Nicholas Morris

aEEG and NIRS during transition and resuscitation after birth: Promising additional tools; an observational study

AIM OF THE STUDY During resuscitation no routine cerebral monitoring is available. We aimed at monitoring cerebral activity and oxygenation continuously during neonatal transition and resuscitation. METHODS Neonates ≥34 weeks of gestation born via cesarean section were included. Cerebral activity was continuously measured with amplitude-integrated-EEG (aEEG) and cerebral oxygenation (rSO2) with near-infrared-spectroscopy (NIRS) during the first 10 min after birth. For quantitative analysis of aEEG every minute the mean minimum amplitude (V(min)) and maximum amplitude (V(max)) was determined. Uncompromised neonates were compared to neonates in need of resuscitation. RESULTS Out of 224 eligible neonates 31 uncompromised and 15 in need of respiratory support were included. Uncompromised neonates showed higher values for V(min) in the third minute and higher values for V(max) in the third and fourth minute compared to the tenth minute post-partum. In uncompromised neonates rSO2 values during the first 6 min after birth were lower compared to minute ten. Neonates in need of respiratory support had lower rSO2 values over the first 8 min after birth compared to minute ten. CONCLUSIONS This is the first study demonstrating that monitoring of aEEG and NIRS to measure cerebral activity and oxygenation during immediate postpartum transition is feasible. During transition compromised neonates requiring resuscitation showed a different cerebral activity pattern compared to uncompromised neonates.

A Left-to-Right Shunt via the Ductus Arteriosus Is Associated with Increased Regional Cerebral Oxygen Saturation during Neonatal Transition

Background: Oxygen delivery to the brain is dependent on cardiac output and arterial oxygen content. Objectives: The study was designed to investigate the influence of a left-to-right shunt via the ductus arteriosus (DA) on regional oxygen saturation (rSO2) of the brain and peripheral tissue during postnatal transition. Methods: Nested case-control study. In term neonates after elective cesarian section, rSO2 of the brain and pre- and postductal peripheral tissue were measured 15 min after uncomplicated postnatal transition. Two groups were formed according to shunt flow characteristics via the DA: shunt group (with a left-to-right shunt), and nonshunt group (no shunt). Results: Of 80 infants, in 58 (72%) a left-to-right shunt was identified, and in 22 (28%) no flow was seen via the DA. The 22 infants formed the nonshunt group. They were matched with 22 newborn infants with a left-to-right shunt via the DA (shunt group). Infants in the nonshunt group had significantly lower cerebral rSO2 values and higher fractional tissue oxygen extraction and heart rate values. There were no significant differences in regard to peripheral rSO2 values. Conclusion: During postnatal transition, term infants with a left-to-right shunt via the DA have significantly higher cerebral rSO2 values compared to infants without shunt flow.

Respiratory syncytial virus- and influenza virus-associated hospitalizations in infants less than 12 months of age.

Infants hospitalized because of respiratory syncytial virus (RSV) infection (n = 388) were significantly younger, had longer hospital stays, had a more severe course of disease, and required supplemental oxygen more often with longer duration of treatment as compared with those with influenza virus (n = 37) infection. Seasonal distribution varied, with RSV-associated hospitalizations peaking in January and influenza virus-associated hospitalizations in February. Congenital heart disease was more commonly a risk factor in infants with RSV infection.

Congenital pulmonary lymphangiectasis.

Congenital pulmonary lymphangiectasis (CPL) is a rare vascular malformation causing dilated lymph vessels and disturbed drainage of lymph fluid. Based on the pathogenesis and clinical phenotype it can be classified as primary or secondary CPL. Associated genetic syndromes with or without lymphedema, familial occurrence and gene mutations have been described. In utero, it may present as non-immune hydrops with pleural effusions. At birth neonates may have respiratory failure due to chylothorax and pulmonary hypoplasia, causing very high short term mortality rates. Other cases may become symptomatic any time later in childhood or even during adult life. CPL is usually diagnosed based on the combination of clinical signs, imaging and histological findings. Open-lung biopsy is considered the gold standard for the diagnosis of CPL. Treatment is primarily supportive featuring aggressive mechanical ventilation and the management of problems associated with congenital chylothorax including chest-drainage, medium-chain triglycerides (MCT) diet, and octreotide.

