Neonatal Intensive Care Research Articles

A survey on management practices of hypotension in preterm neonates: an Indian perspective

BackgroundHypotension is a common entity in the neonatal intensive care unit (NICU) and is reported in 24%–50% of preterm infants with birth weight less than 1,500 g. Rapid diagnosis and aggressive management is crucial to reduce its detrimental effects on end-organs especially the brain. Physicians often rely on blood pressure alone as a reliable indicator of tissue perfusion, but variations exist in the definition of this crucial parameter. There are also practice variations in the use of diagnostic tools and management modalities among physicians.MethodologyA physician-based cross-sectional survey of management practices of hypotension in preterm neonates in Indian NICUs was conducted using an online survey tool. The questionnaire addressed diagnostic criteria used, utility of echocardiography for the assessment of hypotension, and management strategies used, such as volume expansion, inotropes and steroids.ResultsThree hundred and twenty physicians, working predominantly in Level III NICUs, responded to the survey. The practice of delayed cord clamping was followed in the units of 78% respondents. Only 44% respondents had an institutional written protocol for the management of hypotension. The criteria for the diagnosis of hypotension varied, with 52% using mean blood pressure (BP) less than gestational age as the criteria. Capillary refill time, blood pressure and heart rate were the most common clinical criteria used. 85% respondents used echocardiography in the NICU, but only 73% utilised it for assessment of a hypotensive neonate. Physicians preferred a ‘volume-inotrope-echo-steroid’ strategy, with 85% respondents using volume expansion. Dopamine was the preferred first line inotrope, followed by norepinephrine and low-dose epinephrine.ConclusionThis survey reflects significant variations in practice amongst neonatal physicians in India. Bedside targeted echocardiography needs to be better utilised as a vital tool to determine the pathophysiology of disease and hemodynamic monitoring in the management of hypotension in neonates. While further research is needed on outcome-oriented objectives, awareness and dissemination of already existing guidelines would be useful to standardize clinical practice.

Associations of maternal sedentary behavior and physical activity levels in early to mid-pregnancy with infant outcomes: A cohort study.

Physical activity during pregnancy is beneficial for the woman and the fetus. However, non-objective methods are often used to measure physical activity levels during pregnancy. This study aimed to evaluate objectively measured maternal early to mid-pregnancy sedentary behavior and physical activity in relation to infant well-being. This cohort study included 1153 pregnant women and was performed at Uppsala University Hospital, Uppsala, Sweden, between 2016 and 2023. Sedentary behavior and physical activity levels were measured by accelerometers during 4-7 days in early to mid-pregnancy. Outcome measures were infant birthweight standard deviation score, small-for-gestational-age, large-for-gestational-age, preterm birth (<37 weeks' gestation), spontaneous preterm birth, iatrogenic preterm birth, Apgar <7 at 5 min of age, umbilical artery pH ≤7.05, and admission to the neonatal intensive care unit (NICU). There were no associations of sedentary behavior and physical activity levels with infant birthweight standard deviation score, small-for-gestational-age, or large-for-gestational-age. After adjustment for BMI, age, smoking, parity, maternal country of birth, and a composite of pre-pregnancy disease, the most sedentary women had higher odds of preterm birth (adjusted odds ratio (AOR) 2.47, 95% confidence interval (CI) 1.17-5.24, p = 0.018), and NICU admission (AOR 1.93, CI 1.11-3.37, p = 0.021) than the least sedentary women. The most physically active women had lower adjusted odds for NICU admission (AOR 0.45, CI 0.26-0.80, p = 0.006) than the least physically active women. Objectively measured levels of sedentary behavior and physical activity in early to mid-pregnancy were not associated with standardized infant birth size. Sedentary behavior was associated with an increased likelihood of preterm birth and NICU admission, while high level of physical activity was associated with a decreased likelihood of admission to NICU.

Routine Transvaginal Ultrasound at the Time of the Anatomy Scan: To Do or Not To Do?

