Jacob Kuint

Maternal Depression and Anxiety Across the Postpartum Year and Infant Social Engagement, Fear Regulation, and Stress Reactivity

OBJECTIVE To examine the effects of maternal depression on infant social engagement, fear regulation, and cortisol reactivity as compared with maternal anxiety disorders and controls and to assess the role of maternal sensitivity in moderating the relations between maternal depression and infant outcome. METHOD Using an extreme-case design, 971 women reported symptoms of anxiety and depression after childbirth and 215 of those at the high and low ends were reevaluated at 6 months. At 9 months, mothers diagnosed with a major depressive disorder (n = 22) and anxiety disorders (n = 19) and matched controls reporting no symptoms across the postpartum year (n = 59) were visited at home. Infant social engagement was observed during mother-infant interaction, emotion regulation was microcoded from a fear paradigm, and mothers and infants cortisol were sampled at baseline, reactivity, and recovery. RESULTS The infants of depressed mothers scored the poorest on all three outcomes at 9 months-lowest social engagement, less mature regulatory behaviors and more negative emotionality, and highest cortisol reactivity-with anxious dyads scoring less optimally than the controls on maternal sensitivity and infant social engagement. Fear regulation among the children of anxious mothers was similar to that of the controls and their stress reactivity to infants of depressed mothers. Effect of major depressive disorder on social engagement was moderated by maternal sensitivity, whereas two separate effects of maternal disorder and mother sensitivity emerged for stress reactivity. CONCLUSIONS Pathways leading from maternal depression to infant outcome are specific to developmental achievement. Better understanding of such task-specific mechanisms may help devise more specifically targeted interventions.

Methicillin-resistant Staphylococcus aureus in Neonatal Intensive Care Unit

A neonatal intensive care unit outbreak was caused by a strain of methicillin-resistant Staphylococcus aureus previously found in the community (ST45-MRSA-IV). Fifteen infected neonates were identified, 2 of whom died. This outbreak illustrates how a rare community pathogen can rapidly spread through nosocomial transmission.

Necrotizing Enterocolitis in Full-Term Infants: Case-Control Study and Review of the Literature

OBJECTIVE: To examine the increasing number of full-term infants at our hospital exhibiting necrotizing enterocolitis (NEC) in order to characterize these cases and to discover common risk factors.METHODS: Medical charts were reviewed for all full-term infants (gestational age > 36 weeks) that were born in our institution during a 5-year period (from January 1, 1998 to December 31, 2002) and that developed definite NEC. Data regarding the rate of Cesarean section (CS) in our institution over the study period and five years prior to the study was also recorded.RESULTS: During the 5 years of the study, 14 full-term infants were found to have NEC. The incidence of NEC in full-term infants increased from 0.16 to 0.71 per 1000 live births in the 5-year period. Mean birth weight was 2829 g. All the NEC infants except one were delivered by CS, and all of them were fed either with a mixture of breast milk and formula or entirely by formula. Seven of the infants (50%) had no major known risk factors predisposing them for NEC. Mean age of disease onset was very early (4.1 days) in most of the infants (12 infants), and the colon was the main NEC site. The short-term outcome was favorable in all but one case, which required explorative laparotomy for intestinal perforation. The number of infants born by CS has been steadily increasing, and was almost three times greater during the study period in comparison to the preceding years.CONCLUSIONS: The etiology of NEC in the full-term population seems to differ from the etiology for the preterm group in its intestinal location and in the timing of its onset. The increase in the rate of CS over the years might be related to the concurrent increase in NEC, and this relationship should be further investigated.

Transillumination of the palm for venipuncture in infants

Aim To assess the efficacy of transillumination of the palm of the hand in establishing venous access in small infants. Methods One hundred infants aged 2 to 36 months were considered for venipuncture under transillumination following failure to find an accessible vein or a failed venipuncture attempt. Results In 40 of the 100 infants, a vein was visible with transillumination. In 22 of these children, previous attempts to achieve a venous line failed (mean number of failed venipunctures 2.11 ± 0.6) and in 18 infants, no vein could be identified. Using transillumination, venous access was established with just one venipuncture in 39 of the 40 patients. Conclusions Transillumination of the palm can aid in establishing venous access in infants. This can be easily carried out using a common otoscope.

Hypoglycemia rates in the first days of life among term infants born to diabetic mothers.

