Compromised Newborns Research Articles

Resuscitation of Term Compromised and Asphyctic Newborns: Better with Intact Umbilical Cord?

The authors hypothesize that particularly severely compromised and asphyctic term infants in need of resuscitation may benefit from delayed umbilical cord clamping (after several minutes). Although evidence is sparse, the underlying pathophysiological mechanisms support this assumption. For this review the authors have analyzed the available research. Based on these data they conclude that it may be unfavorable to immediately clamp the cord of asphyctic newborns (e.g., after shoulder dystocia) although recommended in current guidelines to provide quick neonatological support. Compression of the umbilical cord or thorax obstructs venous flow to the fetus more than arterial flow to the placenta. The fetus is consequently cut off from a supply of oxygenated, venous blood. This may cause not only hypoxemia and consecutive hypoxia during delivery but possibly also hypovolemia. Immediate cord clamping may aggravate the situation of the already compromised newborn, particularly if the cord is cut before the lungs are ventilated. By contrast, delayed cord clamping leads to fetoplacental transfusion of oxygenated venous blood, which may buffer an existing acidosis. Furthermore, it may enhance blood volume by up to 20%, leading to higher levels of various blood components, such as red and white blood cells, thrombocytes, mesenchymal stem cells, immunoglobulins, and iron. In addition, the resulting increase in pulmonary perfusion may compensate for an existing hypoxemia or hypoxia. Early cord clamping before lung perfusion reduces the preload of the left ventricle and hinders the establishment of sufficient circulation. Animal models and clinical trials support this opinion. The authors raise the question whether it would be better to resuscitate compromised newborns with intact umbilical cords. Obstetric and neonatal teams need to work even closer together to improve neonatal outcomes.

Sex-Specific Survival, Growth, Immunity and Organ Development in Preterm Pigs as Models for Immature Newborns.

Background: After very preterm birth, male infants show higher mortality than females, with higher incidence of lung immaturity, neurological deficits, infections, and growth failure. In modern pig production, piglets dying in the perinatal period (up to 20%) often show signs of immature organs, but sex-specific effects are not clear. Using preterm pigs as model for immature infants and piglets, we hypothesized that neonatal survival and initial growth and immune development depend on sex.Methods: Using data from a series of previous intervention trials with similar delivery and rearing procedures, we established three cohorts of preterm pigs (90% gestation), reared for 5, 9, or 19 days before sample collection (total n = 1,938 piglets from 109 litters). Partly overlapping endpoints among experiments allowed for multiple comparisons between males and females for data on mortality, body and organ growth, gut, immunity, and brain function.Results: Within the first 2 days, males showed higher mortality than females (18 vs. 8%, P < 0.001), but less severe immune response to gram-positive infection. No effect of sex was observed for thermoregulation or plasma cortisol. Later, infection resistance did not differ between sexes, but growth rate was reduced for body (up to −40%) and kidneys (−6%) in males, with higher leucocyte counts (+15%) and lower CD4 T cell fraction (−5%) on day 9 and lower monocyte counts (−18%, day 19, all P < 0.05). Gut structure, function and necrotizing enterocolitis (NEC) incidence were similar between groups, but intestinal weight (−3%) and brush-border enzyme activities were reduced at day 5 (lactase, DPP IV, −8%) in males. Remaining values for blood biochemistry, hematology, bone density, regional brain weights, and visual memory (tested in a T maze) were similar.Conclusion: Following preterm birth, male pigs show higher mortality and slower growth than females, despite limited differences in organ growth, gut, immune, and brain functions. Neonatal intensive care procedures may be particularly important for compromised newborns of the male sex. Preterm pigs can serve as good models to study the interactions of sex- and maturation-specific survival and physiological adaptation in mammals.

Dysregulated Mucosal Immunity and Associated Pathogeneses in Preterm Neonates.

Many functions of the immune system are impaired in neonates, allowing vulnerability to serious bacterial, viral and fungal infections which would otherwise not be pathogenic to mature individuals. This vulnerability is exacerbated in compromised newborns such as premature neonates and those who have undergone surgery or who require care in an intensive care unit. Higher susceptibility of preterm neonates to infections is associated with delayed immune system maturation, with deficiencies present in both the innate and adaptive immune components. Here, we review recent insights into early life immunity, and highlight features associated with compromised newborns, given the challenges of studying neonatal immunity in compromised neonates due to the transient nature of this period of life, and logistical and ethical obstacles posed by undertaking studies newborns and infants. Finally, we highlight how the unique immunological characteristics of the premature host play key roles in the pathogenesis of diseases that are unique to this population, including necrotizing enterocolitis and the associated sequalae of lung and brain injury.

