Reactive hyperemia of skin microcirculation in septic neonates

Reactive hyperemia after 1 min of arterial occlusion was studied in back, thigh and heel skin of 40 preterm and full-term neonates using laser Doppler flowmetry. Twelve infants had clinical signs of septicemia, but normal laboratory tests at the time of fluxmetry. However, CRP, leukocyte count and the ratio of immature to total neutrophils increased during the following days and septicemia was confirmed by positive blood cultures (septic group). Seven neonates with clinical signs of septicemia had developed neither positive blood cultures nor laboratory signs (non-septic group). Fifteen were healthy neonates. In the septic neonates, time to reach maximal hyperemia, maximum post-occlusive hyperemia and recovery time of skin perfusion were increased significantly in back and thigh skin and the heal skin temperature was decreased when compared to healthy neonates. Healthy and non-septic neonates showed no significant difference in any of the parameters. We conclude that altered reactive hyperemia in the skin may be an earlier sign of neonatal septicemia than laboratory tests.     

尿胱抑素C对危重新生儿死亡的早期预测价值

目的 探讨尿胱抑素C(uCys C)对危重新生儿病死率的早期预测价值.方法 选择2011年5月至2012年10月在出生6h内入住苏州大学附属儿童医院新生儿重症监护病房的新生儿为研究对象,进行前瞻性研究.根据自入院在1周内是否死亡分为死亡组和生存组(对照组).检测患儿入院当日uCys C水平,并于入院24 h内进行新生儿急性生理学评分(SNAP).多因素Logistic回归分析评估在校正混杂因素后uCys C与死亡的关系,用受试者工作特征曲线及曲线下面积(AUC)评估uCys C对死亡的预测价值.结果 研究期间共纳入155例新生儿,12例(7.1％)新生儿在入院1周内死亡.死亡组胎龄(t =2.810,P=0.006)、出生体质量(t=3.245,P=0.001)均显著低于对照组,uCys C(2=-3.426,P=0.001)、SNAP评分(z=-3.308,P=0.001)、机械通气(x2=23.877,P=0.000)的使用率均显著高与对照组.Logistic回归分析显示,在校正胎龄、出生体质量等因素后,uCys C水平仍与死亡显著相关.uCys C水平预测新生儿死亡的AUC值为0.81(95％ CI:0.71 ～0.92,P=0.001);联合SNAP和机械通气后,其预测死亡的AUC为0.93(95％ CI:0.86 ～1.00,P=0.000).结论 uCys C是新生儿死亡的独立预测指标,将其与SNAP、机械通气联合后有更好的预测价值.     

Clinical sepsis in neonates is responsible for the lower prevalence of developing allergy

BACKGROUND: The hygiene hypothesis proposes an association between the change in exposure to microbes and the increased incidence of atopic disease. The purpose of the present study was to perform a prospective epidemiological study of the effect of perinatal infection on the development of allergy. METHODS: Eight hundred and ten children were born at Umeda Gynecological Hospital in Yamaguchi prefecture in Japan between April 1997 and March 1998. A questionnaire survey on the development of allergic diseases was sent by mail in 2002. The presence or absence of neonatal infectious disease (clinical sepsis) and maternal complications during the gestational period and delivery, and the incidence of bacterial infection during the perinatal period, were investigated by examining hospital records. RESULTS: Data were obtained for 410 children (51%). One hundred and forty-eight children (36.1%) developed allergic diseases. Among children whose mothers had allergies, the percentage of children who developed allergic disease(s) was significantly lower in children who had had clinical sepsis in the neonatal period than in those without clinical sepsis (26.1% vs 49.7%, P < 0.03). CONCLUSIONS: Clinical sepsis in neonates might reduce the risk of developing allergic diseases in early childhood in children whose mothers have allergies.     

