Jörg Ersch

Near-Infrared Spectroscopy Measurements of Cerebral Oxygenation in Newborns during Immediate Postnatal Adaptation

OBJECTIVE In view of growing concerns regarding the optimal supplementation of oxygen at birth, we measured cerebral oxygenation during the first minutes of life. STUDY DESIGN Using near-infrared spectroscopy, changes in cerebral oxygenated hemoglobin (O(2)Hb), dexoxygenated hemoglobin (HHb), and tissue oxygenation index (TOI) were measured during the first 15 minutes of life in 20 healthy newborn infants delivered at term by elective cesarean section. RESULTS O(2)Hb and TOI increased rapidly within the first minutes of life (median slope for O(2)Hb, 3.4 micromol/L/min; range, 1.4 to 20.6 micromol/L/min; median slope for TOI, 4.2 %/min; range, -0.4 to 27.3%/min), and cerebral HHb decreased (median slope, -4.8 micromol/L/min; range, -0.2 to -20.6 micromol/L/min). O(2)Hb, TOI, and HHb all reached a plateau within 8 minutes. CONCLUSIONS A significant increase in cerebral O(2)Hb and TOI and a significant decrease in HHb occur during immediate adaptation in healthy term newborns, reaching a steady plateau at around 8 minutes after birth.

Assessing gestational age from histology of fetal skin: an autopsy study of 379 fetuses

OBJECTIVE To develop guidelines for recognizing stages of fetal skin development to allow objective assessment of gestational age. METHODS Three hundred seventy-nine human fetuses with known gestational ages of 12-30 weeks were examined at autopsy. Skin samples were taken from the abdomen. Two hundred fifty samples constituted a reference to establish histologic criteria from the development of skin appendages, hair, and apocrine and eccrine glands. One hundred twenty-nine additional skin samples were evaluated as a test set by the same investigators without knowledge of the condition of pregnancy or gestational age. RESULTS The assessment of 250 skin samples allowed a description of those features that are suddenly discernible and can be used to determine gestational age as having reached or passed weeks 14, 16, 18, 20, 23, 25, and 29 or 30 (after the last menstrual period). Two examiners assessed these histologic features in a random and masked manner in the 129 skin samples of the test set. A 97% agreement with the actual gestational age of the fetus was achieved. CONCLUSION Skin development is a continuous process, but some discrete patterns are strongly related to fetal age, are easy to recognize, and are insensitive to artifacts. In our institution, they have become indispensable in evaluating fetal and neonatal pathology.

Fetal varicella syndrome: disruption of neural development and persistent inflammation of non-neural tissues.

Abstract Primary varicella zoster virus (VZV) infection during pregnancy is rare. If it occurs between the 8th and 20th week of gestation, fetal varicella syndrome results in 1–2% of the fetuses. We report about a varicella infection that affected a pregnant mother in the 12th week of gestation. At 33 weeks, a premature girl was born with destruction of neurons in spinal cord, spinal ganglia and plexus myentericus, and secondary developmental disturbance including mummification of one arm and segmental intestinal atresia. The brain did not show any abnormalities. However, VZV DNA could be detected by PCR in tissues from the brain and spinal ganglia. Chronic necrotizing inflammation was found in the placenta, fetal membranes, and one ovary. These locations showed nuclear inclusions which by in-situ-hybridization were proven to be VZV derived. This case demonstrates that in the fetal age, ’neurotropism’ of VZV signifies severe destruction but not necessarily persistent inflammation of neural tissue. However, due to the inefficient fetal immune system, inflammation can go on for weeks, preferentially in non-neural tissues.

Involvement of parents in critical incidents in a neonatal–paediatric intensive care unit

Background: With more liberal visiting hours in paediatric intensive care practice, parents’ presence at the bedside has increased. Parents may thus become involved in critical incidents as contributors or detectors of critical incidents or they may be affected by critical incidents. Methods: Voluntary, anonymous, non-punitive critical incident reporting system. Parents’ involvement in critical incidents has been evaluated retrospectively (January 2002 to August 2007). The reports were analysed regarding involvement of parents, age of child, unit (paediatric intensive care or intermediate neonatal nursery), critical incident severity, critical incident category, actual or potential harm to patient and/or parent (minor, moderate, major), delay between the critical incident and its detection, and implemented system changes. Results: Overall, 2494 critical incidents have been reported. There were 101 critical incidents with parental involvement: parents as contributors to critical incident (18; 0.7%), parents discovering a critical incident (11; 0.4%), parents affected by critical incident (72; 2.9%). The most vulnerable categories regarding contribution and detection were drugs, line/drain disconnection, trauma and hygiene. Ten critical incidents precipitated by parents were of moderate severity and seven of potential major severity (six line/drain disconnections). The majority of the events (six) detected by parents were of potential moderate severity and four were of major severity. Conclusion: Because of their presence at the bedside, parents in the paediatric intensive care unit are inevitably involved in safety issues. It is not the parents’ duty to guarantee the safety for their children, but parents should be encouraged to report anything that worries them. Only an established safety culture allows parents to articulate their concerns.

17-Hydroxyprogesterone in premature infants as a marker of intrauterine stress.

