Clinical Application of Near-Infrared Spectroscopy in Neonates

The Effect of Breast Milk Odor on Feeding Cues, Transition Time to Oral Feeding, and Abdominal Perfusion in Premature Newborns: A Randomised Controlled Trial

PURPOSE

The present study was conducted to determine the effect of odor stimulation with breast milk (BM) applied to premature newborns before and during enteral feeding on feeding cues, transition time to oral feeding and abdominal perfusion.

DESIGN

This study was a parallel group pretest-post test randomised controlled trial (RCT).

METHODS

The study was conducted in the neonatal intensive care unit (NICU) in Türkiye. Study data were collected from 32 premature newborns between October 2020 and December 2021. Newborns were randomly assigned to either intervention (n = 16) or control (n = 16) groups. Odor stimulation with BM was applied to newborns in the intervention group (IG) before and during enteral feeding for 3 days. Data were collected with the Newborn Information Form, Abdominal Perfusion Follow-up Form, and Feeding Cues Follow-up Form. Yates corrected and Fisher chi-squared test, Mann-Whitney U test, Cohen Kappa statistics, Permanova analysis, and Wilcoxon test were used in the analysis. The study was registered in ClinicalTrials.gov (NCT04843293).

RESULTS

The frequency of feeding cues in newborns who were exposed to the odor of BM, was higher than in the control group (CG) (p < .05). The transition times to oral feeding were similar in newborns in the IG and CG (p > .05). Abdominal perfusion level of newborns in the IG was higher than the CG (p < .05), and the level of abdominal perfusion showed a significant difference in terms of group*time interaction (p < .05).

CONCLUSION

Our findings suggest that odor stimulation with BM will be beneficial in improving the digestive functions of premature newborns.

The Use of Cerebral Near-Infrared Spectroscopy in Neonatal Hypoxic-Ischemic Encephalopathy: A Systematic Review of the Literature

BACKGROUND

Cerebral near-infrared spectroscopy (cNIRS) is a noninvasive technology used to trend cerebral perfusion at the bedside. cNIRS has potential as a valuable tool in the evaluation of infants with suspected hypoxic-ischemic encephalopathy (HIE). Trending cerebral perfusion with cNIRS can provide information regarding cerebral metabolism as HIE is evolving, which may offer insight into the extent of brain injury.

PURPOSE

The purpose of this systematic review is to investigate the use of cNIRS as a neurocritical tool in the management of neonatal HIE by evaluating its ability to detect acute neurological compromise, including acute brain injury and seizure activity, as well as its potential to identify infants at high risk for long-term neurodevelopmental impairment.

METHODS

A literature search was conducted using PubMed, CINAHL, and Web of Science databases to review articles investigating cNIRS technology in the acute management of HIE.

RESULTS

Eight studies were identified and included in this systematic review. Correlations were observed between cNIRS trends and neurological outcomes as later detected by MRI. cNIRS has potential as a bedside neuromonitoring tool in the management of HIE to detect infants at high risk for brain injury.

IMPLICATIONS FOR PRACTICE

Existing research supports the value of trending cNIRS in HIE management. Documented normal cNIRS values for both term and preterm infants in the first few days of life is approximately 60% to 80%. A steadily increasing cNIRS reading above an infant's baseline and a value of more than 90% should prompt further evaluation and concern for significant neurological injury.

Measuring and imaging of transcutaneous bilirubin, hemoglobin, and melanin based on diffuse reflectance spectroscopy

Significance

Evaluation of biological chromophore levels is useful for detection of various skin diseases, including cancer, monitoring of health status and tissue metabolism, and assessment of clinical and physiological vascular functions. Clinically, it is useful to assess multiple different chromophores in vivo with a single technique or instrument.

Aim

To investigate the possibility of estimating the concentration of four chromophores, bilirubin, oxygenated hemoglobin, deoxygenated hemoglobin, and melanin from diffuse reflectance spectra in the visible region.

Approach

A new diffuse reflectance spectroscopic method based on the multiple regression analysis aided by Monte Carlo simulations for light transport was developed to quantify bilirubin, oxygenated hemoglobin, deoxygenated hemoglobin, and melanin. Three different experimental animal models were used to induce hyperbilirubinemia, hypoxemia, and melanogenesis in rats.

