Search

Classic metaphyseal lesions (CML) or bucket handle fractures are usually associated with child abuse or non-accidental injury. The most common sites affected are the distal femur, proximal and distal tibia, and proximal humerus. Few case reports documented its association with difficult extraction at delivery in term large for gestational age (LGA) neonates. We present a case of CML in an extremely preterm neonate following abnormal presentation and difficult cesarean delivery. Management of CML is usually conservative, and fractures heal without any deformities. Thorough history taking is essential in the diagnosis of CML.

To evaluate impact of a quality improvement (QI) outreach education on incidence of acute brain injury in transported premature neonates.Neonates born atlt;33 weeks gestation outside the tertiary center were included. The QI intervention was a combination of neuroprotection care bundle, in-person visits, and communication system improvement. Descriptive and regression (adjusting for Gestational Age, Birth Weight, Gender, and antenatal steroids, Mode of delivery, Apgars at 5 minutes, Prophylactic indomethacin, PDA, and Inotropes use) analyses were performed. The primary outcome was a composite of death and/or severe brain injury on cranial ultrasound using a validated classification.181 neonates studied (93 before and 88 after). The rate and adjusted odds of death and/or severe brain injury reduced significantly post intervention (30% vs 15%) and (AOR 0.36, 95%CI, 0.15-0.85, P = 0.02) respectively.Implementation of outreach education targeting neuroprotection can reduce acute brain injury in transported premature neonates.

Objectives: Describe oxygen saturation (SpO2) values and their variability in the newborn period for healthy term infants at moderate altitude. Methods: Prospective observational study in postnatal wards with follow-up in the Public Health Nurse Clinic (PHNC). We recruited healthy term infants (≥37weeks) between 6-24 hours of age. Infants underwent simultaneous pre- (90mins) and post-ductal (10mins) transcutaneous SpO2 recordings every 12-24 hours until hospital discharge. Simultaneous pre- and post-ductal SpO2 measurements (15mins) were performed again in the PHNC within a few days after discharge. Infants were followed for eight weeks to ascertain their health status. Results: We included 252 infants with a complete in-hospital data set. Median age at the time of first SpO2 measurement in the hospital was 16.5 h, and 65.7 h in the PHNC (n=105). In hospital, the mean pre- and post-ductal SpO2 were 94.3% (SD 2.5) and 96.0% (SD 3.0), respectively. In the PHNC, mean pre- and post-ductal SpO2 were 94.4% (SD 2.8) and 95.6% (SD 2.7), respectively. Preductal desaturation episodes to SpO22 thresholds examined (PConclusion: SpO2 levels in healthy term newborns are approximately 94% over the first few days after birth at moderate altitude. Desaturation episodes are common in the immediate newborn period, but the duration of desaturation episodes decreases over time.

Background Increasing rates of obesity are of growing concern to maternal and child health as mothers with obesity are at risk of pregnancy complications. Infants of mothers with overweight/obese pre-pregnancy body mass index (BMI) may also be at risk of significant neurodevelopmental disorders. The relationship between maternal pre-pregnancy BMI and neurodevelopmental outcomes in preterm infants is not yet clearly defined. Objectives To determine the association of pre-pregnancy BMI of mothers of infants born Design/Methods Preterm infants born NDI was defined as the presence of Bayley-III Results Of 771 eligible infants, 53 not seen in the follow-up clinic and 21 born to mothers with BMI Conclusion Pre-pregnancy body mass index was not associated with death or neurodevelopmental impairment in very preterm infants at 18-24 months corrected age. However, infants born to mothers who were overweight were more likely to have lower language scores.

