Fetal Third-Trimester Functional Cardiovascular Abnormalities and Neonatal Elevated Bilirubin Level

BACKGROUND

The aim of the study was to analyze the neonatal outcomes of fetuses with diagnosed functional cardiovascular abnormalities, also considering the connection with neonatal hyperbilirubinemia.

MATERIALS AND METHODS

It was an observational study of 100 neonates who had fetal echocardiography examinations in the third trimester (mean gestational age during the last echocardiography was 34 ± 3 weeks and mean birth weight was 3550 g). There were two groups: A: normal heart anatomy + no functional anomalies; group B: normal heart anatomy + functional abnormalities. Hyperbilirubinemia was defined as a bilirubin level of >10 mg%.

RESULTS

In group A, there were 72 cases and only 5 cases despite having normal heart anatomy and normal heart study that presented additional problems. In group B (28 cases), the prenatal functional findings included tricuspid regurgitation (TR) (15 cases, 53%), pericardial effusion (4 cases, 14%), myocardial hypertrophy (4 cases, 14%), cardiomegaly (2 cases, 7%), abnormal bidirectional blood flow across the foramen ovale (3 cases, 11%), aneurysm of atrial septum (2 case, 7%), abnormal E/A ratio for mitral and tricuspid valve (1 case, 3%), bright spot (3 case, 11%), abnormal Doppler flow in ductus arteriosus compared to aortic arch (difference >60 cm/s) (1 case, 3%), supraventricular tachycardia (SVT) (1 case), and mitral regurgitation (1 case, 3%). In group A (n = 72 cases), bilirubin levels of >10 mg/dL were observed in 8% of newborns. In group B (n = 28), bilirubin levels of > 10 m/dL were observed in 46% of cases and TR was present in group B in 53% of cases (15/28 cases). The difference between group A and B in terms of elevated bilirubin levels was statistically significant (p < 0.001).

CONCLUSIONS

In the case of fetal normal heart anatomy and normal heart study, a good neonatal outcome may be expected. When fetal cardiovascular functional abnormalities in normal heart anatomy are detected, with special attention paid to tricuspid valve regurgitation, a neonatal elevated bilirubin level (mean 11 mg/dL, range 10-15 mg/dL) may be expected.

The COVID-19 pandemic impact on the Polish medical personnel work: a survey and in-depth interviews study

Objective

The objective of the study was to examine the impact of the COVID-19 pandemic on the work of medical personnel in terms of: task scope, preparation to perform medical tasks related to the pandemic, team collaboration, involvement in tasks performed, concerns about performing tasks related to the pandemic, stress levels.

Methods

The mixed-method approach was applied to this cross-sectional study. The online questionnaire which included 40 questions was completed via Google among medical personnel in Poland. Eight semi-structured, in-depth interviews were conducted to deepen the data obtained with the questionnaires.

Participants

The questionnaire was completed by 215 healthcare professionals, with the largest group being nurses (56.3%) followed by physicians (22.3%), midwives (11.6%) and other healthcare professionals (e.g., physiotherapists, paramedics, nutritionists - 9.8%). Among the respondents were people who worked in the hospital in the so-called "covid wards" (31.2%) and other hospital wards (60%) as well as people who were employed outside the hospital (8.8%).

Results

The pandemic affected the nature and range of tasks performed by health professionals. Initially, respondents felt unprepared to work under pandemic conditions, but over time their ratings increased in all areas studied. More than half of respondents reported no change in interpersonal relationship within the team, but nearly 35% noted a worsening and only one in 10 claimed improvement. Study participants rated their own commitment to tasks slightly higher than that of their colleagues (mean 4.9 and 4.4 respectively) but the overall rating was high. The mean self-rating of work stress increased from 3.7 before the pandemic to 5.1 during the pandemic. Most of the respondents were afraid of transmission of the infection to their relatives. Other fears included the possibility of making a medical error, not being able to help the patient, not having enough personal protective equipment (PPE) and contracting SARS-CoV-2.

Conclusion

The conducted study revealed that the organization of medical care in the initial period of the pandemic, especially the hospital care of patients infected with SARS-CoV-2, was quite chaotic. The most affected were the people who were transferred to work in the covid wards. Not all medical professionals were prepared to work with the COVID-19 patients, as they lacked experience working in such facilities, especially in intensive care units (ICU). Working under time pressure and under new conditions led mainly to an increase in perceived stress and conflicts between staff.

Advantages of side-lying position. A comparative study of positioning during bottle-feeding in preterm infants (≤34 weeks GA)

BACKGROUND

The quality and safety of bottle-feeding in premature infants can be improved by optimal positioning. This study analysed the advantages of side-lying position (SLP) and semielevated position (SEP) during bottle-feeding in premature infants.

MATERIAL AND METHODS

A total of 42 neonates (n=42) born ≤34 weeks of gestational age were included in the study. Four feeding sessions-two in SLP and two in SEP- were analysed for each newborn. The level of saturation (SpO₂) and heart rate, which are the parameters assessing the physiological stability, were measured in the studied newborns. The other factors that were examined to determine the quality of feeding included the total time of decline of SpO₂ to ≤85%, level of the newborn's alertness measured using the Neonatal Behavioral Assessment Scale, and the frequency of choking episodes. The proportion of milk consumed (volume of milk consumed relative to the volume expected) and the feeding duration as well as the total time of feeding session were recorded.

RESULTS

SLP was safer in terms of the frequency of choking episodes. Choking episodes were more frequently observed with feeding in SEP (p<0.001). Moreover, the proportion of milk consumed by infants was statistically significantly higher in SLP (p<0.046) compared to SEP. No significant differences in the other tested parameters were noted in infants fed in SLP and infants fed in SEP.

CONCLUSIONS

This study demonstrated that SLP is effective in reducing the number of choking episodes during feeding. The proportion of milk consumed was better when the neonates were fed in SLP.

Small prenatal diameter of the ascending aorta is associated with increased mortality risk in neonates with congenital diaphragmatic hernia

INTRODUCTION

The aim of this study was to evaluate whether selected prenatal markers obtained from fetal echocardiography can predict postnatal outcome in congenital diaphragmatic hernia (CDH) patients. We also aimed to verify the prognostic value of lung-to-head ratio (LHR).

MATERIAL AND METHODS

The study group included 29 fetuses with CDH. We analyzed potentially prognostic parameters measured using fetal echocardiography and fetal ultrasound. The assessed parameters were compared between the group of patients with CDH who survived to discharge (n = 21) and the subset of patients who died before discharge from hospital (n = 8).

RESULTS

In survivors, mean z-score for ascending aorta (AAo) diameter was 0.23 ±0.98 vs. - 1.82 ±1.04 in patients who died (t-test, p = 0.0015). In survivors, the main pulmonary artery/ascending aorta ratio was 1.22 ±0.17 vs. 1.46 ±0.21 in patients who died (t-test, p = 0.017). In survivors, the LHR was 1.81 ±0.96 vs. 0.95 ±0.6 in patients who died (t-test, p = 0.019). In survivors, the observed to expected LHR was 57 ±30% vs 30 ±18% in patients who died (t-test, p = 0.018).

CONCLUSIONS

Narrowing of the ascending aorta in CDH fetuses is a poor prognostic factor associated with increased mortality in neonates. Our study also confirmed the prognostic value of LHR.