There are no universal guidelines for transvaginal ultrasound (TVUS) at the time of the anatomy scan. TVUS can provide information on placental location and cervical length (CL) but may lead to more interventions. As a quality assurance initiative, a universal TVUS (UTVUS) protocol at the time of the anatomy scan was started at our institution. This study was conducted to assess whether there was a decrease in preterm birth (PTB), postpartum hemorrhage (PPH), and neonatal intensive care unit (NICU) admission once UTVUS was implemented. This was a retrospective cohort study performed on singleton gestations from February 2021 to January 2022. In the first 6 months of the study period, patients only had TVUS based on risk factors (pre group). In the second half of the study period, UTVUS was implemented at the time of the anatomy scan (post group). A total of 2,118 patients were included in the study. There were 1,037 patients in the pre group, of which 161 underwent TVUS based on high-risk factors (history of the cervical procedure, history of prior PTB, and placenta appearing low lying or cervix appearing short on abdominal ultrasound). The post group/UTVUS included 1,081 patients. Patients in the pre group had statistically significantly earlier gestational age at first TVUS (p < 0.0001), were less likely to have had a prior PTB <36 weeks (p = 0.03), and were more likely to have a history of cervical procedure (p = 0.0006) than patients in the post group. There was an increased use of vaginal progesterone in the UTVUS with 33 patients (as opposed to 10 patients in the pre group; p = 0.0007). The proportion of patients with PTB, PPH, or NICU admission did not significantly differ between the two groups even after adjusting for cofounders (p > 0.05). Our data show that UTVUS did not decrease the adverse pregnancy outcomes. In addition, the implementation of UTVUS adds more discomfort for a patient, more time to the patient's scan, and is an additional cost. Therefore, surveillance by abdominal ultrasound and adding TVUS based on risk factors may be a reasonable alternative. · UTVUS showed no difference between CLs.. · There is not sufficient evidence to conclude a difference between PTB or PPH in the two groups.. · There was significantly more placenta previa diagnosed in the post group, yet most resolved..

Fatherhood in the context of preterm birth: A narrative review of contemporary research evidence

AbstractLong focused on maternal roles in infancy, research is now exploring fathers' contributions to child development. Current public policy emphasizes early prevention and intervention for child and parent well‐being, especially for at‐risk infants such as those born prematurely. A literature review was conducted following the approach of a narrative review, to examine fatherhood in the context of preterm birth, highlighting the stress and emotional vulnerability experienced by fathers of preterm infants. Promoting early paternal presence and involvement in infant care helps fathers cope with this emotionally challenging experience. Despite limited data on premature fatherhood, fathers are active partners in dyadic interactions and play a significant role in their infant's neonatal intensive care unit journey and family dynamics. The discussion underscores the importance of father‐focused interventions and the paternal contribution to child development, framed within the authors' proposed integrative and developmental model of the family triad.

Early detection and management of congenital pulmonary airway malformation in a newborn with stable clinical course

Introduction: Congenital pulmonary airway malformation (CPAM) is a rare developmental lung anomaly characterized by cystic lung lesions, constituting about 25% of congenital pulmonary anomalies. It typically occurs sporadically and is not significantly associated with race, age, or other maternal factors. The prenatal course of CPAM can vary based on factors such as lesion size, mediastinal shift, and associated anomalies. While the overall prognosis is generally favorable in the absence of severe complications like hydrops fetalis, which can adversely affect outcomes, management strategies include corticosteroids, thoracoamniotic shunt (TAS), and, in severe cases, open fetal surgery or the EXIT procedure. Postnatal surgical excision usually offers a curative outcome with an excellent prognosis. Without surgical intervention, there are risks of recurrent infections and, rarely, malignant transformation. Effective prenatal detection significantly impacts clinical decision-making and neonatal outcomes, and the necessity and timing of surgery for asymptomatic infants remain subjects of ongoing debate, underscoring the need for personalized, multidisciplinary care. Case Report: A female infant, delivered at 38 weeks via Cesarean section, was diagnosed with CPAM following routine prenatal ultrasound. Presence of extensive cystic regions in the right lung confirmed the diagnosis and a CPAM volume ratio (CVR) of 0.37 indicated a low risk of severe complications. The pregnancy was largely uneventful, with maternal chronic hypertension managed by Nifedipine and mild intermittent asthma. Postnatal chest radiography corroborated the CPAM diagnosis, while an abdominal ultrasound investigated intrahepatic calcifications. Maternal screening for cytomegalovirus and toxoplasmosis yielded negative results, and postnatally, the infant also tested negative for both infections. The neonate, though asymptomatic and stable, required close monitoring in the neonatal intensive care unit to prevent potential respiratory compromise. Conclusion: Advances in prenatal imaging have greatly improved the early detection and management of CPAM, allowing for targeted neonatal care and strategic planning. This case highlights the importance of a multidisciplinary approach involving obstetricians, maternal-fetal medicine specialists, neonatologists, and pediatric thoracic surgeons in the effective management of CPAM. Early identification and diligent postnatal monitoring are essential for ensuring optimal outcomes and minimizing the risk of complications. The coordinated care and strategic decision-making exemplified in this case underscore the potential for enhanced neonatal health and long-term well-being through comprehensive management of congenital anomalies.

