A.B. te Pas

Is Routine TORCH Screening Warranted in Neonates with Lenticulostriate Vasculopathy

Background: Congenital infections are associated with a wide spectrum of clinical symptoms, including lenticulostriate vasculopathy (LSV). Objective: To determine the relationship between LSV and congenital infections, as diagnosed by TORCH serology and viral culture for cytomegalovirus (CMV). Methods: All neonates with LSV admitted to our neonatal intensive-care unit from 2004 to 2008 were included in the study. Results of maternal and neonatal TORCH testing were evaluated. Results: During the study period, cranial ultrasound scans were performed in 2,088 neonates. LSV was detected in 80 (4%) neonates. Maternal and/or neonatal serological TORCH tests were performed in 73% (58/80) of cases. None of the mothers or infants (0 of 58) had positive IgM titres for Toxoplasma, rubella, CMV or herpes simplex virus. Additional urine culture for CMV was performed in 38 neonates. None of the infants (0 of 38) had a positive CMV urine culture test. Conclusions: Routinely applied efforts to diagnose congenital infections in cases presenting with LSV have a poor yield. Routine TORCH screening in neonates with LSV cases should only be regarded as mandatory once well-designed studies demonstrate a clear diagnostic benefit.

The risk for hyperoxaemia after apnoea, bradycardia and hypoxaemia in preterm infants

Objective To investigate the occurrence and duration of oxygen saturation (SpO2) ≥95%, after extra oxygen for apnoea, bradycardia, cyanosis (ABC), and the relation with the duration of bradycardia and/or SpO2 ≤80%. Methods All preterm infants <32 weeks’ gestation supported with nasal continuous positive airway pressure (nCPAP) admitted to our centre were eligible for the study. We retrospectively identified all episodes of ABCs. In ABCs where oxygen supply was increased, duration and severity of bradycardia (<80 bpm), SpO2 ≤80%, SpO2 ≥95% and their correlation were investigated. Results In 56 infants, 257 ABCs occurred where oxygen supply was increased. SpO2 ≥95% occurred after 79% (202/257) of the ABCs, duration of extra oxygen supply was longer in ABCs with SpO2 ≥95% than without SpO2 ≥95% (median (IQR) 20 (8–80) vs 2 (2–3) min; p<0.001)). The duration of SpO2 ≥95% was longer than bradycardia and SpO2 ≤80% (median (IQR) 13 (4–30) vs 1 (1–1) vs 2 (1–2) min; p<0.001). SpO2 ≥95% lasted longer when infants were in ambient air than when oxygen was given before the ABC occurred (median (IQR)15 (5–38) min vs 6 (3–24) min; p<0.01). Conclusions In preterm infants supported with nCPAP in the neonatal intensive care unit (NICU), SpO2 ≥95% frequently occurred when oxygen was increased for ABCs and lasted longer than the bradycardia and SpO2 ≤80%.

The 'Effects of Transfusion Thresholds on Neurocognitive Outcome of Extremely Low Birth-Weight Infants (ETTNO)' Study: Background Aims, and Study Protocol

Background: Infants with extremely low birth weight uniformly develop anemia of prematurity and frequently require red blood cell transfusions (RBCTs). Although RBCT is widely practiced, the indications remain controversial in the absence of conclusive data on the long-term effects of RBCT. Objectives: To summarize the current equipoise and to outline the study protocol of the ‘Effects of Transfusion Thresholds on Neurocognitive Outcome of extremely low birth-weight infants (ETTNO)’ study. Methods: Review of the literature and design of a large pragmatic randomized controlled trial of restrictive versus liberal RBCT guidelines enrolling 920 infants with birth weights of 400–999 g with long-term neurodevelopmental follow-up. Results and Conclusions: The results of ETTNO will provide definite data about the efficacy and safety of restrictive versus liberal RBCT guidelines in very preterm infants.