Accuracy of anthropometric measurements in predicting symptomatic SGA and LGA neonates

Mid-arm circumference, mid-arm circumference/head circumference ratio, ponderal index and skinfold thickness at five sites (biceps, triceps, quadriceps, subscapular and flank) were measured in 91 small-for-gestational-age (SGA) and 101 large-for-gestational-age (LGA) neonates to investigate their accuracy in identifying neonates at high risk of complications resulting from disturbed intrauterine growth. Thirty-one of 91 SGA and 19 of 101 LGA neonates who developed hypoglycaemia and/or polycythaemia were regarded as symptomatic. Mean values of all of the anthropometric parameters differed significantly between symptomatic and asymptomatic SGA or LGA neonates. The quadriceps skinfold thickness was the most sensitive index in predicting symptomatic SGA and LGA neonates (sensitivity 0.93 and 0.95, respectively). The mid-arm circumference was also a very sensitive index in predicting symptomatic SGA neonates (sensitivity 0.94) but its specificity was extremely low (0.20). The rest of the parameters showed lower sensitivity than quadriceps skinfold thickness associated with similarly low specificity and validity. The findings of this study indicate that the quadriceps skinfold thickness is the most reliable index for use as a screening test for clinical evaluation of SGA and LGA neonates who are likely to develop complications as a result of disturbed intrauterine nutrition.     

Feasibility and efficacy of gentamicin for treating neonatal sepsis in community-based settings: a systematic review

Background

Neonatal sepsis is a leading cause of neonatal deaths in developing countries. The current recommended in-hospital treatment is parenteral ampicillin (or penicillin) and gentamicin in young infants for 10- 14 days; however, very few could access and afford. The current review is to evaluate the feasibility of gentamicin in community based settings.

Methods

Both observational and randomized controlled trials were included. Medline, Embase, Cochrane Central Register of Controlled Trials and Central Trial Register of India were searched until September 2013. We assessed the risk of bias by Cochrane Collaboration’s "risk of bias" tool.

Results

Two observational studies indicated feasibility ensuring coverage of population, decrease in case fatality rate in the group treated by community health workers. In an RCT, no significant difference was observed in the treatment failure rates [odds ratio (OR)=0.88], and the mortality in the first and second week (OR=1.53; OR=2.24) between gentamicin and ceftriaxone groups. Within the gentamicin group, the combination of penicillin and gentamicin showed a lower rate of treatment failure (OR=0.44) and mortality at second week of life (OR=0.17) as compared to the combination of gentamicin and oral cotrimoxazole.

Conclusion

Gentamicin for the treatment of neonatal sepsis is both feasible and effective in community-based settings and can be used as an alternative to the hospitalbased care in resource compromised settings. But there was less evidence in the management of neonatal sepsis in hospitals as was seen in this review in which we included only one RCT and three observational studies.

     

Pharmacokinetics of antibiotics in neonates

The pharmacodynamics in neonates are different from those in adults and children because the absorption, distribution, metabolism and excretion of drugs in neonates are always changing for the following reasons. In neonates, the proportion of extracellular fluid is large; the amount of plasma protein is small; renal function is immature; and the hepatic enzyme system is immature. In addition, individual birthweights, gestational ages in weeks, cardiopulmonary functions and renal excretory functions vary. All of these factors should be considered when selecting the dose and administration method of a drug. In concrete terms the distribution volume is large, which causes a low maximum concentration. In addition neonate renal excretory function is low and the hepatic enzyme system is immature, thus the half-life of drugs is prolonged. Therefore, the same dose per unit time as that for children (including infants) needs to be administered to neonates at dosing intervals that may be prolonged according to renal function.     

Microdialysis for metabolic monitoring in neonates after surgery

Microdialysis is a new method for continuous metabolic monitoring. We studied the possibility of using microdialysis in neonates treated in a paediatric intensive care unit after surgery. A microdialysis catheter was inserted in the abdominal subcutaneous adipose tissue in 14 neonates for a median of 93 h (range 24–106h). In four neonates, two microdialysis catheters were used simultaneously. Samples were taken hourly for analysis of glucose, lactate and glycerol. Dialysate and blood concentrations were compared. Serum/whole blood glucose values ( n = 68) were in the range 2.1–15.4 mM. The serum glucose levels showed good agreement with the dialysate concentrations of glucose, although these infants were subjected to various forms of stress, drugs and glucose infusions. The whole blood glucose levels were significantly lower than the dialysate levels. The microdialysis concentrations of glucose varied considerably. As almost identical dialysate glucose levels were found when two microdialysis catheters were used simultaneously, the variability probably reflects true changes in blood glucose levels. Our results indicate that microdialysis can be used in neonates.     

