Christoph Vogtmann

Hemodynamics among neonates with hypoxic-ischemic encephalopathy during whole-body hypothermia and passive rewarming.

OBJECTIVE. To assess changes in cardiac performance, with Doppler echocardiography, among newborns with hypoxic-ischemic encephalopathy during mild therapeutic hypothermia and during rewarming. METHODS. For 7 asphyxiated neonates (birth weight: 1840–3850 g; umbilical artery pH: 6.70–6.95) who received mild whole-body hypothermia, the following hemodynamic parameters were determined immediately before rewarming (33°C) and during passive rewarming (35°C and 37°C): heart rate, systolic and diastolic blood pressure, core and peripheral temperatures, left ventricular ejection time, mean velocity of aortic flow, stroke volume, and cardiac output. RESULTS. Heart rate decreased during hypothermia. Bradycardia, with heart rates below 80 beats per minute, did not occur. The median difference between core and peripheral temperatures decreased from 2.0°C (range: 0–6.2°C) during hypothermia to 0.7°C (range: 0.4–1.9°C) at normothermia. Cardiac output was reduced to 67% and stroke volume to 77% of the posthypothermic level. The median heart rate was 129 beats per minute before rewarming and increased to 148 beats per minute during complete rewarming. Before and during passive rewarming, hypotension was not observed. Before, during, and at the end of rewarming, the following parameters increased: mean velocity of aortic flow (median: 44, 55, and 58 cm/second, respectively), stroke volume (median: 1.42, 1.55, and 1.94 mL/kg, respectively), and cardiac output (median: 169, 216, and 254 mL/kg per minute, respectively). Left ventricular ejection time remained unchanged. CONCLUSIONS. Whole-body hypothermia resulted in reduced cardiac output, which reached normal levels at the end of passive rewarming, at normothermia. Physiologic cardiovascular mechanisms seemed to be intact to provide sufficient tissue perfusion, with normal blood lactate levels.

Transcutaneous bilirubinometry in preterm infants

The aim of this study was to evaluate the accuracy and safety of transcutaneous bilirubinometry in preterm infants using the new bilirubin analyser BiliCheck±. The study included 145 preterm children (23–36 wk gestation). Capillary blood sampling for determination of serum bilirubin (BS) was combined with transcutaneous bilirubin measurement (BTc) every morning until the sixth postnatal day and related to several clinical data (phototherapy (PT), infection signs, breathing disturbances, skin bleeding, etc.). Overall bilirubin concentration ranged from 17 to 371 μmol/l, and from 21 to 325 μmol/l for BS and BTc, respectively. Mean values obtained by BTc were significantly higher than BS values. The correlation coefficient between BS and BTc was r= 0.64 for the whole group, and r= 0.73 in infants without PT. As demonstrated by multiple regression analysis, BS‐BTc correlations were related only to gestational age (beta ‐0.32) and breathing disturbances (beta 0.29), indicating that the lower the gestational age and the more seriously ill the baby, the higher the incoherence between BS and BTc.

Cardiac adaptation in small for gestational age neonates after prenatal hemodynamic disturbances

BACKGROUND Small for gestational age neonates with prenatal hemodynamic disturbances are at increased risk for neonatal morbidity. Investigations of fetal cardiac function have proved some functional impairments. The aim of the study was to investigate postnatal cardiac adaptation in these neonates in comparison with neonates without prenatal hemodynamic impairments. METHODS AND RESULTS Forty-one neonates with prenatal hemodynamic disturbances and 40 neonates with undisturbed prenatal hemodynamics were observed during the first 5 days of life. Doppler sonographic measurements of left ventricular time intervals, stroke volume, cardiac output and the incidence of patent ductus arteriosus were obtained in all neonates of both groups. Heart rate and blood pressure were recorded simultaneously. RESULTS A higher incidence of patent ductus arteriosus and a diminished stroke volume, but increased cardiac output, based on a significantly increased heart rate, were determined in SGA neonates with prenatal hemodynamic disturbances. In contrast, systolic left ventricular time intervals were not changed in these neonates, as expected. CONCLUSIONS The described findings could be signs of persistent hemodynamic impairments in growth-retarded neonates with prenatal disturbed hemodynamics. The neonates revealed a reduced ability to compensate the prenatal hemodynamic disturbances. This aspect should be included in the discussion of perinatal management in cases of severe growth retardation.