The prevalence of hypothyroxinemia in premature newborns

Congenital hypothyroidism diagnosed by TSH assessment in bloodspot screening may be overlooked in preterm newborns due to immaturity of the hypothalamus-pituitary-thyroid axis in them. The purpose of the study was to determine the prevalence and causes of hypothyroxinemia in preterm newborns, determined by TSH and FT4 serum concentration measurement, performed on the 3-5^th day of life. We assessed TSH, FT4 and FT3 serum concentration on the 3-5^th day of life in preterm children born at our centre within three consecutive years. We assessed the incidence of hypothyroxinemia, and its cause: primary hypothyroidism, secondary hypothyroidism or low FT4 syndrome - with normal TSH concentration, its dependence - among others - on gestational age (GA), birth body weight (BBW) and being SGA. A total of 525 preterm children were examined. FT4 concentration was decreased in 14.9% of preterm newborns. The most frequent cause of hypothyroxinemia was low FT4 syndrome (79.5%). More than 92% cases of hypothyroxinemia occurred in children born before the 32^nd week and/or with BBW below 1500 g. Thus, every fourth child in these groups had a reduced FT4 concentration. Neonates with hypothyroxinemia were significantly lighter than those with normal FT4. In older and heavier neonates with hypothyroxinemia, serious congenital defects were observed. Neither IVH nor SGA nor twin pregnancies predispose children to hypothyroxinemia. Among newborns with untreated hypothyroxinemia in whom TSH and FT4 assessment was repeated within 2-5 weeks, a decreased FT4 concentration was confirmed in 56.1% of cases. As hypothyroxinemia affects 25% of newborns born before the 32^nd week of gestation and those in whom BBW is less than 1500g, it seems that in this group of children the newborn screening should be extended to measure serum TSH and FT4 concentration between the 3-5^th day of life. In older and heavier neonates, additional serum TSH and FT4 assessment should be limited to children with severe congenital abnormalities but not to all SGA or twins. Despite the fact that the most common form of preterm hypothyroxinemia is low FT4 syndrome, it should be emphasized that FT4 remains lowered on subsequent testing in more them 50% of cases.

The influence of the technique of surfactant administration (LISA vs INSURE) on the outcomes of respiratory distress syndrome treatment in preterm infants

OBJECTIVE

Intratracheal administration of exogenous surfactant is a well-established therapy for respiratory distress syndrome in preterm infants. The two preferred methods for respiratory support in neonates that contribute to limiting the risk of lung damage associated with mechanical ventilation include nCPAP and non-invasive ventilation. The increasing popularity of surfactant administration techniques is due to the fact they reduce the time of mechanical ventilation until this medication is administered. In some cases a short period of mechanical ventilation follows (INSURE: INtubation-SURfactant-Extubation). There are also methods that make it possible to completely avoid intubation and help maintain spontaneous breathing during surfactant administration (LISA: Less Invasive Surfactant Administration, MIST: Minimal Invasive Surfactant Therapy). Aim: To analyze treatment outcomes in preterm infants who suffer from respiratory distress syndrome and require exogenous surfactant administration depending on the technique used: LISA vs INSURE.

PATIENTS AND METHODS

Material and methods: The present retrospective analysis included 129 infants born at a gestational age of between 24 and 33 weeks who were hospitalized in the Neonatology Department in the years 2014-2016, were administered surfactant and remained on non-invasive ventilation. All the subjects received only proractant alfa. Both study groups: LISA (n=83) and INSURE (n=46) were analyzed in terms of respiratory distress treatment outcomes and the presence of complications of prematurity.

RESULTS

Results: There were no significant differences in patient characteristics between the two study groups (LISA vs INSURE: mean birth body weight was 1210 g vs 1275 g, respectively; mean gestational age at birth was 30 weeks vs 29 6/7 weeks, respectively). The comparison of respiratory support method and FiO2 concentration within the first 72 hours after surfactant administration showed no significant differences between the groups. Similarly, respiratory outcomes did not significantly differ between the LISA and INSURE groups and were: the need for intubation ⎼ 42.2% vs 32.6%, p=0.201, duration of mechanical ventilation - median days 0 vs 0, p=0.377, duration of nCPAP - median days 5 vs 5, p=0.379, duration of oxygen supplementation - median days 1 vs 1, p=0.555, and the incidence of bronchopulmonary dysplasia - 28.9% vs 23.9%, p=0.506. Also, the incidence of complications was similar in both study groups.

CONCLUSION

Conclusions: Our retrospective analysis of preliminary outcomes of surfactant administration involving the use of the LISA technique showed no statistically significant differences as compared with the INSURE method. The randomized, prospective study that is currently being conducted at our Neonatology Department and includes biochemical markers of lung damage, will bring more objective data on the safety and effectiveness of both surfactant administration techniques (LISA vs INSURE).

The impact of positioning on bottle-feeding in preterm infants (≤ 34 GA). A comparative study of the semi-elevated and the side-lying position - a pilot study

OBJECTIVE

Objective: The aim of the study was to compare the advantages of semi-elevated and side-lying positioning during bottle-feeding of preterm infants ≤ 34 weeks gestational age (34+0/7).

PATIENTS AND METHODS

Material and methods: The study included six neonates (n=6) born ≤ 34 weeks gestational age who reached the age ≥ 32 weeks of postmenstrual age on the day when the study began and were hospitalized in the neonatology ward. Four bottle-feeding sessions were tested in each of the newborns: two in the side-lying and two in the semi-elevated position. The position for the first test was chosen randomly. For each of the positions twelve feeding sessions were examined and each preterm infant had bottle-feeding sessions analyzed both in the semi-elevated and side-lying positions. The level of saturation and heart rate were measured as the parameters indicative of the newborn's physiological stability. The factors determining the qualitative aspect of feeding included the level of the newborn's alertness and the occurrence of choking episodes. The amount of food consumed and the duration of the feeding were also recorded.

RESULTS

Results: The side-lying position was more effective with regard to the total amount of sustenance consumed as compared to the semi-elevated feeding position and the study result was statistically significant (p=0.007). The difference in the number of chokes between the study groups was not statistically significant, although a trend towards a reduced number of choking episodes was observed among infants fed in the side-lying position (p=0.090). There were no significant differences in oxygen saturation, heart rate and level of activity between the study groups.

CONCLUSION

Conclusions: The effects of this pilot study demonstrate the efficacy of the side-lying feeding position regarding the final amount of milk intake. The side-lying position may also reduce the number of choking episodes during the feeding. The results suggest the need to extend the study in order to confirm the potential benefits of using the side-lying position.

Fraction of Inspired Oxygen as a Predictor of CPAP Failure in Preterm Infants with Respiratory Distress Syndrome: A Prospective Multicenter Study

INTRODUCTION

There are limited data available regarding the fraction of inspired oxygen (FiO2) predictive of the failure of continuous positive airway pressure (CPAP) in preterm infants with respiratory distress syndrome (RDS). Therefore, we investigated factors predictive of CPAP failure in the first 72 h of life, with special attention to the prognostic role of FiO2.

METHODS

This multicenter, prospective study enrolled infants <30 weeks gestation in whom CPAP was initiated within the first 15 min after birth. In the univariate and multivariate logistic regression models, demographic, perinatal, and respiratory parameters were analyzed. The FiO2 threshold was determined with ROC curve analysis.

RESULTS

Of 389 recruited newborns, CPAP failure occurred in 108 infants (27.8%). In the univariate model, each gestational week reduced the odds of CPAP failure by 19%, and each 100 g of birth weight reduced the odds by 16% (both p < 0.05). The risk was increased by 4.2 and 7.5% for each 0.01 increase in FiO2in the first and second hours of life, respectively. In the final multivariate model, birth weight and FiO2 in the second hour of life were the predictive measures. The prognostic threshold was FiO2 = 0.29 in the second hour of life (AUC 0.7; p < 0.0001), with a sensitivity of 73% and a specificity of 57%. CPAP failure implied a more than 20-fold higher risk of death and pneumothorax and a 2- to 5-fold higher risk of typical complications of prematurity, including bronchopulmonary dysplasia and severe intraventricular hemorrhage.

CONCLUSION

FiO2 in the second hour of life is a significantpredictor of CPAP failure. The threshold of 0.29 best discriminates the CPAP outcome. Nonresponders to CPAP have a remarkably higher incidence of complications and a higher mortality rate.

[Biomarkers of intrauterine growth restriction]

Intrauterine growth restriction (IUGR) is a serious clinical problem affecting about 10% of all pregnancies, and even up to 15% of all monochorionic twin pregnancies. This disorder is accompanied by strongly increased perinatal mortality. IUGR has multiple causes including maternal, fetal, placental, and environmental factors. Importantly, IUGR is associated with a number of negative effects exerted just after the birth, as well as during the later years of life. Despite multiple clinical trials conducted for many years, there is no reliable algorithm to diagnose the disease at an early stage, and lack of efficient therapy increases the risk of abnormal fetus development. In this short review, we present recent progress on potential IUGR biomarkers that could be determined during pregnancy and in the umbilical blood after delivery to provide more accurate diagnosis, prophylaxis and efficient treatment.