Gastric pneumatosis in neonates: revisited

Pneumatosis intestinalis, found commonly in neonatal necrotising enterocolitis (NEC), can occur in any part of the gastrointestinal tract, from the oesophagus to the rectum. Gastric pneumatosis, defined as air within the wall of the stomach, however, is an extremely rare sign during infancy and is usually secondary to gastric outlet obstruction. The clinical course and outcome of a neonate with gastric pneumatosis associated with NEC is reported along with a brief review of the literature. The findings illustrate that gastric pneumatosis can be the presenting feature of fulminant NEC and may indicate widespread, severe gastrointestinal insult.     

Non invasive continuous anterior fontanel tension monitoring in neonates

Anterior fontanel tension (AFT) has been shown to reflect the intracranical pressure (ICP). A new transducer was designed for AFT measurement which overcomes the problems of replacement in subsequent use. Using the transducer AFT was monitored noninvasively over extended periods in about 200 normal and sick neonates. The results indicate that the technique can be used to identify elevated pressure due to different disease conditions and it has a potential to help in understanding physiological and pathological mechanisms causing alterations in the normal cerebrospinal dynamics. Further studies are underway to establish the full potentials of the technique.     

新生儿胃食管返流的24小时食管内pH监测

目的探讨新生儿胃食管返流食管内pH的变化及其临床意义。方法疑诊为新生儿胃食管返流36例，以无症状新生儿15例作对照。用便携式24小时食管、胃pH自动记录仪（Digitrapper型）在常态下作24小时食管内pH监测。食管pH降至4以下持续15秒钟以上定义为一次返流。结果疑诊为新生儿胃食管近流的36例中14例Boix－Ochoa评分＞11．99为病理性返流，22例为生理性返流。15例对照组中2例为生理性返流，13例为正常。结论24小时新生儿食管内pH监测为早期诊断新生儿胃食管返流提供客观依据。     

Administration of recombinant human granulocyte-colony stimulating factor to septic neonates induces neutrophilia and enhances the neutrophil respiratory burst and β2 integrin expression Results of a randomized controlled trial

The objective of this study was to investigate the effect of treatment with recombinant human granulocyte-colony stimulating factor (rhG-CSF) on the neutrophil count and function of preterm neonates with documented sepsis. For this purpose 62 preterm neonates with proven sepsis and 19 healthy preterm ones were studied. Of the 62 patients, 27 septic neonates had an absolute neutrophil count (ANC) >5000/mm³ (group A) and were scheduled not to receive rhG-CSF and 35/62 had an ANC <5000/mm³ (n= 35) and were randomly assigned either to receive rhG-CSF (group B) or not to receive it (group C). rhG-CSF (10 μg/kg) was administered for 3 consecutive days (0, 1, 2). The ANC, plasma levels of G-CSF (ELISA), neutrophil respiratory burst activity (NRBA) and neutrophil expression of CD11a, CD11b and CD11c (flow cytometry) were measured in all septic neonates on days 0 (onset of sepsis), 1, 3 and 5 and in the healthy neonates once within the first 2 days of life. We found that on day 0, G-CSF levels of all groups of septic neonates were significantly higher than those of the healthy ones. The highest levels were observed in group A. NRBA was diminished only in groups B and C and the expression of CD11a and CD11c was reduced in all groups of septic neonates. Administration of rhG-CSF resulted in a rapid and significant increase in ANC, NRBA and CD11a, CD11b and CD11c expression that persisted throughout the follow up. Conclusion The administration of granulocyte colony stimulating factor to septic neonates significantly increases the absolute granulocyte count and enhances the neutrophil respiratory burst and β₂ integrin expression. Received: 25 March 1997 and in revised form: 5 August 1997 / Accepted: 14 October 1997     

Maternal and cord plasma selenium levels in full term neonates

Selenium is a part of the enzyme glutathione peroxidase and has an important role in the prevention of oxygen free radical injury. Hence good selenium nutrition is of special relevance to the neonate. The present study evaluated plasma selenium levels in cord plasma of 82 full term, appropriate for gestational age babies and their mothers at delivery. The plasma selenium levels in babies were 54.17±1.34 ppb which was significantly lower than 70.63±1.62 ppb seen in their mothers. Anemic mothers with a Hb <8 gJ/dl had a plasma selenium level (60.74±4.57 ppb) which was lower than those with a Hb >8 gJdl i.e. 74.19±2.17 ppb. Maternal age, parity, literacy and socio-economic status did not affect the plasma selenium levels.     