Primary Subject area Neonatal-Perinatal Medicine Background Preterm infants who are also intrauterine growth restricted (IUGR) experience more frequent and earlier hemodynamic consequences of patent ductus arteriosus (PDA). This may be related to altered levels of prostaglandins or altered number or sensitivity of their receptors in IGUR infants. Few studies have examined the efficacy of pharmacologic therapy (non-steroidal anti-inflammatory drugs [NSAIDs]: indomethacin, ibuprofen, or acetaminophen) for PDA closure among preterm infants based on their degree of IUGR with differing results. Objectives Primary: To determine if the degree of IUGR [defined by birth weight (BW) z-score] affects the efficacy of pharmacologic PDA closure and rate of surgical PDA ligation in preterm infants. Secondary: To compare the side effects of NSAIDs and neonatal outcomes based on the severity of IUGR. Design/Methods This retrospective cohort study included infants of < 30 weeks’ GA, admitted to a tertiary neonatal intensive care unit (NICU) between 2010 and 2018, with hemodynamically significant PDA and treated with NSAIDs. Infants with major congenital anomalies, those who received prophylactic Indomethacin and those who died in the first 48 hours were excluded. Birth weight (BW) z-scores were calculated using Olsen nomograms and classified into 3 categories: z-score > −0.5 (normal), z-score −0.5 to −2.0 (mild to moderate growth restriction), z-score Results Of the 1511 eligible infants, 769 (51%) had a diagnosis of PDA. Of 517 included infants, 323 (62.5%) had BW z-score >− 0.5, while 154 (29.8%) had z-scores − 0.5 to −2.0 and 40 (7.7%) had z-score < −2. Table 1 shows their demographic characteristics. Efficacy of first course of NSAIDs was not different among these birth weight groups (Table 2). There was no difference in the side effects and neonatal morbidities amongst the three groups (Table 2). Multivariate logistic regression analysis after controlling for GA, gender, antenatal steroids, C-section, and SNAP II showed that the odds of PDA ligation was significantly higher among infants with BW z-score < −2 (aOR 2.68, 95% CI 1.13- 6.36) but not among infants with z-score −0.5 to−2.0 (aOR 1.41, 95% CI 0.84, 2.39) as compared to z-score >-0.5. Conclusion Preterm severe IUGR infants with z-score < −2 have an associated increased risk of PDA ligation following pharmacologic treatment as compared to normally grown infants.

Objectives Brain injury in preterm neonates may cause clinical deterioration and requires timeous bedside diagnosis. Teaching cranial ultrasound (US) skills using fragile preterm neonates is challenging. The purpose of this study was to test the effectiveness and feasibility of using task-trainer computer-based simulators and US-suitable cranial phantoms in combination with teaching sessions in teaching novices to perform focused cranial US evaluations for identifying substantial intraventricular hemorrhage. Methods This was a prospective interventional educational study targeting participants with no prior skills in neonatal cranial US. Participants attended a 2-day training workshop, with didactic and hands-on interactive sessions using computer-based and 3-dimensional printed phantom simulators. Participants then performed a cranial US scan on a healthy neonate to assess the diagnostic quality of the images acquired. Individual precourse and postcourse knowledge tests were compared. To test recall, participants also submitted US images acquired on neonates within 3 and 6 months of attending the course. Results Forty-five participants completed the training modules. Mean knowledge scores increased significantly (in brain anatomy, brain physiology, intracranial disorders, and US physics domains). Thirty-eight cranial US scans were acquired during the course, 22 within 3 months after completion, and 34 within 6 months after completion. Thirty-two (84%) of the initial 38 case images, 17 (77%) of 22 images submitted within 3 months, and 32 (94%) of 34 images submitted within 6 months after course completion were of diagnostic quality. Conclusions A structured training module with didactic and hand-on training sessions using simulators and phantoms is feasible and supports training of clinicians to perform focused cranial US examinations.

Objective To study the effect of early and late onset preeclampsia (EOPE, LOPE, respectively) on outcomes of late preterm infants. Study design Cohort study of late preterm infants admitted to a tertiary care NICU from January 2014–July 2015. Outcomes of late preterm infants of EOPE mothers were compared with the next late preterm infant of a LOPE mother and the next two late preterm infants of normotensive non-PE mothers. Primary outcome comprised use of continuous positive airway pressure, mechanical ventilation and/or surfactant in the 24 h after birth. Results Compared to normotensives (n = 131), adjusted odds ratio (AORs) of the primary outcome was higher in the EOPE (n = 64) and LOPE (n = 65) groups but reached statistical significance only in the EOPE group, AORs 12.9, 95% CI 3.5–37 and 2.7, 95% CI 0.95–8.1, respectively. Conclusions Compared to late preterm infants of normotensive and LOPE mothers, infants of mothers with EOPE have significantly higher respiratory morbidity.

