Horacio Osiovich

Perinatal Outcomes Associated With Preterm Birth at 33 to 36 Weeks’ Gestation: A Population-Based Cohort Study

OBJECTIVE. The aim of our population-based study was to compare the mortality and morbidity of late-preterm infants to those born at term. Advancement in the care of extremely preterm infants has led to a shift of focus away from the more mature preterms, who are being managed as “near terms” and treated as “near normal.” Some recent studies have suggested an increased risk of mortality and morbidity in this group compared with infants born at term. However, there are few population-based mortality and morbidity statistics for this cohort, particularly reflecting current practice. METHODS. Using data from the British Columbia Perinatal Database Registry we analyzed all singleton births between 33 and 40 weeks’ gestation from April 1999 to March 2002 in the province of British Columbia, Canada. We divided this birth cohort into late preterm (33–36 weeks, n = 6381) and term (37–40 weeks, n = 88 867) groups. We compared mortality and morbidity data and associated maternal factors between the 2 groups. RESULTS. Stillbirth rate and perinatal, neonatal, and infant mortality rates were significantly higher in the late-preterm group. Infants in this group needed resuscitation at birth more frequently than those in the term group. Late-preterm infants had a significantly higher incidence of respiratory morbidity and infection and had a significantly longer duration of hospital stay. Maternal factors that were more common in the late-preterm group included chorioamnionitis, hypertension, diabetes, thrombophilia, prelabor rupture of membranes, primigravida, and teenage pregnancy. CONCLUSIONS. Our data support recent literature regarding neonatal mortality and morbidity in late-preterm infants and warrants a review of care for this group at the local, national, and global levels. Reorganization of services and increased resource allocation may be needed in most hospitals and community settings to achieve optimization of care for this group of infants.

Persistent Bacteremia and Severe Thrombocytopenia Caused by Coagulase-Negative Staphylococcus in a Neonatal Intensive Care Unit

OBJECTIVE. Coagulase-negative Staphylococcus (CoNS) is the most frequent cause of late-onset sepsis in NICUs, but mortality is rare and morbidity is unusual. We report a new syndrome of CoNS sepsis characterized by significant morbidity and persistent bacteremia despite aggressive antibiotic therapy and no identified focus of infection. METHODS. We conducted a retrospective review of infants in the NICU with CoNS bacteremia between 2000 and 2002. Statistical analysis included an initial exploratory analysis followed by logistic regression. Microbiological identification of all isolates and molecular typing were performed. RESULTS. Thirty-one neonates with persistent CoNS bacteremia were compared with 60 randomly selected neonates from a group of 140 with nonpersistent CoNS bacteremia. The clinical manifestations at presentation, gestational ages, and birth weights were similar in the 2 groups. Thrombocytopenia was present in 26 (84%) neonates with persistent CoNS bacteremia but only in 8 (13%) neonates in the nonpersistent group. Central venous catheterization increased the risk for persistent CoNS bacteremia, but 42% of the persistent group was never catheterized. Staphylococcus epidermidis was the most common isolate in both groups. Molecular typing failed to identify a predominant clone. CONCLUSIONS. The syndrome of persistent CoNS septicemia is remarkable for thrombocytopenia and persistence in the absence of central venous catheterization. Clinical manifestations at presentation and demographic characteristics did not discriminate between the persistent and nonpersistent groups. We did not identify the emergence of a particularly virulent clone, but it is possible that some strains of CoNS have acquired the capacity to persist under different conditions.

Is it painful or not? Discriminant validity of the Behavioral Indicators of Infant Pain (BIIP) scale.

Objectives To evaluate the ability of the Behavioral Indicators of Infant Pain (BIIP) scale to discriminate between skin-breaking and nonskin breaking procedures, and to identify sensitized pain responses in preterm infants in the neonatal intensive care unit (NICU). Methods Sixty-nine infants born between 24 and 32 weeks gestational age were assessed at 32 weeks postconceptional age during blood collection on one day (procedure A), and then on another day during blood collection preceded by a diaper change (procedure B). Procedure order was randomized. Outcome measures were changes in BIIP coded from continuous bedside video recordings and changes in heart rate (HR). Results During blood collection (procedure A), BIIP scores (P<0.0001) and mean HR (P<0.0001) were higher than during the diaper change and higher when the infants had had a preceding diaper change (procedure B vs. procedure A) (P<0.03). HR changed from baseline to the stressors for each procedure. No differences in mean HR were observed during Lance phase between the procedure A and the B blood collection; however, HR remained elevated significantly during the Recovery phase when blood collection was preceded by the diaper change (P<0.03). Discussion The BIIP scale is reliable, accurate, and valid assessment for measuring acute pain in preterm infants in the NICU. This assessment combines the relatively most specific, anatomically based, theoretically derived indicators; and it allows evaluation of behavioral and physiologic pain responses separately.