Incidence of Acute Kidney Injury in Asphyxiated Neonates and Its Relationship with Severity of Hypoxic-Ischemic Encephalopathy: Experience from a Medical College Hospital, Bangladesh.

Background: Perinatal asphyxia (PNA) is one of the leading causes of neonatal morbidity and mortality in Bangladesh. Among others, hypoxic-ischemic encephalopathy and acute kidney injury are two common complications of perinatal asphyxia. Morbidity and mortality increases when PNA is associated with these two complications. Objective: The objectives of the study were to determine the incidence of acute kidney injury (AKI) among asphyxiated neonates associated with various stages of hypoxic-ischemic encephalopathy (HIE) and to find out the relationship between AKI and HIE stages. Materials and Methods: This cross-sectional study was conducted in the neonatal unit of Jalalabad Ragib-Rabeya Medical College Hospital, Sylhet, between the periods of January 2018 and June 2018. A total of 130 newborns admitted in the neonatal ward within 24 hours of age with perinatal asphyxia and hypoxic-ischemic encephalopathy were included in the study by the consecutive sampling method. Serum creatinine level was measured at 24 hours after birth. AKI was considered if serum creatinine level was ³1.5 mg/dL. Result: Among 130 neonates, 35.4% had HIE stage-I, 56.1% had HIE stage-II and 8.5% had HIE stage-III. AKI was present in 12.3% of the asphyxiated neonates. There were no significant relationship between AKI and demographic variables like gender, birth weight, and place of delivery, mode of delivery and parity of the mothers. AKI was significantly associated with HIE stage-II and stage-III compared to HIE stage-I (p=0.02). The mean serum creatinine level was significantly higher in HIE stage-II and stage-III than HIE stage-I (p=0.001). Among the study neonates, 28.5% died. There was no significant relationship between death and AKI (p=0.74). The Pearson correlation test revealed no statistically significant relationship between serum creatinine levels and hospital stay. Conclusion: The incidence of acute kidney injury was 12.3% among asphyxiated newborn associated with HIE. Frequency of AKI significantly associated with severity of HIE. BANGLADESH J CHILD HEALTH 2023; VOL 47 (1) : 24-29

Supplemental oxygen alters the pentose phosphate pathway in the developing mouse brain through SIRT signaling

Oxygen support plays a critical role in the management of preterm infants in neonatal intensive care units. On the other hand, the possible effects of oxygen supplementation on cellular functions, specifically glucose metabolism, have been less understood. Purposeof the study is to investigate whether supplemental oxygen alters glucose metabolism and pentose phosphate pathway (PPP) activity in the brain tissue and its relevance with silent information regulator proteins (SIRT) pathway. For this purpose, newborn C57BL/6 pups were exposed to 90% oxygen from birth until postnatal day 7 (PN7) and metabolites of glysolysis and PPP were investigated through metabolomics analysis. SIRT1, glucose-6-phosphate dehydrogenase (G6PD) and transaldolase (TALDO) proteins were examined immunohistochemically and molecularly in the prefrontal and hippocampus regions of the brain. Later on, SIRT1 inhibition was carried out.Our results indicate that supplemental oxygen causes an increase in PPP metabolites as well as activation of G6PD enzyme in the brain tissue, which is reversed by SIRT1 inhibition. Our study underlines a connection between supplemental oxygen, glucose metabolism, PPP pathway and the SIRT signaling. Understanding these intricate relationships not only deepens our knowledge of cellular physiology but also holds promise for therapeutic interventions for creating neuroprotective strategies in preterm brain.

Neuropromotion in the neonatal intensive care unit: A step up from neuroprotection and a new norm.

Neuropromotion in the neonatal intensive care unit: A step up from neuroprotection and a new norm.