Recommendations “Cardio-Prenatal 2017” From Poland

On 27.10.2017, in the course of the CARDIO-PRENATAL Conference at the Polish Mother’s Memorial Institute and Health Centre in Lodz, we presented, among others, the following problems:

classification of prenatal heart defects, fetal hemodynamic status evaluation in the third trimester, expected neonate’s clinical condition, planned procedures to be conducted just after birth and also planned medical staff to be present in the delivery room. Here are our main recommendations following the meeting and discussion.

Five-country manikin study found that neonatologists preferred using the LISAcath rather than the Angiocath for less invasive surfactant administration

Aim

Less invasive surfactant administration (LISA) has been shown to decrease the risk of death and bronchopulmonary dysplasia in preterm neonates. The LISAcath is the first catheter to be specifically developed for LISA, and we compared the clinical impressions of neonatologists using the LISAcath and the commonly used Angiocath in a simulated setting.

Methods

This was a multinational, multicentre study, conducted in October 2016, which involved 39 neonatologists who were recruited by employees of the sponsor from large, well‐recognised neonatal intensive care units across Europe. LISA was not the standard of care in these units in Austria, Belgium, Poland, Spain and the United Kingdom at the time of the study. After training, participants simulated LISA on a neonatal manikin, once with the LISAcath and once with Angiocath, then answered a 10‐item questionnaire.

Results

The responses to nine of 10 questions showed that 67‐95% of the respondents preferred the LISAcath to the Angiocath, with most of the remainder indicating no preference. The only exception was the luer connection question, with two‐thirds expressing no preference. The LISAcath was considered potentially safer by 33 of 39 participants, with no votes for the Angiocath.

Conclusion

Overall, neonatologists preferred using the LISAcath rather than the Angiocath on a neonatal manikin.

New method to predict need for Rashkind procedure in fetuses with dextro-transposition of the great arteries

OBJECTIVE

Prenatal congenital heart disease classification systems distinguish between critical dextro-transposition of the great arteries (d-TGA) with restriction of the foramen ovale (FO) (which requires a Rashkind procedure within the first 24 h following delivery) and d-TGA for which surgery is planned (after prostaglandin perfusion or Rashkind procedure later than 24 h after delivery). However, current prenatal diagnostic criteria for postnatal FO restriction in d-TGA are inadequate, resulting in a high false-negative rate. We aimed to identify echocardiographic features to predict the urgent need for Rashkind procedure.

METHODS

We identified retrospectively 98 patients with singleton pregnancy diagnosed prenatally with fetal d-TGA at two European centers from 2006 to 2013. Two groups were compared: (1) those in whom the Rashkind procedure was performed within the first 24 h postnatally; and (2) those who did not undergo a Rashkind procedure before cardiac surgery. Exclusion criteria were: (1) no fetal echocardiography within 3 weeks prior to delivery (n = 18); (2) delivery before 37 weeks of gestation (n = 6); (3) improper or lack of measurement of pulmonary vein maximum flow velocity (n = 10); (4) lack of neonatal follow-up data (n = 9); (5) Rashkind procedure performed more than 24 h after delivery (n = 4).

RESULTS

Fifty-one patients met the inclusion criteria: 29 who underwent the Rashkind procedure and 22 who did not. There were no differences between these two study groups in terms of maternal age, gestational age at time of fetal echocardiography, fetal biometric measurements, estimated fetal weight, rate of Cesarean delivery, newborn weight or Apgar score at 1 min. There were also no differences during prenatal life between the two groups in terms of fetal cardiac size (heart area/chest area ratio), rate of disproportion between left and right ventricle, FO diameter and maximum velocity of flow through the FO. However, the pulmonary vein maximum velocity was significantly higher in the group requiring a Rashkind procedure (47.62 ± 7.48 vs 32.21 ± 5.47 cm/s; P < 0.001). The cut-off value of 41 cm/s provided maximum specificity (100%) and positive predictive value (100%) at only a slight cost of sensitivity (82%) and NPV (86%). The prenatal appearance of the FO also differed between the groups, the FO valve being flat in 52% of those requiring a Rashkind procedure.

CONCLUSIONS

In fetuses with d-TGA, prenatal sonographic findings of increased pulmonary venous blood flow and flattened FO valve were associated with the need for a Rashkind procedure within the first 24 h postnatally; these echocardiographic features could be used to predict prenatally a need for the procedure following delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Fetal Macrosomia, Polyhydramnios and Cardiac Anomalies may be Helpful to Predict Poor Outcome in Neonate – Case Report of a Possible Fetal Rasopathy with Sonographic and Neonatal Findings and Genetic Evaluation

This is a case report about very rare findings in 2nd half of pregnancy (after normal 1 trimester scan ) at 18th week of gestation fetal macrosomia was detected unrelated to maternal diabetes, and acceleration fetal growth later on with unusual cardiac abnormalities (fetal cardiomegaly, cardiomyopathy, partial abnormal venous connection ). Progressive features of congestive heart failure with polyhydramnios in a fetus with estimated 5500 g predicted a poor outcome and severe neonatal condition, which was presented and discussed with the parents to be. Casearean section was performed at 33rd weeks of gestation due to maternal dyscomfort, severe legs edema and her tachypnoe. Baby boy was delivered with birth weight of 5050g, Apgar 4 with mutiple tumors. Conservative care was introduced and neonated died on the 3rd day. Differential diagnosis was discussed with special attention to Costello syndrome however without proved by genetic make-up from neonatal blood.

Intraventricular hemorrhage in premature infants with Respiratory Distress Syndrome treated with surfactant: incidence and risk factors in the prospective cohort study

Background

Intraventricular hemorrhage (IVH) is a common pathology in preterm infants with extremely and very low birth weight. It is particularly often seen in newborns with Respiratory Distress Syndrome (RDS).

Aim

To assess the incidence of IVH in preterm newborns with RDS treated with surfactant, and to identify factors that might reduce the risk of IVH in this population.

Material and methods

This multicenter, prospective cohort study is part of the “Neo-pro” study project. The investigations were carried out in 936 newborns, including 652 survivors. We enrolled a consecutive sample of infants born before 32 weeks’ gestation. IVH was diagnosed with trans-fontanel ultrasonography, performed according to the approved standards and classified according to Papile’s grading system.

Results

Intraventricular hemorrhage was diagnosed in 462/936 infants (49.4%), and in 43.3% of the survivors. Grade 3 and 4 IVH occurred in 14.8% and 13.8% of the infants, respectively, and in 10.6% and 5.7% of the survivors. Lack of antenatal application in mothers of corticosteroids increased the incidence rate of severe IVH from 14.2% to 22.1% (p=0.0087). The risk of IVH was reduced with early (from the first day of life) initiation of caffeine citrate (OR: 0.63, 95% CI: 0.45-0.88), delivery by cesarean section (OR: 0.50, 95% CI: 0.36-0.69), and the risk of severe IVH - from treatment with antenatal corticosteroids (OR: 0.58, 95% CI: 0.39-0.87). The most significant factor which increased the risk of hemorrhage was invasive mechanical ventilation (OR: 2.90, 95% CI: 2.07-4.07). The risk was further increased if the duration of mechanical ventilation was greater than seven days (OR: 3.02, 95% CI: 2.21-4.12).

Conclusions

The incidence of IVH in newborns with RDS is significant and the risk of IVH is increased by mechanical ventilation. Antenatal exposure to corticosteroids and delivery by cesarean section have a protective effect, and the former also reduces the risk of the most severe manifestations of IVH. Caffeine citrate initiated from the first day of life is another protective strategy.

Antibiotic consumption in laboratory confirmed vs. non-confirmed bloodstream infections among very low birth weight neonates in Poland

BACKGROUND

Newborns are a population in which antibiotic consumption is extremely high. Targeted antibiotic therapy should help to reduce antibiotics consumption. The aim of this study was an assessment of antibiotic usage in bloodstream infections treatment in the Polish Neonatology Surveillance Network (PNSN) and determining the possibility of applying this kind of data in infection control, especially for the evaluation of standard methods of microbiological diagnostics.

METHODS

Data were collected between 01.01.2009 and 31.12.2013 in five teaching NICUs from the PNSN. The duration of treatment in days (DOT) and the defined daily doses (DDD) were used for the assessment of antibiotics consumption.

