Romaine Arlettaz

Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: Practice Guidelines and Recommendations for Training Writing group of the American Society of Echocardiography (ASE) in collaboration with the European Association of Echocardiography (EAE) and the Association for European Pediatric Cardiologists (AEPC)

Luc Mertens, MD, PhD, FASE, FESC, Istvan Seri, MD, PhD, HonD, Jan Marek, MD, PhD, FESC, Romaine Arlettaz, MD, Piers Barker, MD, FASE, Patrick McNamara, MD, MB, FRCPC, Anita J. Moon-Grady, MD, Patrick D. Coon, RDCS, FASE, Shahab Noori, MD, RDCS, John Simpson, MD, FRCP, FESC, Wyman W. Lai, MD, MPH, FASE, Toronto, Ontario, Canada; Los Angeles and San Francisco, California; London, United Kingdom; Zurich, Switzerland; Durham, North Carolina; Philadelphia, Pennsylvania; New York, New York

Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: Practice Guidelines and Recommendations for Training

AAP : American Academy of Pediatrics AEPC : Association for European Paediatric Cardiology ASE : American Society of Echocardiography CDH : Congenital diaphragmatic hernia CHD : Congenital heart disease EAE : European Association of Echocardiography ECMO : Extracorporeal membrane oxygenation EF : Ejection fraction LV : Left ventricular MPI : Myocardial performance index mVCFc : Mean velocity of circumferential fiber shortening NICU : Neonatal intensive care unit PA : Pulmonary artery PDA : Patent ductus arteriosus RA : Right atrial RV : Right ventricular RVSp : Right ventricular systolic pressure SF : Shortening fraction SVC : Superior vena cava TEE : Transesophageal echocardiography TNE : Targeted neonatal echocardiography TVI : Time-velocity integral 2D : Two-dimensional VLBW : Very low birth weight The role of echocardiography in the neonatal intensive care unit (NICU) has changed over the past few years. Previously, nearly all echocardiographic studies in the NICU were performed by pediatric cardiologists to diagnose or monitor congenital heart disease (CHD) and to screen for patent ductus arteriosus (PDA). More recently, neonatologists have become interested in the echocardiographic assessment of hemodynamic instability in infants. The terms functional echocardiography and point-of-care echocardiography have been introduced to describe the use of echocardiography as an adjunct in the clinical assessment of the hemodynamic status in neonates.1–4 The increasing availability of echocardiography, with miniaturization of the technology, has resulted in more widespread use of echocardiography in NICUs around the world.5 Perhaps the most significant challenge for the application of so-called functional studies is that newborns in the NICU with hemodynamic instability are at a much higher risk for having underlying CHD. In addition, newborns in the NICU are unique in that they are in the process of …

The contribution of pulse oximetry to the early detection of congenital heart disease in newborns

Approximately half of all newborns with congenital heart disease are asymptomatic in the first few days of life. Early detection of ductal-dependant cardiac malformations prior to ductal closure is, however, of significant clinical importance, as the treatment outcome is related to the time of diagnosis. Pulse oximetry has been proposed for early detection of congenital heart disease. The aims of the present study were: 1) to determine the effectiveness of a pulse-oximetric screening performed on the first day of life for the detection of congenital heart disease in otherwise healthy newborns and 2) to determine if a pulse-oximetric screening combined with clinical examination is superior in the diagnosis of congenital heart disease to clinical examination alone. This is a prospective, multi-centre study. Postductal pulse oximetry was performed between six and twelve hours of age in all newborns of greater than 35 weeks gestation. If pulse-oximetry-measured arterial oxygen saturation was less than 95%, echocardiography was performed. Pulse oximetry was performed in 3,262 newborns. Twenty-four infants (0.7%) had repeated saturations of less than 95%. Of these infants, 17 had congenital heart disease and five of the remaining seven had persistent pulmonary hypertension. No infant with a ductal-dependant or cyanotic congenital heart disease exhibited saturation values greater or equal to 95%. Conclusion: postductal pulse-oximetric screening in the first few days of life is an effective means for detecting cyanotic congenital heart disease in otherwise healthy newborns.

Methadone maintenance program in pregnancy in a Swiss perinatal center (II): neonatal outcome and social resources

Background:  The aim of the study was to analyze the neonatal impact of a methadone maintenance program in pregnancy, and the social resources of the families involved.

End-of-life decisions in delivery room and neonatal intensive care unit.

