Neonatal Adaptation Research Articles

Effect of Age on Nitric Oxide Level in Murrah Buffalo (Bubalus bubalis) Neonates

Immune system of calf is more susceptible to oxidative stress during neonatal period due to immature defense system against superoxide radicals. Nitric oxide (NO), a component of bactericidal mechanisms of phagocytic leukocytes, plays a pivotal role in cell-mediated immunity. Present research has addressed many NO-related aspects of neonatal adaptation in the postpartum period. The experiment was conducted on twenty Murrah buffaloes selected from NDRI herd. Approximately 15 ml blood was drawn in sterile heparinised vacutainer tubes from each calf born from these buffaloes, by jugular veni-puncture on day 0 (Before colostrum feeding), followed by day 1, 3, 7, 14, 21, 28, 42, 56, 70, 84, 98, 112 and 126 post birth at 6.00 AM in the morning. Plasma was aliquoted and analysed for total NO by modified Griess Reaction as described by Shoker et al. (1997). Plasma nitrate and nitrite levels were significantly elevated (P<0.01) at birth in buffalo calves and decreased rapidly within first week of life with mean values decreasing more than 80%. The mean values declined from 797.08±43.62 μM/L (Precolostral levels) to 78.97±68.97 μM/L on day 126 post- birth. The levels afterwards though less than day 7 but were not comparable to mature buffaloes (1.09±0.41 μM/L to 7.63±2.75 μM/L) even after 126 days post birth exhibiting fluctuations in between. Therefore, we can say that buffalo neonates have an immature immune system as compared to the adult. Leukocytes from neonates produce unusually high concentrations of NO when compared with those produced by adult buffalo, thus, buffalo neonates have an immature immune system. Therefore, further research is needed in this aspect to explore the possibility of nitric oxide involvement in the extra-uterine adjustment of buffalo neonate.

Adapted Finnegan scoring list for observation of anti-depressant exposed infants

Objective: The Finnegan scoring list (FSL) is widely used to screen for poor neonatal adaptation in infants exposed to anti-depressants in utero. However, the large number of FSL-items and differential weighing of each item is time consuming. The aim of this study was to shorten and simplify the FSL yet preserving its clinimetric properties. Methods: This observational study examined infants exposed to an anti-depressant during pregnancy admitted for at least 72 h on a maternity ward. Trained nurses completed the FSL three times daily. Items for the adapted FSL were selected through forward analysis whereby the number of selected items was based on the area under the curve (AUC). Internal validity was assessed by cross-validation. Results: 183 infants met the inclusion criteria. By forward analysis eight equally-weighed items resulted in an AUC of 0.91. In cross-validation, the mean AUC was 0.89 for 8 items. This adapted FSL had a sensitivity of 97.7% and specificity of 37.0% and a sensitivity of 41.9% and specificity of 86.2% regarding a cut-off of, respectively, 1 and 2. Conclusions: An adapted FSL with eight equally-weighed items has acceptable clinimetric properties and can serve as an easy to apply screening tool in infants exposed to anti-depressants during pregnancy.

Neonatal adaptation in infants prenatally exposed to antidepressants--clinical monitoring using Neonatal Abstinence Score.

BackgroundIntrauterine exposure to antidepressants may lead to neonatal symptoms from the central nervous system, respiratory system and gastrointestinal system. Finnegan score (Neonatal Abstinence Score, NAS) has routinely been used to assess infants exposed to antidepressants in utero.AimThe purpose was to study neonatal maladaptation syndrome in infants exposed to selective serotonin reuptake inhibitors (SSRI) or serotonin-norepinephrine reuptake inhibitors (SNRI) in utero.MethodRetrospective cohort study of women using antidepressants during pregnancy and their infants. Patients were identified from the electronic health record system at Karolinska University Hospital Huddinge containing pre-, peri- and postnatal information. Information was collected on maternal and infant health, social factors and pregnancy. NAS sheets were scrutinized.Results220 women with reported 3rd trimester exposure to SSRIs or SNRIs and who gave birth between January 2007 and June 2009 were included. Seventy seven women (35%) used citalopram, 76 used (35%) sertraline, 34 (15%) fluoxetine and 33 (15%) other SSRI/SNRI. Twenty-nine infants (13%) were admitted to the neonatal ward, 19 were born prematurely. NAS was analyzed in 205 patients. Severe abstinence was defined as eight points or higher on at least two occasions (on a scale with maximum 40 points), mild abstinence as 4 points or higher on at least two occasions. Seven infants expressed signs of severe abstinence and 46 (22%) had mild abstinence symptoms. Hypoglycemia (plasma glucose <2.6 mmol/L) was found in 42 infants (19%).ConclusionSevere abstinence in infants prenatally exposed to antidepressants was found to be rare (3%) in this study population, a slightly lower prevalence than reported in previous studies. Neonatal hypoglycemia in infants prenatally exposed to antidepressant may however be more common than previously described.