The influence of perinatal asphyxia on peripheral oxygenation and perfusion in neonates

BACKGROUND Perinatal asphyxia influences peripheral oxygenation and perfusion in neonates. OBJECTIVES The aim was to investigate the influence of perinatal asphyxia on peripheral oxygenation and perfusion in neonates by using near-infrared spectroscopy (NIRS). METHODS Prospective observational study. Neonates with gestational age >34 weeks and birth weight >2000 g without infection or congenital malformations were included. Peripheral muscle NIRS measurements in combination with venous occlusion were performed once in the first 48 h 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. Furthermore arterial oxygen saturation, heart rate, blood pressure and temperatures were measured. Neonates with a UapH≤7.15 and an Apgar 5≤6 were compared to neonates with a UapH≥7.15, an Apgar 5≥7 (control group) and a UapH was correlated to NIRS parameters. RESULTS 8 asphyxiated neonates were compared to 30 neonates in the control group. TOI (67.7±5.5%) and DO2 (29.0±14.2 μmol/100 mL/min) were significantly lower in asphyxiated neonates compared to the controls (TOI 71.8±4.9%, p=0.045; DO2 43.9±16.9 μmol/100 mL/min, p=0.028) and FOE was significantly higher (0.33±0.05) compared to the controls (0.28±0.06, p=0.028). Furthermore significant correlations between UapH and DO2 (r=0.78, p=0.022), VO2 (r=0.80, p=0.018) and FOE (r=-0.75, p=0.034) in the asphyxiated group were found. CONCLUSION Peripheral oxygenation and perfusion measured with NIRS are compromised in neonates with perinatal asphyxia with worsening of parameters and degree of acidosis in the umbilical cord blood.

Cerebral regional oxygen saturation (crSO2): are different sensors comparable?

Background:  For measurement of cerebral regional oxygen saturation (crSO2) in neonates, one of the frequently used near‐infrared spectroscopy devices is the INVOS 5100 with either the neonatal or pediatric sensor. Measurements between adult and pediatric sensors use different algorithms and differ by 10%. There are no published data comparing neonatal and pediatric sensors.

‘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.

Nutritional/Growth Status in a Large Cohort of Medically Fragile Children Receiving Long-Term Enteral Nutrition Support.

Objective: The aim of the present study was to assess the nutritional status and growth of medically fragile children receiving long-term enteral nutritional support (ENS). Methods: A retrospective cross-sectional survey was conducted at a tertiary-level pediatric hospital. Growth features and nutritional intake of children (n = 287) receiving ENS were evaluated. During a period of 5 years (2009–2013), study patients in the age group of 1 to 36 months had been referred for the explicit reason of tube weaning. Data were documented with the help of ARCHIMED (version 46.2) and analyzed using SPSS for Windows version 21. Nutritional/growth status was determined by using World Health Organization growth standard tables. Results: Anthropometric parameters of children were compared with World Health Organization standards, and the prevalence of underweight, wasting, and stunting was very high despite being exclusively or predominantly on ENS. Results revealed that the age of a child, inadequate amount of caloric supply/day, the diagnosis of small-for-gestational age, and the type of tube (nasogastric tube) were significantly associated with growth/nutritional status (P < 0.05). Duration of ENS in the percentage of the cohorts lifetime and the main diagnosis were not associated with nutritional/growth outcomes. Conclusions: In medically fragile children, ENS does not ensure adequate growth per se. ENS requires highly specialized and individually tailored management and in many cases regular adjustments. Long-term tube feeding plans often seem unable to ensure the required amount of nutritional support, which surely compromise the individual efficacy of ENS.

Extensive blueberry muffin rash in a neonate

A full-term boy was delivered by caesarean section due to macrosomia (birth weight 4920 g, maternal diabetes White A). The baby had multiple blue-livid purpura interspersed with purple, elevated and dense papules, and a petechial rash covering the entire surface of his trunk, limbs and face (figure 1). He also had bilateral periorbital haematoma (figure 2 …

224 aEEG and NIRS During Transition after Birth

Background and aims Easily applicable non-invasive devices to monitor cerebral activity and oxygenation continuously during neonatal transition and resuscitation are lacking. We aimed to identify a method of directly monitoring cerebral activity and oxygenation during transition and resuscitation after birth. Methods Neonates >34 weeks gestation born via caesarean section were included. Cerebral activity was continuously measured with amplitude integrated EEG (aEEG) and cerebral oxygenation (rSO2) with near-infrared-spectroscopy during the first ten minutes after birth. For quantitative analysis of aEEG the mean minimum amplitude (Vmin) and maximum amplitude (Vmax) was determined at every minute. Neonates with normal transition were compared to neonates with need of resuscitation. Results Out of 224 eligible neonates 63 were included and 46 had reliable measurements: 31 with normal transition and 15 in need of resuscitation. Neonates with normal transition showed higher values for Vmin in the third minute and higher values for Vmax in the third and fourth minute compared to minute 10. Neonates requiring respiratory support had lower values for Vmin in the ninth minute compared to minute 10. In neonates with normal transition rSO2 values during the first six minutes were lower when compared to minute 10. rSO2 values in neonates requiring respiratory support remained lower over the first eight minutes when compared to minute 10. Conclusions This is the first study demonstrating the feasibility of aEEG and rSO2 monitoring during neonatal transition. The cerebral activity pattern in compromised infants requiring resuscitation was different when compared to infants with normal transition.