Shigeharu Hosono

Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeks’ gestation: a randomised controlled trial

Objective: To investigate the effects of umbilical cord milking on the need for red blood cell (RBC) transfusion and morbidity in very preterm infants. Patients and Methods: 40 singleton infants born between 24 and 28 weeks’ gestation were randomly assigned to receive umbilical cord clamped either immediately (control group, n = 20) or after umbilical cord milking (milked group, n = 20). Primary outcome measures were the probability of not needing transfusion, determined by Kaplan–Meier analysis, and the total number of RBC transfusions. Secondary outcome variables were haemoglobin value and blood pressure at admission. Results: There were no significant differences in gestational age and birth weight between the two groups. The milked group was more likely not to have needed red cell transfusion (p = 0.02) and had a decreased number (mean (SD)) of RBC transfusions (milked group 1.7 (3.0) vs controls 4.0 (4.2); p = 0.02). The initial mean (SD) haemoglobin value was higher in the milked group (165 (14) g/l) than in the controls (141 (16) g/l); p<0.01). Mean (SD) blood pressure at admission was significantly higher in the milked group (34 (9) mm Hg) than in the controls 28 (8) mm Hg; p = 0.03). There was no significant difference in mortality between the groups. The milked group had a shorter duration of ventilation or supplemental oxygen than the control group. Conclusion: Milking the umbilical cord is a safe procedure, reducing the need for RBC transfusions, and the need for circulatory and respiratory support in very preterm infants.

Guidelines for the Management of Extremely Premature Deliveries: A Systematic Review.

BACKGROUND AND OBJECTIVES: Available data on survival rates and outcomes of extremely low gestational age (GA) infants (22–25 weeks’ gestation) display wide variation by country. Whether similar variation is found in statements by national professional bodies is unknown. The objectives were to perform a systematic review of management from scientific and professional organizations for delivery room care of extremely low GA infants. METHODS: We searched Embase, PubMed, and Google Scholar for management guidelines on perinatal care. Countries were included if rated by the United Nations Development Programme’s Human Development Index as “very highly developed.” The primary outcome was rating of recommendations from “comfort care” to “active care.” Secondary outcomes were specifying country-specific survival and considering potential for 3 biases: limitations of GA assessment; bias from different definitions of stillbirths and live births; and bias from the use of different denominators to calculate survival. RESULTS: Of 47 highly developed countries, 34 guidelines from 23 countries and 4 international groups were identified. Of these, 3 did not state management recommendations. Of the remaining 31 guidelines, 21 (68%) supported comfort care at 22 weeks’ gestation, and 20 (65%) supported active care at 25 weeks’ gestation. Between 23 and 24 weeks’ gestation, much greater variation was seen. Seventeen guidelines cited national survival rates. Few guidelines discussed potential biases: limitations in GA (n = 17); definition bias (n = 3); and denominator bias (n = 7). CONCLUSIONS: Although there is a wide variation in recommendations (especially between 23 and 24 weeks’ GA), there is general agreement for comfort care at 22 weeks’ GA and active care at 25 weeks’ GA.

A role of end-tidal CO(2) monitoring for assessment of tracheal intubations in very low birth weight infants during neonatal resuscitation at birth.

Abstract Aim: To investigate whether end-tidal CO2 monitoring is useful for more rapid recognition of tracheal vs. esophageal intubation as compared to standard clinical evaluation in very low birth weight infants during neonatal resuscitation at birth. Patients and methods: Forty infants were prospectively identified. Tracheal tube placement was evaluated either using an end-tidal CO2 monitor by an investigator not involved in the resuscitation, or by evaluation of clinical parameters by a resuscitation team unaware of the end-tidal CO2 data. The time taken to detect accurate placement of the tube using capnometory vs. clinical determination of tracheal or esophageal tube placement was compared. Results: A total of 54 intubations was analyzed from 40 neonates. End-tidal CO2 monitoring correctly identified all 40 tracheal and all 11 esophageal intubations with 100% accuracy. On the other hand, clinical evaluation demonstrated discrepancies in three cases. The mean time in seconds for capnographic determination was significantly faster than clinical determination for both tracheal (7.5±1.3 vs. 17.0±3.4, P<0.01) and esophageal intubation (6.5±0.7 vs. 19.9±1.8, P<0.01). Conclusion: Exhaled CO2 detection is a sensitive and accurate technique to confirm tracheal tube placement in very low birth weight infants during neonatal resuscitation.