Effects of Umbilical Cord Milking on the Need for Packed Red Blood Cell Transfusions and Early Neonatal Hemodynamic Adaptation in Preterm Infants Born ≤1500 g

The aim of this study was to evaluate the effects of umbilical cord milking (UCM) on the need for packed red blood cell (PRBC) transfusion and hematologic and hemodynamic parameters in very-low-birth-weight infants. The infants were randomized into 2 groups: group 1 (UCM) and group 2 (control). The primary outcome was the number of PRBC transfusions during the first 35 days of life. The secondary outcome measures were the hemodynamic variables during the first 24 hours of life. A total of 44 infants were included with 22 infants in each group. Two of 21 infants in group 1 and 4 of 21 infants in group 2 received transfusion in the first 3 days of life (P=0.384). The number and volume of PRBC transfusions were similar in both groups. However, the levels of hemoglobin (Hb) at the first and 24th hour of life were significantly higher in group 1. Phlebotomy volume was found as a statistically significant risk factor for the need for PRBC transfusion (P=0.005). UCM in delivery room results in a higher Hb level in the first day of life. In these groups of infants, phlebotomy losses may impact the transfusion need.

Treating Perinatal Depression

Treating Perinatal Depression

PS-385 Outcomes Of A Feasibility Study On Co2 Monitoring In The Delivery Suite

Background CO 2 is not routinely measured in the delivery suite during neonatal resuscitation. Objectives To determine Is capnography feasible in the delivery suite for preterm infants ( Does capnography use in the delivery suite enhance neonatal adaptation as determined by incidence of normocarbia following neonatal unit admission? Methods 2 groups of infants were included. The first cohort did not have capnography used during their care in the delivery suite and were part of a study assessing blood sampling in preterm infants (Nov 12 – April 2013). The second group of infants had capnography performed in the delivery suite. A blood gas analysis reading of 5–8 Kpa was deemed to be within a normal range and was the determinant of a positive outcome. Ethics approval was granted and parental consent was obtained in all. Physicians were not instructed to achieve any particular EtCO 2 reading whilst in the delivery room. Results 83 infants were included in this study, 48 in the first cohort and 35 in the capnography cohort. Capnography was used in all infants in the prospective cohort. There was no difference in mean gestational age between the groups (28.4 ± 3.1 weeks versus 28.7 ± 1.8 weeks). The percentage of normocarbia was 47.9%(n = 23) in the first cohort compared to 51.4% (n = 18) in the second cohort (p-value 0.52). There was no difference in the incidence of hypocarbia between the groups (8.8% vs. 8.5%). Discussion Our results have shown that it is feasible to use capnography in the delivery suite. Capnography appears safe and was not associated with an increased incidence of hypocarbia. Randomised controlled trials with pre-determined acceptable EtCO 2 levels are needed to determine whether capnography for PPV is associated with improved neonatal outcomes.

Timing of cord clamping in very preterm infants: more evidence is needed

In December 2012, the American College of Obstetricians and Gynecologists published a Committee Opinion entitled "Timing of umbilical cord clamping after birth." It stated that "evidence exists to support delayed cord clamping in preterm infants, when feasible. The single most important benefit for preterm infants is the possibility for a nearly 50% reduction in IVH." However, the Committee Opinion added that the ideal timing of umbilical cord clamping has yet to be determined and recommended that large clinical trials be conducted in the most preterm infants. Published randomized controlled trials include <200 infants of <30 weeks' gestation, with assessments of neurodevelopmental outcome in less than one-half of the children. This is a major gap in the evidence. Without reliable data from randomized controlled trials that optimally include childhood follow-up evaluations, we will not know whether delayed cord clamping may do more overall harm than good. Ongoing trials of delayed cord clamping plan to report childhood outcomes in >2000 additional very preterm infants. Current recommendations may need to change when these results become available. Greater international collaboration could accelerate resolution of whether this promising intervention will improve disability-free survival in about 1 million infants who will be born very preterm globally each year.

