Predictors of early-onset neonatal sepsis in premature newborns: Case-control study

INTRODUCTION

Early-onset neonatal sepsis (EOS) is difficult to diagnose clinically because the semiology of premature newborns is poor during the first days of life. This study aimed to identify predictive factors of EOS in neonates less than 37 weeks' gestational age in neonatal care at Louis Mourier Hospital, France.

METHOD

This was a case-control study of all newborns less than 37 weeks of gestational age diagnosed and managed for EOS from January 1 to December 31, 2019. The main parameters studied were demographic characteristics, risk factors, laboratory, and bacteriological characteristics. At the benchmarking level, the statistical tests used were the McNemar test for qualitative variables and the paired Student's t-test for quantitative variables.

RESULTS

A total of 50 mother-child pairs were included in this study (25 cases and 25 matched controls). The results showed a statistically significant relationship between the birth of a child with EOS and between a premature rupture of membranes of > 18 h (68% of cases vs. 36% of controls; p = 0.042); a positive culture of the placenta (p = 0.0002); C-reactive protein levels of > 6 mg/L (88% of cases vs. 20% of controls; p = 0.001); a procalcitonin level of > 0.6 ng/mL (72% of cases vs. 16% of controls; p = 0.001). Gram-negative bacteria including Escherichia coli (44.5%) and Haemophilus influenzae (14.8%) were the most common pathogens found.

CONCLUSION

The search for risk factors must be systematic and the clinic must remain at the center of the diagnostic approach.

Contribution of vaginal culture to predict early onset neonatal infection in preterm prelabor rupture of membranes

BACKGROUND

Preterm prelabor rupture of membranes (PPROM) is a major cause of morbidity and mortality for both the mother and the newborn. The vaginal germ profile in PPROM is poorly known, particularly regarding the risk of early-onset neonatal infection (EONI).

OBJECTIVE

To determine microbiological risk factors for EONI in case of PPROM before 34 weeks of gestation (WG).

STUDY DESIGN

A retrospective single-center cohort of patients with PPROM before 34 W G from 2008 to 2016. Vaginal swabs were obtained at admission and at delivery as per usual care and were analyzed by Gram stain and culture for vaginal dysbiosisi.e lactobacilli depletion and/or presence of potential pathogens.

RESULTS

Among 268 cases of PPROM, 39 neonates had EONI 14.55 %; (95 %CI 0.11 - 0.19) Overall, vaginal samples culture was positive in 16.67 % (95 %CI 11.95 %-22.32 %) at the time of rupture and 24.76 % (95 %CI 19.02 %-31.23 %) at delivery, with no significant differences between EONI and no-EONI groups (p = 0.797 and 0.486, respectively), including for Group B Streptococci (GBS) and Escherichia coli. EONI was significantly associated with dysbiosis at the time of rupture (23.94 % versus 10.35 % in the absence of dysbiosis, p = 0.009) and at delivery (19.70 % versus 3.90 % if no dysbiosis, p < 0.001). Clinical intra-uterine infection was present in 78.5 % (n = 31) of the EONI group versus 37.2 % (n = 85) in the non-EONI group (p < 0.001) and chorioamnionitis and/or funisitis were found in 97.3 % and 91.9 %, respectively in the EONI group, versus 56.11 % and 53.96 %, respectively, in the non-EONI group (p < 0.001).

CONCLUSION

Dysbiosis following rupture and at delivery, but not the presence of pathogens in the VS culture, was associated with the risk of EONI in case of PPROM.

Staphylococcus capitis isolated from bloodstream infections: a nationwide 3-month survey in 38 neonatal intensive care units

To increase the knowledge about S. capitis in the neonatal setting, we conducted a nationwide 3-month survey in 38 neonatal intensive care units (NICUs) covering 56.6% of French NICU beds. We demonstrated 14.2% of S. capitis BSI (S.capBSI) among nosocomial BSIs. S.capBSI incidence rate was 0.59 per 1000 patient-days. A total of 55.0% of the S.capBSIs were late onset catheter-related BSIs. The S. capitis strains infected preterm babies (median gestational age 26 weeks, median birth weight 855 g). They were resistant to methicillin and aminoglycosides and belonged to the NRCS-A clone. Evolution was favorable in all but one case, following vancomycin treatment.