Objectives: To discover the risk factors for developing hypoglycemia in newborns born to diabetic mothers and to characterize the rates of glucose concentrations in the first two days of life. Methods: Retrospective recordings of medical charts of 576 healthy term infants of diabetic mothers during an 18-month period. We determined the following pre-feeding glucose concentrations: ‘normoglycemia’ (≥47 mg/dl = 2.6 mmol/l), ‘mild hypoglycemia’ (40–46 mg/dl = 2.2– 2.5 mmol/l), ‘moderate hypoglycemia’ (30–39 mg/dl = 1.7–2.1 mmol/l) and ‘severe hypoglycemia’ (<30 mg/dl = 1.7 mmol/l). Results: Glucose concentrations below ‘normoglycemia’ and ‘severe hypoglycemia’ were observed in 280 (48.6%) and 23 (4%) of the infants, respectively. The main risk factors for developing glucose concentrations below ‘normoglycemia’ in the first day of life were large size for gestational age and maternal insulin-dependent diabetes mellitus. ‘Severe hypoglycemia’ was more common among infants born to mothers who needed insulin (either type A2 or insulin-dependent diabetes mellitus). Infants born to mothers with insulin-dependent diabetes mellitus were less mature, heavier, large for their gestational age and exhibited more ‘severe and moderate hypoglycemia’ in the first day of life as compared to infants born to diabetes type A1 and A2 mothers. In addition, infants who were large for gestational age tended to have more ‘moderate hypoglycemia’ when born to diabetes type A1 mothers compared to small and appropriate-for-gestational-age infants. Thirty infants (5%) still had hypoglycemia on the second day of life. This subgroup of infants did not differ with regard to maternal-type diabetes. Conclusions: Infants born to diabetic mothers tend to have a high rate of hypoglycemia on the first day of life when a relatively high cut-off point (≥47 mg/dl = 2.6 mmol/l) is used. Infants born large for gestational age as well as those born to mothers with juvenile diabetes mellitus are at higher risk and should be closely monitored.

Massage therapy by mothers enhances the adjustment of circadian rhythms to the nocturnal period in full-term infants.

ABSTRACT. The objective of this study was to investigate the effect of massage therapy on phase adjustment of rest-activity and melatonin secretion rhythms to the nocturnal period in full-term infants. Rest-activity cycles of infants (measurement 1, n = 16) were measured by actigraphy before and after 14 days of massage therapy (starting at age 10 [±4] d) and subsequently at 6 and 8 weeks of age. 6-Sulphatoxymelatonin excretion was assessed in urine samples at 6, 8, and 12 weeks of age (measurement 2, n = 21). At 8 weeks the controls revealed one peak of activity at approximately 12 midnight (11 p.m.–3 a.m.) and another one at approximately 12 noon (11 a.m.–3 p.m.), whereas in the treated group, a major peak was early in the morning (3 a.m.–7 a.m.) and a secondary peak in the late afternoon (3 p.m.–7 p.m.). At 12 weeks, nocturnal 6-sulphatoxymelatonin excretions were significantly higher in the treated infants (1346.38 ± 209.40 μg/night vs 823.25 ± 121.25 μg/night, respectively;p < .05). It is concluded that massage therapy by mothers in the perinatal period serves as a strong time cue, enhancing coordination of the developing circadian system with environmental cues.

Comparison of community-acquired methicillin-resistant Staphylococcus aureus bacteremia to other staphylococcal species in a neonatal intensive care unit

Hospital acquired infections including staphylococcal species are common in neonatal intensive care units. Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) was recently observed in our unit. The clinical and laboratory characteristics of all neonates with Staphylococcus aureus bacteremia during an 11-year period were retrospectively reviewed. Three groups of patients were compared: 1. Patients with CA-MRSA defined as MRSA-resistant only to β-lactams, but sensitive to all other antibiotic groups and carried SCCmec IV. 2. Patients with multi-drug-resistant (MDR)-MRSA and 3. Patients with MSSA (methicillin-sensitive S. aureus). Forty-three neonates with documented S. aureus bacteremia were included. Of these 41 were preterm babies. Eleven infants had CA-MRSA, 20 had MDR-MRSA and 12 had MSSA bacteremia, the Panton-Valentine-Leukocidine gene (pvl-gene) was not present in any of these strains. Risk factors, clinical manifestations and laboratory tests were similar in all three groups studied. Although neonates infected with CA-MRSA were more premature and had more related diseases, the mortality rate was similar in all groups (9.1% in the CA-MRSA group). Skin infections, osteomyelitis or pneumatocele were not observed more frequently in the CA-MRSA group. We did not find significant differences in risk factors or outcomes in neonates in the three groups. One possible explanation for this observation is that the CA-MRSA outbreak strain did not contain the pvl-gene, which has been suggested to be a significant virulence factor.

