Daisuke Sunohara

Umbilical Cord Milking Stabilizes Cerebral Oxygenation and Perfusion in Infants Born before 29 Weeks of Gestation

OBJECTIVE To investigate the effects of umbilical cord milking at birth on cerebral perfusion and systemic perfusion in very low birth weight (VLBW) infants. STUDY DESIGN Cerebral tissue oxygenation index and cerebral fractional tissue oxygen extraction were monitored in 50 stable VLBW infants (gestational age <29 weeks, birth weight <1250 g), with 26 allocated to the milked group and 24 to the control group. We used near-infrared spectroscopy 3-6, 12, 18, 24, 36, 48, and 72 hours after birth. Left ventricular end-diastolic dimension, left ventricular ejection fraction, left ventricle (LV) Tei index (measurement of left ventricular systolic and diastolic function), left ventricular cardiac output, and superior vena cava flow were measured concurrently using echocardiography. RESULTS There were no significant differences in gestational age and birth weight between the 2 groups. Hematocrit, left ventricular end-diastolic dimension, left ventricular cardiac output, and superior vena cava flow were higher in the milked group than in the control group, with improvement in the LV Tei index despite the absence of left ventricular ejection fraction changes within 24 hours after birth. Tissue oxygenation index increased and cerebral fractional tissue oxygen extraction decreased in the milked group within 24 hours after birth. CONCLUSION Umbilical cord milking stabilized cerebral oxygenation and perfusion in VLBW infants by improving LV diastolic function by increasing LV preload.

Changes in cerebral perfusion in extremely LBW infants during the first 72 h after birth.

Cerebral perfusion and its relation with systemic circulation in extremely LBW (ELBW) infants in the early neonatal period are not well understood. The cerebral tissue oxygenation index (TOI) and cerebral fractional tissue oxygen extraction (FTOE) were monitored in stable 16 ELBW infants (GA <29 wk) using near-infrared spectroscopy (NIRS) at 3–6, 12, 18, 24, 36, 48, and 72 h after birth. The left ventricular end-systolic wall stress (ESWS), left ventricular ejection fraction (LVEF), left ventricular cardiac output (LVCO), and superior vena cava (SVC) flow were also measured simultaneously using echocardiography. The ESWS increased till 18 h and then decreased; LVEF, LVCO, and SVC flow decreased till 12 h and increased thereafter. The TOI decreased till 12 h and correlated with SVC flow; FTOE increased until 12 h and then decreased. These changes in variables of NIRS and echocardiographic measurements contrasted to changes in mean arterial blood pressure (MABP), which showed trends of continuous and gradual increase after birth. We conclude that even stable ELBW infants undergo evident transitional changes in cerebral oxygenation and perfusion in the early postnatal period, which may reflect changes in cardiac function and cardiac output.

Difference in cerebral and peripheral hemodynamics among term and preterm infants during the first three days of life.

Background: The relationship between cerebral and peripheral hemodynamics during the early postnatal period has not been clarified. Objectives: To evaluate cerebral and peripheral oxygenation and blood volumes between term and preterm infants during the first 3 days of life. Materials and Methods: We performed near-infrared time-resolved spectroscopy on 32 term infants (term group) and 40 preterm infants (preterm group), with an optode placed on their forehead and upper arm. The cerebral blood volume (CBV), peripheral blood volume (PBV), cerebral Hb oxygen saturation (cSO2) and peripheral Hb oxygen saturation (pSO2) were measured at 3-6, 12, 24, 48 and 72 h after birth. Results: The CBV in the term group (2.45 ± 0.47 ml/100 g) was significantly higher than that in the preterm group (1.97 ± 0.33 ml/100 g). In contrast to the CBV, the PBV in the preterm group (3.63 ± 0.76 ml/100 g) was significantly higher than that in the term group (3.26 ± 0.56 ml/100 g). In the preterm group, there was a significant positive relationship between the CBVs and PBVs at each time point except at 72 h after birth. Despite the differences in blood volumes, there were no differences in the cSO2 and pSO2 between the two groups. Conclusions: The contrasting results in the CBV and PBV between the term and preterm infants might be explained by differences in the maturation of the physiological mechanism to control CBV and PBV.

Congenital cytomegalovirus infection in monozygotic twins with twin-to-twin transfusion syndrome

BackgroundSymptoms of congenital cytomegalovirus infection remains unclear.Case characteristicsExtremely low birth weight twins with twin-to-twin transfusion syndrome were infected with cytomegalovirus congenitally.ObservationThe donor showed neuronal impairment, whereas the recipient showed hepatic dysfunction.MessageIntrauterine hemodynamics may be important in pathophysiology of congenital cytomegalovirus infection.

Effects of rapid rewarming on cerebral nitric oxide production and cerebral hemodynamics after hypothermia therapy for kainic acid-induced seizures in immature rabbits

Abstract  Background : The aim of the present study was to investigate whether rapid rewarming after hypothermia therapy during seizures alters the endogenous nitric oxide (NO) production in and around hippocampus, cortical cerebral blood flow (cCBF), and mean arterial blood pressure (MABP) in immature rabbits.

Correlations of Enzyme Levels at Birth in Stressed Neonates with Short-Term Outcomes

ABSTRACT Introduction: Multi-organ injury causes leakage of several intracellular enzymes into the circulation. We evaluated the correlation between the serum-leaked intracellular enzyme levels at the beginning of treatment and the outcome in perinatally stressed neonates. Materials and methods: We retrospectively studied neonates whose 1 minute Apgar score was < 7. We collected initial venous blood sample data, including aspartate transaminase (AST), alanine transaminase (ALT), lactate dehydrogenase (LDH), and creatine kinase (CK) levels, and correlated these with patient short-term outcomes. Results: Of 60 neonates, nine patients were treated with therapeutic hypothermia, and 32 needed mechanical ventilation. The therapeutic hypothermia group showed significantly larger base deficit, and higher lactate, AST, ALT, LDH, and CK (all p < 0.01). The duration of mechanical ventilation significantly correlated with AST, ALT, LDH, and CK levels (all p < 0.01). Conclusion: Initial enzyme levels are useful for predicting the duration of mechanical ventilation in stressed neonates.