Study of the Factors Leading to Fetal and Neonatal Dysthyroidism in Children of Patients With Graves Disease

CONTEXT

Neonatal hyperthyroidism was first described in 1912 and in 1964 was shown to be linked to transplacental passage of maternal antibodies. Few multicenter studies have described the perinatal factors leading to fetal and neonatal dysthyroidism.

OBJECTIVE

To show how fetal dysthyroidism (FD) and neonatal dysthyroidism (ND) can be predicted from perinatal variables, in particular, the levels of anti-thyrotropin receptor antibodies (TRAbs) circulating in the mother and child.

DESIGN AND PATIENTS

This was a retrospective multicenter study of data from the medical records of all patients monitored for pregnancy from 2007 to 2014.

SETTING

Among 280,000 births, the medical records of 2288 women with thyroid dysfunction were selected and screened, and 417 women with Graves disease and positive for TRAbs during pregnancy were included.

RESULTS

Using the maternal TRAb levels, the cutoff value of 2.5 IU/L best predicted for FD, with a sensitivity of 100% and specificity of 64%. Using the newborn TRAb levels, the cutoff value of 6.8 IU/L best predicted for ND, with a sensitivity of 100% and a specificity of 94%. In our study, 65% of women with a history of Graves disease did not receive antithyroid drugs during pregnancy but still had infants at risk of ND.

CONCLUSIONS

In pregnant women with TRAb levels ≥2.5 IU/L, fetal ultrasound monitoring is essential until delivery. All newborns with TRAb levels ≥6.8 IU/L should be examined by a pediatrician with special attention for thyroid dysfunction and treated, if necessary.

Impact of fetal growth restriction on neurodevelopmental outcome at 2 years for extremely preterm infants: a single institution study

AIM

We evaluated the impact of fetal growth restriction on neurodevelopmental outcomes at 2 years corrected age for infants born before 27 weeks gestational age.

METHOD

Data on infants born before 27 weeks gestational age between 1999 and 2008 (n=463), admitted to a tertiary neonatal unit in Paris, were used to compare neurological outcomes at 2 years for infants with birthweight lower than the 10th centile and birthweight of at least the 10th centile, using intrauterine reference curves. Outcomes were cerebral palsy (CP) and the Brunet-Lézine assessment of cognitive development, which provides age-corrected overall and domain-specific (global and fine motor skills, language and social interaction) developmental quotients. Models were adjusted for perinatal and social factors.

RESULTS

Seventy-two percent of infants were discharged alive. Eighty-three percent (n=268) were evaluated at 2 years. Six percent had CP. Fetal growth restriction was not associated with the risk of CP. After adjustment, children with a birthweight lower than the 10th centile had a global developmental quotient 4.7 points lower than those with birthweight of at least the 10th centile (p<0.001); differences were greatest for fine motor and social skills (-4.7, p=0.053 and -7.3, p<0.001 respectively).

INTERPRETATION

In extremely preterm children, fetal growth restriction was associated with poorer neurodevelopmental outcomes at 2 years, but not with CP.

Quiescence and γH2AX in neuroblastoma are regulated by ouabain/Na,K-ATPase

Background:

Cellular quiescence is a state of reversible proliferation arrest that is induced by anti-mitogenic signals. The endogenous cardiac glycoside ouabain is a specific ligand of the ubiquitous sodium pump, Na,K-ATPase, also known to regulate cell growth through unknown signalling pathways.

Methods:

To investigate the role of ouabain/Na,K-ATPase in uncontrolled neuroblastoma growth we used xenografts, flow cytometry, immunostaining, comet assay, real-time PCR, and electrophysiology after various treatment strategies.

Results:

The ouabain/Na,K-ATPase complex induced quiescence in malignant neuroblastoma. Tumour growth was reduced by >50% when neuroblastoma cells were xenografted into immune-deficient mice that were fed with ouabain. Ouabain-induced S-G2 phase arrest, activated the DNA-damage response (DDR) pathway marker γH2AX, increased the cell cycle regulator p21^Waf1/Cip1 and upregulated the quiescence-specific transcription factor hairy and enhancer of split1 (HES1), causing neuroblastoma cells to ultimately enter G0. Cells re-entered the cell cycle and resumed proliferation, without showing DNA damage, when ouabain was removed.