Short-Term Outcomes and Complications of Premature Infants with a Birth Weight ≤ 1500g

prognosis of a premature infant is correlated with the conditions of medical care, both during and after birth, as well as the quality of the environment they are welcomed into. Objective: The aim of our study is to highlight the complications and outcomes of premature infants with a birth weight ≤ 1500g, by identifying the factors of morbidity and mortality, and then comparing our results with other studies. Materials and Methods: This is a retrospective descriptive, epidemiological, clinical, therapeutic, and developmental study conducted over a two-year period, from June 1, 2019, to June 30, 2021, in the neonatology and neonatal resuscitation unit at CHU HASSAN II of Fès. Results: We reported a mortality rate of 54% among the newborns, with the main causes of death being alveolar hemorrhage (43.41%), septic shock (29.45%), and severe respiratory distress (20.93%). The main complications and conditions observed during the hospital stay were: hyaline membrane disease (35.26%), alveolar hemorrhage (26.14%), patent ductus arteriosus (14.93%), hemodynamic instability (56.01%), electrolyte imbalances (44.81%), neonatal jaundice (54.77%), anemia (46.05%), thrombocytopenia (54.77%), apnea of prematurity (51.81%), intraventricular hemorrhage (12.86%), and neonatal infection (85.89%). Conclusion: The results of our study serve as a wake-up call for the necessity of implementing a management and prevention plan to improve the prognosis of premature infants with a birth weight ≤ 1500g.

Maternal and neonatal outcomes of congenital syphilis at a tertiary care center in Turkey; a retrospective observational study

Background Maternal syphilis (MS) can lead to significant maternal morbidity and neonatal morbidity and mortality if inadequately treated. This study is aimed to retrospectively analyse the maternal and neonatal outcomes of pregnant women diagnosed with MS at our clinic. Materials and Methods We accessed the medical records of 64 cases diagnosed with MS between 2020 and 2022 from our hospital database and the perinatology clinic archives in this retrospective observational study. Case distributions by years, sociodemographic characteristics, and maternal and neonatal outcomes were recorded. Results The distribution of MS cases was 16 (25.0%) in 2020, 20 (31.25%) in 2021, and 28 (43.75%) in 2022. The mean age of the patients was 26.4 ± 6.3 years, mean BMI was 23.36 ± 3.14, the smoking rate was 31.25%, and the majority of patients were educated to primary level (37.5%). Most were housewives (43.75%), lived in urban areas (43.75%), and had lower-level incomes (68.75%). In addition, 43.75% received adequate maternal treatment, the caesarean delivery rate was 43.25%, 31.25% had preterm births, and the mean birth weight was 2956.36 + 514.46 g. CS was largely diagnosed during delivery or the postpartum period (43.75%). Fifty percent of patients were in the latent stage, gestational hypertension and preeclampsia were present in four case each (6.25%), and gestational diabetes mellitus in eight (12.5%). Twenty babies (31.25%) were admitted to the neonatal intensive care unit, eight (12.5%) had congenital anomalies, 12 had foetal growth restriction (18.25%), stillbirth was present in four (6.25%) case, and early neonatal death in four (6.25%). Conclusions Delayed diagnosis and inadequate treatment of MS can lead to significant maternal and neonatal morbidity and mortality. Well-planned antenatal care services should be provided for all expectant mothers in order to reduce these adverse outcomes.

Can a Shorter Dwell Time Reduce Infective Complications Associated with the Use of Umbilical Catheters?

Umbilical venous catheters (UVCs) are the standard of care in neonatal intensive care units (NICUs) to administer fluids, parenteral nutrition and medications, although complications may occur, including central line-associated blood stream infections (CLABSIs). However, the dwell time to reduce CLABSI risk remains an open issue. We performed a single-center retrospective study of newborns hospitalized in the Modena NICU with at least one UVC inserted over a 6-year period (period 1: January 2011-December 2013; period 2: January 2019-December 2021). We selected a non-consecutive 6-year period to emphasize the differences in UVC management practices that have occurred over time in our NICU. The UVC dwell time and catheter-related complications during the first 4 weeks of life were examined. The UVC dwell time was shorter in period 2 (median 4 days vs. 5 days, p < 0.00001). Between the two periods, the incidence of CLABSIs remained unchanged (p = 0.5425). However, in period 2, there was an increased need for peripherally inserted central catheters (PICCs) after UVC removal, with a rise in PICC infections after UVC removal (p = 0.0239). In our NICU, shortening UVC dwell time from 5 to 4 days did not decrease the UVC-related complications. Instead, the earlier removal of UVCs led to a higher number of PICCs inserted, possibly increasing the overall infectious risk.