Renal Development and Neonatal Adaptation

The structural and functional development of the kidney is responsible for a significant impact on postnatal adaptation to extrauterine life. Prenatal or neonatal impairment of nephrogenesis may carry long term, lifelong consequences in terms of reduced nephron endowment, chronic kidney disease, and cardiovascular risks at adulthood. Intrauterine growth restriction, preterm birth, congenital renal, and urinary tract anomalies are for long widely incriminated. Neonatal administration of nephrotoxic drugs has been associated with short-term acute kidney injury and longer chronic kidney disease. This review attempts at offering a comprehensive understanding of the renal development, the neonatal renal transition to extrauterine life and subsequent maturation phase during early infancy. It also focuses on developmental and maturational changes that impact lifelong renal function and adult health.

Neonatal Hypoglycemia: Are Evidence-based Clinical Guidelines Achievable?

Differing risk factors, biological variability, and lack of high-quality research studies lead to the impossibility of “genuine evidence-based clinical guidelines” for neonatal hypoglycemia. However, texts to date have described a pragmatic approach that, in the absence of high-quality evidence, should be adopted. Understanding of normal physiology should also inform practice. Blood glucose levels fall in the hours after birth in all infants. For most, the normal process of neonatal metabolic adaptation initiates glucose release and production, as well as the mobilization of alternative fuels (eg, ketone bodies) from stores so that the physiologic fall in blood glucose is tolerated. However, some infants are at risk of impaired neonatal metabolic adaptation in that blood glucose levels may not rise and the protective metabolic responses do not occur. For these infants, it is important to prevent hypoglycemia, to recognize clinically significant hypoglycemia, and to manage this situation without causing unnecessary separation of mother and infant or disruption of breastfeeding. Investigations for the underlying cause of hypoglycemia should be performed if hypoglycemia is persistent, resistant, or unexpected.

CORTISOL LEVELS IN CORD BLOOD WITH VARIOUS VIOLATIONS OF NEONATAL ADAPTATION

Shifting extra uterine existence is a serious test of maturity of all functional systems of the newborn, so in recent years, the more attention is payed for the adaptation of the newborn. It is known that the pathological course of pregnancy is a violation of the functional state of the adrenal cortex, and prolonged exposure of the pathological factor leads to the inhibition of adrenocortical function and a decrease of the adaptive capabilities of a newborn. Therefore, serum cortisol levels could be a predictor of complications in preterm infants. Based on this, it seems appropriate to study changes in the content of serum cortisol cord blood prior to the development of various syndromes neonatal maladjustment. The clinical and laboratory examination of term infants with various disorders of adaptation: regurgitation, pain, hyperexcitability , depression, cardio-respiratory depression, bleeding in the skin, toxic erythema. It is shown that the most prominent violations maladjustment processes occur on the background of decreased cortisol. Border states, which are formed on the background of normal or elevated cortisol, are not accompanied by significant impairments of adaptation processes. On the basis of the data was drawn a conclusion about the possibility of using changes of cortisol in cord blood as a reliable indicator of neonatal adaptation processes, pointing to the possibility of the development of pathological conditions.

Use of antidepressants during pregnancy: a better choice for some.