Conclusion:

These findings demonstrate a novel action of ouabain/Na,K-ATPase as a regulator of quiescence in neuroblastoma, suggesting that ouabain can be used in chemotherapies to suppress tumour growth and/or arrest cells to increase the therapeutic index in combination therapies.

Unbound bilirubin does not increase during ibuprofen treatment of patent ductus arteriosus in preterm infants

OBJECTIVE

To determine whether ibuprofen displaces bilirubin from albumin in preterm infants.

STUDY DESIGN

A total of 34 preterm neonates (<32 weeks gestation) treated by ibuprofen (10-5-5 mg/kg) were included in this prospective open-label study. Total bilirubin (TB), unbound bilirubin (UB), and ibuprofen concentrations were measured before, 1 hour, and 6 hours after the first dose; before and 1 hour after the second dose; and 72 hours after the beginning of treatment. The infants were screened by auditory brainstem responses and by neurologic examination at term.

RESULTS

At baseline, TB, UB, apparent binding affinity of albumin (Ka), and albumin concentrations were 6.0±1.6 mg/dL, 1.9±2.2 μg/dL, 14.1±5.8 L·μmol(-1), and 28.7±2.3 g/L, respectively. Ibuprofen treatment had no effect on TB, UB, or Ka values. No correlation between UB or Ka and ibuprofen concentrations was found. No neurologic symptoms or significant modifications of auditory brainstem responses were observed at term.

CONCLUSION

Ibuprofen (10-5-5 mg/kg) did not displace bilirubin in preterm infants with a baseline TB concentration <8.8 mg/dL.

Transient inhibition of astrocytogenesis in developing mouse brain following postnatal caffeine exposure

Caffeine is frequently administered in human preterm newborns. Although some data suggest a potential risk for the developing brain, its impact has not been fully evaluated. We used a murine model of postnatal caffeine treatment in which mouse pups received intraperitoneal injections of caffeine from postnatal days 3 to 10. Caffeine exposure resulted in a transient reduction of glial fibrillary acidic protein and S100beta protein expression in various brain areas during the first 2 postnatal weeks (19.8% and 23.2% reduction in the hippocampus at P15, respectively). This effect was dose-dependent and at least partly involved a reduction of glial proliferation, as a caffeine-induced decrease of 5-bromodeoxyuridine incorporation was observed in the dentate gyrus and subventricular zone (25.8% and 26.6%, respectively) and no increase of programmed cell death (cleaved caspase-3 immunostaining) was observed at postnatal day 7. This effect could be reproduced with an antagonist of A(2a) adenosine receptor (A(2a)R) and was blocked by co-injection of an agonist. These results suggest that postnatal caffeine treatment might induce an alteration of astrocytogenesis via A(2a)R blockade during brain development. Although no obvious neuritic abnormalities (microtubule-associated protein 2 and synaptophysin immunostaining) were observed, postnatal caffeine treatment could have long-term consequences on brain function.

Dose-finding study of ibuprofen in patent ductus arteriosus using the continual reassessment method

OBJECTIVE

Intravenous ibuprofen (IBU) has been found to be as effective as indomethacin for the treatment of patent ductus arteriosus (PDA) in preterm infants and has been associated with fewer adverse effects in comparative phase III studies. The dose regimen used (10-5-5 mg/kg/day) was based on limited pharmacokinetic data and no phase II study was available to determine the optimal dose of IBU for this indication. The present study was designed to determine the minimum effective dose regimen (MEDR) of IBU (one course) required to close ductus arteriosus in preterm infants.

METHOD

A double-blind dose-finding study was conducted using the continual reassessment method, a Bayesian sequential design. Two distinct target closure rates were initially chosen according to postmenstrual age (PMA) at birth: 80% in infants with a PMA of 27-29 weeks, and 50% in infants with a PMA < 27 weeks. Forty neonates (20 in each PMA group) with PDA were treated between days 3 and 5 of life. Four different dose regimens were tested: loading doses of 5, 10, 15 or 20 mg/kg, followed by two doses (1/2 loading dose) at 24-h intervals. Efficacy was evaluated by echocardiography 24 h after the third infusion.