RESULTS

The median DOT for a single case of BSI amounted to 8.0 days; whereas the median consumption expressed in DDD was 0.130. In the case of laboratory confirmed BSI, median DOT was 8 days, and consumption-0.120 DDD. Median length of therapy was shorter for unconfirmed cases: 7 days, while the consumption of antibiotics was higher-0.140 DDD (p < 0.0001). High consumption of glycopeptides expressed in DOTs was observed in studied population, taking into account etiology of infection.

CONCLUSIONS

Even application of classical methods of microbiological diagnostics significantly reduces the consumption of antibiotics expressed by DDD. However, the high consumption of glycopeptides indicates the necessity of applying rapid diagnostic assays. Nevertheless, the assessment of antibiotic consumption in neonatal units represents a methodological challenge and requires the use of different measurement tools.

Bronchopulmonary dysplasia in very and extremely low birth weight infants - analysis of selected risk factors

AIM

The aim of the study was to analyze the role of specific risk factors affecting the development and clinical course of BPD in infants born before 32 weeks of gestation with a birth weight ≤ 1500g.

MATERIALS AND METHODS

The study included 222 infants born and hospitalized at the Department of Neonatology, Polish Mother's Memorial Hospital-Research Institute. At their 28-th day of life, the patients were divided into two groups: with and without BPD. The grade of BPD severity was determined at 36 weeks of postmenstrual age.

RESULTS

BPD was diagnosed in 117 (52.7%) of infants, 65 (55,6%) of them developed its mild, 29 (24,8%) moderate and 23 (19,7%) severe form. Infants with BPD had significantly lower gestational age than those without BPD: 27.0 weeks (IQR 26.0-28.3 weeks) vs. 30.0 weeks (IQR 29.3-31.0 weeks), and lower birth weight: 900g (IQR 740.0-1050.0g) vs. 1290g (IQR 1100.0-1370.0g). A significantly lower gestational age R=-0.70, p < 0.0001 and birth weight R=-0.66, p<0.0001 were observed in correspondence with the increase of BPD severity. In BPD group there were 72 (61.5%) male infants, whereas in that without BPD 54 (51.4%) of them, p=0.1290. In the group with mild form of BPD, there were 29 (44.6%) males, with moderate 23 (79.3%) and severe 20 (87.0%), p=0.0002. A statistically significant difference was found for: respiratory distress syndrome 116 (99.2%) vs. 83 (79.1%), p<0.0001, congenital infection 70 (59.8%) vs. 40 (38.1%), p=0.0012, patent ductus arteriosus 61 (52.1) vs. 28 (26.7), p=0.0001, complete prenatal steroid therapy 77 (65.8%) vs. 85 (81.0%), p=0.0112 and Apgar score of 1 min., p<0.0001 and 5 min., p<0.0001. In the group with BPD significantly more frequent were: intraventricular hemorrhage 87 (74.4%) vs. 37 (35.2%), p<0.0001, periventricular leukomalacia 11 (9.4%) vs. 0 (0.0%) p=0.0009 and retinopathy of prematurity 47 (40.2%) vs. 6 (5.7%), p<0.0001. No statistical significance was found for: premature rupture of membranes, the route of delivery, Ureaplasma spp. infection and necrotizing enterocolitis. Independent factors affecting the risk of BPD are: gestational age (OR 0.3213, p<0.0001), birth weight (OR 0.9968, p=0.0036), and respiratory distress syndrome (OR 3.9388; p=0.0142).

CONCLUSIONS

Lower gestational age, low birth weight, respiratory distress syndrome, Apgar score, congenital infection, lack of prenatal steroid therapy, patent ductus arteriosus and male gender are the risk factors for the development of BPD.

Antenatal corticosteroids and respiratory distress syndrome - the first Polish national survey

OBJECTIVES

Our retrospective study aimed to evaluate the rate and the appropriate use of antenatal corticosteroid therapy, and their effect on the incidence and treatment of respiratory distress syndrome (RDS) and its complications.

MATERIAL AND METHODS

A retrospective analysis of clinical practice in Poland was performed using standard investigating tools: a questionnaire on the frequency of using antennal corticosteroids in the selected centers, as well as neonatal data. A total of 987 newborns at ≤ 32 weeks of gestation, treated in 54 centers (including 42 tertiary and 12 secondary referral centers) over a period of 6 months in 2013, were deemed eligible. The study group consisted of 749 newborns whose mothers received antenatal steroids. The non-steroid group included 238 newborns.

RESULTS

Antenatal corticosteroids were administered to 75.89% of the neonates from the study group, with 79% and 21% receiving one and two courses, respectively. Children whose mothers received prenatal steroids presented with less extensive radiographic changes typical of RDS, and less often required surfactant therapy (70% vs. 78%; p = 0.0143). In the group of children undergoing antenatal steroid therapy, the percentage of BPD was lower (13.27% vs. 18.63%) (p = 0.0881). The mortality rates were 20.91% and 10.81% in controls and the study group, respectively (p = 0.0001).

CONCLUSIONS

The percentage of antenatal steroid use in secondary and tertiary referral centers in Poland is unsatisfactorily low (76%). Antenatal corticosteroids demonstrated high efficacy in decreasing severe forms of RDS, less need for surfactant therapy, and reduced BPD and mortality rates.

SUBGALEAL HEMATOMA AS A PERINATAL PRESENTATION OF RARE HEMATOLOGIC PROBLEMS IN NEWBORNS. OWN EXPERIENCE

INTRODUCTION

Bleeding to the subgaleal space is a rare and often serious complication of childbirth. Delivery with the use of vacuum or forceps is considered as the main risk factor of subgaleal hemorrhage. Reports of other possible causes (including fetal ones) appear rarely.

OBJECTIVES

The aim of this study is to present and analyze two unusual cases of bleeding to subgaleal space in neonates delivered through caesarean section, in whom two different concomitant hematologic problems were diagnosed. The authors demonstrate also the mechanisms leading to the formation of subgaleal hematoma as well as discuss the impact of the final diagnosis on the course of the perinatal period and the need to modify medical practice in a variety of clinical situations in both newborns and their mothers.

MATERIAL AND METHODS

Authors present two consecutive cases of severe subgaleal hemorrhage.

RESULTS

In the first newborn hemophilia was finally diagnosed. The second neonate was diagnosed with neonatal alloimmune thrombocytopenia.

CONCLUSIONS

Subgaleal hemorrhage is a rare complication of delivery. In severe cases, other possible risks should be considered apart from the traumatic delivery only. An early identification of potential hematological risk factors can influence the effectiveness of the treatment and help to modify the follow-up of both the infant and its mother.

PRACTICAL ASPECTS OF THERAPEUTIC HYPOTHERMIA IN NEONATES WITH HYPOXIC ISCHEMIC ENCEPHALOPATHY--QUESTIONS AND ANSWERS. PART I. PROVIDING NEWBORN CARE BEFORE AND DURING TRANSFER TO THE REFERENCE CENTER

The first decade of the 21st century saw the worldwide spread of therapeutic hypothermia as a beneficial therapeutic procedure in neonates with hypoxic-ischemic encephalopathy. New guidelines for the resuscitation of newborns confirm that therapeutic hypothermia should be the standard method of treatment offered to neonates with acute perinatal hypoxia. The quality of care which an asphyxiated newborn receives during and immediately after resuscitation, as well as the mode of preparation for transport, can have a significant impact on improving the outcome, but it can also result in the deterioration of neonates treated with hypothermia. Since to a considerable degree the therapeutic effect depends on the time of beginning the cooling procedure, there is no reason to unnecessarily delay treatment. For this purpose, neonatologists or pediatricians from referring hospitals who do not have the equipment for hypothermia can and even should begin the cooling process while waiting for the arrival of the neonatal transport team. In that short period a number of concerns arise regarding the optimal methods of child care and preparation for transport to the hypothermia center. The authors discuss the possibility of initiating cooling before transportation using simple, so called low-tech cooling methods, the possible risks associated with the incidence of hyperthermia, difficulties in the interpretation of the eligibility criteria, supportive therapy, and the problems connected with the communication process between the medical team and the parents. The aspects that have been analyzed should be helpful for professionals in neonatal wards, outside hypothermia centers.

