/2010] [Accepted: 07/13/2010] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to test the efficacy of treating the pain among newborn infants associated with a medical procedure with sucrose with regard to overall physiological and behavioral stability. METHODS 103 newborn infants were enrolled in this study. The control group (n=63) did not receive any treatment. The experimental group (n=40) received 2 mL of 24% sucrose solution two minutes before a routine heel stick. The pain was assessed by measurements of physiological changes [e.g. pulse rate, oxygen saturation, salivary cortisol (hydrocortisone)] and behavioral changes [e.g. crying time, and the neonatal infant pain scale (NIPS) for neonates]. RESULTS There were no differences among the groups with respect to physiological changes associated with the pain from the procedure. However, there were significant group differences in behavioral changes to the pain. In the control group, the median crying time was 13 seconds, while in the experimental group, the median crying time was 3.5 seconds (P=.000). In the control group the median NIPS score was 4, while in the experimental group the median NIPS score was 2 (P=.000). CONCLUSIONS These findings suggest that sucrose can be an effective method for the management of stress responses in infants with regard to behavior. However, this treatment had no significant physiological effects.
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Affiliation(s)
| | - Soo Chul Cho
- Department of Pediatrics, Chonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
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Abstract
PURPOSE OF REVIEW Relative adrenal insufficiency is a controversial phenomenon described in adults and children with critical illness, especially septic shock. In the past 2 decades, relative adrenal insufficiency has also been reported in the critically ill premature as well as term newborn. The present study will review the initial and more recent studies addressing adrenal insufficiency in the premature infant. RECENT FINDINGS Studies suggest that 'relative adrenal insufficiency' is a contributing factor to hemodynamic instability in the sick preterm newborn. Many ill preterm newborns have inappropriately low serum cortisol concentrations and respond to steroid administration. Adrenal insufficiency is transient and likely reflects normal adrenal physiology at younger gestational ages. There is no general consensus on its diagnosis, effective minimum dose for treatment and duration of treatment. SUMMARY More large scale, multicenter, randomized, double-blind studies are needed to make the diagnosis of relative adrenal insufficiency and to determine the indication, dose, complications and outcome of glucocorticoid therapy.
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Affiliation(s)
- Jose B Quintos
- Department of Pediatrics, Division of Endocrinology and Metabolism, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, Rhode Island 02903, USA.
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24
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Ballerini MG, Chiesa A, Scaglia P, Gruñeiro-Papendieck L, Heinrich JJ, Ropelato MG. 17alpha-hydroxyprogesterone and cortisol serum levels in neonates and young children: influence of age, gestational age, gender and methodological procedures. J Pediatr Endocrinol Metab 2010; 23:121-32. [PMID: 20432815 DOI: 10.1515/jpem.2010.23.1-2.121] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To determine the influence of age, gestational age, gender and methodological protocol on serum 17OHP and cortisol concentrations. 17OHP in non-extracted (NE) and extracted (E) sera was measured by RIA in 319 full-term (FT) (1 d-5 yr) infants, 38 pre-term (PT) and in 19 neonates with classical CAH at diagnosis. 17OHP (NE- and E-) decreased with age in normal children. The extraction procedure significantly reduced 17OHP by eliminating interfering steroids in children < 1 year. Sexual dimorphism was only observed in NE-17OHP. 17OHP in PT was always higher than in FT up to 2 months of age (p < 0.001). Neither NE- nor E-17OHP in CAH overlapped with those of FT or PT (p < 0.001) allowing to omit the extraction procedure to confirm CAH diagnosis. Cortisol levels were within normal range in neonates with CAH, thus not adding useful information about adrenal function. Chronological and gestational age, gender, and extraction for 17OHP measurement are important factors to know when assessing adrenal function during the first year of life.
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Affiliation(s)
- María Gabriela Ballerini
- División de Endocrinología, Centro de Investigaciones Endocrinológicas, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina.