新生儿高胆红素血症听觉诱发电位检测的临床意义

目的　 通过对新生儿高胆红素血症患儿进行脑干听觉诱发电位 (BAEP)检测 ,评估高胆红素血症在未发生核黄疸时对脑损害及听力的影响。 方法 　对新生儿高胆红素血症患儿入院后进行脑干听觉诱发电位的测定。 结果 　 49例高胆红素血症患儿中异常BAEP发生率为 3 7%( 18/ 49例 ) ,表现为各波潜伏期 (PL)及波间潜伏期 (IPL)的延长和听阈值的增高 ,听阈值随胆红素浓度的增高而增高 ,经治疗后黄疸消退 ,脑干听觉诱发电位大部分恢复正常。 结论 　高胆红素血症对新生儿可造成听力损害 ,BAEP是检测高胆红素血症患儿听力筛查的重要手段之一     

Changes in ventricular and muscle volumes of neonates

Abstract Background : To examine the changes in cardiac ventricular and muscle volumes in neonates, echocardiography was performed in 25 normal neonates at 3–5 and 30–35 days after birth.
Methods : A standard apical four chamber view and a parasternal short axis view were used for the analysis of the left ventricle. For the analysis of the right ventricle, only an apical four-chamber view was used. A formula based on the area length method was used to calculate the left ventricular and muscle volumes and the single plane Simpson's rule was used for the right ventricular and muscle volumes.
Results : The left ventricular and muscle volumes per body surface did not change during the month following birth. The ratio of the muscle to ventricular volume of the left ventricle was also unchanged. However, the ratios of the right muscle volume to body surface and to the ventricular volume decreased after one month.
Conclusions : The authors suggest that the decreases in pulmonary hypertension and right ventricular stroke volume play a role in the changes of right muscle volume.     

Different functional cardiac characteristics observed in term/preterm neonates by echocardiography and tissue doppler imaging

Background and aim

To establish, using echocardiography, color-flow Doppler and tissue doppler imaging (TDI), physiological values of systolic/diastolic indexes in healthy term/pre-term newborns, and to identify how different degrees of maturity influence morpho-functional cardiac alterations during the transitional period.

Study design and subjects

33 term newborns (M = 19, F = 14; gestational ages: 37th-41st week), and 20 pre-term infants (M = 11, F = 9; gestational ages: 31st-36th week) admitted to our department were studied. All infants underwent to clinical and Doppler ultrasound evaluations, carried out by the third to fourth day. Investigations included: M-mode echocardiography, color-flow Doppler and TDI.

Outcome measures and results

Term and preterm neonates differed for: interventricular septum and left systolic/diastolic ventricle diameters (p < 0.01 and < 0.05 respectively); left ventricle posterior wall in systole (p < 0.01); shortening and ejection fraction (p < 0.05). Color-flow Doppler parameters on the tricuspid (peak E, peak A, ratio E/A; p < 0.05) and on the mitral (peak E and E/A ratio; p < 0.01) significantly differed between the two groups. Significant differences were also present for basal left ventricular lateral wall and right ventricular lateral wall in the Ew (p < 0.01 and < 0.05 respectively), Sw peak (p < 0.01 and < 0.05 respectively), and Ew/Aw (p < 0.05). The isovolumetric relax time and the E/Ew measured on the medial mitral annulus also demonstrated significant differences (p < 0.01) between the two groups.

Conclusions

TDI is feasible in preterm neonates and enables assessment of myocardial velocities. With increasing gestational age, higher myocardial velocities and lower E/E′ Œ ratios were found. TDI addition to standard neonatal echocardiography may provide further important information about cardiac function.     

Analgesic effect of expressed breast milk in procedural pain in neonates

Prevention, treatment and assessment of neonatal pain have been of major clinical and scientific interest the last decades. Non-pharmacological interventions such as sweet oral solutions are successful in pain relief. Whether breast milk, with its lactose content of 7%, has any effect on the prevention of pain has been debated.