Stabilisasi dan Transportasi Neonatus

Approximately 10 percent of newborns will require some level assistance with breathing, and a few (&lt;1 percent) will require resuscitation in the birthing room. After resuscitation, many of these newborns require acute transport to a different facility. Stabilisation prior to transport is essential and the principles of neonatal transportation are independent of distance. Hypothermia and hypoglycaemia should be prevented in neonates during transport as they adversely affect the outcome. This article provides an overview of principles from the STABLE Program, which guides clinicians in providing postresuscitation care and pretransport and during transport stabilization for compromised newborns.

Providing Ventilation to the Newborn Infant in the Delivery Room

* Abbreviations: BPD: : bronchopulmonary dysplasia CPAP: : continuous positive airway pressure ETT: : endotracheal tube FiO2: : fraction of inspired oxygen NRP: : Neonatal Resuscitation Program PEEP: : positive end-expiratory pressure PIP: : peak inspiratory pressure PPV: : positive pressure ventilation Ventilating the lungs of the newborn is the most important element of neonatal resuscitation. Recognizing and delivering effective ventilation remains a critical skill for all attendants at a newborn delivery. After completing this article, readers should be able to: 1. Recognize the critical role of ventilation in the delivery room. 2. Identify the signs of effective ventilation. 3. Understand devices that deliver positive pressure ventilation. The Neonatal Resuscitation Program (NRP) emphasizes the importance of ventilation in the resuscitation of compromised newborns. (1) The purpose of this review is to explain the physiologic necessity of ventilation in newborn resuscitation and to describe the different methods of providing ventilation in the delivery room. We will also discuss the assessment of ventilation to ensure efficacy. Blood flow during fetal life is focused on perfusion of the brain and major organs with oxygenated blood and avoidance of fluid-filled lungs (Fig 1A). This blood flow is dependent on oxygenated umbilical venous blood from the placenta. Figure 1. A. Fetal circulation path. Only a small amount of blood travels to the lungs. There is no gas exchange in the lung. Blood returning to the right side of the heart from the umbilical vein has the highest oxygen saturation. B. Transitional circulation path. The infant breathes, pulmonary resistance decreases and blood travels to the lungs. Gas exchange occurs in the lungs. Blood returning to the left side of the heart from the lungs has the highest oxygen saturation. (From Textbook of Neonatal Resuscitation, 7th ed. , 2016. Reproduced with permission from the American Academy of Pediatrics.) Normal cardiopulmonary transition of the newborn from intra- to extrauterine life requires a rapid and complex process of fetal lung fluid clearance, expansion of the alveolar spaces with air, and redirection of cardiac output toward the lungs. All of these events take place independent of intervention …

Supplementation with Lactobacillus paracasei or Pediococcus pentosaceus does not prevent diarrhoea in neonatal pigs infected with Escherichia coli F18.

Infectious diarrhoea is a worldwide problem in newborns. Optimal bacterial colonisation may enhance gut maturation and protect against pathogenic bacteria after birth. We hypothesised that lactic acid bacteria (LAB) administration prevents pathogen-induced diarrhoea in formula-fed newborns. Newborn caesarean-delivered, colostrum-deprived term piglets on parenteral nutrition for the first 15 h, were used as models for sensitive newborn infants. A commercially available probiotic strain, Lactobacillus paracasei F19 (LAP, 2·6×108 colony-forming units (CFU)/kg per d) and a novel LAB isolate, Pediococcus pentosaceus (PEP, 1·3×1010 CFU/kg per d), were administered for 5 d with or without inoculation of the porcine pathogen, Escherichia coli F18 (F18, 1010 CFU/d). This resulted in six treatment groups: Controls (n 9), LAP (n 10), PEP (n 10), F18 (n 10), F18-LAP (n 10) and F18-PEP (n 10). The pathogen challenge increased diarrhoea and density of F18 in the intestinal mucosa (P<0·05). LAB supplementation further increased the diarrhoea score, relative to F18 alone (P<0·01). Intestinal structure and permeability were similar among groups, whereas brush border enzymes were affected in variable intestinal regions with decreased activities in most cases after F18 and LAB inoculation. Bacterial density in colon mucosa increased after F18 inoculation (P<0·05) but was unaffected by LAB supplementation. In colon contents, acetic and butyric acids were increased by PEP (P<0·05). The LAB used in this study failed to reduce E. coli-induced diarrhoea in sensitive newborn pigs. In vulnerable newborns there may be a delicate balance among bacterial composition and load, diet and the host. Caution may be required when administering LAB to compromised newborns suffering from enteric infections.