Epidemiology, antibiotic consumption and molecular characterisation of Staphylococcus aureus infections--data from the Polish Neonatology Surveillance Network, 2009-2012

Background

Our aim was to determine and characterize S. aureus (SA) isolated from infections in newborns for antibiotic resistance, virulence factors, genotypes, epidemiology and antibiotic consumption.

Methods

Prospective surveillance of infections was conducted. Data about antibiotic treatment were analyzed. Antimicrobial susceptibility was assessed. PCR amplification was used to detect resistance and virulence genes. Typing methods such as PFGE, spa-typing and SCCmec were used.

Results

SA was found to be associated with 6.5% of infections. Methicillin-Resistant Staphylococcus aureus accounted for 32.8% of SA-infections. An incidence of MRSA-infections was 1.1/1000 newborns. MRSA-infections were diagnosed significantly earlier than MSSA-infections in these newborns (14th day vs. 23rd day (p = 0.0194)). MRSA-infections increased the risk of newborn’s death. Antibiotic consumption in both group was similar, but a high level of glycopeptides-usage for MSSA infections was observed.

In the MRSA group, more strains were resistant to erythromycin, clindamycin, gentamicin and amikacin than in the MSSA group. Hla gene was present in 93.9% of strains, and seg and sei in 65.3% of strains, respectively. One dominant clone was found among the 14 MRSA isolates. Fifteen strains belonging to SCCmec type IV were spa-t015 and one strain belonging to SCCmec type V was spa-t011.

Conclusions

Results obtained in the study point at specific epidemiological situation in Polish NICU (more detailed studies are recommended).

High usage of glycopeptides in the MSSA infections treatment indicates the necessity of antimicrobial stewardship improvement and introducing molecular screening for early identification of infections.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-0890-3) contains supplementary material, which is available to authorized users.

[Fetal therapy--evaluation of ventriculo-amniotic shunts in the treatment of hydrocephalus]

OBJECTIVE

The aim of the study was to establish optimal diagnostic and therapeutic scheme and to assess the efficacy of intrauterine therapy of hydrocephalus.

MATERIAL AND METHODS

The study was carried out between 1992-2012 on the total of 222 fetuses with hydro- cephalus, using Orbis-Sigma and ACCU-Flow valves (168 cases) and Cook8 shunts, according to a strictly defined diagnostic and therapeutic scheme.

RESULTS

In the first stage of the study (between 1992-2001), a total of 168 fetuses with prenatally diagnosed hydrocephalus received intrauterine therapy In 91.6% of the cases the therapy resulted in a decreased size of cerebral ventricles. The valve dislocated in 23 cases (13.6%). Preterm delivery occurred in 44% of the affected neonates. Severe mental impairment occurred in 17.76%, average in 36.8%, and slight in 32.9% of the infants. Normal mental development at the age of 3 was observed in 12.5% of the children. A total of 11.2% of chldren did not require further neurosurgical treatment. In the second stage of the study (between 2006-2012) after therapy the size of the right lateral cerebral ventricle decreased by 54.76% (average of27.54 mm to 12.46 mm) and the left lateral cerebral ventricle decreased by 53.12% (average of 26.41 mm to 12.38 mm) (p=0.0018). The maximum and minimum width of the cerebral cortex increased by 23.06% and 27% (average of 9.04 mm to 11.75 mm vs. 3.65 mm to 5 mm), respectively Early complications were observed in 22% of the cases: PROM (6), intrauterine fetal death (4), intrauterine infection (1), and premature detachment of the placenta (1). Average gestational age at delivery was 34 weeks, and 24% of the patients delivered at term.

CONCLUSIONS

Implantation of ventriculoamniotic shunts proved to be an effective form of therapy resulting in normalization of intracranial pressure. In both stages of therapy reduction of ventricular size in patients with hydrocephalus and good neurological outcome (45.4% in I stage, 60% in II stage) were observed. In the second stage of therapy the size of lateral brain ventricles after fetal therapy was significantly lower (54%). A total of 18% of the neonates did not require neurosurgical treatment.

Mode of delivery and other risk factors for Escherichia coli infections in very low birth weight infants

Background

Infections in newborns remain one of the most significant problems in modern medicine. Escherichia coli is an important cause of neonatal bloodstream and respiratory tract infections and is associated with high mortality. The aim of our study was to investigate the epidemiology of E. coli infection in Polish neonatal intensive care units (NICUs) and resistance to antibiotics, with particular reference to the safety of very low birth weight infants.

Methods

Continuous prospective infection surveillance was conducted in 2009–2012 in five NICUs, including 1,768 newborns whose birth weight was <1.5 kg. Escherichia coli isolates from different diagnostic specimens including blood, tracheal/bronchial secretions and others were collected. All isolates were tested using disk diffusion antimicrobial susceptibility methods. Pulsed-field gel electrophoresis was used to determine the possible horizontal transfer of E. coli among patients.

Results

The incidence of E. coli infections was 5.4% and 2.0/1,000 patient-days. The occurrence of E. coli infections depended significantly on the NICU and varied between 3.9% and 17.9%. Multivariate analysis that took into account the combined effect of demographic data (gender, gestational age and birth weight) and place of birth showed that only the place of hospitalisation had a significant effect on the E. coli infection risk. The highest levels of resistance among all E. coli isolates were observed against ampicillin (88.8%) and amoxicillin/clavulanic acid (62.2%). Among E. coli isolates, 17.7% were classified as multidrug resistant. Escherichia coli isolates showed different pulsotypes and dominant epidemic clones were not detected.

Conclusions

Our data indicate that antibiotic prophylaxis in the presence of symptoms such as chorioamnionitis and premature rupture of membranes did not help reduce the risk of E. coli infection. Multivariate analysis demonstrated only one significant risk factor for E. coli infection among infants with a birth weight <1.5 kg, that is, the impact of the NICU, it means that both neonatal care and care during pregnancy and labour were found to be significant.

Successful treatment of fetal bilateral primary chylothorax--report of the two cases

Primary fetal chylothorax is an uncommon complication, associated with high perinatal morbidity and mortality. In our report, we describe two cases of fetal bilateral primary chylothorax successfully treated with pleuro-amniotic shunting. In both cases, ultrasound scans showed bilateral, hypoechoic fluid in the pleural space without any associated structural malformations and features of infection and aneuploidy Laboratory analysis of pleural fluids revealed 79% and 92% of lymphocytes, respectively confirming chylothorax in both fetuses. In the first case, pleuro-amniotic shunts were successfully inserted at 31 weeks and 6 days of gestation. Ultrasound scan after two weeks showed expansion of the left lung and lack of fluid in both pleural cavities. At 39 weeks of gestation, a 2660 g baby boy was delivered by cesarean section (Apgar score: 9). The child did not require surgical intervention and was discharged home on day 16 of life. In the second case, the insertion of shunts (at 24 weeks and 6 days of gestation) also significantly reduced the amount of the fluid in the pleural cavities, but one shunt had to be surgically removed after birth. At 30 weeks and 2 days of gestation, a cesarean section was performed due to maternal cholestasis. A female weighing 1400 g was delivered (Apgar score: 7). The chest X-ray revealed only a small amount of fluid in the left pleural cavity The infant was discharged on postnatal day 26, in good condition and with body weight of 2150 g. Pleuro-amniotic shunt insertion is a method of choice in the treatment of confirmed primary fetal chylothorax.

Late-onset bloodstream infections of Very-Low-Birth-Weight infants: data from the Polish Neonatology Surveillance Network in 2009-2011

Background

Late-Onset Bloodstream Infections (LO-BSI) continue to be one of the most important complications associated with hospitalization of infants born with very low birth weight (VLBW). The aims of this study were to assess the epidemiology of LO-BSI together with the risk factors and the distribution of causative pathogens at six Polish neonatal intensive care units that participated in the Polish Neonatology Surveillance Network from January 1, 2009 to December 31, 2011.

Methods

The surveillance covered 1,695 infants whose birth weights were <1501 grams (VLBW) in whom LO-BSI was diagnosed >72 hours after delivery. Case LO-BSI patients were defined according to NeoKISS.

