Elisabeth Pichler-Stachl

C reactive protein: impact on peripheral tissue oxygenation and perfusion in neonates

Objective C reactive protein (CRP) is a sensitive marker of acute inflammation of infectious and non-infectious origin. Aim was to use near-infrared spectroscopy (NIRS) to analyse peripheral oxygenation and perfusion in term and preterm neonates with elevated CRP levels, at a time when routine haemodynamic variables are still normal. Design Prospective observational study. Settings Peripheral-muscle NIRS was performed in the first week of life. Tissue-oxygenation index (TOI), mixed venous oxygenation (SvO2), fractional oxygen extraction (FOE), haemoglobin flow (Hbflow), oxygen delivery (DO2) and oxygen consumption (VO2) were assessed. Blood samples were taken within 3 h of the NIRS measurements. Patients Cardiocirculatory stable term and preterm neonates with infection-related and infection-unrelated CRP elevations >10 mg/l were compared with neonates without CRP elevation. The two groups were matched for gestational and postnatal age. Results 33 neonates with CRP elevation (gestational age 37.7±2.9 weeks) were compared with 33 controls (gestational age 37.3±2.9 weeks). In neonates with CRP elevation, TOI (68.9±6.6%), SvO2 (66.9±7.3%) DO2 (39.2±16.1 µmol/100ml/min) and VO2 (10.9±3.4 µmol/100ml/min) were significantly lower compared with controls (TOI 72.9±3.8%, SvO2 70.2±4.7%, DO2 48.8±18.4 µmol/100ml/min, VO2 12.3±3.8 µmol/100ml/min). There was no significant difference in any other NIRS or routine haemodynamic parameter between the two groups. Conclusion Inflammatory processes with CRP elevation cause impaired peripheral oxygenation and perfusion in neonates even when routine haemodynamic variables are still normal. NIRS might offer a new non-invasive tool for the early recognition and diagnosis of infectious and non-infectious inflammatory processes.

‘Multi-associations’: predisposed to misinterpretation of peripheral tissue oxygenation and circulation in neonates

Interpretation of peripheral circulation in ill neonates is crucial but difficult. The aim was to analyse parameters potentially influencing peripheral oxygenation and circulation. In a prospective observational cohort study in 116 cardio-circulatory stable neonates, peripheral muscle near-infrared spectroscopy (NIRS) with venous occlusion was performed. Tissue oxygenation index (TOI), mixed venous oxygenation (SvO(2)), fractional oxygen extraction (FOE), fractional tissue oxygen extraction (FTOE), haemoglobin flow (Hbflow), oxygen delivery (DO(2)), oxygen consumption (VO(2)), and vascular resistance (VR) were assessed. Correlation coefficients between NIRS parameters and demographic parameters (gestational age, birth weight, age, actual weight, diameter of calf, subcutaneous adipose tissue), monitoring parameters (heart rate, arterial oxygen saturation (SaO(2)), mean blood pressure (MAP), core/peripheral temperature, central/peripheral capillary refill time) and laboratory parameters (haemoglobin concentration (Hb-blood), pCO(2)) were calculated. All demographic parameters except for Hbflow and DO(2) correlated with NIRS parameters. Heart rate correlated with TOI, SvO(2), VO(2) and VR. SaO(2) correlated with FOE/FTOE. MAP correlated with Hbflow, DO(2), VO(2) and VR. Core temperature correlated with FTOE. Peripheral temperature correlated with all NIRS parameters except VO(2). Hb-blood correlated with FOE and VR. pCO(2) levels correlated with TOI and SvO(2). The presence of multiple interdependent factors associated with peripheral oxygenation and circulation highlights the difficulty in interpreting NIRS data. Nevertheless, these findings have to be taken into account when analysing peripheral oxygenation and circulation data.

