Majeeda Kamaluddeen

Intratracheal Administration of Budesonide‐Surfactant in Prevention of Bronchopulmonary Dysplasia in Very Low Birth Weight Infants: A Systematic Review and Meta‐Analysis

Despite the near universal adaptation of gentle mechanical ventilation, surfactant use and non‐invasive respiratory support, bronchopulmonary dysplasia (BPD) remains one of the most common respiratory morbidities in very low birth weight (VLBW) infants. Thus, the objective of this review was to evaluate the efficacy of intra‐tracheal administration of budesonide‐surfactant mixture in preventing bronchopulmonary dysplasia (BPD) in very low birth weight (VLBW) infants. MEDLINE, EMBASE, and PubMed were searched for randomized clinical trials in which intra‐tracheal administration of budesonide‐surfactant was used to prevent BPD in infants. The primary outcomes were BPD and composite outcome of death or BPD. Meta‐analysis of the two clinical trials revealed that infants who received intra‐tracheal instillation of budesonide‐surfactant mixture demonstrated 43% reduction in the risk of BPD (RR: 0.57; 95%CI: 0.43‐0.76, NNT = 5). Although mortality was not different between the groups (OR: 0.61; 95%CI: 0.34‐1.04), a 40% reduction was observed in the composite outcome of death or BPD in the budesonide‐surfactant group (RR: 0.60; 95%CI: 0.49‐0.74, NNT = 3). Thus, this review concludes that intra‐tracheal administration of budesonide‐surfactant combination was associated with decreased incidence of BPD alone or composite outcome of death or BPD in VLBW infants though there is a need for larger trials before it can be recommended as a standard of care.

Comparison of Presentation, Course, and Outcome of Congenital and Acquired Cytomegalovirus Infection in Twins

Background Cytomegalovirus (CMV) is one of the most common causes of serious viral intrauterine infections. It is universally distributed among the human population with an average incidence of 0.15 to 2%. Indeed, at least half of the women in the reproductive age have evidence of prior CMV infection. Epidemiology and Pathogenicity However, it is not a usual practice to screen asymptomatic pregnant woman or neonates for CMV. Even if a mother developed a primary CMV infection during pregnancy, up to 90% of the newborns with congenital CMV will be asymptomatic at the time of birth. Only 5 to 7% of the infected babies will be acutely symptomatic, and the typical clinical presentation includes intrauterine growth restriction, microcephaly, various cutaneous manifestations (including petechiae and purpura), hematological abnormalities (particularly resistant thrombocytopenia), hepatosplenomegaly, chorioretinitis, hepatitis, etc. In contrast, acquired CMV infection is extremely unlikely to cause any serious sequelae for the infant. Cases  We present a case of congenital and acquired CMV infection in twins with a focus of dissimilarity in presentation, clinical course, and outcome.

The mystery of persistent pulmonary hypertension: an idiopathic infantile arterial calcification

BackgroundIdiopathic infantile arterial calcification (IIAC) is a rare autosomal recessive disorder, characterized by wide spread calcifications in arterial walls, leading to vaso-occlusive ischaemia of multiple organs. Mortality is high, and there is no definitive treatment.Case presentationA male neonate, 36+5 weeks gestation, 2.81 kg, was admitted to NICU for respiratory distress. At one hour of age, he was noted to be pale, hypoperfused, with weak pulses, a hyperdynamic precordium and a grade IV/VI pansystolic murmur. The rest of his examination was normal. A chest X-ray showed massive cardiomegaly and pulmonary oedema. An echocardiogram (ECHO) indicated moderate persistent pulmonary hypertension (PPHN) of unclear etiology. A diagnosis of Idiopathic infantile arterial calcification was made and a trial of Editronate therapy was given without success.ConclusionIIAC is a rare disorder, it should be considered whenever a neonate presents with unexplainable cardiac failure, PPHN, echogenic vessels on X-ray/ultrasound and, or concentric hypertrophic ventricles on ECHO. Serial antenatal ultrasound findings of echogenic cardiac foci should raise the suspicion of IIAC. Further studies to determine the long term effects of Editronate on vascular calcifications, disease outcome, and other treatment options are needed.

Non-Rotavirus infection causing apnea in a neonate

Apnea in a premature infant is not always due to immaturity and caffeine is not always the answer. We report a case of apnea in a preterm infant who presented at two weeks of life with increase in frequency of apnea that did not respond to caffeine. Family history was significant for diarrhea in a sibling. Stool PCR was positive for Norovirus Genogroup II. Enteric isolation was instituted and the apnea resolved spontaneously with conservative management. Re-emergence of apnea or persistent apnea necessitates further investigation to elucidate the etiology.

Carboxyhemoglobin levels in umbilical cord blood of women with pre-eclampsia and intrauterine growth restriction

Abstract Objective: Pre-eclampsia (PE) and intrauterine growth restriction (IUGR) are associated with abnormal placentation. Heme oxygenase (HO) and carbon monoxide (CO) are involved in normal placental development and function and vasomotor control in the placenta. The objective of our study was to measure CO levels, as assessed by carboxyhemoglobin (COHb) levels in the umbilical cord arterial blood of women with PE, normotensive IUGR (<10th percentile for birth weight), and normotensive pregnancies with appropriate-for-gestational age (AGA) infants. Design and methods: We prospectively analyzed COHb levels in the umbilical arterial blood of women with PE, normotensive IUGR, and normotensive AGA pregnancies. Exclusion criteria included cigarette smoke exposure, hemolytic disorders, a positive direct anti-globulin test, chronic hypertension, fever, and any significant medical illness. COHb levels were measured using the ABL 725 blood gas analyzer. Results: There were 41 women in the normotensive AGA group, 42 in the PE group, and 36 in the normotensive IUGR group. Maternal age, mode of delivery, gravidity, parity, and gender of the infants were similar in the three groups. Gestational age and birth weight were significantly higher in the normotensive AGA group compared with the other two groups. COHb levels were significantly lower in the PE group compared with the normotensive AGA group (0.38±0.06% vs. 0.77±0.11%, P<0.05). COHb levels, although lower in the normotensive IUGR group compared with the normotensive AGA group, did not reach statistical significance. Conclusion: Our data suggests the HO-CO system may have a role in the pathogenesis of PE. We also, for the first time, provide information on umbilical arterial COHb levels in normotensive IUGR pregnancies.

Is Less Noise, Light and Parental/Caregiver Stress in the Neonatal Intensive Care Unit Better for Neonates?

In utero sensory stimuli and interaction with the environment strongly influence early phases of fetal and infant development. Extremely premature infants are subjected to noxious procedures and routine monitoring, in addition to exposure to excessive light and noise, which disturb the natural sleep cycle and induce stress. Non-invasive ventilation, measures to prevent sepsis, and human milk feeding improve short-term and long-term neurodevelopmental outcomes in premature infants. To preserve brain function, and to improve quality of life and long-term neurodevelopmental outcomes, the focus now is on the neonatal intensive care unit (NICU) environment and its impact on the infant during hospital stay. The objectives of this write-up are to understand the effects of environmental factors, including lighting and noise in the NICU, on sensory development of the infant, the need to decrease parental and caregiver stress, and to review existing literature, local policies and recommendations.