Results

Four hundred twenty seven episodes of LO-BSI were diagnosed with a frequency of 25.3% and an incidence density of 6.7/1000 patient-days (pds). Results of our multivariate analysis demonstrated that surgical procedures and lower gestational age were significantly associated with the risk of LO-BSI. Intravascular catheters were used in infants with LO-BSI significantly more frequently and/or for longer duration: Central venous cathters (CVC) (OR 1.29) and Peripheral venous catheters (PVC) (OR 2.8), as well as, the total duration of total parenteral nutrition (13 vs. 29 days; OR 1.81). Occurrence of LO-BSI was significantly associated with increased the length of mechanical ventilation (MV) (OR 2.65) or the continuous positive airway pressure (CPAP) (OR 2.51), as well as, the duration of antibiotic use (OR 2.98). The occurrence of more than one infection was observed frequently (OR 9.2) with VLBW with LO-BSI. Microorganisms isolated in infants with LO-BSI were dominated by Gram-positive cocci, and predominantly by coagulase-negative staphylococci (62.5%).

Conclusions

Independent risk factor for LO-BSI in VLBV infants are: low gestational age and requirement for surgery. The incidence rates of LO-BSI especially CVC-BSI were higher in the Polish NICUs surveillance than those of other national networks, similar to the central- and peripheral utilization ratio.

[Intrauterine therapy for nonimmune hydrops fetalis (NIHF)--analysis of 38 cases]

OBJECTIVE

The aim of the study was to perform an audit the results of fetal therapy in cases of nonimmune hydrops fetalis (NIHF), isolated hydrothorax and isolated ascites.

METHODS

A total of 38 fetuses (17-35 weeks of pregnancy) were included in the study whereas 6 patients were excluded due to abnormal karyotype. NIHF was diagnosed in 24 cases, hydrothorax in 4 cases, and ascites in 4 cases. Shunts were implanted in 26 (81%) cases and 7 (19%) participants underwent therapeutic cordocentesis.

RESULTS

After therapy anterior-posterior diameter of the right and the left lung increased to 9.6 mm (27%) and 12.4 mm (35%), respectively. Early complications were observed in 5 (16%) cases. PROM 2 (40%), fetal death 1 (20%), infection 1 (20%), and preterm delivery 1 (20%). Out of the 27 patients, 65% had a caesarian section without early complications and 35% had a vaginal delivery with 58% at term and 42% pre-term.

CONCLUSIONS

Preceding results show that intrauterine therapy significantly improves prognosis of fetuses with NIHF.

Necrotising enterocolitis in preterm infants: epidemiology and antibiotic consumption in the Polish neonatology network neonatal intensive care units in 2009

The aim of this study was to describe the epidemiology of necrotising enterocolitis (NEC), antibiotic consumption and the usefulness of microbiological tests in very low birth weight (VLBW) Polish newborns.

METHODS

Prospective surveillance was performed in the year 2009 by local infection control teams. The study covered 910 infants hospitalized in six Polish neonatal intensive care units. Two kinds of indicators were used for the description of antibiotic usage: the duration of treatment (days of treatment, DOTs) and the defined daily dose (DDD).

RESULTS

NEC incidence was 8.7% and fatality rate was 19%. Chorioamnionitis, late gestational age and low birth weight were identified as risk factors for NEC. Catheterization, mechanical ventilation and other selected procedures were used considerably longer in newborns with NEC than in the remaining neonates. Total usage of antibiotics reached 2.9 DDDs or 1.437 days; the average use of drugs per case of NEC amounted to 0.47 DDD or 23.2 DOTs. The level of antibiotic usage was analysed with correlation to microbiological tests performed and it was non-significantly greater in the group of children with NEC in whom the tests were performed.

CONCLUSIONS

A high risk of developing NEC is closely associated with VLBW and with inflammation of the amnion during labour. We observed no relationship between the consumption of antibiotics in neonates with NEC and positive results of microbiological testing indicating sepsis accompanying NEC or gut colonization with pathogens.

Elevated frequencies of micronuclei in pregnant women with type 1 diabetes mellitus and in their newborns

Pregestational diabetes mellitus (type 1 and type 2) affects about 1% of the obstetric population. In diabetes, persistent hyperglycemia can be a source of DNA damage via overproduction of reactive oxygen species (ROS). Using the cytokinesis-block micronucleus (CBMN) test, we measured the frequencies of micronuclei (MN) per 1000 binucleated (BN) cells in pregnant women (mothers) with type 1 diabetes mellitus (T1DM) and in their newborns. Peripheral blood lymphocytes were collected from 17 pregnant women with T1DM and cord-blood lymphocytes from their 17 newborns. The control group included 40 pregnant women (mothers) without diabetes mellitus (DM) and their 40 newborns. In the group of pregnant women with T1DM, the mean number of MN per 1000 BN cells was 2.35 (±1.07), significantly (p<0.001) higher than in the control group of pregnant women (0.86±0.90). The frequency value in the group of newborns of T1DM mothers was 1.42 (±0.60), significantly (p<0.05) higher than in the corresponding control group (0.67±0.79). The value in the group of mothers with T1DM was significantly (p<0.05) higher than in their newborns. Comparing mothers without DM with their newborns, no significant frequency differences were observed. No significant correlations were observed between MN frequencies in mothers with T1DM and either the frequencies in their newborns, the duration of diabetes, or HbA1C levels. Our results indicate that T1DM is accompanied by increased frequencies of MN in pregnant women and their newborns.

[Epidemiology of infections in very low birth weight infants. Polish Neonatology Network research]

AIM OF STUDY

1. prospective record of infections; 2. prevention of nosocomial infections by providing current data about infections, which are significant for making therapeutic decisions.

MATERIAL AND METHODS

Recorded infections: early-onset sepsis (congenital), late-onset sepsis (acquired in hospital), necrotising enterocolitis (NEC), pneumonia. Infections were diagnosed and qualified on the basis of definitions of infections based on the National Nosocomial Infections Surveillance (NNIS) criteria, developed by CDC, USA, including modifications of German Neo-KISS programme. Infection control was realised as a part of common research project of "Polish Neonatology Network", appointed by the decision of the Minister of Science and Higher Education no. 669/E-215/BWSN- 0180/2008 dated 20.05.2008 r. The study was conducted by 6 Polish neonatology units, Microbiology Chair of Jagiellonian University Collegium Medicum and Institute of Theoretical and Applied Computer Science. Infants with birth weight lower than 1500 g were qualified for the study.

RESULTS

Between 1.01.2009 and 31.12.2009, 910 patients were registered, i.e. 19.1% of VLBW infants born in that period. The conducted analysis showed significant differences between centres in gestational age, birth weight, hospitalisation, use of invasive procedures, antibiotics and parenteral feeding. Cumulative morbidity rate was 68.5% total. Blood infection (sepsis) was the most commonly observed type of infection: 268 cases - 43.1% of all recorded forms of infection. Pneumonia was diagnosed in 242 cases, 38.8% total. NEC constituted 12.7% studied infections (79 cases). Apart from NEC, the risk of other forms of infection differed between centres. Dominant etiologic factor of all infections were Gram-positive cocci, which constituted 565 isolated microorganisms. Among them coagulase-negative staphylococci (CNS) were the most common (41.7%), while Staphylococcus aureus was fourth most frequent etiologic factor of infections (6.3% total).

CONCLUSIONS

1. Introduction of unified definition and criteria for diagnosing infections and the use of morbidity rates enables comparative analysis of epidemiology of infections in neonatal intensive care units. 2. Due to significant differences observed between prophylactic and therapeutic procedures in various units, it is essential to propose Polish recommendations regarding control over etiology of infections and use of invasive procedures, such as intravenous catheters and ventilation. 3. It is essential to undertake action leading to fully rational antibiotic therapy, because overuse of antibiotics leads to bacterial resistance and increases incidence of infections.

Infections reported in newborns with very low birth weight who required surgical treatment. Data from the Polish Neonatology Surveillance Network

AIM

To determine the risk of various forms of infections appearing in very low birth weight newborns (VLBW) during the period of 30 days after surgical treatment in hospitals which have perinatal care departments with neonatal intensive care units that form the Polish Neonatology Surveillance Network (PNSN).