Feeding Tolerance in Preterm Infants: Randomized Trial of Bolus and Continuous Feeding

Objective: To test the hypothesis that continuous gastric infusion (CGI) is better tolerated than intermittent gastric bolus (IGB) in small very low birth weight (VLBW) infants. Design: Two-center, prospective, randomized, unmasked clinical trial. Patients: 28 VLBW infants (birth weight <1250 g). A strict feeding protocol was followed. Intervention: Patients were randomized to IGB or CGI. Main outcome measures: Time to reach full feeds (160 cc/kg/d)(by design and real), daily weight, caloric intake, residual gastric volume and type of feeding (formula vs. human milk vs. both). Results: Five infants failed to complete the study because of death (n = 4) or protocol violation (n = 1). The two groups did not differ by birth weight or gestational age; infants fed via IGB reached full feeds earlier (p = 0.03) and had less delay in reaching full feeds than infants fed via CGI. Conclusion: Contrary to our hypothesis, gravity IGB is more effective than CGI in improving feeding tolerance in small VLBW infants.

Early Treated Hypotension and Outcome in Very Low Birth Weight Infants

Background: Early hypotension is a common problem among preterm infants. Studies have shown conflicting data regarding the definition of hypotension, the way to treat it and the correlation to outcome. Objectives: To investigate the risk factors for developing hypotension and its relations to short- and long-term outcomes. Methods: Medical charts of all surviving very low birth weight infants were retrospectively reviewed during a 4-year period. The data of infants suffering from early hypotension and needed treatment were compared with those of a control group with ‘normal’ blood pressure. In addition, medical charts were reviewed for neurodevelopment outcome. Results: The study and control groups comprised 109 infants each. The mean blood pressures were 24.1 ± 3.2 and 30.3 ± 4.3 mm Hg in the study and control groups (p < 0.0001). No significant perinatal variables were found to predict hypotension. Bronchopulmonary dysplasia and retinopathy of prematurity were related to treated hypotension. Logistic regression analysis found that neonatal treated hypotension was related to periventricular leukomalacia, with an odds ratio of 2.61 (95% CI 1.0–7.12), p = 0.049. Intraventricular hemorrhages grades 2–4 were found to be related to lower mean blood pressure, with an odds ratio of 1.3 (95% CI 1.12–1.51), p < 0.01. Major long-term neurological disability was found by regression analysis to be related to periventricular leukomalacia and treated hypotension, with odds ratios of 63.1 (95% CI 13.3–299, p < 0.001) and 5.4 (95% CI 1.29–22.7, p = 0.01). Conclusions: This study supports the hypothesis that early provision of antihypotensive therapy is related to intraventricular hemorrhage, periventricular leukomalacia and major neurodevelopment impairment.

Clot formation of neonates tested by thromboelastography correlates with gestational age

Evaluation of clot formation in neonates is troublesome. Our aim was to investigate cord blood clot formation of pre-term versus full-term infants and adults, using rotating thromboelastogram (ROTEM), Pentafarm, Munich, Germany). ROTEM was investigated in cord blood of 184 full-term and 47 pre-term infants. Measurements of the clotting time (CT), clot formation time (CFT) and maximal clot firmness (MCF) were obtained in order to asses reference values for this age group, and compare between full-term and pre-term neonates and compared to adult controls. For each infant demographic information and data regarding pregnancy and delivery were gathered. Infants were prospectively followed until discharge. CT and CFT were significantly shorter among pre-term and term infants as compared to adults [median CT: 185, 194, 293 seconds respectively, p pound0.001, CFT: 80, 76, 103 seconds respectively, p pound0.001). MCF was lower in pre-term and term as compared to adults (p pound0.001) with significantly lower values in pre-term as compared to full-term neonates (p=0.004). Clotting time and MCF correlated with gestational age (R=0.132, p=0.045, R= 0.259, p<0.001, respectively). No association was found between any ROTEM values and the occurrence of post-natal complications in infants of our study group. This is the first study assessing clot formation by ROTEM in pre-term infants. Clot formation parameters of term and premature infants correlated with gestational age. The predictive value of clot formation tests in neonates deserves further attention.