Use of neonatal lung ultrasound in European neonatal units: a survey by the European Society of Paediatric Research

ObjectiveRegarding the use of lung ultrasound (LU) in neonatal intensive care units (NICUs) across Europe, to assess how widely it is used, for what indications and how its implementation might...

Respiratory outcomes and survival after unplanned extubation in the NICU: a prospective cohort study from the SEPREVEN trial

ObjectiveTo compare reintubation rates after planned extubation and unplanned extubation (UE) in patients in neonatal intensive care units (NICUs), to analyse risk factors for reintubation after UE and to compare...

Skin-to-skin stabilisation and uninterrupted respiratory support for preterm infants after birth: feasibility of a new and simplified rPAP system

BackgroundThe rPAP respiratory support system, used for delivery room stabilisation with nasal prongs, has been shown to reduce the need for intubation in extremely preterm infants. A simplified version of...

A time series algorithm to predict surgery in neonatal necrotizing enterocolitis

BackgroundDetermining the optimal timing of surgical intervention for Neonatal necrotizing enterocolitis (NEC) poses significant challenges. This study develops a predictive model using the long short-term memory network (LSTM) with a focal loss (FL) to identify infants at risk of developing Bell IIB + NEC early and issue timely surgical warnings.MethodsData from 791 neonates diagnosed with NEC are gathered from the Neonatal Intensive Care Unit (NICU), encompassing 35 selected features. Infants are categorized into those requiring surgical intervention (n = 257) and those managed medically (n = 534) based on the Mod-Bell criteria. A fivefold cross-validation approach is employed for training and testing. The LSTM algorithm is utilized to capture and utilize temporal relationships in the dataset, with FL employed as a loss function to address class imbalance. Model performance metrics include precision, recall, F1 score, and average precision (AP).ResultsThe model tested on a real dataset demonstrated high performance. Predicting surgical risk 1 day in advance achieved precision (0.913 ± 0.034), recall (0.841 ± 0.053), F1 score (0.874 ± 0.029), and AP (0.917 ± 0.025). The 2-days-in-advance predictions yielded (0.905 ± 0.036), recall (0.815 ± 0.057), F1 score (0.857 ± 0.035), and AP (0.905 ± 0.029).ConclusionThe LSTM model with FL exhibits high precision and recall in forecasting the need for surgical intervention 1 or 2 days ahead. This predictive capability holds promise for enhancing infants’ outcomes by facilitating timely clinical decisions.

Nutrition management of intestinal failure: From neonates to the elderly

Double enterostomies (DES) and necrotising enterocolitis (NEC) are prevalent in neonatal intensive care units (NICU), commonly resulting from surgical removal of diseased intestine. Sarcopenia prevalence is &gt;40% in community dwelling elderly &gt;65 yrs and is associated with poor nutritional status before/after abdominal surgery, with intestinal failure (IF) and high output stoma losses. Parenteral Nutrition (PN) is the standard of care for Type 2 IF patients with DES or enteroatmospheric fistulas (EAF), but risks catheter-related complications, infection, gut and hepatobiliary dysfunction. Chyme reinfusion therapy (CRT) is a recommended distal feeding technique that may minimise these risks.

Factors that impact second attempt success for neonatal intubation following first attempt failure: a report from the National Emergency Airway Registry for Neonates

ObjectiveTo determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation.DesignRetrospective analysis of prospectively collected data on...

Maternal and infant outcomes in women with sickle cell disease: a matched cohort study

ObjectiveWomen with sickle cell disease (SCD) have adverse maternal and infant outcomes. Our aim was to determine whether the outcomes of SCD mothers and their infants differed from African or...

Early and extended erythropoietin monotherapy after hypoxic ischaemic encephalopathy: a multicentre double-blind pilot randomised controlled trial

ObjectiveTo examine the feasibility of early and extended erythropoietin monotherapy after hypoxic ischaemic encephalopathy (HIE).DesignDouble-blind pilot randomised controlled trial.SettingEight neonatal units in South Asia.PatientsNeonates (≥36 weeks) with moderate or severe...

Vibration-based mitigation of noxious-evoked responses to skin puncture in neonates and infants: a randomised controlled trial

ObjectiveTo assess the effect of a non-noxious vibratory stimulus on noxious-evoked cortical responses to skin puncture and to determine whether the presence of certain behavioural components may be used to...