Higher Rate of Cord-Related Adverse Events in Neonates with Dry Umbilical Cord Care Compared to Chlorhexidine Powder

Objective: Best practice for umbilical cord care (UC) still remains controversial in developed countries with aseptic perinatal care. A bicenter randomized clinical trial was performed to evaluate the efficacy of chlorhexidine (CX) powder versus dry cord care (DC) for UC. Patients and Methods: All neonates of two neonatal care units were invited to take part in the study. Participants were randomized to either DC or UC with CX powder (0.1%). Primary study outcome was the cord separation time. Secondary outcomes were omphalitis, granuloma of the umbilical ground, adverse events and parents’ treatment satisfaction. The outcome parameters were documented at a hospital-located study visit 10–14 days after birth. Results: 669 neonates were enrolled in the trial. 337 were randomized to receive CX powder for umbilical cord care, 332 to DC. Cord separation time was 7.0 ± 2.5 days in CX-treated neonates and 7.8 ± 2.9 days in DC (p < 0.001). There were 9 cases of omphalitis, 2 in the CX group, 7 in the DC group (p = 0.1). No difference in the occurrence of umbilical granuloma between the treatment regimens was detected. Neonates randomized to CX were less likely to have an adverse event (140 in 109 subjects vs. 205 in 149 subjects in the DC neonates; p = 0.001). Half of these adverse events were cord-related. Neonates randomized to DC had nearly twice as many cord-related adverse events as those with CX treatment (CX: 58 in 54 patients vs. DC: 110 in 97 patients; p < 0.001). Parents’ treatment satisfaction was significantly higher in the neonates with CX cord care. Conclusions: Cord-related adverse events in neonatal umbilical cord care remain a clinical issue. Even in an aseptic birth context in a developed country, cord care with CX powder showed a reduction of cord-related adverse events.

Determination of Secretory IgA and Albumin in Saliva of Newborn Infants

As a first line of defence against microbial invasion, secretory IgA (sIgA) is the dominant immunoglobulin on all mucosal surfaces. In this study sIgA was determined by radial immunodiffusion in saliva samples of 63 newborn infants divided into the following age groups: (1) 1 day and younger, (2) 2–10 days. Concentrations of sIgA and albumin as well as their relation to age, postprandial time, gestational age and birth weight were analysed. sIgA could be detected in 75.0% (group 1) and 77.1% (group 2) of the saliva samples with a mean concentration of 190.2 mg/l (group 1) and 216.4 mg/l (group 2). Differences failed to reach significance. Concentration of sIgA was found to be independent of age but positively related to the concentration of albumin in the same saliva sample. In conclusion, this study provides evidence that high levels of sIgA are found in saliva of newborn infants, indicating the existence of a competent oral mucosal immune system as early as within the first 10 days of life.

Aminophylline influences cerebral hyperperfusion after severe birth hypoxia

Doppler sonographic investigations have presented cerebral hyperperfusion in neonates after severe asphyxia. Neonates with disturbed cerebral blood flow velocity (CBFV) tend to have poor outcomes. The purpose of this clinical study was to examine the influence of aminophylline on cerebral hyperperfusion. An intravenous bolus of 4 mg/kg aminophylline was given to nine neonates with Doppler sonographic signs of cerebral hyperperfusion. CBFV was determined before, 5 min, 60min and 120 min after aminophylline administration and on the following day. After aminophylline the mean systolic (56.5 vs. 41.6 cm/s) and end diastolic (21.0 vs. 12.3 cm/s) blood flow velocity decreased and the mean pulsatility index (0.83 vs. 1.1) increased significantly. Repeated measurements showed a decrease in blood flow velocities and an increase in pulsatility index on the following days. Heart rate, mean arterial blood pressure and pCO2 were not significantly changed.