RESULTS

In infants with a PMA of 27-29 weeks, the estimated MEDR was 10-5-5 mg/kg with a final estimated probability of success of 77% (95% credibility interval: 56-92%). The 15-7.5-7.5 mg/kg dose regimen had a better estimated probability of success (88%, 95% credibility interval: 68-97%), but resulted in more minor renal adverse effects. In contrast, in infants with a PMA < 27 weeks, the estimated MEDR was 20-10-10 mg/kg with an estimated probability of success of 54.8% (95% credibility interval: 22-84%), whereas the conventional dose regimen resulted in a low estimated probability of success (30.6%, 95% credibility interval: 13-56%). In these infants, compared with those with a PMA of 27-29 weeks, minor renal adverse effects were more frequent from the 10-5-5 mg/kg/day dose regimen and did not appear to be clearly dose related.

CONCLUSION

This study confirms that the currently recommended dose regimen (10-5-5 mg/kg) of IBU is associated with a high closure rate (80%) and few adverse effects in premature infants with a PMA of 27-29 weeks. The failure rate was much higher below 27 weeks. A higher dose regimen (20-10-10 mg/kg) might achieve a higher closure rate. However, tolerability and safety of this dose regimen should be assessed in a larger population before considering the use of these doses for ductus arteriosus closure.

Increased incidence of necrotizing enterocolitis in premature infants born to HIV-positive mothers

OBJECTIVE

To examine if being born to an HIV-positive mother may increase the risk of necrotizing enterocolitis in premature infants.

DESIGN

Case-control study.

SETTING

Neonatal unit of a level 3 perinatal centre.

METHODS

: Over a period of 8.5 years, all cases of necrotizing enterocolitis occurring in premature infants admitted to the neonatal unit were identified. For each case, two controls were retrospectively chosen that matched for postmenstrual age at birth, intrauterine growth and year of birth. Perinatal characteristics were studied in all infants.

MAIN RESULTS

There were 79 cases of necrotizing enterocolitis, which were compared with 158 controls. Using multivariate analysis, multiple pregnancy [odds ratio (OR), 2.29; 95% confidence interval (CI), 1.23-4.25; P = 0.009], abnormal umbilical artery velocity (OR, 2.21; 95% CI, 1.08-4.54; P = 0.030), abnormal fetal heart rate (OR, 2.14; 95% CI, 1.05-4.36; P = 0.036) and HIV-positive mother (OR, 6.63; 95% CI, 1.26-34.8; P = 0.025) were significantly more frequent in fetuses who subsequently developed necrotizing enterocolitis.

CONCLUSIONS

This preliminary report suggests an association, not previously reported, between maternal HIV-positive status and an increased risk of necrotizing enterocolitis in premature infants. Despite the limitations of this study, we suggest that premature newborn infants of HIV-positive mothers should be monitored very carefully for a possible increased risk of necrotizing enterocolitis.

Sevrage de l’oxygène

Oxygen weaning is a controversial problem which can be summarized in three questions: what do we expect from oxygen supplementation? what are the optimal targets? with what sort of monitoring? We shall try to evaluate these different questions assuming the uncertainty of the proposed answers and the short-lived character of them.

Critères de réanimation des prématurissimes en salle de naissance : quel discours en anténatal ?

The resuscitation of extremely preterm infants presents complex medical, social and ethical issues for the families and the health professionals. The principle of a systematic resuscitation "temporary intensive care" does not prohibit the question of a limit in terms of gestational age and birth weight. In France, a do not resuscitate order (comfort care alone) is appropriate for newborns weighing less than 500g and/or with a gestational age of less than 24 weeks' since the mortality is nearly 100%. The survival of infants born at 24 weeks' gestational age remains low with significant risks of chronic medical problems and neurodevelopmental disabilities. The decisions regarding the extent of resuscitative efforts depend on antenatal factors, condition of the neonate at birth and the parental opinion. Before the delivery, parents should receive appropriate information about survival and risks of adverse long-term outcome. The physician should follow the parents' desires whenever the parents' decision would not obviously violate the infants' best interests. However, they must be informed that decisions about neonatal management made before the delivery can have to be changed in the delivery room, depending on the condition of the neonate at birth. At 25 weeks of gestational age, the prognosis is better and the resuscitation should be more intensive.