Conclusion: Randomized studies of breast milk in prevention and treatment of neonatal pain are needed.     

新生儿小肠闭锁的诊断及治疗

目的探讨新生儿小肠闭锁的临床特点、诊断及治疗。方法对收治的80例小肠闭锁患儿的资料进行同顾性分析。结果80例新生儿小肠闭锁中，治愈62例（77．5％），死亡18例（22．5％），30％伴发畸形，随诊1～7年，生长发育良好。结论早期诊断、早期治疗有利于提高疗效。产前超声检查有利于早期诊断。对于单发小肠闭锁，肠切除肠单层吻合术为理想术式，多个肠端端吻合术＋长胃肠减压硅胶管是治疗多发肠闭锁的理想术式。     

Methaemoglobinaemia among neonates in a neonatal intensive care unit

After detection of a few clinical cases of methaemoglobinaemia (methb) in our NICU, a prospective clinical study was undertaken to determine the extent of the problem and to identify the causes. Consequently, during the following 8 months all haemoglobin tests included simultaneous measurements of methb on an OSM 3 hemoximeter (Radiometer): 8% (n= 33) of 415 neonates were found to be methb positive (denned as ≥6% methb). Mean methb was 19% (range 6.5–45.5%). Maximum methb concentrations were found on day 4–31 postpartum (mean 12 days) and the number of days with a positive methb sample ranged from 1 to 18 days (mean 6 days). About 40% of the neonates born at 25–30 weeks of gestation and 60%) with a birth weight < 1000 g were methb positive. Also, there was a negative correlation between the size of the methb positive concentration and gestational age (r=– 0.38,p= 0.02). Measurements of C–reactive protein and leucocytes, NADH reductase, pH, CI, nitrate and nitrite were carried out in methb positive patients. The tests were repeated 1 week after cessation of methb. The only significant difference was an increase in NADH reductase at the second measurement. Likewise, a wide range of clinical parameters were registered and they occurred with a higher frequency among the methb positive patients when compared with a methb negative control group matched with regard to gestational age and the closest possible birth weight. The mean birth weight of methb positive patients was 1170g and that of negative controls 1380g (p < 0.006). Epidemiological data and intervention studies indicated that para–chloraniline was the direct cause of the epidemic. The substance was derived from 0.02% chlorhexidine being inadvertently added to the humidifying fluid of the new incubators. Treatment of severe methb in premature neonates with 0.3–1.0mg methylene blue/kg body weight proved efficient. In conclusion, premature neonates developed severe methb when exposed to even small amounts of para–chloraniline. Immaturity, severe illness, the time exposed to para–chloraniline and low concentrations of NADH reductase probably played a part while other well known factors such as increased nitrite and nitrate concentrations, acidosis and hyperchloraemia did not seem to be significant.     

Comparison between tape-recorded and amplitude-integrated EEG monitoring in sick newborn infants

In 15 ill newborn infants a comparison between long-term multichannel and single-channel recordings of simultaneously tape-recorded (Medilog system) and amplitude-integrated EEG (Cerebral Function Monitor) was made. There was good agreement between the main type of background activity diagnosed with the tape-recorded and the amplitude-integrated EEG for all recordings. Two infants had repetitive subclinical and subtle seizure activity, lasting for several hours, which was detected by both techniques. Short, single seizures were diagnosed in the recordings of nine infants. When a single electrographic seizure appeared in an otherwise stable recording, it was identified by both the tape-recorded and the amplitude-integrated EEG. Very short (5-30 s) seizure patterns, which were diagnosed with the tape-recorded EEG, were not identified in the cerebral function monitor recordings. In the single-channel recordings of both the EEG and the cerebral function monitor there were, on some occasions, difficulties in distinguishing single seizures from interference due to external artefacts. In the multichannel recordings the diagnosis of seizure patterns was facilitated by comparison with the other channels. Both the Medilog EEG and the cerebral function monitor are feasible techniques for following cerebral electrical activity in sick neonates, although neither technique is specifically constructed for this purpose. For clinical use in the neonatal intensive care unit the advantage with the cerebral function monitor is the immediately available recording. The tape-recorded EEG offers possibilities of more channels and a higher reliability when diagnosing short subclinical seizures, however, only after offline analysis.