Wilhelm Mueller

Thrombophilic polymorphisms – factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutations – and preterm birth

SummaryAIM OF THE STUDY: To evaluate the influence of three common thrombophilic polymorphisms, factor V Leiden (FV), prothrombin G20210A (PT), and methylenetetrahydrofolate reductase (MTHFR) C677T mutations, on preterm birth of unknown cause. PATIENTS AND METHODS: A single-centre case-control study of women with preterm infants of ≤35 weeks of gestation, in whom obvious maternal, uterine, and fetal causes responsible for preterm birth were excluded (n = 35). The controls were 54 women with term infants hospitalised in the same ward. RESULTS: There were no significant differences between the groups of mothers in history of fetal loss, venous or familial thrombosis, or previous preterm birth. FV was found in 8.6% of the cases, PT in 5.7%, and MTHFR mutation (homozygous) in 4.8% compared with 5.4% (p = 0.292; OR, 1.594; CI 95%, 0.303–8.384), 7.4% (p = 0.379; OR, 0.758; CI 95%, 0.131–4.374), and 4.5% (p = 0.485; OR, 1.050; CI 95%, 0.090–12.276), respectively, in the controls. Differences in the three thrombophilic polymorphisms in the two groups of infants were also not significant. CONCLUSION: We could not demonstrate a distinct association between these thrombophilic polymorphisms and preterm birth.

Bladder voiding in sleeping infants is consistently accompanied by a cortical arousal

The aim of the study was to find out whether bladder voiding in healthy sleeping infants was accompanied by any arousal reaction. Polygraphic recordings were performed in 21 healthy infants (11 female) born at term. The infants’ age at study entry was 42 ± 4 days and actual body weight was 4852 ± 689 g (mean ± SD). Bladder voiding was recorded by an adapted enuresis detector which was connected to the polygraphic computer unit. Arousals were defined as suggested by the ‘International Paediatric Work Group on Arousals’. Awakenings were excluded from the study. Bladder voiding was recorded at a mean time of 68 ± 7 min after the infant had fallen asleep and occurred during quiet sleep (QS). Electroencephalogram frequency (P < 0.01) and heart rate (P < 0.05) were higher during the 5‐s period before and after bladder voiding when compared with a 30‐s interval before voiding. Furthermore, bladder voiding was accompanied by body movements in all infants. Respiratory frequency did not change significantly. We could demonstrate for the first time in sleeping infants, that bladder voiding during QS was accompanied by a cortical arousal.

Two nosocomial norovirus outbreaks in the neonatal intensive and intermediate care unit