Congenital idiopathic chylothorax in neonates: chemical pleurodesis with povidone-iodine (Betadine)

Chylothorax is defined as an accumulation of chyle in the pleural space. This condition usually occurs after an operation, the congenital idiopathic form being rare (1/15<thin>000 births). Recovery is observed within four to six weeks of diagnosis in most cases. Treatment is either conservative or surgical. Four cases are reported of congenital chylothorax (three idiopathic, one accompanied by diffuse lymphangectasia) managed by chemical pleurodesis (intrapleural injection of povidone-iodine). Tolerance was satisfactory: unaltered thyroid function in the three cases explored; one case of transient generalised oedema. Treatment was deemed successful in three of the four cases. One child died from renal failure (unrelated to the chemical pleurodesis). Pleurodesis by povidone-iodine appears to be well tolerated and may represent a good alternative to mechanical abrasion or surgery for congenital idiopathic chylothorax. Its use for refractory chylothorax may also decrease the morbidity related to prolonged hospital stay.

Impact of delayed repair and elective high-frequency oscillatory ventilation on survival of antenatally diagnosed congenital diaphragmatic hernia: first application of these strategies in the more "severe" subgroup of antenatally diagnosed newborns

OBJECTIVE

a) To analyze the influence of a new management strategy on the outcome of neonates with antenatally diagnosed congenital diaphragmatic hernia (CDH); b) to determine early prognosis respiratory factors with the new strategy.

DESIGN

Retrospective study.

SETTING

Level III perinatal center.

PATIENTS AND METHOD

Between 1985 and 1997, 51 consecutive neonates with antenatally diagnosed CDH were admitted to our level III neonatal intensive care unit. Before 1992 (period 1; n = 19), we used conventional mechanical ventilation and early surgery requiring transfer. Since 1992 (period 2; n = 32), we prospectively tested a new approach including (a) systematically use of high-frequency oscillatory ventilation (HFOV) regardless of the initial clinical severity, (b) delayed surgery following stabilization requiring transfer to a different surgical unit, but (c) no transfer of unstable patients with surgery under HFOV in our neonatal intensive care unit (n = 10). The two cohorts were comparable in terms of potential ante and postnatal prognostic indicators.

RESULTS

Survival was improved with the new strategy: 21/32 (66%) vs. 5/19 (26%); P < 0.02. This improvement between periods 1 and 2 was due to a decrease in both preoperative and postoperative deaths in the later period. The better survival during period 2 was associated with the appearance of very late deaths, frequent pleural effusions, and the survival of more severe forms having evolved to a chronic respiratory insufficiency. Survivors were ventilated for longer time with longer duration of oxygen supplementation. The best oxygenation index (OI), alveolar arterial difference and oscillation amplitude (P/P) during the first 24 h, but not the best PaCO2, were the most reliable prognostic indicators during period 2. An OI < or = 10 with a P/P < or = 55 cmH2O was associated with a very good prognosis (94% survival).

CONCLUSIONS

The prognosis of antenatally diagnosed CDH was improved by systematic HFOV on admission, no systematic transfer, and delayed surgery. This improvement is associated with modification of postnatal outcome.

Estimation of inspiratory pressure drop in neonatal and pediatric endotracheal tubes

Endotracheal tubes (ETTs) constitute a resistive extra load for intubated patients. The ETT pressure drop (DeltaP(ETT)) is usually described by empirical equations that are specific to one ETT only. Our laboratory previously showed that, in adult ETTs, DeltaP(ETT) is given by the Blasius formula (F. Lofaso, B. Louis, L. Brochard, A. Harf, and D. Isabey. Am. Rev. Respir. Dis. 146: 974-979, 1992). Here, we also propose a general formulation for neonatal and pediatric ETTs on the basis of adimensional analysis of the pressure-flow relationship. Pressure and flow were directly measured in seven ETTs (internal diameter: 2.5-7.0 mm). The measured pressure drop was compared with the predicted drop given by general laws for a curved tube. In neonatal ETTs (2.5-3.5 mm) the flow regime is laminar. The DeltaP(ETT) can be estimated by the Ito formula, which replaces Poiseuille's law for curved tubes. For pediatric ETTs (4.0-7.0 mm), DeltaP(ETT) depends on the following flow regime: for laminar flow, it must be calculated by the Ito formula, and for turbulent flow, by the Blasius formula. Both formulas allow for ETT geometry and gas properties.