Prematurity: Influence on mother's locus of control

ZusammenfassungIn der vorliegenden Arbeit wurde erstmals die Kontrollüberzeugung von Krankheit und Gesundheit bei Müttern von Frühgeborenen untersucht und mit jener von Müttern Reifgeborener verglichen. Die mütterlichen Einschätzungen wurden auf drei Ebenen erhoben: Internale Ebene (der Krankheits- bzw. Gesundheitszustand ist von der Person selbst abhängig), sozial-externale Ebene (der Krankheits- bzw. Gesundheitszustand ist von anderen Personen abhängig) und sozial-fatalistische Ebene (der Krankheits- bzw. Gesundheitszustand ist von äußeren unkontrollierbaren Faktoren abhängig: Schicksal, Glück, Religion, … ). In der Studie nahmen 35 Mütter von Frühgeborenen (<32 SSW) und 35 Mütter von Reifgeborenen (≥37 SSW) teil, wobei die Datenerhebung innerhalb der ersten drei Tage nach der Geburt durchgeführt wurde. In der Kontrollüberzeugung von Krankheit und Gesundheit zeigte sich ein signifikanter Unterschied zwischen den Müttern von Früh- und Reifgeborenen im Bereich der sozial-fatalistische Ebene, während in den Bereichen der internalen und sozial-externalen Ebene keine signifikanten Unterschiede nachgewiesen werden konnten. Diese Einschätzung des Krankheits- bzw. Gesundheitszustandes von Müttern Frühgeborener, sollte in der mütterlichen Behandlung und Elternbetreuung miteinbezogen und berücksichtigt werden, um sowohl den unmittelbaren Kontaktaufbau zwischen Mutter und Kind zu unterstützen, als auch in weiterer Folge die zukünftige psychosoziale Entwicklung des zu früh geborenen Kindes zu gewährleisten.SummaryThe aim of the present study was to compare the beliefs of mothers of term infants with the beliefs of mothers of preterm infants in regards to their locus of control mainly influencing their personal health and well-being. Mothers beliefs regarding the level of internal (self), social external (other individuals) and fatalistic external control (e.g. chance, destiny, and religion) were assessed while mothers were admitted to hospital postnatally. Thirty-five mothers of preterm infants under 32 weeks of gestation, and 35 mothers of term infants (≥37weeks of gestation) were included and participated within the first three days after delivery. Between the group of mothers of term infants and the group of mothers of preterm infants there was a significant difference in the level of fatalistic external control of health and disease they experienced. Mothers beliefs regarding internal and social external control did not differ between the two groups. When dealing with the mothers of preterm infants one should consider their strong beliefs that health and disease are largely dependent on fatalistic external factors. This might help to improve mother-child interaction and as a consequence also neurobehavioral development of the preterm infant.

Quality of Life of Children with Cystic Periventricular Leukomalacia – A Prospective Analysis with the Child Health Questionnaire-Parent Form 50

Objective Cystic periventricular leukomalacia (PVL) is associated with moderate to severe physical and mental handicaps in preterm infants. We hypothesized whether or not those handicaps were associated with a poorer quality of life (QOL) of affected children and their families compared to matched controls. Patients and methods All children with the diagnosis PVL collected from a local database of the Division of Neonatology of the Medical University of Graz, Austria, and born between 1997 and 2008 were included in the study group. Preterm infants matched for gestational age, birth weight, year of birth, and gender without PVL served as controls. Selected perinatal data and neurological outcome were documented. The interview of the parents was conducted using the Child Health Questionnaire-Parent Form 50 (CHQ-PF50), German version. The CHQ-PF50 consists of 50 items divided over 11 multi-item scales and 2 single-item questions. Results The CHQ-PF50 was answered by 21 parents of the study (26%) and 44 of the control (39%) group. Cases were diagnosed as having developmental delay, dystonia, strabismus, central visual impairment, seizures, and cerebral palsy (81 vs. 7%, p < 0.001) more common than controls. Analysis of the CHQ-PF 50 revealed significantly poorer results for cases regarding physical health (physical functioning: p < 0.001, physical social limitations: p < 0.001, and physical summary score: p < 0.001). Several psychosocial categories (behavior, mental health, and self-esteem) and the psychosocial summary score did not differ between groups. Only two categories (parental impact concerning time p = 0.004 and family activities: p = 0.026) revealed significantly poorer results in the cases as it was for the global category for health (p = 0.009). Conclusion Children with PVL had an overall poorer QOL regarding physical aspects. However, PVL was not generally associated with a poorer QOL regarding psychosocial aspects.

Antenatal Consultation and Postnatal Stress in Mothers of Preterm Neonates (A Two-Center Observational Case–Control Study)

Background During antenatal consultation of women hospitalized for preterm labor, information of possible adverse outcomes is provided. This may however create additional maternal stress and raise some ethical concerns. Objective The aim of the present study was to evaluate the influence of antenatal consultation by a neonatologist on maternal stress after delivery of a preterm infant admitted to NICU. Methods In this study, secondary outcome parameters of a prospective two-center pilot observational study were analyzed. Mothers of preterm neonates < 36 weeks of gestation admitted at two tertiary-level Neonatal-Intensive-Care-Units (NICU) were included. Maternal stress was assessed with the Parental-Stress-Scale:NICU (PSS:NICU) within 72 h after birth. PSS:NICU measures three scales: “relationship and parental role,” “sights and sounds,” and “baby looks and behaves.” Maternal sociodemographic data were collected by questionnaire administered at the same time. Mothers who received antenatal neonatal consultation were matched for gestational age and compared to mothers who had no antenatal consultation by a neonatologist. Results A total of 46 mothers of preterm neonates were included, 23 mothers in each group. There was no significant difference in sociodemographic data between the two groups regarding neonates and mothers. There were no significant differences between the two groups regarding stress scales of “sights and sounds” (2.00 ± 0.76 versus 2.19 ± 0.79; p = 0.402), “looks and behaves” (2.55 ± 0.90 versus 2.48 ± 0.94; p = 0.732) and “relationship and parental role” (3.28 ± 1.23 versus 3.46 ± 1.07; p = 0.517). Conclusion Our study demonstrated that antenatal consultation by a neonatologist had no substantial influence on postnatal maternal stress in mothers of preterm neonates admitted to the NICU.