Gastric perforation in a newborn.

THE LANCET • Vol 363 • February 28, 2004 • www.thelancet.com 703 35 Anastasiou R, Papadelli M, Georgalaki MD, Kalantzopoulos G, Tsakalidou E. Cloning and sequencing of the gene encoding X-prolyldipeptidyl aminopeptidase (PepX) from Streptococcus thermophilus strain ACA-DC 4. J Appl Microbiol 2002; 93: 52–59. 36 Goldstein JM, Banbula A, Kordula T, Mayo JA, Travis J. Novel extracellular x-prolyl dipeptidyl-peptidase (DPP) from Streptococcus gordonii FSS2: an emerging subfamily of viridans Streptococcal x-prolyl DPPs. Infect Immun 2001; 69: 5494–501. 37 Jones CH, Bolken TC, Jones KF, Zeller GO, Hruby DE. Conserved DegP protease in gram-positive bacteria is essential for thermal and oxidative tolerance and full virulence in Streptococcus pyogenes. Infect Immun 2001; 69: 5538–45. 38 Harris TO, Shelver DW, Bohnsack JF, Rubens CE. A novel streptococcal surface protease promotes virulence, resistance to opsonophagocytosis, and cleavage of human fibrinogen. J Clin Invest 2003; 111: 61–70.

Treatment of myocardial dysfunction and pulmonary oedema in an infant chimpanzee.

Abstract:  The care of any critically ill infant requires special technical equipment for monitoring of cardiac and pulmonary functions including mechanical ventilators and blood gas analysers. The present paper describes the treatment of myocardial dysfunction and pulmonary distress, complicated by severe brain oedema in an infant chimpanzee admitted to an intensive care unit in the Department of Neonatology of the Childrens Hospital of the University of Leipzig. The condition of the chimpanzee was diagnosed and monitored by standard clinical tooös including radiography, echocardiography, cerebral Doppler sonography and laboratory parameters. The chimpanzee was treated in close cooperation between veterinarians and paediatricians.

Predictive value of umbilical cord blood bilirubin for postnatal hyperbilirubinaemia: Umbilical cord blood bilirubin and hyperbilirubinaemia

Aim: The study investigated the predictive value of umbilical cord serum (UCS) bilirubin for the postnatal course of bilirubinaemia in healthy term and near‐term newborns. Methods: Term appropriate‐for‐gestational‐age (AGA; n=1100), small‐for‐gestational‐age (SGA; n=163) and near‐term infants (GA 34–36 wk; n=78) were included and separated according to their UCS bilirubin levels, starting from <20 (group 1), 20–<30 (2), 30–40 (3) and >40 (4) μmol/l. The newborns were followed for at least 5 postnatal days, and UCS bilirubin values were correlated with the development of hyperbilirubinaemia and phototherapy (PT) treatment. Results: A clear relation between UCS bilirubin and the development of hyperbilirubinaemia was found in all three patient populations. None of the 75 AGA patients of group 1 developed postnatal bilirubin values above 300 μmol/l, whereas 0.3, 3.4 and 8.6% of the patients in groups 2–4, respectively, did so. The frequency of PT increased from 0% in group 1 up to 9.6% in group 4. For the prediction of further need of PT using a UCS bilirubin cut‐off level of 30 μmol/l, we found a sensitivity of 90% and a negative predictive value of 99.1%, indicating that all patients with UCS bilirubin values below 30 μmol/l (443/1100 or 40.2%) were at a very low risk of developing dangerous hyperbilirubinaemia. Similar results were obtained in SGA children with a sensitivity of 94.1% and a negative predictive value of 98.6%. In comparison to term newborns, we generally found higher bilirubin values in preterms. A total of 6.4% of preterm children developed bilirubin values over 300 μmol/l, compared with 3% of term children, and 47.4% of preterms had to be treated with PT. Predicting the need of PT by using a UCS bilirubin cut‐off level of 30 μmol/l revealed a sensitivity of 70.3% and a negative predictive value of 65.6%.