Can we back off using antibiotics in the NICU?

Antibiotics are extensively and inconsistently prescribed in neonatal ICUs, and usage does not correlate with rates of culture positive sepsis. There is mounting data describing the short and long-term adverse effects associated with antibiotic overuse in neonates, including the increased burden of multi-drug resistant organisms. Currently there is considerable variation in antibiotic prescribing practice among neonatologists. Applying the practice of antibiotic stewardship in the NICU is crucial for standardizing antibiotic use and improving outcomes in this population.Several approaches have been proposed to identify neonatal sepsis, with the hope of reducing antibiotic utilization. These strategies all have their limitations, and often include laboratory testing and treatment of well-appearing, non-septic, infants. A conservative “watch and wait” algorithm is suggested as an alternative method for when to initiate antibiotics. This observational approach relies on availability of trained personnel able to examine infants at specified intervals, without delaying antibiotics, should signs of sepsis arise.     

Changing populations being treated with ECMO in the neonatal period – who are the others?

Extracorporeal life support via extracorporeal membrane oxygenation (ECMO) has served the sickest of neonates for almost 50 years. Naturally, the characteristics of neonates receiving ECMO have changed. Advances in care have averted the need for ECMO for some, while complex cases with uncertain outcomes, previously not eligible for ECMO, are now considered. Characterizing the disease states and outcomes for neonates on ECMO is challenging as many infants do not fall into classic categories, i.e. meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), or congenital diaphragmatic hernia (CDH). Since 2017, over one third of neonatal respiratory ECMO runs reported to the Extracorporeal Life Support Organization Registry are grouped as Other, a catch-all that encompasses those with a diagnosis not included in the classic categories. This review summarizes the historical neonatal ECMO population, reviews advances in therapy and technology impacting neonatal care, and addresses the unknowns in the ever-growing category of Other.     

Medico-legal considerations in the context of neonatal encephalopathy and therapeutic hypothermia

Neonatal encephalopathy (NE) is a significant complication of the peripartum period. It can lead to lifelong neurologic disabilities, including cerebral palsy, cognitive impairments, developmental delays, and epilepsy. Induced hypothermia is the first therapy, which has shown promise in improving the outcomes for neonates with moderate to severe NE following a presumed intrapartum insult.NE is also a frequent source of medical malpractice litigation. In this paper, we will review salient features of the American Tort System as it pertains to medical malpractice. We will discuss the obstetric medico-legal implications of therapeutic hypothermia and suggest a five-step approach to analyzing neonatal cases for causation, etiology, timing of occurrence, responsibility, and liability. We will close with three illustrative clinical cases.     

抚触护理在病理性黄疸患儿中的应用效果

目的:观察抚触护理在病理性黄疸患儿中的应用效果。方法:选取114例病理性黄疸患儿作为研究对象,按照随机数字表法分为观察组与对照组各57例。对照组实施常规护理,观察组在对照组的基础上实施抚触护理,比较两组黄疸消退时间、护理前后血清总胆红素(TSB)水平、护理总有效率和患儿家长护理满意度。结果:观察组黄疸消退时间为(7.85±1.36)d,明显短于对照组的(9.56±2.85)d,差异有统计学意义(P<0.05);护理后,观察组血清TSB水平低于对照组,差异有统计学意义(P<0.05);观察组护理总有效率为96.5%,明显高于对照组的73.7%,差异有统计学意义(P<0.05);观察组患儿家长满意度为98.2%,明显高于对照组的82.4%,差异有统计学意义(P<0.05)。结论:在常规护理基础上采用抚触护理可缩短病理性黄疸患儿黄疸消退时间,降低血清TSB水平,提高护理总有效率和患儿家长护理满意度,其效果优于单纯常规护理。     

Outcomes of infants born at 23 and 24 weeks' gestation with gut perforation

PurposeThe provision of neonatal intensive care to infants born at 23 or 24 weeks' gestation poses medical, surgical and ethical challenges. Gastrointestinal perforation is a well-recognized complication of preterm birth, occurring most often as a result of necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). Given the risk of morbidity and mortality in these ‘periviable’ infants, this complication may prompt transition from active management to palliative care. In our institution, the surgical care of periviable infants with gut perforation has not been dictated by gestational age. This study reports our outcomes.MethodsA retrospective cohort analysis of integrated neonatal medical and surgical care of all infants born between 23^{+ 0} and 24^{+ 6} weeks' gestation admitted to a tertiary level neonatal intensive care unit (NICU) during a 16 year period (2002–2017).ResultsA total of 198 periviable neonates (73 born at 23 weeks' gestation and 125 born at 24 weeks) were admitted during the 16-year period; most were inborn with only 26 retrieved from regional centers. Twenty-six of these infants developed gut perforation: 14 SIP, 8 NEC, 3 esophageal perforation and one after reduction of an incarcerated inguinal hernia. Twelve (46%) periviable infants with gut perforation survived to discharge home, seven of whom had no/mild disability at 2–3 years corrected gestational age. Of the 198 periviable infants admitted to NICU, 116 (58%) were alive at a corrected gestational age of 2–3 years and 29 of the 56 (51%) assessed had mild or no disability.ConclusionsIn the setting of combined medical and surgical care in a tertiary level NICU almost half of all periviable infants with a gut perforation survived, many with no/mild disability at 2–3 years corrected gestational age. Rigid protocols that rely on gestational age alone to guide treatment are not appropriate. These results support the contention that, when possible, extremely preterm infants should be born and cared for in units with combined medical and surgical expertise.Level of evidenceLevel III cohort study.     

Interleukin-8 dysregulation is implicated in brain dysmaturation following preterm birth

BackgroundPreterm birth is associated with dysconnectivity of structural brain networks, impaired cognition and psychiatric disease. Systemic inflammation contributes to cerebral dysconnectivity, but the immune mediators driving this association are poorly understood. We analysed information from placenta, umbilical cord and neonatal blood, and brain MRI to determine which immune mediators link perinatal systemic inflammation with dysconnectivity of structural brain networks.MethodsParticipants were 102 preterm infants (mean gestational age 29⁺¹ weeks, range 23⁺³-32⁺⁰). Placental histopathology identified reaction patterns indicative of histologic chorioamnionitis (HCA), and a customized immunoassay of 24 inflammation-associated proteins selected to reflect the neonatal innate and adaptive immune response was performed from umbilical cord (n = 55) and postnatal day 5 blood samples (n = 71). Brain MRI scans were acquired at term-equivalent age (41⁺⁰ weeks [range 38⁺⁰-44⁺⁴ weeks]) and alterations in white matter connectivity were inferred from mean diffusivity and neurite density index across the white matter skeleton.ResultsHCA was associated with elevated concentrations of C5a, C9, CRP, IL-1β, IL-6, IL-8 and MCP-1 in cord blood, and IL-8 concentration predicted HCA with an area under the receiver operator curve of 0.917 (95% CI 0.841 – 0.993, p < 0.001). Fourteen analytes explained 66% of the variance in the postnatal profile (BDNF, C3, C5a, C9, CRP, IL-1β, IL-6, IL-8, IL-18, MCP-1, MIP-1β, MMP-9, RANTES and TNF-α). Of these, IL-8 was associated with altered neurite density index across the white matter skeleton after adjustment for gestational age at birth and at scan (β = 0.221, p = 0.037).ConclusionsThese findings suggest that IL-8 dysregulation has a role in linking perinatal systemic inflammation and atypical white matter development in preterm infants.