Cerebral hypoxia during immediate transition after birth and short term neurological outcome

In preterm neonates we investigated cerebral hypoxia assessed with near-infrared-spectroscopy during immediate transition after birth and general movement optimality score assessed before discharge. General movement optimality score decreased with increasing cerebral hypoxia. Burden of cerebral hypoxia during immediate transition might be associated with impaired short-term neurological outcome in preterm neonates.

Blood Glucose and Cerebral Tissue Oxygenation Immediately after Birth—An Observational Study

Objective To assess a possible association of blood glucose concentration with cerebral regional oxygen saturation (crSO2) and cerebral fractional tissue oxygen extraction (cFTOE) in neonates born at term and preterm 15 minutes after birth. Study design A post‐hoc analysis of secondary outcome measures of 2 prospective observational studies was performed. Neonates born at term and preterm via cesarean delivery were included if cerebral near‐infrared spectroscopy measurements were performed during the immediate transition after birth and blood glucose concentrations were measured at 15‐20 minutes after birth. Arterial oxygen saturation and heart rate were measured with pulse oximetry. cFTOE was calculated from arterial oxygen saturation and crSO2 values. crSO2 and cFTOE 15 minutes after birth were correlated with blood glucose concentrations. Results Seventy‐five infants were included. In 50 neonates born at term, crSO2 and cFTOE 15 minutes after birth were 83 ± 7.7% and 0.14 ± 0.08, respectively. In 25 neonates born preterm, crSO2 and cFTOE 15 minutes after birth were 80.2 ± 12.1%, and 0.15 ± 0.1, respectively. crSO2 and cFTOE correlated significantly with blood glucose concentrations in neonates born at term and preterm. Increasing blood glucose concentrations were associated with decreasing crSO2 in neonates born at term (q = –0.35, P = .01) and neonates born preterm (q = –0.69, P = .01) and with increasing cFTOE in neonates born at term (q = 0.31, P = .03) and neonates born preterm (q = 0.67, P = .01). Conclusions Blood glucose concentration was associated with cerebral oxygenation during the immediate transition after birth in neonates born at term and preterm.

Eine neue deutschsprachige Skala zur Erfassung von elterlichem Stress nach Frühgeburtlichkeit (PSS:NICU_German/2-scales)

Background Preterm birth is known to be a stressful and anxious situation for parents, which might have long-term impact on the psychological health of mothers and even on the development of their preterm infants. Objective The Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) was developed to assess parental stress after preterm birth through three subscales [1]. The aim of the present study was to examine the psychometric properties and the dimensionality of the German version of the PSS:NICU to develop a reliable German version of the PSS:NICU. Methods For the development (exploratory factor analysis) 100 parents of preterm infants answered the questionnaire. Results The Sights and Sounds subscale was removed from the German version of the PSS:NICU due to low number of items. A PSS NICU_German/2-scales was developed consisting of 2 subscales: Infant Behavior and Appearance (7 Items, Cronbachs α=0,82) and Parental Role Alteration (6 Items, Cronbachs α=0,87). Conclusions The PSS:NICU_German/2-scales is a reliable and economic scale for the assessment of parental stress after preterm birth.

26 Impact of Severity Of Perinatal Asphyxia on Peripheral Oxygenation and Perfusion in Neonates

Objective The aim was to investigate the influence of perinatal asphyxia on peripheral oxygenation and perfusion in neonates in a prospective observational study. Methods Neonates with over 34 weeks gestational age and birth weight >2000g without sepsis or connatal malformations were included. Neonates with an umbilical artery pH of (UapH) ≤7.15 and 5 minute APGAR score ≤6 were investigated. Neonates with an UapH ≥7.15, and 5 minute APGAR score ≥7 served as control group. Peripheral muscle near infrared spectroscopy (NIRS) measurement in combination with venous occlusion was performed once in the first 48 hours after birth. Tissue oxygenation index (TOI), mixed venous oxygen saturation (SvO2), fractional oxygen extraction (FOE), haemoglobin flow (Hbflow), oxygen delivery (DO2) and oxygen consumption (VO2) were assessed. Furthermore arterial oxygen saturation, heart rate, blood pressure und temperatures were measured. UapH was correlated to NIRS parameters. Results Eight asphyxiated neonates were included. In the asphyxiated group significant correlations between UapH and DO2 (r=0.78), VO2 (r=0.80) and FOE (r=–0.75) were found. The asphyxiated neonates were compared to 30 neonates in the control group. TOI (67.7±5.5%) and DO2 (29.0±14.2 µmol/100/l/min) were significantly lower in asphyxiated neonates compared to the controls (TOI 71.8±4.9%, DO2 43.9±16.9 µmol/100/l/min), FOE was significantly higher (0.33±0.05) compared to the controls (0.28±0.06). No correlation of UapH with NIRS parameters was observed in the control group. Conclusion Peripheral oxygenation and perfusion measured with NIRS is compromised in neonates with perinatal asphyxia with worsening of parameters with severity of asphyxia.