Norovirus is one of the major causes of non-bacterialacute gastroenteritis worldwide. Diagnostic methods in-clude electron microscopy, enzyme-linked immunosorbentassay (ELISA) and reverse-transcription polymerase chainreaction (RT-PCR) [1]. Electron microscopy has previous-ly been regarded as the gold standard for the diagnosis ofnorovirus, but RT-PCR appears to be a more sensitiveassay (36 to 58% versus 94 to 98%), with similarspecificity(96to98%and92to100%)[2, 3]. Studieson the sensitivity and specificity of the RIDASCREENenzyme immunoassay reported a broad range of 36 to 59%and73to100%,respectively[4, 5] (CDC, Atlanta, GA,USA). However, data for preterm and term born babies israre. Recent studies of norovirus in very young infantshave presumed many false-positive results and havequestioned the high specificity of enzyme immunoassay[2, 6]. The aim of this report is to characterise twooutbreaks of norovirus in neonatal nurseries by raisingquestions about the performance of diagnostic assays fornorovirus and the clinical presentation of norovirusinfectioninveryyounginfants.Faecal specimens of all tested persons were sent to theInstitute of Hygiene, Microbiology and EnvironmentalMedicine of the Medical University of Graz immediatelyafter collection or on the following day. Analysis wasdone for norovirus, adenovirus and rotavirus using anenzyme immunoassay (RIDASCREEN Norovirus ELISAkit, 3rd Generation) and/or real-time PCR (ANDIATECNorovirus real-time PCR kit, Bioproducts Company,designed to detect norovirus genotypes I and II). There-fore, stool cultures on bacteria and parasites were alsodone. To assess the clinical severity of disease, a 14-pointscoring system by Colomba et al. [7] was used. Duringboth outbreaks, the clinical records of all patients werecarefully documented and strict hygienic measures, in-cluding the cohorting of patients, mandatory use of glovesand gowns, and hand washing with disinfecting agents(Skinman® Soft N, Ecolab, Vienna, Austria), wereimplemented at the particular unit. Approval by theEthical Review Board was not necessary since the studywas performed by means of prospective surveillanceinvolving both outbreaks.First outbreak: January to March 2007In January 2007, a neonatologist on duty developedsymptoms of gastroenteritis, including fever, vomiting anddiarrhoea. The day after, the index patient (see Table 1),hospitalized at the Neonatal Intensive Care Unit (NICU) ofthe Pediatric Department of the Medical University Hospi-tal of Graz, Austria, recalled symptoms of bloody tingedstools for one day (14-point severity score: 6). Faecalspecimens of this infant and of the staff member were testedon virus, bacteria and parasites, and turned out to bepositive for norovirus tested by ELISA. Subsequently,faecal specimens of all neonates admitted to and treated atthe NICU were routinely tested three times a week byELISA and, due to repeatedly positive results, some of thespecimens were additionally tested by RT-PCR.

Detection of Psychic Ear Acupuncture Points in a Newborn Infant with Neonatal Abstinence Syndrome

Dear Editor: We would like to comment about new insights concerning active ear points in neonates. There are only a few data available about the presence or absence of ear acupuncture points in newborn infants. Stähler van Ämerongen et al. demonstrated recently that vegetative points and organ points are detectable in neonates. The most important point was the psychovegetative rim besides other points, such as the mouth-esophagus point, the urinary bladder point, and the Darwin point. However, no psychic points were detectable in these 50 healthy neonates. This corresponds with the fact that psychic diseases in newborns are not known. The aim of this case report was to detect psychic points in a neonate with neonatal abstinence syndrome (NAS). For the detection of ear points, we used the PS 3 (Silberbauer, Vienna, Austria) ear-point detection pen, an electrical device that is placed loosely on the whole ear. Electrical conductivity in ear points differs from that in the surrounding skin surface; this is indicated by a light flash and a silent noise of the PS 3 pen. Active ear points were noted on a schematic ear graph according to the French and Chinese system. The infant was a spontaneously term-delivered female newborn with 39þ3 weeks of gestation (weight at delivery 3258 g, length at delivery 50 cm, Apgar score 9=10=10, umbilical arterial pH 7.28). We investigated the child 22 hours after delivery. The infant was in acute distress caused by a NAS, with periods of crying and fidgetiness (Finnegan score 16). We detected the psychovegetative rim (2=3 and 3=3) on the left and right ear, the mouth-, the esophagus-, and the lung point on the right earlobe. We also detected the R point and the frustration point on the left and right earlobes. Both points are known as psychotropic points. Frustration point is described 3–4 mm cranial from the point external ear on the Incisura supratragica. R point (first described by R.J. Bourdiol) is also known as ‘‘supporting point of psychotherapy’’ and is described close to the nasal border on the rising Helix in the passage to the facial skin. So for the first time it was possible to demonstrate the presence of psychic ear acupuncture points in newborn infants. Using acupuncture as complementary treatment for detoxification based on the National Acupuncture Detoxification Association (NADA) protocol is widely used for 25 years in the United States and in the recent 10 years in Europe. The NADA treatment (NADA protocol) is a basic treatment of addiction, psychiatric diseases, and posttraumatic patients. Ear acupuncture is an important part of the treatment process. There are multiple scientific studies about the effects of ear acupuncture in patients with addictions. Using needle acupuncture for newborns is not practicable, but it seems that using laser acupuncture is a good alternative. In addition to the medical treatment and care program, we decided to use laser acupuncture as alternative therapy to medical treatment, to relieve the withdrawal symptoms using the described protocol.