Hypoplastic left heart syndrome: "to treat or not to treat".

OBJECTIVE:To review our experience in managing infants with hypoplastic left heart syndrome (HLHS) and to establish a consistent approach in counseling families based on our experience and on review of medical literature.METHODS:Infants were divided into three group periods based on significant changes in the approach to treatment. After a diagnosis of HLHS was made, a multidisciplinary team met the family to discuss different management options: compassionate care, active treatment by heart transplantation, or Norwood staged surgery.RESULTS:Parents of 58 infants (58%) opted for compassionate care, and 41 (42%) opted for active treatment. Seven infants underwent heart transplantation and all remain alive. A total of 27 infants underwent Norwood stage I, and 19 (70%) survived. There was a significant increase in parental choice for active treatment over the three time periods.CONCLUSION: These results indicate that HLHS can no longer be regarded as a uniformly fatal congenital anomaly. However, due to uncertainty about long-term outcome, discussion with parents should be open, and compassionate care should be presented as a management option until long-term data are available.

Brainstem Involvement in Neonatal Herpes Simplex Virus Type 2 Encephalitis

Herpes simplex virus encephalitis in the newborn typically involves the cerebral cortex in a widespread manner. Herpes simplex virus type 2 rarely involves the brainstem. Here we report a 16-day-old infant with predominant brainstem and cerebellar involvement secondary to herpes simplex virus type 2 infection. Diffusion-weighted MRI performed 3 days after the onset of symptoms revealed restricted diffusion mainly in brainstem and cerebellar structures. No abnormal findings were seen on conventional MRI. Subsequent MRI scans showed evolution of the brain injury with extension along the corticospinal tracts. However, there was no evidence of any other supratentorial gray or white matter injury. This is the first report of predominant brainstem involvement in neonatal herpes simplex virus type 2 encephalitis. In addition, the importance of performing diffusion-weighted sequences to detect early central nervous system involvement and serial MRI to follow the evolution of central nervous system lesions is emphasized.

The use of high flow nasal cannulae in neonatal intensive care units: Is clinical practice consistent with the evidence?

Background: In the recent years, a new treatment modality, high-flow nasa l cannulae (HFNC) has become widely used despite limited systematic evaluation. Objective: To survey the attitudes and practices in academic neonatal units in the United States regarding the use of HFNC and to review the current literature on HFNC. Methods: A questionnaire regarding HFNC use was distributed to all (n = 97) Neonatal-Perinatal Medicine Fellowship Training Program Directors in the United States. Results: Fifty eight (60%) program directors responded to the questionnaire. Of these 40 (69%) reported using heated humidified HFNC (HHHFNC) and 18 (31%) not using this modality. Reported starting flows ranged from 1 to 6 L/min and maximal flows from 2 to 8 L/min. The indication for use of HHHFNC varied between units. Conclusions: The findings of our survey and our review of the literature sug gest that the use of HHHFNC is widespread despite lack of evidence of efficacy from large clinical trials. The i ndications for HHHFNC and the initial, minimal and maximal fl ows varied widely among the centers. This report supports the need for well designed randomized controlled clinical trials to evaluate the efficacy and safety of HHHFNC for a variety of clinical ind ications.

Congenital mesoblastic nephroma presenting with neonatal hypertension.

Congenital mesoblastic nephroma (CMN) is a rare tumor with an estimated incidence of about 8/million in children under 15 years of life. It is, however, the most common renal tumor in neonates, with more than 80% of CMN tumors presenting in the neonatal period. In 1967, Bolande et al. described CMN as a separate entity from congenital Wilms’ tumor and it is now considered a generally benign renal tumor (as opposed to its variant, the atypical mesoblastic nephroma; AMN). Nephrectomy alone is the treatment of choice with a reported survival of over 98%. Hypertension has been reported with many renal tumors, with or without hyper-reninemia. To date, only nine patients with CMN and hypertension have been reported, out of which six were neonates. We describe the clinical presentation and discuss the findings on abdominal imaging in a 30-week gestation infant with hypertension and CMN.