Background Limited point-of-care ultrasound skills for ultrasound-naive neonatal transport clinicians could enhance clinical evaluation and decision making. Teaching Respiratory Therapists and Nurses to assess cardiac filling and contractility may be feasible. Methods Prospective educational study using educational materials, didactic theoretical, and hands-on practical sessions, followed by assessment of practical and theoretical skills. Results A total of 18 participants completed the study meeting the predefined standard, proving feasibility. Nine (50%) participants had ≤ 10 years of NICU experience. The mean time required for complete training was 8.6 ± 2.1 hours. Time was spent on average on 269 ± 104 minutes for hands-on practice, 171 ± 96 minutes on didactic training, and 76 ± 16 minutes on testing sessions. The median number of hands-on sessions per participant was 5 [Interquartile range (IQR) 5, 7]. The median number of infants required to complete training was 9 infants (IQR 7, 11). RRTs required less time than RNs. Evaluations and feedback from participants on the training program was positive. Conclusion Neonatal RNs and RTs can be trained to perform focused cardiac ultrasound examinations with average time of 8.6 hours. This skill could enhance clinical care on neonatal transport with appropriate interventions to manage suspected hypotension or shock.

Objective The objective of our study was to determine levels of endothelial progenitor cells (EPCs) in preeclampsia and normotensive pregnant women. Study design Prospective cohort study of women with preeclampsia and normotensive pregnancies. EPCs were estimated by flow cytometry. Multiple linear regression was used to assess the association of EPCs with preeclampsia adjusting for maternal age, body mass index (BMI), gestation and ethnicity. Main Outcome Measure: Levels of EPCs in preeclampsia and normotensive pregnancies, with CD-34 and vascular endothelial (VE)-cadherin as markers of EPCs. VE-cadherin is an endothelial cell adhesion molecule used to delineate endothelial lineage of EPCs. Results There were thirty women in the preeclampsia group and thirty-three in the normotensive group. The two groups were similar except for the BMI and blood pressures, which were higher in preeclampsia. On multiple linear regression, EPCs numbers were significantly higher by 29 (95% confidence interval 11.7–46.6, p = 0.001) in preeclampsia compared to the normotensive group. There was significant positive correlation between EPCs and systolic blood pressure in preeclampsia (Spearman correlation coefficient 0.39, p = 0.03). Conclusion Although widely used in cardiovascular disease other than preeclampsia, this is the first study using VE-cadherin as a marker of endothelial lineage to define EPCs in preeclampsia. Our results suggest the higher number of EPCs in preeclampsia may be a response of the bone marrow to endothelial injury.

BACKGROUND: Diabetes insipidus (DI) is a disease resulting from defects in the arginine vasopressin system responsible for regulating body water homeostasis. It is characterized by polyuria with increased serum osmolality and sodium and can result from congenital or acquired disorders. CLINICAL PRESENTATION: A baby was admitted to NICU for extreme prematurity (25 weeks gestation), extreme low birth weight (900 grams) and respiratory distress. He received one dose of Surfactant and was ventilated using high frequency jet ventilation for development of pulmonary interstitial emphysema. After nine days, he still required high settings with development of early chronic lung changes in the form of atelectasis. Therefore, he was started on a course of dexamethasone following the DART study protocol (Dexamethasone: A Randomized Trial). However, after six days (cumulative dose of 0.75 mg/kg/day) he developed polyuria (7.4 ml/kg/h) with increased serum sodium (150 mmol/L) and osmolality (348 mmol/L). He lost 85 grams of his weight in 24 hours, which represented a 9.8 %weight loss. The findings were suggestive of DI and given there were no apparent causes other than dexamethasone, it was discontinued. Over the following 48 hours, polyuria and hypernatremia gradually resolved, reaching 3.5 ml/kg/h, and 140 mmol/L respectively. CONCLUSION: The use of dexamethasone is not an uncommon practice in tertiary care neonatal units. To our knowledge, our case is the first report of neonatal DI secondary to the use of dexamethasone. We recommend closely monitoring urine output and serum electrolytes in preterm infants receiving dexamethasone.

Introduction: Extremely premature infants are susceptible to fluctuations in cerebral blood flow due to immaturity of cerebral autoregulation. Inotropes may cause rapid changes to systemic blood pr...