Results

The estimated bilirubin concentration increased after ligation of the bile duct and reached around 18    mg / dl at 50 h after the onset of ligation, which corresponds to the reference value of bilirubin measured by a commercially available transcutaneous bilirubin meter. The concentration of oxygenated hemoglobin and that of deoxygenated hemoglobin decreased and increased, respectively, as the fraction of inspired oxygen decreased. Consequently, the tissue oxygen saturation dramatically decreased. The time course of melanin concentration after depilation of skin on the back of rats was indicative of the supply of melanosomes produced by melanocytes of hair follicles to the growing hair shaft.

Conclusions

The results of our study showed that the proposed method is capable of the in vivo evaluation of percutaneous bilirubin level, skin hemodynamics, and melanogenesis in rats, and that it has potential as a tool for the diagnosis and management of hyperbilirubinemia, hypoxemia, and pigmented skin lesions.

Advanced Neuromonitoring Modalities on the Horizon: Detection and Management of Acute Brain Injury in Children

Timely detection and monitoring of acute brain injury in children is essential to mitigate causes of injury and prevent secondary insults. Increasing survival in critically ill children has emphasized the importance of neuroprotective management strategies for long-term quality of life. In emergent and critical care settings, traditional neuroimaging modalities, such as computed tomography and magnetic resonance imaging (MRI), remain frontline diagnostic techniques to detect acute brain injury. Although detection of structural and anatomical abnormalities remains crucial, advanced MRI sequences assessing functional alterations in cerebral physiology provide unique diagnostic utility. Head ultrasound has emerged as a portable neuroimaging modality for point-of-care diagnosis via assessments of anatomical and perfusion abnormalities. Application of electroencephalography and near-infrared spectroscopy provides the opportunity for real-time detection and goal-directed management of neurological abnormalities at the bedside. In this review, we describe recent technological advancements in these neurodiagnostic modalities and elaborate on their current and potential utility in the detection and management of acute brain injury.

Hierarchical improvement of regional tissue oxygenation after packed red blood cell transfusion

Background

It is well established that counter-regulation to hypoxia follows a hierarchical pattern, with brain-sparing in preference to peripheral tissues. In contrast, it is unknown if the same hierarchical sequence applies to recovery from hypoxia after correction of anemia with packed red blood cell transfusion (PRBCT).

Objective

To understand the chronology of cerebral and splanchnic tissue oxygenation resulting after correction of anemia by PRBCT in preterm infants using near-infrared spectroscopy (NIRS).

Design

Prospective cohort study.

Setting

Neonatal intensive care.

Patients included

Haemodynamically stable infants: <32 weeks gestation, <37weeks postmenstrual age, <1500 grams birth weight; and ≥120 mL/kg/day feeds tolerated.

Intervention

PRBCT at 15 mL/Kg over 4 hours.

Main outcome measures

Transfusion-associated changes were determined by comparing the 4-hour mean pre-transfusion cerebral and splanchnic fractional tissue oxygen extraction (FTOEc0; FTOEs0) with hourly means during (FTOEc1-4; FTOEs1-4) and for 24 hours after PRBCT completion (FTOEc5-28; FTOEs5-28).

Results

Of 30 enrolled infants, 14[46.7%] male; median[IQR] birth weight, 923[655–1064]g; gestation, 26.4[25.5–28.1]weeks; enrolment weight, 1549[1113–1882]g; and postmenstrual age, 33.6[32.4–35]weeks, 1 infant was excluded because of corrupted NIRS data. FTOEc significantly decreased during and for 24 hours after PRBCT (p < 0.001), indicating prompt improvement in cerebral oxygenation. In contrast, FTOEs showed no significant changes during and after PRBCT (p>0.05), indicating failure of improvement in splanchnic oxygenation.