MATERIAL AND METHODS

Continuous prospective monitoring of infections was carried out from January 1st to December 31st 2009 in six neonatal intensive care units which form the Polish Neonatal Surveillance Network. (PNSN). 910 newborns with very low birth weight (VLBW) were included in the study programme. 91 (10%) of this group underwent 118 surgical interventions. 12 newborns needed two or more surgeries. The most common procedure was the closure of persistent ductus artesiosus (PDA) and photocoagulation of vascular damage in the eye fundus.

RESULTS

In the period of 30 days after surgery the following were diagnosed: in 3 newborns - necrotizing enterocolitis (NEC), in 22 newborns - sepsis (BSI) and in 54 newborns - pneumonia (PNEU). Symptoms of BSI and PNEU were on average observed on the 10th day after surgical intervention, while in the case of NEC on the 17th day. The highest incidence of infection (148.4%) was observed after PDA closure and in connection with introducing a drain into the pleural cavity through the intercostal space. The incidence of PN EU (37.3%) was twice as high as the incidence of BSI (18.6%). Surgical procedure was a factor significantly increasing the risk of infection and morbidity (RR 2.1, P<001) In our investigations there was no case of the local infection of a surgical site. 11 newborns died (mortality was 12.1%). The most common bacterial strains found in our investigation were coagulase-negative Staphylococcus and Escherichia Coli.

CONCLUSIONS

Taking into consideration the fact that surgical procedure in VLBW-newborns significantly increases the risk of pneumonia and to a minor degree the risk of NEC and BSI, further detailed investigation in the field of perisurgical epidemiology is needed in order to elaborate a more deeply oriented and more effective strategy of infection prevention in the group of VLBW newborns.

[The use of therapeutic whole body cooling in treating hypoxic-ischemic encephalopathy in the newborn--the first case in Poland]

Hypoxic-ischemic encephalopathy (ENN) concerns neonates born after 35 completed weeks of gestation. The incidence rate has been shown to be 1-6/1000 births and can lead to significant permanent neurological damage, cerebral palsy and even death. Until the whole body cooling and selective brain cooling methods have been accepted, the treatment of children with ENN was only symptomatic. The article describes the first case of ENN neonatal treatment with the whole body hypothermia in Poland, which took place at the Department of Neonatology Poznań University of Medical Sciences. Currently both methods--whole body hypothermia and selective brain cooling--offer a chance for a normal neurological development and a better life for children born with ENN. Both methods are accessible in a few centers in Poland.

[The first application of therapeutic hypothermia in Poland--selective head cooling (Cool-Cap) with whole-body moderate hypothermia in a newborn with features of hypoxic ischemic encephalopathy]

The authors present the first application of therapeutic hypothermia in a newborn in Poland. The female newborn, born with severe asphyxia, was transported to a referral perinatal center where the method of brain cooling was possible. Severe hypoxic ischemic encephalopathy was confirmed by an integrated EEG. During the cooling procedure (which lasted 72 hours), no important side effects were noticed. The neurodevelopmental outcome of the baby assessed during the first 2 years of her life is normal.

[Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy]

Hypoxia-ischemia in the perinatal period is a serious condition affecting infants, which can result in death and cerebral palsy and associated disabilities. There has been significant research progress in hypoxic-ischemic encephalopathy over the last 2 decades. Many new molecular mechanisms of asphyxia have been identified. Despite all these advances, therapeutic interventions in HIE remain to be limited. Recently it has been revealed that mild therapeutic hypothermia is the only modality shown to improve neurologic outcome. The authors present a summary of pathogenesis of HIE, animal studies of cooling for hypoxic and ischemic models, and first publications on human therapeutic hypothermia trials. The diagnosis of encephalopathy in full-term neonates and enrollment criteria for hypothermia are also discussed. The current data from randomized control trials of hypothermia as neuroprotection for full and near-term infants are presented along with the results of meta-analyses of these trials. Finally the status of ongoing neonatal hypothermia trials as well as status of therapeutic hypothermia in Poland is summarized.

[Antibiotic consumption and its costs of purchase in Polish neonatology networks units]

AIM

The study presents the results of the analysis of antibiotic consumption and its direct costs in selected neonatal units.

MATERIAL AND METHODS

Data were collected retrospectively (the year 2007) in five hospitals, during the pilot phase of the Polish Neonatal Network . Antibiotic consumption was assessed using the Defined Daily Dose (DDD). The costs were assessed as the costs of purchase of one DDD.

RESULTS

The study included 11 922 children hospitalized in the period from 1.01 to 31.12.2007. In this group, 731 infants have birth weight < 1500 grams (from 2.2% to 64.2% in individual units, median--7.3%). The mean consumption of antibacterial drugs was 48.52 DDD/1 000 person-days (P-D) of stay among the entire study population (median--42,52), and varied from 23.13 to 85.82 DDD/1,000 P-D. However, this difference has not been statistically significant. The most commonly used group of antibiotics were beta-lactams--in four out of five units the percentage of its usage ranged from 48.71% to 74.67%. Next group were aminoglicosides--in one unit its usage reached 56.97% and in other ranged from 5.01% to 22.53%. Glycopeptides and macrolides were also used in every unit of the studied group. The usage of glycopeptides ranged from 1.7% to 10.81% and of macrolides from 1.32% to 15.71%. Different kinds of antibiotics were used occasionally. The differences of costs of purchase of one DDD between hospitals were greater and varied from 17,64 PLN/ DDD to 84,58 PLN/ DDD (average costs). A considerable range of costs index values was also noted for different groups of antibiotics. The costs of purchase of one DDD of beta-lactams varied from 19.54 PLN/ DDD to 68.35 PLN/ DDD; for aminoglicosides the cost varied from 4.61 PLN/ DDD to 122.9 PLN/ DDD, for glycopeptides--from 31.40 PLN/ DDD to 283.13 PLN/ DDD and in case of macrolides: from 12.05 PLN/ DDD to 90.77 PLN/ DDD. This differentiation of the cost of purchasing a single defined daily dose, taking into account the specific groups of antibiotics, did not have the characteristics of statistical significance.

CONCLUSIONS

As expected, the antibiotic regimens in the studied wards were similar. This is due to a homogeneous population of hospitalized patients. However, the differences of costs of purchase of antibiotics observed in the study, indicate the considerable variety of the treatment patterns in Polish neonatology units and the need to develop and implement recommendations of effective pharmacotherapy for patients in intensive neonatal care units and the implementation of a unified model of infections surveillance.

[Umbilical cord entanglement in monoamniotic twin preganacy--case presentation and literature review]

Monoamniotic twins are at most increased risk of perinatal complications with perinatal mortality of 28-60 % reported in literature. The most specific complication to monoamniotic twins is entanglement and (or) knotting of the cords leading to intrauterine death of both (more often) or one twin. In first presented case 1, 23-year-old primigravida in 33wks of twin monoamniotic gestation was reffered to our Institute due to intrauterine death of one co-twin caused by umbilical cord entanglement. In second case, 26-year-old multigravida in monoamniotic twin gestation was admitted to our institution. A serious umbilical cord entanglement was observed and a presence of true knot of umbilical cord was suspected. Presented cases indicate that establishing a chorionicity and amniocity in twin pregnancy is an essential part of ultrasound examination. The diagnosis of cord entanglement in monoamniotic twin pregnancy enables a forecasting of possible complications. According to the established diagnosis future protocols of perinatal management could be proposed. Due to possible complications counseling and management of monoamniotic twins should be performed in tertiary medical centers.

[Midazolam--how safe is it in sedation of newborn?]

Since the nineties, while both pain and stress reactions in newborn were revealed, the period of opioid analgesia as well as benzodwuazepin sedation was initiated. Midazolam is the drug which is particularly willingly used in neonatal intensive care units. Although commonly accepted as a safe drug, midazolam produced adverse effects which could make early as well late treatment outcome worse. In this paper the results of pharmacokinetics studies and studies concerning the adverse effects of midazolam among low birth weight newborn are collected and the current opinion of experts dedicates regarding analgetic and sedative procedures in neonatal period are presented. On the basis of the results of the previous studies, it seems reasonable to be more critical of our sedation approach with midazolam and pay more attention to appropriate administration of midazolam in neonatal period.

[Can we expect decreasing the incidence of patent ductus arteriosus (PDA) in the population of premature neonates who had received antenatal steroid therapy?]