Background: The increase in neonatal survival in recent decades has been followed by an increase in later disabilities. This has given rise to many new ethical issues. In different countries, efforts are being made to define ethical guidelines regarding withholding or withdrawing intensive care and end‐of‐life decisions in critically ill newborn infants. These guidelines have to be differentiated from ethical decision‐making models which structure the process of decision making for an individual child. Such a framework has been in existence in our clinic for 10 years. Aim: The aims of this study were to evaluate how end‐of‐life decisions are taken in our perinatal centre and to analyse whether these decisions are consistent with our framework for structured ethical decision making.

Methadone maintenance program in a Swiss perinatal center: (I): Management and outcome of 89 pregnancies

Background.  Although methadone maintenance is the standard treatment of opiate addiction in pregnancy, opinion as to its utility is divided. The aim of this study was to analyze polydrug abuse, pregnancy outcome and fetomaternal complications among pregnant women in a major Swiss methadone maintenance program.

Neonatal morbidity in singleton late preterm infants compared with full-term infants.

Aim:  The aim of this study was to test the hypothesis that singleton late preterm infants (34 0/7 to 36 6/7 weeks of gestation) compared with full‐term infants have a higher incidence of short‐term morbidity and stay longer in hospital.

Case Series of Bifidobacterium longum Bacteremia in Three Preterm Infants on Probiotic Therapy

Background: The use of probiotics as prophylaxis for necrotizing enterocolitis (NEC) in preterm infants is being increasingly practised. Objective: We report, for the first time, a case series of 3 preterm, very-low-birth-weight (VLBW) infants who developed bacteremia with Bifidobacterium longum on probiotic therapy with Infloran® containing viable B. longum. Methods: We retrospectively reviewed data of 3 infants (of gestational age <30 weeks and birth weight <1,230 g). They were admitted to the neonatal intensive care unit. Clinical data were retrieved from their medical records. Results: In infants 1 and 2, B. longum was isolated from the blood cultures when they were on probiotic therapy with Infloran or shortly after, respectively, and was interpreted as transient bacteremia. The clinical presentation of these infants did not require antibiotic treatment after the isolation of B. longum. Infant 3 developed an NEC despite probiotic therapy with Infloran and the blood cultures showed B. longum growth. This infant required explorative laparotomy and antibiotic treatment. The clinical isolates of B. longum and the strain of the Infloran capsule showed an identical profile on biochemical, mass-spectrometric and molecular analyses, suggesting a direct correlation between the administration of probiotics and bacteremia with B. longum in all 3 infants. Conclusions: The occurrence of bacteremia with bifidobacteria after its prophylactic administration in VLBW infants and its possible clinical consequences are a matter of concern. In the interests of safety, the use of probiotics in such a population should be indicated with caution and requires further investigation.

Assessment of jaundice in preterm neonates: comparison between clinical assessment, two transcutaneous bilirubinometers and serum bilirubin values.

Aim: 1) To compare the clinical assessment of craniocaudal progression of jaundice and two transcutaneous bilirubinometers with serum bilirubin values in preterm neonates; 2) to identify factors affecting the difference between non‐invasive bilirubin estimation and serum bilirubin. Methods: Serum bilirubin was clinically estimated in healthy preterm newborn infants (34 to 36.9 gestational weeks) independently by a primary investigator and by nurses, and subsequently compared with separate measures of two transcutaneous bilirubinometers. Results: A total of 107 measurements were performed on 69 infants. Minolta JM‐102 showed the best performance, with ROC area under the curve of 0.96, followed by BiliCheck™ over the sternum (0.89) and over the forehead (0.88), clinical assessment by nurses (0.73) and by a physician (0.70). Serum bilirubin <190 μmol/l can be detected with 95% sensitivity with Minolta JM–102 ≫19 units, with BiliCheck™≫145 μmol/l over the sternum and ≫165 μmol/l over the forehead and with jaundice progression to the trunk or further (Kramer zone ≫2). Gestational age affects all non‐invasive methods in the estimation of serum bilirubin, whereas skin colour affects both BiliCheck™ and clinical assessment. Ambient light affects only clinical assessment.

Agreement between capillary and arterial lactate in the newborn.

Arterial blood lactate is a reliable indicator of tissue oxygen debt and is of value in expressing the degree and prognosis of circulatory failure as a result of various diseases. Therefore, the practical issue of whether capillary lactate measurements might be of equal value was investigated in newborns. In total, 193 simultaneous measurements of capillary and arterial blood lactate concentrations were performed in 25 newborn babies with an indwelling umbilical arterial catheter. A strong linear correlation was found between capillary and arterial lactate concentration (Lcap= 1.02 Lart+ 0.04; r= 0.98; p < 0.001). The mean difference was −0.08 mmol/1 and the limits of agreement (± 2 SD) were ± 0.69 mmol/1 (−0.77 to 0.61 mmol/1).