Variability in the Assessment of ‘Adequate’ Chest Excursion during Simulated Neonatal Resuscitation

Background: International neonatal resuscitation guidelines recommend assessing chest excursion when the heart rate is not improving. However, the accuracy in assessing ‘adequate’ chest excursion lacks objectivity. Aim: It was the aim of this study to test the accuracy in the assessment of ‘adequate’ chest excursion by measuring intra- and inter-observer variability of participants during simulated neonatal resuscitation. Methods: Thirty-seven staff members (8 neonatologists, 8 registrars, 21 nurses) of the Neonatal Intensive Care Unit, Leiden University Medical Center, Leiden, The Netherlands, ventilated 2 different intubated, leak-free manikins at 2 attempts, each with a different compliance. Blinded to the manometer, participants could change the peak inflation pressure until chest movement was adequate according to their perception. Inflating pressures were recorded. Results: According to the participants, a median (interquartile range) pressure of 18 cm H2O (16–22) at the first and 18 cm H2O (16–25) at the second attempt were needed to reach adequate chest excursion in the Laerdal manikin. The HAL manikin needed 26 cm H2O (19–31) and 24 cm H2O (22–33), respectively. The inter-observer coefficient of variance was 30% with the Laerdal manikin at both attempts, and 35 and 40% with the HAL manikin, respectively. The intra-observer coefficient of variance was 15% (8–23) with the Laerdal and 13% (9–20) with the HAL manikin. In both manikins and attempts, no significant differences in pressures and variances of pressures between the 3 groups were found. Conclusion: ‘Adequate’ chest excursion is a subjective parameter for guidance of appropriate ventilation during neonatal resuscitation.

Auditing documentation on delivery room management using video and physiological recordings

Objective Neonatal resuscitation is often retrospectively documented, which can lead to inaccuracy and incomplete recording of delivery room management. In this study, we assessed the accuracy and completeness of neonatal resuscitation documentation in our neonatal intensive care unit. Methods Recordings of physiological parameters and video data were performed in the delivery room and used to deduct the clinical condition of the infant, the interventions done and their effect on the infants condition. The data from the recordings were compared with the documentation on neonatal stabilisation in the medical records (paper or digital). Results Recordings of 54 infants were compared with the documentation in their medical records. In 93% of the medical records delivery room management was documented. The clinical condition of the infant at birth was documented in 76% and 1 min Apgar scores in 98%. Respiratory support was correctly documented in 83%, heart rate in 37% and oxygen saturation in 13%. In 57% use of supplemental oxygen and its indication were correctly reported. Seven infants were intubated and this was correctly documented in 57%. Apgar scores were compared between the recordings and the medical records. At 1 min, 5 min and 10 min after birth the Apgar score, given by the researcher using the recordings, was similar to the scores in the medical records in 33%, 44% and 53%, respectively. Conclusions Accurate and complete documentation of neonatal resuscitation continues to be a challenge. Recordings of physiological parameters and video imaging can improve documentation by providing detailed information.

Changes in Respiratory Support of Preterm Infants in the Last Decade: Are We Improving?

Background: Ventilator-induced lung injury has been recognized as a major contributing factor for bronchopulmonary dysplasia (BPD) in preterm infants. In the last decade, focus has shifted towards a more gentle respiratory approach. Aim: To evaluate whether guideline changes in respiratory management in the delivery room and the unit improved the incidence of BPD in very preterm infants. Methods: Three cohorts of infants <30 weeks of gestation, born at the Leiden University Medical Center in the Netherlands in 1996–1997 (cohort ’96), 2003–2004 (cohort ’03) and 2008–2009 (cohort ’08), were compared retrospectively. The major change was increasing use of continuous positive airway pressure in time, and monitoring the tidal volume during mechanical ventilation in cohort ’08. The primary outcome was BPD at 36 weeks. Results: The incidence of BPD did not change from 47% in cohort ’96 to 55% in cohort ’03 (n.s.), but decreased significantly to 37% in cohort ’08 (cohort ’96 vs. ’08 and cohort ’03 vs. ’08: p < 0.01). We observed the same effect when only moderate and severe BPD were counted with 27% in cohort ’96, 31% in cohort ’03 and 14% in ’08 (cohort ’96 vs. ’03: p = n.s., cohort ’96 vs. ’08: p < 0.01, cohort ’03 vs. ’08: p < 0.05). The mortality rate was not significantly different between the three cohorts. Conclusion: The incidence of BPD in our cohort of preterm infants has decreased during the last decade and could be due to the changes in respiratory management.

Severe hemorrhage after low-molecular-weight heparin treatment in a preterm neonate.

Thromboembolic events in preterm neonates are increasingly being diagnosed due to the increasing use of umbilical catheters and central venous catheters. Whether thromboembolic events should be treated routinely with low-molecular-weight heparin (LMWH) is controversial and the optimal management is still not clear due to the lack of randomized controlled trials. Most importantly, knowledge about the safety of treatment with LMWH in neonates with thromboembolic events is very limited. We present a case of severe hemorrhage in a preterm neonate after LMWH treatment and summarize the scarce data reported in the literature.