OBJECTIVES

The efficacy of antenatal steroid therapy (ANS--use with the recommendation from 1999; therapy repeated every 7-10 days; dexamethasone was used) on the incidence of RDS in neonates born before 34 weeks of gestation has been well documented in several studies. However, we know very little about the influence of ANS on patent ductus arteriosus (PDA).

DESIGN

The purpose of this study was to assess the influence of ANS on the incidence of PDA in neonates born before 35 weeks of gestation.

MATERIALS AND METHODS

The analysed population consisted of 425 newborns delivered at Research Institute Polish Mother's Memorial Hospital between 1996-1998. Patients were enrolled in three groups according to mode of ANS: Group I--complete ANS; Group II--partial ANS; Group III--without ANS (reference group, OR = 1). The complete ANS consisted of at least 24 mg of dexamethasone with a first dose given not earlier then 24 hours before delivery. The analysis was based on retrospective evaluation of patient's medical records. PDA was diagnosed during echocardiographic examination or during autopsy. The incidence and risk of significant PDA in enrolled groups were estimated.

RESULTS

Use of complete ANS has no influence of the incidence of PDA. In the partial ANS group the risk of PDA (OR 1,89; p = 0,052 vs group III) was increased. Risk of PDA was also higher in patients born before 29 weeks of gestation, especially from the partial ANS group.

CONCLUSIONS

The antenatal steroid therapy has influence of the incidence of PDA. We observed higher risk of PDA in the group of neonates born before 29 weeks of gestation and in the partial ANS group.

[Use of prenatal health care and risk of infants born small-for-gestational-age. Preliminary results of a case-control study in the Lódź voivodeship]

It is well documented that small-for-gestational age (SGA) infants are at an increased risk of perinatal mortality and morbidity. In order to identify the major modifiable risk factors of SGA birth, a case-control study was launched in the area of Lódź voivodeship, Poland. The project was focused on the evaluation of the role of perinatal health services and avoidance of exposure to tobacco smoke in the prevention of SGA births. The study population consisted of mothers of 153 SGA infants (cases) and 93 mothers of control infants. SGA infants were identified as infants with body weight below 10th percentile for gestational age, using Ballarda scale. The controls were non-SGA infants delivered after 37 week of gestation. The infants from both groups were delivered in 26 maternity wards in the Lódź voivodeship within the period of June 1-November 1, 2003. One month after delivery, each mother of SGA and control infants was visited by an interviewer who collected information about her profile of use of perinatal health care and on active and passive exposure to tobacco smoke in pregnancy. Odds ratios and 95% confidence units (CU) were calculated using EpiInfo software developed by CDC, Atlanta, Georgia, US. Late booking for perinatal care (after 12 week of gestation) and less than 5 visits during pregnancy was found to be related to an increased risk of SGA, however, the OR values included unity. About 1/3 of mothers of SGA infants and "of the controls were served mainly by the private health sector. The use of private care was related to a lower risk of SGA: OR= 0.55 95% CI (0.31-0.96). This protective pattern was observed in the population of women aged 19-25 living in rural areas years and with only primary education. The preconception visits to obstetricians and contacts with health educators during pregnancy were also found to have some protective effect, however, the ORs were not statistically significant. The adverse effect of smoking during pregnancy was clearly confirmed in the study population, OR= 2.69 95%CI (1.37-5.33), while the role of passive smoking was difficult to assess due to the small number of nonsmoking women exposed to ETS. There are some indications that the poor use of perinatal health services may account for the elevated risk of SGA births in the Lódź voivodeship. The use of the private health sector is growing and seems to be related to a lower risk of SGA births. More effective tools to prevent maternal smoking have to be developed and implemented in routine perinatal care.

[Neonatal outcome multiple pregnancies at the Neonatal Department of Research Institute of Polish Mother's Memorial Hospital]

OBJECTIVES

The purpose of this study was to analyze the course of neonatal period among babies born from truly higher-order multiple pregnancies (> or = 3).

DESIGN

The retrospective analysis included 81 infants born from multiple pregnancies (> or = 3), hospitalized in Neonatal Department of Research Institute of Polish Mother's Memorial Hospital between 1995-2001.

MATERIALS AND METHODS

Studied population contained 63 babies delivered from 21 triplet pregnancies, 8 newborns from 2 quadruplet pregnancies and ten quintuplets. The groups were analyzed according to gestational age, birth weight, ventilation and hospitalization time as well as early and late consequences of prematurity.

RESULTS

Among the multiples (> or = 3) the mean birth weight of triplets, quadruplets and quintuplets was respectively: 1656 g vs 1166 g vs 725 g, the diminished gestational age was also noticed: 32.4 vs 30 vs 26.5 GA. The cesarean section ratio in triplet deliveries was 95%, while quadruplets and quintuplets pregnancies were always delivered by operative interventions. The increase in number of fetuses was significantly associated with prolonged ventilation time (mean 9.5 vs 22.2 vs 57.5 days) as well as the hospitalization (mean 29.1 vs 64.1 s 79.6 days). The differences between mentioned above values reached statistical significance (p < 0.001). One out of three neonates born from triplet pregnancy required ventilatory support (36.6%), whereas in quadruplets and quintuplets this ratio reached 100%. The respiratory distress syndrome treated with surfactant was diagnosed in 7.9% (5/63) of triplets, 37.5% (3/8) quadruplets and 100% of quintuplets among whom 8 babies needed more than one dose of surfactant. The increased risk of unfavorable prematurity outcome (PDA, ROP, BPD, IVH) and neonatal death was highly related to plurality of pregnancy.

CONCLUSIONS

Multiple pregnancies resulting from infertility treatment cause many medical problems. Undesirable outcome among neonates delivered from higher-order multiple pregnancies (> or = 3 fetuses) predestine to more judicious approach in the application of assisted reproductive techniques and multiple pregnancies prophylaxis.

[Single nasal prong versus infant flow driver in very low birth weight infants: clinical efficacy of two modes of nasal continuous positive airway pressure (CPAP)]

The authors compared efficacy of two different NCPAP techniques in VLBW newborn with respiratory insufficiency. Among the patients with IFD support the higher weaning rate and the lower supplemental oxygen requirement as well as secondary infections incidents was observed.

[Influence of antenatal steroid therapy on newborn nervous system]

OBJECTIVES

Analysis of the impact of prenatal glucocorticoids on the neurological outcome of a newborn.

DESIGN

The authors reviewed the most current reports concerning the influence of antenatal steroid therapy (used to accelerate of fetal lung maturation) on neonates. In the study we discussed the influence of steroid therapy on growth and development of the brain, as well as the occurrence rate of the most common neurological abnormalities, such as: intraventricular haemorrhage and periventricular leukomalacia.

MATERIALS AND METHODS

Recent literature review.

RESULTS

We believe that use of antenatal corticosteroids remains a major factor in reducing neonatal mortality. Treatment with one course of betamethasone, as we know at the present time, is completely safe for a newborn's nervous system. Many courses of antenatal steroids may decrease fetal brain growth. Antenatal steroid therapy reduced the incidence of intraventricular haemorrhage in preterm infants. Use of betamethasone, but probably not dexamethasone, in antenatal therapy reduced the incidence of periventricular leukomalacia in extremely low weight infants.

CONCLUSIONS

According to recent studies regarding probable unfavourable role of dexamethasone in neonatal neurological development we are of opinion that dexamethasone should be replaced by betamethasone in therapy of imminent preterm labour.

Can magnesium sulfate reduce the risk of cerebral injury after perinatal asphyxia?

Hypoxia-ischemia produces brain damage by processes that continue for many hours after reoxygenation/reperfusion. This provides a window of opportunity for therapy aimed at preventing further loss of brain cells. Sulfate magnesium can prevent posthypoxic brain injury by blocking glutamate receptors within the calcium (Ca++) ion channel. We used sulfate magnesium in nine newborn infant after perinatal hypoxia. We investigated the brain damage, by ultrasound examination, on third day, in first, second and third week, and third, sixth month of life. We have estimated the neurological development in the first week of life and third and twelfth month of life. We did not find deviations in ultrasound examination. We did not observe convulsions. We did not observe any side effect of this therapy. The examination at 1 of year of life in all of children was correct.