Conclusion

Improvement in regional oxygenation after PRBCT follows the same hierarchical pattern with a prompt improvement of cerebral but not splanchnic tissue oxygenation. We hypothesise that this hierarchical recovery may indicate continued splanchnic hypoxia in the immediate post-transfusion period and vulnerability to transfusion-associated necrotizing enterocolitis (TANEC). Our study provides a possible mechanistic underpinning for TANEC and warrants future randomised controlled studies to stratify its prevention.

Recent Review of Germinal Matrix Hemorrhage-Intraventricular Hemorrhage in Preterm Infants

Germinal matrix hemorrhage-intraventricular hemorrhage (GMH-IVH) is a particular type of intracranial hemorrhage that affects the preterm population. GMH-IVH originates from bleeding within the highly vascular area near the center of the brain known as the germinal matrix. The pathogenesis of GMH-IVH is unclear; it is likely related to hemodynamic changes and fluctuations in cerebral blood flow within a fragile developing brain. Cranial ultrasound is the primary diagnostic test and reveals the degree of GMH-IVH based on a grading system. Management includes prevention of preterm delivery with meticulous antenatal and postnatal preventative strategies. This article discusses current evidence specific to the pathogenesis, risk factors, diagnosis, grading scales, and management approaches with GMH-IVH in preterm infants.

Cerebral near-infrared spectroscopy monitoring (NIRS) in children and adults: a systematic review with meta-analysis

BACKGROUND

Cerebral oxygenation monitoring utilising near-infrared spectroscopy (NIRS) is increasingly used to guide interventions in clinical care. The objective of this systematic review with meta-analysis and Trial Sequential Analysis is to evaluate the effects of clinical care with access to cerebral NIRS monitoring in children and adults versus care without.

METHODS

This review conforms to PRISMA guidelines and was registered in PROSPERO (CRD42020202986). Methods are outlined in our protocol (doi: 10.1186/s13643-021-01660-2).

RESULTS

Twenty-five randomised clinical trials were included (2606 participants). All trials were at a high risk of bias. Two trials assessed the effects of NIRS during neonatal intensive care, 13 during cardiac surgery, 9 during non-cardiac surgery and 1 during neurocritical care. Meta-analyses showed no significant difference for all-cause mortality (RR 0.75, 95% CI 0.51-1.10; 1489 participants; I2 = 0; 11 trials; very low certainty of evidence); moderate or severe, persistent cognitive or neurological deficit (RR 0.74, 95% CI 0.42-1.32; 1135 participants; I2 = 39.6; 9 trials; very low certainty of evidence); and serious adverse events (RR 0.82; 95% CI 0.67-1.01; 2132 participants; I2 = 68.4; 17 trials; very low certainty of evidence).

CONCLUSION

The evidence on the effects of clinical care with access to cerebral NIRS monitoring is very uncertain.

IMPACT

The evidence of the effects of cerebral NIRS versus no NIRS monitoring are very uncertain for mortality, neuroprotection, and serious adverse events. Additional trials to obtain sufficient information size, focusing on lowering bias risk, are required. The first attempt to systematically review randomised clinical trials with meta-analysis to evaluate the effects of cerebral NIRS monitoring by pooling data across various clinical settings. Despite pooling data across clinical settings, study interpretation was not substantially impacted by heterogeneity. We have insufficient evidence to support or reject the clinical use of cerebral NIRS monitoring.

Role of Near-infrared Spectroscopy in the Diagnosis and Assessment of Necrotizing Enterocolitis

Near-infrared spectroscopy (NIRS) is a noninvasive, bedside diagnostic tool that could assist in the early diagnosis of necrotizing enterocolitis (NEC) in preterm neonates. NIRS is a safe and effective clinical tool in the neonatal intensive care unit to detect abnormal alterations in tissue perfusion and oxygenation. In addition, NIRS could also detect the complications of NEC, such as bowel necrosis and perforation. NEC is the most common gastrointestinal complication associated with preterm birth and critically ill infants. It is observed in 6-10% of preterm neonates, weighing below 1500 g, leading to considerable morbidity, mortality, and healthcare cost burden. The mortality rate ranges from 20 to 30%, highest in NEC infants undergoing surgery. NIRS is a promising diagnostic modality that could facilitate the early diagnosis of NEC and early detection of complications alone or with the imaging modalities.