Leak during manual neonatal ventilation and its effect on the delivered pressures and volumes: an in vitro study.

Background: Mask leak is a frequent problem during manual ventilation. Our aim was to investigate the effect of predefined leaks on delivered peak inflation pressure (PIP), positive end-expiratory pressure (PEEP) and tidal volume (Vt) when using different neonatal manual ventilation devices. Methods: A neonatal-lung model was ventilated at different respiratory rates (RRs, 40, 60, 80/min) using a mechanically operated self-inflating bag (SIB) and a manually operated T-piece resuscitator (PIP = 20 cm H2O, PEEP = 5 cm H2O). Four open tubes of different lengths, which produced up to 90% leak, were consecutively attached between the ventilation device and the lung model. A pneumotachograph was used to measure pressures, flow and volume. Results: With increasing leak (0–90%) PIP and PEEP decreased significantly (p < 0.001) for both devices. Using the SIB, the mean ± SD PIP fell from 20.1 ± 0.3 to 15.9 ± 7 cm H2O and PEEP fell from 5.0 ± 0 to 0.3 ± 0.5 cm H2O, leading to an increased pressure difference (Δp); Vt increased from 8.8 ± 0.7 to 11.1 ± 0.8 ml (p < 0.001). With increasing RRs, the leak-dependent changes were significantly lower (p < 0.001). Using the T-piece resuscitator, PIP dropped independent of RRs from 20.3 ± 0.5 to 18.5 ± 0.6 cm H2O and PEEP from 5.1 ± 0.4 to 4.0 ± 0 cm H2O, while Δp and Vt did not differ significantly. Conclusion: The decrease in PIP and PEEP with increasing leak is RR dependent and distinctly higher when using an SIB compared to a T-piece device. In contrast to Vt delivered with the SIB, Vt delivered by the T-piece resuscitator was nearly constant even for leaks up to 90%.

Diagnostic and therapeutic management for suspected neonatal herpes simplex virus infection

BACKGROUND Neonatal herpes simplex virus (HSV) is a rare disease associated with high mortality and morbidity rates. HSV infection can be subdivided into 3 clinical manifestations: isolated skin, eye and mouth (SEM) disease, central nervous system (CNS) disease and disseminated disease. Consensus guidelines for diagnostic and therapeutic management are not available. OBJECTIVES To evaluate the diagnostic work-up and therapeutic management in neonates with suspected or proven HSV infection. STUDY DESIGN Retrospective study of diagnostic and therapeutic management in all neonates with suspected HSV infection admitted to our neonatal nursery between January 2005 and July 2010. RESULTS A total 53 neonates with suspected HSV infection were included in the study and classified as SEM disease (n=2), CNS disease (n=41) or disseminated disease (n=10). None of the included infants tested positive for HSV infection. Correct and complete diagnostic work-up was performed in only 11% (6/53) of the cases. All neonates were treated with intravenous acyclovir. CONCLUSIONS None of the neonates with suspected HSV tested positive. Diagnostic management in neonates with suspected HSV infection was often improper and incomplete. Consensus guidelines to identify low-risk infants in whom HSV testing and acyclovir treatment is not warranted, are urgently needed.

Routine TORCH screening is not warranted in neonates with subependymal cysts

BACKGROUND Congenital infections are associated with a wide variety of clinical symptoms, including subependymal cysts (SEC). OBJECTIVE To determine the co-occurrence of SEC and congenital infections, as diagnosed by TORCH serologic tests and/or cytomegalovirus (CMV) urine culture. METHODS We performed a retrospective study of all neonates admitted to our neonatal intensive care unit from 1998 to 2009 in whom SEC were detected on cranial ultrasound and TORCH serologic tests and/or CMV urine cultures were performed. RESULTS Fifty-nine neonates fulfilled the inclusion criteria. TORCH serologic tests were performed in 69% (41/59) of cases. Urine CMV culture was performed in 68% (40/59) of cases. None of the neonates tested positive for IgM Toxoplasma gondii, Rubella and Herpes simplex virus. Positive CMV IgM titers and/or a positive urine CMV culture were detected in 2% (1/59) of neonates. CONCLUSION The co-occurrence of TORCH congenital infections in infants with SEC is rare. Routine TORCH screening in neonates with SEC does not seem warranted.