Mood disorders such as depression are more common among women, especially among pregnant women. Some population-based studies report a 20% prevalence of depression among pregnant women.[1],[2] Given this relatively high prevalence, the use of antidepressant medication during pregnancy is not uncommon. A study in the United States reported that at least 10% of pregnant women used antidepressants during pregnancy.[3] However, antidepressants may interfere with fetal growth so there is an ongoing debate about whether or not antidepressants should be used during pregnancy. Like all medications, antidepressants should be used with caution during pregnancy. The use of anti-depressants during pregnancy has been linked to various negative outcomes including miscarriage, pre-term birth, and low birth weight. One study found that within the two weeks of birth, newborns of mothers who used antidepressants during pregnancy were more likely to develop poor neonatal adaptation syndrome (OR=5.07, 95% CI=3.25-7.90), a condition which is characterized by poor temperature control, hypoglycemia, tachypnoea, respiratory distress, nasal congestion or cyanosis and seizures.[4] A systematic review reported a higher risk of developing congenital heart defects among newborns of mothers who used paroxetine during pregnancy (OR=1.36, 95% CI=1.08-1.71); however, this study did not find evidence of an overall association between the use of antidepressants and neonatal birth defects.[5] Untreated depression during pregnancy has been linked to more pre-term births and less breast-feeding.[6] Depression during pregnancy has also been associated with asthma in newborns, and the severity of depression was positively correlated with the severity of asthma (a dose-response relationship).[7] Moreover, the distress experienced by women with depression who are pregnant is similar to that experienced by women with depression who are not pregnant; the decline in their quality of life, impairment in their social functioning, and their risk of suicide are the same.[8] Therefore, treatment of depression during pregnancy is important for both the mother and the child. Psychotherapy, specifically interpersonal psycho-therapy,[9] has been shown to ameliorate depressive mood in pregnant women. However, this has only been studied among pregnant women with mild to moderate depression, not among those with severe depression for whom antidepressant treatment may be necessary. To date, there has been limited evidence about the effectiveness and safety of antidepressant use during pregnancy. Some experts have reached a consensus that antidepressants should be used to treat severe depression during pregnancy.[10] The Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults suggest weighing the adverse effects of antidepressants on the fetus (which occur at a low frequency) against the benefits of treatment. The guidelines list fluoxetine and other selective serotonin re-uptake antidepressants (SSRIs) as first-line antidepressants for use during pregnancy, but they also warn of possible neonatal heart defects after the use of fluoxetine.[11] A small-sample prospective study compared neonatal outcomes between 35 pregnant women who used antidepressants (mainly SSRI) with 23 pregnant women who did not. This study found no differences in cognitive functioning, language, and mobility in the babies at 18 months of age.[12] Another case report found no anomalies in the physical or mental development of a nine-month-old infant born to a mother who had taken duloxetine.[13] We believe that the benefits of antidepressant treatment of pregnant women with depression out-weigh the possible risk to the fetus: (a) if the depression is severe (that is, with suicidal ideation or behavior, psychotic symptoms, or a complete loss of appetite), (b) if there is a family history of re-occurring mental disorders, (c) if the individual lacks family or social support, or (d) if moderate depression persists despite psychotherapeutic treatment. Antidepressant use should be considered for the treatment of pregnant women who meet any of these criteria. The pros and cons of antidepressant treatment should be discussed with the individuals and their family members before obtaining their informed consent. Currently, most guidelines recommend the use of SSRIs (e.g., fluoxetine and citalopram) or tricyclic antidepressants (e.g., nortriptyline) for depression during pregnancy. Psychiatrists should ensure that the depressed woman and her family members are aware of the potential risks and immediately report any related symptoms. Psychiatrists treating pregnant women also need to coordinate their treatment with the responsible obstetrician to ensure the timely prevention of possible negative outcomes.

Pregnancy outcomes following maternal exposure to second-generation antipsychotics given with other psychotropic drugs: a cohort study

ObjectivesSecond-generation antipsychotics (SGAs), in conjunction with other psychotropic medications, are increasingly used to treat psychiatric disorders in pregnancy. The few available studies investigating the reproductive safety of SGAs did not...

Short-term neonatal outcome in diabetic versus non-diabetic pregnancies complicated by non-reassuring foetal heart rate tracings