Blood pressure and urine output during the first 120 h of life in infants born at less than 29 weeks’ gestation related to umbilical cord milking

Objective: To investigate the effects of umbilical cord milking on cardiopulmonary adaptation in very low birth weight infants. Patients and methods: This study was the secondary analysis of a randomised control study of the effect of umbilical cord milking in premature infants. Forty singleton infants born between 24 and 28 weeks’ gestation were randomly assigned to groups in which the umbilical cord was clamped either immediately after birth (control group, n = 20) or after umbilical cord milking (milked group, n = 20). Blood pressure, heart rate, urine output, fluid intake, and ventilatory index values in both groups were measured during the first 120 h after birth. Results: There were no significant differences in gestational age or birth weight between the two groups. The initial haemoglobin value was higher in the milked group (mean (SD) 16.5 (1.4) g/dl in the milked vs 14.1 (1.6) g/dl in the control; p<0.01). During the first 12 h, blood pressure was significantly higher in the milked group. Urine output in the milked group was higher than that in the control group during the first 72 h. There were no significant differences in heart rate, water intake, or ventilatory index values between the groups. Conclusion: Umbilical cord milking may facilitate early stabilisation of both blood pressure and urine output in very low birth weight infants.

Effects of placental transfusion in extremely low birthweight infants: meta-analysis of long- and short-term outcomes.

Risks and benefits of increasing placental transfusion in extremely preterm infants (extremely low birthweight [ELBW], <1000 g) are ill defined. We performed a meta‐analysis to compare long‐ and short‐term outcomes of ELBW infants in trials of enhanced placental transfusion regimens.

Impact of Serum Adiponectin Concentration on Birth Size and Early Postnatal Growth

In term neonates, the adiponectin concentration is higher than it is in adults. To determine the relationship between adiponectin and early neonatal growth in a cohort study. Fifty-two neonates at term were studied. Serum adiponectin concentrations, body sizes, and skinfold thicknesses were measured at birth and at 1 mo of age. At birth, cord blood adiponectin concentration correlated positively with birth weight (r = 0.484, p = 0.0003), birth length (r = 0.524, p < 0.0001), and sum of the four skinfold thickness measurements (r = 0.378, p = 0.0057). In a stepwise regression, birth length was the only determinant of cord blood adiponectin concentration. However, at 1 mo of age, serum adiponectin concentration correlated with no anthropometric parameter at all. Between birth and 1 mo of age, the individual change in adiponectin concentration correlated negatively with birth weight. Thus, serum adiponectin concentrations in cord blood have a strong relationship to birth length rather than to body fatness, and this relationship is not demonstrated in 1-mo-old infants. These results imply that hormonal, substrate, or other mechanisms that regulate the relationship between body composition and growth in fetal life are different from those governing these relationships in early postnatal life.

Trace elements and mineral requirements for very low birth weight infants in rickets of prematurity

To establish mineral and trace element requirements for very low birth it is important to prevent bone mineral disorder. Those infants fed mothers milk only are thought to be at higher risk of this disorder. Both calcium and phosphorus supplementation were thought to be needed to prevent it. Copper and zinc are important as cofactors of major enzymes involved in the synthesis of collagen. These trace elements especially zinc may not be enough for very low birth weight infants fed mothers milk. At present however the relationship between these trace elements and minerals, and bone metabolic disease in preterm infants is not completely clear.