Ventilation fraction during the first 30 s of neonatal resuscitation

AimApproximately 5% of newborns receive positive pressure ventilation (PPV) for successful transition. Guidelines urge providers to ensure effective PPV for 30–60s before considering chest compressions and intravenous therapy. Pauses in this initial PPV may delay recovery of spontaneous respiration. The aim was to find the ventilation fraction during the first 30s of PPV in non-breathing babies. MethodsProspective observational study in two hospitals in Norway. All newborns receiving PPV immediately after delivery were included. Cameras with motion detectors were installed at every resuscitation bay capturing both expected and unexpected compromised newborns. We determined the cumulative number of seconds with PPV efforts excluding pauses in infants without spontaneous breathing and reported ventilation fraction during the first minute. Data are presented as median (IQR). Results110 of 3508 (3%) newborns received PPV and were filmed in the resuscitation bays. PPV started 42 (18–78)s after arrival at the resuscitation bay and median duration was 100 (35–225)s. Forty-eight infants (44%) were ventilated continuously, or with minimal pause (ventilation fraction >90%) during the first 30s of PPV. For the remaining 62 infants ventilation fraction was 60% (39–75). PPV was interrupted due to adjustments, checking heart rate, stimulation, administration of CPAP and suctioning. ConclusionIn 56% of the neonatal resuscitations interruptions in ventilation are frequent with 60% ventilation fraction during the first 30s of PPV. Eliminating disruption for improved quality of PPV delivery should be emphasized when training newborn resuscitation providers.

Postresuscitation Care and Pretransport Stabilization of Newborns Using the Principles of STABLE Transport.

The practice of perinatal regionalization is designed to ensure that newborns are born in facilities with a care level designation that is consistent with expected pregnancy outcomes. Regionalization practices have resulted in lower neonatal mortality and morbidity rates. However, despite regionalization efforts, approximately 10 percent of newborns will require some level assistance with breathing, and a few (<1 percent) will require resuscitation in the birthing room. After resuscitation, many of these newborns require acute transport to a different facility. This column provides an overview of principles from the STABLE Program, which guides clinicians in providing postresuscitation care and pretransport stabilization for compromised newborns.

Postresuscitation Care and Pretransport Stabilization of Newborns Using the Principles of STABLE Transport

The practice of perinatal regionalization is designed to ensure that newborns are born in facilities with a care level designation that is consistent with expected pregnancy outcomes. Regionalization practices have resulted in lower neonatal mortality and morbidity rates. However, despite regionalization efforts, approximately 10 percent of newborns will require some level assistance with breathing, and a few (<1 percent) will require resuscitation in the birthing room. After resuscitation, many of these newborns require acute transport to a different facility. This column provides an overview of principles from the STABLE Program, which guides clinicians in providing postresuscitation care and pretransport stabilization for compromised newborns.

Crocodiles and neonatal resuscitation

Crocodiles and neonatal resuscitation

Strategies for Reducing the Risk of Malpractice Litigation in Perinatal Nursing

Perinatal nurses are involved in malpractice litigation most often as employees of a hospital being sued. Contemporary case examples from malpractice claims provide the foundation for examining how perinatal nurses can become the focus of such litigation. Increasing demand for individual nurse accountability, cost containment strategies that require nurses to broaden their scope of practice and to supervise unlicensed assistive personnel, increasing use of medical technologies, and the reality of compromised newborns and unexplained outcomes place perinatal nurses at risk for continued malpractice vulnerability. Specific strategies for risk reduction can be used by the individual nurse and the institution in relation to hospital policies and procedures, application of the nursing process, documentation, birth videos, and delegation of tasks to unlicensed assistive personnel.