Objective: Analysis of the impact of non-reassuring foetal heart rate patterns (FHR) and suspected foetal distress during active labour on the neonatal outcome in diabetic compared to non-diabetic mothers.Methods: Retrospective case–control study comparing the short-term neonatal outcome including Apgar score at 5 min, and arterial/venous umbilical cord blood pH of 57 deliveries of women with different types of diabetes and 114 healthy controls. Patients were selected out of all deliveries with suspected foetal distress during active labour and performed foetal scalp pH samplings (n = 590) at the Medical University of Graz, Austria, during 2008–2009.Results: Arterial pH was significantly lower in the diabetic group (7.215 versus 7.250, p = 0.007). Apgar scores ( > 8) at 5 min were similar in both groups (96.5% versus 95.6%, p = 0.566). The percentage of cases with foetal scalp blood pH <7.25 was higher in the diabetes group, but did not reach statistical significance (14.1% versus 7.1%, p = 0.166).Conclusions: Newborns of women with gestational and type 1 diabetes and non-reassuring FHR tracing have significantly lower arterial cord blood pH values without consequences on neonatal postpartum adaptation. Special attention to pathological changes in FHR patterns and to the more rapid decline in foetal pH during periods of foetal distress may be warranted in women with gestational and pre-conceptional diabetes during active labour. More frequent foetal scalp pH testing to rule out clinically relevant foetal acidosis needs to be discussed.

Sa1319 Effects of Maternal Diabetes Mellitus on Neonatal Aero-Digestive Adaptation: Role of Gestational Immaturity At Birth

Sa1319 Effects of Maternal Diabetes Mellitus on Neonatal Aero-Digestive Adaptation: Role of Gestational Immaturity At Birth

The Effect of Prenatal Antidepressant Exposure on Neonatal Adaptation

Conflicting reports on potential risks of antidepressant exposure during gestation for the infant have been reported in the literature. This systematic review and meta-analysis on immediate neonatal outcomes were conducted to clarify what, if any, risks are faced by infants exposed to antidepressants in utero. Subanalyses address known methodological limitations in the field. MEDLINE, EMBASE, CINAHL, and PsycINFO were searched from their start dates to June 2010. Various combinations of keywords were utilized including, but not limited to, depressive/mood disorder, pregnancy/pregnancy trimesters, antidepressant drugs, and neonatal effects. English language and cohort and case-control studies reporting on a cluster of signs defined as poor neonatal adaptation syndrome (PNAS) or individual clinical signs (respiratory distress and tremors) associated with pharmacologic treatment were selected. Of 3,074 abstracts reviewed, 735 articles were retrieved and 12 were included in this analysis. Two independent reviewers extracted data and assessed the quality of the articles. Twelve studies were retrieved that examined PNAS or the signs of respiratory distress and tremors in the infant. There was a significant association between exposure to antidepressants during pregnancy and overall occurrence of PNAS (odds ratio [OR] = 5.07; 95% CI, 3.25-7.90; P < .0001). Respiratory distress (OR = 2.20; 95% CI, 1.81-2.66; P < .0001) and tremors (OR = 7.89; 95% CI, 3.33-18.73; P < .0001) were also significantly associated with antidepressant exposure. For the respiratory outcome, studies using convenience samples had significantly higher ORs (Q1 = 5.4, P = .020). No differences were found in any other moderator analyses. An increased risk of PNAS exists in infants exposed to antidepressant medication during pregnancy; respiratory distress and tremors also show associations. Neonatologists need to be prepared and updated in their management, and clinicians must inform their patients of this risk.

Pregnancy outcomes following gabapentin use

Our objectives were to 1) determine whether first-trimester use of gabapentin is associated with an increased risk for major malformations; 2) examine rates of spontaneous abortions, therapeutic abortions, stillbirths, mean birth weight and gestational age at delivery; and 3) examine rates of poor neonatal adaptation syndrome following late pregnancy exposure. The study design was prospective. Women were included who initially contacted the services between 5 and 8 weeks with a comparison group of women exposed to nonteratogens, collected in a similar manner. We have data on 223 pregnancy outcomes exposed to gabapentin and 223 unexposed pregnancies. The rates of major malformations were similar in both groups (p = 0.845). There was a higher rate of preterm births (p = 0.019) and low birth weight <2,500 g (p = 0.033) in the gabapentin group. Among infants who were exposed to gabapentin up until delivery, 23 of 61 (38%) were admitted to either the neonatal intensive care unit or special care nursery for observation and/or treatment, vs 6 of 201 (2.9%) live births in the comparison group (p < 0.001). There were 2 cases of possible poor neonatal adaptation syndrome in neonates exposed to gabapentin close to delivery, compared with none in the comparison group, although it must be noted that these infants were concomitantly exposed to other psychotropic drugs. Among the women who took gabapentin, the major indications were pain (n = 90; 43%) and epilepsy (n = 71; 34%); the remainder were for other indications, mostly psychiatric. Our results suggest that although this sample size is not large enough to make any definitive conclusions, and there was no comparator group treated with other antiepileptic drugs, gabapentin use in pregnancy does not appear to increase the risk for major malformations. This finding and the increased risk for low birth weight and preterm birth require further investigation.