Gray matter volumetric MRI differences late-preterm and term infants

Gray matter develops rapidly during the third trimester of pregnancy, which is a critical period for lipid deposition. We measured brain volume in term and late-preterm infants to determine if it is related to disabilities in late-preterm infants. In addition, we measured serum lipid concentrations to investigate the relationship between brain volume and lipid nutrition. Magnetic resonance imaging scans were obtained in 16 late-preterm and 13 term infants. We measured cerebrum, gray matter, and white matter volumes. We performed serum cholesterol, triglyceride (TG), and lipoprotein analyses in cord blood by high-performance liquid chromatography using gel permeation columns to assess lipid nutritional levels. The gray matter volume and percent cerebrum volume of gray matter were significantly smaller in late-preterm infants (p<0.001). Head circumference and cerebrum and white matter volume did not differ between the two groups. Gray matter volume correlated positively with gestational age (r=0.647, p<0.001), head circumference (r=0.688, p<0.001), and high-density lipoprotein (HDL)-TG levels (r=0.496, p=0.006). Late-preterm infants had a normal head circumference and a lower gray matter volume than term infants. Gestational age and head circumference were significantly associated with gray matter volume. Only HDL-TG levels were significantly associated with gray matter volume. HDL-TG might contribute to the transport of fatty acids and gray matter development during the postnatal period. Thus, delayed gray matter development may partly contribute to neurodevelopmental disabilities in late-preterm infants.

Early postnatal alteration of body composition in preterm and small-for-gestational-age infants: implications of catch-up fat

The concept of the developmental origins of health and disease is based on studies by Barker et al. They proposed a hypothesis that undernutrition in utero permanently changes the body’s structure, function, and metabolism in ways that lead to atherosclerosis and insulin resistance in later life. In addition, profound effects on the extent of body fatness and insulin sensitivity are demonstrated, if there is a “mismatch” between prenatal and postnatal environments. In previous studies, undernutrition in utero has been evaluated simply by birth weight itself or birth weight for gestational age, and the degree of mismatch has been estimated by postnatal rapid weight gain. Recently, we investigated subcutaneous fat accumulation in small-for-gestational-age infants and found that a rapid catch-up in skinfold thickness developed prior to the body weight catch-up. Furthermore, insulin-like growth factor-I and lipoprotein lipase mass concentrations also demonstrate rapid increase during the neonatal period with fat accumulation. Investigating the precise mechanisms of developmental origins of health and disease including mediating metabolic and hormonal factors may provide a new approach to prevent atherosclerosis and insulin resistance. Better management of undernutrition during gestation and neonatal growth during the early postnatal period is an important theme for future health.

Successful transcutaneous arterial embolization of a giant hemangioma associated with high-output cardiac failure and Kasabach-Merritt syndrome in a neonate : A case report

Abstract We describe the case of a patient with a neonatal giant cutaneous hemangioma with high-output cardiac failure and Kasabach-Merritt syndrome and successfully treated with transcutaneous arterial embolization aimed at controlling severe congestive heart failure and consumption coagulopathy. A patient was admitted to the neonatal care unit on the first day of age because of a large hemangioma on his right lateral chest wall and respiratory distress, associated with cardiac failure resulting from arteriovenous shunting. On the second day of age the platelet count decreased to 5.7 × 104/μl and fibrinogen level was 85 mg/dl. The values of prothrombin time and activated partial thromboplastin time were prolonged. Intravenous predonisone therapy was started immediately, but bleeding tendency was getting worse and the evidence of congestive heart failure persisted. On the third day the patient then underwent embolization of feeding arteries with microcoils. The cardiac failure and thrombocytopenic coagulopathy had improved significantly without complications. We conclude that transcutaneous arterial embolization is an effective and safe treatment in this neonate and should be considered for the treatment of control high-output cardiac failure and coagulopathy in infants with hemangioma and Kasabach-Merritt syndrome.