Aim To evaluate the impact of outreach education targeting neuroprotection on outcomes of outborn infants with moderate-to-severe hypoxic ischemic encephalopathy (HIE). Methods A retrospective cohort study of infants admitted with moderate-to-severe HIE was conducted following the implementation of outreach education in January 2016. Key interventions were early identification and referral of infants with encephalopathy utilizing telemedicine and a centralized communication system, hands-on simulation, and interactive case discussion and dissemination of clinical management guidelines and educational resources. The association between the intervention and a composite outcome of death and/or severe brain injury on brain magnetic resonance imaging (MRI) was tested controlling for the confounding factors. Results Of 165 neonates, 37 (22.4%) died and/or had a severe brain injury. This outcome decreased from 35% (27/77) to 11% (10/88) following the implementation of outreach education (P Conclusion Outreach education targeting neuroprotection for infants with moderate-to-severe HIE was associated with a reduction in death and/or severe brain injury.

Objectives: To assess maternal and neonatal risk factors for intraventricular hemorrhage (IVH). To examine the association of patent ductus arteriosus (PDA) and its treatment, with IVH and its severity.Study design: In this retrospective cohort study, we included preterm neonates born at

Persistent left superior vena cava (PLSVC) is a common cardiac anomaly associated with congenital heart diseases. A diagnosis of PLSVC usually warrants a detailed fetal echocardiography. Lesser known associations are the extra cardiac anomalies notably the upper airway and the gastrointestinal tract anomalies. We highlight here the importance of detailed fetal assessment for extra cardiac anomalies in addition to fetal echocardiography in fetuses diagnosed with PLSVC. We hereby present a preterm infant who presented with a triad of PLSVC, laryngeal atresia, and esophageal atresia.

Aim To compare preterm infants with no bronchopulmonary dysplasia (BPD), BPD with chorioamnionitis (BPDC) and BPD with no chorioamnionitis (BPDNC) for the association with neurodevelopmental disability (NDD) at 3 years corrected age. Methods Demographic and outcome data of infants with birth weight (BW) ≤1250 g born during 2 epochs (1995-2000 and 2002-2007 with an interim washout period of 1 year) were compared on the basis of whether they had BPD, chorioamnionitis or both. Any NDD was considered present if there was either mild-severe cerebral palsy (CP), cognitive delay, visual or hearing impairment. Logistic regression modeling was done. Results Infants (n=1009) were included into three groups - No BPD (n=442), BPDNC (n=437) and BPDC (n=130). The adjusted odds ratios of any NDD at 3 years in infants with BPDC versus BPDNC was OR 1.37; 95% CI 0.85-2.20, and for CP the OR was 1.66; 95%CI 0.76-3.62. Infants in the BPDC group were of lower BW, gestational age and had longer length of hospital stay, duration of mechanical ventilation, more blood transfusions and sepsis compared to BPDNC and no BPD groups (all p

Highlights • Laser therapy for fetal reduction could be associate with Aplasia Cutis Congenita. • Despite of size of lesion conservative treatment could be an effective option. • Extreme prematurity did not affected degree of spontaneous epithelization. • Patient was followed up to 5 years and no complications were detected., Monochorionic (MC) twin pregnancies are known to carry a high risk of twin-to-twin transfusion syndrome (TTTS) that could lead to miscarriage and perinatal death. Demise of one fetus is frequently associated with co-fetal death. Fetal reduction by interstitial laser therapy is an effective procedure to prevent this outcome, but it may be associated with significant risks for both mother and fetus. Aplasia Cutis Congenita (ACC) may occur in up to 8% cases of fetal reduction by laser therapy. We report ACC in a preterm infant, a survivor of interstitial laser therapy for fetal reduction in MC pregnancy. Despite of massive skin lesions we were able to manage this case conservatively. Follow-up at 5 years of age revealed minimal scarring and no motor function limitations.

Persistent left superior vena cava (PLSVC) is a common cardiac anomaly associated with congenital heart diseases. A diagnosis of PLSVC usually warrants a detailed fetal echocardiography. Lesser known associations are the extra cardiac anomalies notably the upper airway and the gastrointestinal tract anomalies. We highlight here the importance of detailed fetal assessment for extra cardiac anomalies in addition to fetal echocardiography in fetuses diagnosed with PLSVC. We hereby present a preterm infant who presented with a triad of PLSVC, laryngeal atresia, and esophageal atresia.