Functio laesa: the consequences of the fifth cardinal sign of inflammation in preterm infants

<i>Functio laesa</i>: the consequences of the fifth cardinal sign of inflammation in preterm infants

Pregnancy outcomes following maternal exposure to second generation antipsychotics: considering polytherapy

Studies on the reproductive safety of second generation antipsychotics (SGAPs) are scarce, and none have compared monotherapy to polytherapy. A cohort study using a prospectively collected database was conducted. Pregnancy outcomes of 133 women exposed to SGAPs and other psychotropic drugs and 133 matched healthy controls were assessed. Psychotropic drug polytherapy was documented in 72% of exposed women. The exposed women had significantly higher pre‐pregnancy weight, smoked more cigarettes, experienced more associated comorbidities and instrumental deliveries and delivered more large for gestational age children. More of the exposed neonates were born premature, admitted to the intensive care unit and presented with poor neonatal adaptation signs and higher major malformations rates. In the monotherapy subgroup, no malformations were reported. In utero exposure to antipsychotic polytherapy is associated with adverse pregnancy outcomes for both mother and child. SGAP monotherapy appears to be associated with less risk to the fetus. Future studies should differentiate among the effects of psychotropic medication exposure and the underlying psychopathology and associated comorbidities.

278: Congenital left coronary ostial atresia or stenosis - a series of four neonatal fatal cases

Congenital left coronary ostial atresia or severe stenosis is an extremely rare coronary abnormality. The clinical picture is either cardiac failure in the small infant or chest pain in the older child or adult patient. This report describes four neonatal cases of this rare abnormality. We retrospectively accessed all cases of left coronary ostial stenosis or atresia seen in our center during an 11-year-period (2000 - 2011). Two older patients with this diagnosis seen at 18 months and 4 years were excluded from the study. Four neonates with the diagnosis of left coronary ostial atresia or stenosis were identified during the study period. One newborn died within minutes, the other within hours after birth because of cardiac failure refractory to all treatment strategies. In both cases left coronary stenosis (one case with a “pinpoint” orifice and the other with a “slitlike” orifice) was diagnosed at autopsy. The third neonate was in cardiac failure due to a severe aortic stenosis. Left coronary ostial atresia was diagnosed during emergency catheter procedure. The infant subsequently died after the aortic dilatation. The forth infant had a cardiac arrest at the third day of life after normal delivery and neonatal adaptation. She was diagnosed with left coronary ostium atresia by coronary angiography performed because of persistent biventricular dysfunction. She died during the attempt of revascularization surgery at 2 weeks of life. Congenital left coronary ostium atresia or stenosis is very rare. Coronary angiography is the diagnostic method of choice especially in the small child or infant. Revascularization surgery seems indicated in symptomatic children based on case reports and smalls series. The clinical picture described here for the first time in the neonate is dramatic and quickly fatal with scarce surgical options. Systematic examination of the coronaries should be part of any neonatal autopsy.

Neonatal Immune Adaptation of the Gut and Its Role during Infections

The intestinal tract is engaged in a relationship with a dense and complex microbial ecosystem, the microbiota. The establishment of this symbiosis is essential for host physiology, metabolism, and immune homeostasis. Because newborns are essentially sterile, the first exposure to microorganisms and environmental endotoxins during the neonatal period is followed by a crucial sequence of active events leading to immune tolerance and homeostasis. Contact with potent immunostimulatory molecules starts immediately at birth, and the discrimination between commensal bacteria and invading pathogens is essential to avoid an inappropriate immune stimulation and/or host infection. The dysregulation of these tight interactions between host and microbiota can be responsible for important health disorders, including inflammation and sepsis. This review summarizes the molecular events leading to the establishment of postnatal immune tolerance and how pathogens can avoid host immunity and induce neonatal infections and sepsis.