The use of an early ACTH test to identify hypoadrenalism-related hypotension in low birth weight infants

Objective:To investigate if in preterm newborns, an early adrenocorticotropin hormone (ACTH) test can identify possible transient adrenal insufficiency (TAI), using significant hypotension as a clinical marker.Study Design:We studied 40 premature newborns born 24 to 29 weeks gestational age (GA) before 8 h of life. Serum cortisol levels were obtained before and 40 min after administration of 1.0 mcg kg−1 cosyntropin. Inotropes were used to treat hypotension based on clinical assessment following no response to fluid boluses. Functional echocardiogram was used to support the clinical diagnosis of hypotension. The accuracy of the ACTH test was evaluated using receiver operating characteristic (ROC) curve.Result:Study patients had mean GA of 26.6 weeks and birth weight of 876 g. In all, 30% required inotropes. The area under the ROC curve for the ACTH test was 87%. Using a cutoff of an increase in cortisol below 12% from baseline had 75% sensitivity and 93% specificity for detecting hypotension. This cutoff was associated with bronchopulmonary dysplasia (8/12 vs 7/28, 95% CI: 0.1 to 0.72), but not with other morbidities or death.Conclusion:An early ACTH test using the above cutoff has high specificity for detecting hypotension, and thus, can serve as a marker for potential TAI in preterm newborns. Future studies should focus on identifying those newborns for which steroid supplementation would be most beneficial.

Use of peripherally inserted central catheters (PICC) via scalp veins in neonates

Abstract Objective: The objective of this study is to describe the use and complications of peripherally inserted central catheters (PICC) via scalp veins in neonates. Methods: A retrospective review of neonates who had PICCs inserted, between January 2010 and June 2013, in the NICU at Childrens and Womens Health Center of British Columbia. Results: During the study period, 689 PICCs were inserted over a total of 46 728 NICU patient days. The PICC insertion sites were scalp veins (69), upper limb veins (471), and lower limb veins (149). The mean catheter durations were 17 d, 19 d, and 18 d for PICCs inserted through scalp, upper limb, and lower limb veins, respectively. The complication rates were 23%, 23%, and 15% for insertion via scalp, upper, and lower limb veins, respectively. Centrally placed PICCs at the time of insertion were more likely to remain in situ for longer than one week (p < 0.001). The incidence of central line-associated blood stream infection was 4.4, 6.4, and 3.4 per 1000 catheter days, respectively, for scalp, upper, and lower limb PICCs. Conclusions: Insertion of PICC via the scalp veins are feasible and not associated with higher complication rates compared with insertions via other sites.

Gastric pneumatosis in a preterm infant

1808 www.thelancet.com Vol 366 November 19, 2005 A baby boy at 32 weeks’ gestation was born by spontaneous onset of preterm labour. He weighed 2265 g and had Apgar scores of 7 at 1 min and 9 at 5 min. He was clinically stable for 3 days and was started on enteral feeds. On the fourth day, we noted that he had temperature instability and abdominal distension with sanguineous gastric aspirates. He had poor perfusion, lactic acidaemia, and hyperglycaemia, and needed intubation and fluid resuscitation. Abdominal radiographs showed gastric and intestinal pneumatosis without any evidence of free intraperitoneal or portal venous air (figure). Leucopenia, neutropenia, and thrombocytopenia were also present, and we started the boy on antibiotics after blood culture. Because no organism was isolated, we did not do a laparotomy. He improved over the next month but became intolerant to the enteral feeds. We did a contrast study, which showed small bowel obstruction. At laparotomy we found several old small bowel perforations with associated strictures, and resected two small ileal segments. His stomach and duodenum did not show any abnormality. Histopathology was consistent with necrotising enterocolitis with perforation, and a rectal biopsy showed submucosal ganglia with normal cholinesterase pattern. Although necrotising enterocolitis is common in babies in neonatal intensive care, gastric pneumatosis is rare and usually follows cardiac surgery, pyloric or duodenal stenosis, or intramural misplacement of a feeding catheter. Gastric pneumatosis in a preterm infant