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O'Mara K, Gal P, Ransommd JL, Wimmermd JE, Carlosmd RQ, Dimaguilamd MAV, Davonzomd C, Smithmd M. Successful use of dexmedetomidine for sedation in a 24-week gestational age neonate. Ann Pharmacother 2009; 43:1707-13. [PMID: 19755621 DOI: 10.1345/aph.1m245] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe a case of dexmedetomidine use for sedation in a 24-week gestational age premature neonate. CASE SUMMARY A 9-day-old, 24-week gestational age male neonate on high-frequency oscillatory mechanical ventilation was experiencing severe agitation refractory to high-dose intravenous narcotics and benzodiazepines. Since the infant's respiratory stability was reliant on adequate sedation, he was given dexmedetomidine after several days of suboptimal response to escalation of standard agents. Treatment prior to dexmedetomidine included continuous-infusion fentanyl 10 microg/kg/h, intravenous lorazepam 0.6 mg/kg every 4 hours, intermittent doses of both lorazepam and midazolam as needed, and a single bolus dose of phenobarbital. The patient calmed markedly during the dexmedetomidine loading dose infusion and remained adequately sedated while the drug was continued. The dexmedetomidine infusion allowed weaning of mechanical ventilation settings and eventual extubation of the infant, as well as rapid tapering of other sedative medications. The maximum dexmedetomidine infusion rate was 0.7 microg/kg/h, and total duration of therapy was 19 days. No significant adverse effects were directly attributed to dexmedetomidine use during this time. DISCUSSION Dexmedetomidine is a novel alpha(2)-agonist approved for short-term sedation in mechanically ventilated adults. Data describing its use in pediatric and neonatal patients continue to emerge. The prolonged use of dexmedetomidine in very-low-birth-weight neonates has not been described in the literature. CONCLUSIONS Dexmedetomidine was an effective sedative and analgesic in a 24-week gestational age neonate treated for refractory agitation while on mechanical ventilation. Based on its documented efficacy for pain and sedation and its favorable adverse effect profile, dexmedetomidine warrants further study as first-line or adjunct therapy with narcotics for sedation in ventilated newborns.
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Hyman SJ, Novoa Y, Holzman I. Perinatal endocrinology: common endocrine disorders in the sick and premature newborn. Endocrinol Metab Clin North Am 2009; 38:509-24. [PMID: 19717002 DOI: 10.1016/j.ecl.2009.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Endocrine disorders are common in infants in the neonatal ICU. They often are associated with prematurity, low birth weight or very low birth weight, and small size for gestational age. They also frequently occur in infants who are critically ill or stressed. This article describes the most common conditions and current knowledge regarding management.
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Affiliation(s)
- Sharon J Hyman
- Division of Pediatric Endocrinology and Diabetes, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1616, New York, NY 10029, USA.
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27
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Abstract
Brain abnormality in surviving premature infants is associated with an enormous amount of neurodevelopmental disability, manifested principally by cognitive, behavioral, attentional, and socialization deficits, most commonly with only relatively modest motor deficits. The most recognized contributing neuropathology is cerebral white matter injury. The thesis of this review is that acquired cerebellar abnormality is a relatively less recognized but likely important cause of neurodevelopmental disability in small premature infants. The cerebellar disease may be primarily destructive (eg, hemorrhage, infarction) or primarily underdevelopment. The latter appears to be especially common and relates to a particular vulnerability of the cerebellum of the small premature infant. Central to this vulnerability are the extraordinarily rapid and complex developmental events occurring in the cerebellum. The disturbance of development can be caused either by direct adverse effects on the cerebellum, especially the distinctive transient external granular layer, or by indirect remote trans-synaptic effects. This review describes the fascinating details of cerebellar development, with an emphasis on events in the premature period, the major types of cerebellar abnormality acquired during the premature period, their likely mechanisms of occurrence, and new insights into the relation of cerebellar disease in early life to subsequent cognitive/behavioral/attentional/socialization deficits.
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Affiliation(s)
- Joseph J. Volpe
- From the Department of Neurology, Children’s Hospital and Harvard Medical School, Boston, Massachusetts
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