Body weight distribution and organ size in newborn swine (sus scrofa domestica) — A study describing an animal model for asymmetrical intrauterine growth retardation

Normal growth is the expression of the genetic potential to growth which is neither abnormally constrained nor promoted by internal or external factors. Restricted fetal growth is common in human pregnancy and is associated with increased perinatal morbidity and mortality. Because of ethical restrictions, pathogenetical studies are necessarily dependent on appropriate animal models. In the studies presented, evidence will be provided that the naturally occurring distribution of body weight in newborn piglets, obtained from n = 512 newborn piglets (about 12 hours old) in 50 consecutive deliveries in the breed cohort of the mixed German domestic breed - "Deutsches Land-/Edelschwein" gives an appropriate sampling for providing a statistically reliable basis with which to determine different degrees of fetal growth for further pathophysiological studies intended. A strong inverse correlation (r = -0.66, p < 0.05) was found between the mean weight of the litter and the number of piglets per litter, and an inverse correlation (r = -0.64, p < 0.05) was found between the lowest weight of the littermate and the number of piglets per litter. Moreover, gravimetric investigations were made into an additional 53 one-day-old newborn piglets reflecting the naturally occurring birth weight distribution determined. A marked linear correlation between body weights and various organ weights was found (values of the correlation coefficient amounted to between 0.45 and 0.98; p < 0.05). The lowest variation of organ weights was found in the CNS structures (0.68-1.33). Skeleton and heart exhibited similar ranges of weight variation (0.35-1.81 and 0.38-2.00 of the means) to body weight (0.38-1.77 of the means). This was also expressed in the regression analysis, because the slope values were 0.99 and 0.97 respectively. The hormonal glands investigated, the kidneys, and the abdominal parenchymal organs exhibited the largest ranges of weight variation. Moreover, regression analysis gives evidence that the weight restriction was more pronounced than expected concerning respective body weight. This is indicated by slope values > 1 in almost all of those organs. Plasma concentration of IGF-1 showed an inverse correlation with body weight (r = -0.42; p < 0.05, fig 4). IGF-1 concentration of intrauterine growth retarded (IUGR) newborn piglets was in the mean nearly double that of normal weight animals (p < 0.05) and the brain weight to liver weight ratio was increased more than 2.5 times in IUGR newborn (fig 5 A, p < 0.05). This investigation provides information on the naturally occurring body weight distribution of one-day-old piglets, which was obviously a result of epigenetic factors. Gravimetrical estimation showed clearly that body weight variety is most probably caused by alterations of placental functioning. Severe alterations resulted in asymmetrical growth retardation, which was proved by a significantly increased brain to liver ratio in animals with a body weight < 10th centile. Thus, evidence is provided that naturally occurring asymmetrical intrauterine growth restricted newborn piglets can be identified simply by body weight measurement, so that convenient conditions are given for pathogenetically motivated studies on intrauterine compromised newborns.

Selective nontreatment of handicapped newborns: A critical essay

The neonatal intensive care unit is the site of some of the most dramatic technology, complex decision-making and costly activity in the current range of medical institutions. Thus, the decisions made there are particularly visible, and of concern to a society which has increasingly scrutinized and challenged medical practices. Questions of marginal utility and cost-benefit relationships are becoming increasingly prominent. These concerns are heightened by the social and political tensions over issues of the time of initiation of life, quality of life, and assurances of equity for those less well off or handicapped from birth. Robert Weir's book, Selective Nontreatment of Handicapped Newborns, successfully summarizes the current dilemmas and identifies areas of uncertainty and lack of knowledge which cloud the decision-making processes. The book reviews the positions of the major protagonists of the last several years; inevitably, their positions will undergo continuous evolution in response to new data and vigorous political and public policy activity. Weir appropriately identifies the difficulty in arriving at an accurate prognosis as an important and prominent problem in decision-making about defective newborns. The population of surviving, compromised newborns is relatively unfamiliar and their problems remain largely unstudied. Weir's discussion of the desirability of the establishment of Infant Care Review Committees in those institutions which care for defective and handicapped newborns thoughtfully concludes that such committees are, on the balance, desirable. As experience accumulates with Infant Care Review Committees, they should serve the positive purpose of generating open discussion of legitimate disagreements. These committees will provide a forum in which decision-makers can disclose uncertainty, consider alternatives, and receive counsel. To achieve this purpose, the committees must be appropriately structured, and explicitly defined as deliberative rather than judgmental in intent. Infant Care Review Committees should ideally serve the interests both of society and of medicine in reassuring the public that critical decisions about defective newborns are not made capriciously, and are not influenced by professional coercion or conspiracy. The increased visibility of the decision-making process may help to restore the eroding public confidence in the medical professions as well as to increase the level of knowledge among both professionals and lay people concerning the difficult choices faced in contemporary neonatal medicine.