Abstract Aims: Amniotic infection (AI) and preeclampsia (PE), which are commonly the reason for prematurity, inflict stress of different duration on immature fetuses. Whether chronic stress, as reflected by intrauterine growth retardation, influences the level of 17-OH progesterone (17-OHP), was not previously examined. Methods: We analyzed 17-OHP and TSH levels during neonatal screenings in the first hours of life of 90 premature infants born between 25 and 33 weeks of gestation in infants with AI (n=37) or with PE (n=53). Control of acute stress parameters was derived from umbilical arterial cord blood pH and base excess (BE). Results: Mean 17-OHP levels of infants born to mothers with PE were 85.7 nmol/L compared to 54.6 nmol/L (P<0.001) in AI infants. 17-OHP was even higher when intrauterine growth restriction was present (99.8 nmol/L). Antenatal steroids and mode of delivery did not significantly affect 17-OHP levels. Conclusions: Stress of relatively long duration, as in cases of PE, leads to a significant increase of 17-OHP level in preterm infants. The postnatal 17-OHP level may be considered as a measure for severity of intrauterine stress and might be used as an individualized indicator for earlier intensive care.

Frequency and potential cause of bronchus-associated lymphoid tissue in fetal lungs.

Bronchus‐associated lymphoid tissue consists of lymphoid follicles with or without a germinal center within the bronchial wall. Bronchus‐associated lymphoid tissue is part of the integrated mucosal immune system and present in about 50% of healthy infants. We examined a series of 141 fetal and neonatal lungs and detected bronchus‐associated lymphoid tissue in 100% of cases with amniotic infection while postpartum perinatal pneumonia did not elicit bronchus‐associated lymphoid tissue formation. Only rarely and in low density, bronchus‐associated lymphoid tissue was present in non‐infected fetuses. The in utero formation of bronchus‐associated lymphoid tissue seems to be a reactive phenomenon and – as has been shown in another study – does not portend an adverse prognosis.

Longtime performance and reliability of two different PtcCO2 and SpO2 sensors in neonates

Objectives:  Blood gas monitoring is necessary in treatment of critically ill neonates. Whereas SaO2 can be estimated by pulse oximetry, PaCO2 is still most often assessed from blood samples.

Early enteral feeding in conservatively managed stage II necrotizing enterocolitis is associated with a reduced risk of catheter-related sepsis

Abstract Aims: To compare the effect of fasting period duration on complication rates in neonates managed conservatively for necrotizing enterocolitis (NEC) Bell stage II. Methods: We conducted a multicenter study to analyze retrospectively multiple data collected by standardized questionnaire on all admissions for NEC between January 2000 and December 2006. NEC was staged using modified Bell criteria. We divided the conservatively managed neonates with NEC Bell stage II into two groups (those fasted for <5 days and those fasted for >5 days) and compared the complication rates. Results: Of the 47 conservatively managed neonates Bell stage II, 30 (64%) fasted for <5 days (range 1–4 days) and 17 (36%) for >5 days (range 6–16 days). There were no significant differences for any of the patient characteristics analyzed. One (3%) and four (24%) neonates, respectively, developed post-NEC bowel stricture. One (3%) and two neonates (12%) suffered NEC relapse. None and five (29%) neonates developed catheter-related sepsis. Conclusion: Shorter fasting after NEC appears to lower morbidity after the acute phase of the disease. In particular, shorter-fasted neonates have significantly less catheter-related sepsis. We found no benefit in longer fasting.

The pulmonary paradox in premature infants: in-utero infected lungs do better than those with accelerated maturation.

Abstract Aims: To document, and explain, the pulmonary paradox whereby despite relative lung immaturity, preterm infants exposed to amniotic infection (AI) have better postnatal pulmonary function than those exposed to preeclampsia (PE). Methods: Lung maturation was characterized in 65 preterm perinatal deaths [AI (n=40) and PE (n=25)] and postnatal respiratory function in 100 preterm survivors [AI (n=50) and PE (n=50)]. Results: At autopsy, lung architecture was in advance of gestational age in 5% of AI infants versus 40% of PE infants (P<0.001). In survivors, the groups were similar in age and Apgar scores. At birth, 40% of the AI group required continuous positive airway pressure or mechanical ventilation versus 24% of the PE group (NS). However, 24 hours later, only 1 AI infant had deteriorated compared to 40% of PE infants (P<0.05). Conclusions: Accelerated morphologic lung maturation in preterm PE infants does not translate into improved postnatal respiratory function. Most likely, this is due to a relative lack of surfactant, ascribable to low stimulant cytokine and high TNF-α levels. An intrauterine history supplemented by an antenatal cytokine profile could identify an increased exogeneous surfactant need in preterm infants exposed to PE.

Feeding problems in preterm infants of preeclamptic mothers

Aim:  Maternal disease can cause prematurity and neonatal complications, notably feeding problems. To determine the relationship between maternal disease and the nature and severity of neonatal feeding problems, we compared feeding profiles, time to demand feeding and length of hospital stay between preterm infants of preeclamptic mothers, mothers with amniotic infection and mothers with other disease causing prematurity.