Subcutaneous fat necrosis (SCFN) is a noninfectious panniculitis that occurs in term infants who experience significant distress in the 1st weeks of life, including hypoxic ischemic encephalopathy (HIE). Since the introduction of therapeutic hypothermia for HIE, there have been a few published case reports of SCFN, following this modality of treatment. Although, most cases of SCFN resolve spontaneously, SCFN may be associated with hypercalcemia, which may sometimes reach dangerous levels. Approaches used for the management of this potentially life-threatening condition, include hyperhydration, calciuric diuretics, corticosteroids, and in more resistant cases pamidronate, a bisphosphonate. We report our experience on the use of pamidronate in two cases of severe hypercalcemia associated with SCFN following therapeutic hypothermia for HIE. We believe that with increasing use of therapeutic hypothermia for HIE, clinicians are likely to encounter this condition more frequently.

Background Cytomegalovirus (CMV) is one of the most common causes of serious viral intrauterine infections. It is universally distributed among the human population with an average incidence of 0.15 to 2%. Indeed, at least half of the women in the reproductive age have evidence of prior CMV infection. Epidemiology and Pathogenicity However, it is not a usual practice to screen asymptomatic pregnant woman or neonates for CMV. Even if a mother developed a primary CMV infection during pregnancy, up to 90% of the newborns with congenital CMV will be asymptomatic at the time of birth. Only 5 to 7% of the infected babies will be acutely symptomatic, and the typical clinical presentation includes intrauterine growth restriction, microcephaly, various cutaneous manifestations (including petechiae and purpura), hematological abnormalities (particularly resistant thrombocytopenia), hepatosplenomegaly, chorioretinitis, hepatitis, etc. In contrast, acquired CMV infection is extremely unlikely to cause any serious sequelae for the infant. Cases We present a case of congenital and acquired CMV infection in twins with a focus of dissimilarity in presentation, clinical course, and outcome.

Umbilical venous catheters (UVCs) are commonly used central venous access in the Neonatal Intensive Care Unit, especially in very low birth weight infants. Chest and abdominal radiograph, taken soon after catheter insertion, is the most common method for confirming catheter tip position. UVC-related complications commonly result from catheter malposition; hence, it is important to determine the catheter tip position accurately. However, complacency when a UVC is initially normal positioned can lead to late detection of subsequent UVC-related complications. We describe two cases of supraventricular tachycardia related to UVC, despite the initial UVC was in optimum position. The use of point-of-care echocardiography helped in the diagnosis of catheter malposition and minimized further medical intervention. We suggest point-of-care ultrasound assessment at regular intervals in all infants with UVC to ensure that the catheter is maintained in the optimum position.

Neonatal hypertension is an uncommon but important problem in Neonatal Intensive Care Unit. The most common cause of neonatal hypertension is renovascular disease. In premature neonates, hypertension has been associated with the use of postnatal steroids, maternal history of hypertension, umbilical artery catheterization, acute kidney injury, and bronchopulmonary dysplasia (BPD). The exact mechanism of hypertension in BPD infants is unknown. We present a case series of premature infants with BPD and hypertension associated with transient hyperaldosteronism in the absence of any other cause for the elevated blood pressure. All infants responded to aldosterone antagonists. Transient hyperaldosteronism may have a role in the pathogenesis of hypertension associated with BPD.

Calcium is essential for normal fetal growth and development. During intrauterine life, the fetus is entirely dependent on the mother and a normally functioning placenta for calcium accretion. Preeclampsia is associated with abnormal calcium metabolism and placental dysfunction. The objective of our study was to investigate ionized calcium levels in the umbilical cord arterial blood of women with preeclampsia and normotensive pregnancies. There were 24 women in the preeclampsia group and 25 in the normotensive group. There was no difference in the cord pH and fetal growth restriction between the two groups. Ionized calcium levels were significantly lower in the preeclampsia group (p < 0.001). Our results emphasize the need for further studies on the calcium status of infants born to mothers with preeclampsia.