A case of pulmonary artery sling where onset Was induced by therapeutic hypothermia

A neonate with severe neonatal asphyxia was treated with therapeutic hypothermia. He developed hypothermia‐induced respiratory deterioration, after which congenital tracheal stenosis and pulmonary artery sling were diagnosed. Even low‐grade hypothermia is likely to induce bronchial narrowing in neonates, especially in neonates with congenital respiratory tract anomalies. Congenital tracheal stenosis represents a potential pitfall in differential diagnosis and should be carefully ruled out in cases of bronchial narrowing episode induced by therapeutic hypothermia. Pediatr Pulmonol. 2017;52:E7–E10.

Legal Problems Surrounding Medical Care for Neonates Born to International Students: Report of Two Families in Japan.

The number of international students studying in Japan has increased dramatically [1]; there has been a fourfold increase over the past 25 years, with international student numbers reaching 184,155 in 2013 [1]. If an international student becomes pregnant while studying in Japan and the mother or infant requires special perinatal care, problems can occur because of cultural differences and the Japanese legal system. The Japanese government has adopted a universal and egalitarian health care system in which the cost of neonatal intensive care is covered by national health insurance or the ‘‘nurture medical care’’ scheme. This scheme is intended for neonates who require hospitalization in a neonatal intensive care unit (NICU). Residents from foreign countries are generally allowed to receive the same health care services as Japanese citizens when they satisfy the following conditions: he/she has (1) acquired Status of Residence, (2) obtained local resident registration in the area where he/she is living, and (3) enrolled in the national health insurance scheme. The two neonatal cases we report here had their treatment in Japan suspended because of legal issues. The first patient was a male neonate of estimated gestational age of 31 weeks. His parents were Vietnamese international students studying at a Japanese language school. The child’s mother had not presented at a prenatal checkup during the entire term of her pregnancy. The patient was born vaginally and transferred to our institute because of severe asphyxia and arthrogryposis multiplex congenita. Facial abnormalities, hypoplasia of the thorax, and abnormality of the central nervous system were also recognized. A diagnosis of congenital cytomegalovirus infection was made using the urine polymerase chain reaction. The patient received intensive care for a few weeks, followed by oxygen therapy and tubal feeding during the chronic phase. The child remained in Japan on a short-term visa for the first 60 days, and his parents had to apply for an extension of this visa every 30 days thereafter. Requests to change to a family visa and enroll in the national health insurance scheme were declined, although his parents had their own health insurance. The authorities explained the reasons why they declined the national health insurance as follows. (1) People from foreign countries are required to register in their residential area. (2) However, in this case the patient’s registration as an inhabitant of the area was not permitted because he was regarded as a transient visitor staying on a short-term visa. (3) Thus, the health care system could not be utilized for this patient. Instead, the ‘‘nurture medical care’’ plan was offered exceptionally; however, such care is limited to the first year after birth. Because the patient was considered to need medical care for more than 1 year, we decided to & Junya Nakajima ob1.3po@hotmail.co.jp

Current status of pediatric human immunodeficiency virus infection in Japan

There are currently very few English reports about Japanese pediatric human immunodeficiency virus (HIV). In this study, we introduce our experience with pediatric HIV in a single hospital, and review the present status of HIV infections in children in Japan. In Japan, the main infection routes of HIV include sexual activity, mother-to-child transmission (MTCT), blood or blood product transfusion, and drug use. Most pediatric HIV patients have been infected by MTCT in recent years. One survey showed that in Japan, 52 babies were infected by MTCT between 1984 and 2011. Only 2 cases of pediatric HIV infection have been reported since 2010. The MTCT rate has decreased to 0.5% owing to several preventive interventions. In addition, the HIV antibody test is now performed in more than 98.3% of pregnant women in Japan.

PO-0412 Relationship Between Cerebral And Systemic Perfusion, And Short-term Outcomes In Infants With Perinatal Asphyxia

Background and aims The effects of haemodynamic changes on cerebral and systemic perfusion in infants with perinatal asphyxia are not well understood. We investigated the relationship between cerebral and systemic perfusion, and short-term outcome in infants with asphyxia. Methods Ten infants (gestation age >35 weeks) with asphyxia (Apgar score <7 at 1 min) were divided into 2 groups: those with hypoxic-ischaemic encephalopathy (HIE; HIE group, n = 4) and those without HIE (non-HIE group, n = 6). Cerebral tissue oxygenation index (TOI) and cerebral fractional tissue oxygen extraction (FTOE) were measured by near-infrared spectroscopy (NIRS) at 12, 24, 48, and 72 h after birth. Superior vena cava (SVC) flow and left ventricular cardiac output (LVCO) were simultaneously measured by echocardiography. Results TOI was significantly higher and FTOE was significantly lower in the HIE group (n = 4) than in the non-HIE group (n = 6) at all measurement time points. Although SVC flow and LVCO were not significantly different between the 2 groups, they were consistently higher in the HIE group than in the non-HIE group at all measurement time points. We found a positive correlation between SVC flow and LVCO in both groups, and between SVC flow and TOI in the non-HIE group. Conclusions Combined bedside monitoring of TOI and FTOE by NIRS and SVC flow may be useful for evaluating secondary energy failure and disrupted regulation of brain circulation in infants with asphyxia.