Comparison of peripheral and cerebral tissue oxygenation index in neonates

Near-infrared spectroscopy (NIRS) is a non-invasive method to measure haemoglobin and tissue oxygenation continuously. Measurement of “cerebral tissue oxygenation index” (c-TOI)1 and “peripheral tissue oxygenation index” (p-TOI)2 is based on spatially resolved spectroscopy (SRS). SRS is realised with one light detector having sensors at different distances. The aim of the present study was to measure c-TOI and p-TOI simultaneously to compare the two values. NIRS measurements were carried out in 20 term and preterm infants (gestational age >29 weeks and birth weight >1200 g) within the first 8 weeks after birth. At time of measurements the infants had …

Tilting the Head Changes Cerebral Haemodynamics in Neonates

Background: Tilting only the head influences cerebral haemodynamics in term and preterm neonates. Objective: To evaluate near-infrared spectroscopy (NIRS) as a method to detect changes of cerebral oxygenated (HbO2) and deoxygenated haemoglobin (Hb) and ‘cerebral tissue-oxygenation-index’ (cTOI) while tilting. Furthermore to investigate whether the comparison of cTOI and ‘cerebral mixed venous oxygen saturation’ (tiltSvO2), calculated out of the increase of HbO2 and Hb, improves reproducibility. Methods: During five ‘reapplication’ periods of NIRS optodes on the left forehead of 40 neonates, five tilting manoeuvres of the head were performed. Changes of NIRS parameters during tilting were analysed. The first quality criterion was defined by a linear increase of total haemoglobin (HbT; r2 > 0.95). The second quality criterion was: cTOI > tiltSvO2 (= cTOI – tiltSvO2> 0). Analysis of variance components and comparison of mean of standard deviations were applied to data after introduction of each quality criterion. Results: While HbO2, Hb and HbT showed a linear increase in all neonates during tilting, cTOI did not change. With the introduction of the second criterion, mean cTOI increased from 73.7 ± 6.9 to 75.1 ± 6.9%, mean tiltSvO2 decreased from 72.6 ± 7.1 to 65.3 ± 6.9% and mean of standard deviations of both parameters decreased. The analysis of variance components showed no significant change. Conclusion: A tilting-down manoeuvre of the head of term and preterm neonates can cause an increase of HbO2, Hb and HbT. tiltSvO2 can be calculated out of these changes. By introducing two quality criteria, reproducibility of cerebral NIRS measurements (cTOI and tiltSvO2) improved.

Periventricular leukomalacia and neurodevelopmental outcome

To the Editor: Cystic periventricular leukomalacia (c-PVL) is a severe complication of preterm birth leading to cerebral palsy in most afflicted children. Despite distinctions in research groups using different classification systems in different cohorts, the incidence of c-PVL is reported to range from 3% to 10%. We read with interested the article by van Haastert et al reporting a decrease in the incidence and severity of cerebral palsy in a 16-years period (1990-2005) that could be attributed to a reduction of 93% in severe c-PVL. The study confirms US data from Hamrick et al who first reported on a decline in c-PVL that was not associated at that time with improved developmental outcome during an 11-years observation period from 1992 to 2002. Our own data collected from 1988 and 2008 revealed 145 of a total of 6200 preterm infants (2.34%) #35 weeks gestational age (median gestational age, 30.8 weeks; median birth weight, 1441 g) had c-PVL with cranial ultrasound scanning. There was a mean incidence rate of 3.1% (98/3187 infants), varying between 1.0% and 5.8% per year, during observational period 1 (1988-1998), compared with 1.5% (59/3103 infants, P = .0014) during period 2 (1999-2008), varying between 0.9% and 2.9%. Some perinatal data changed significantly during these two periods (Table), with some similarities compared with the data of van Haastert et al. With neurodevelopmental follow-up, unchanged rates of cerebral palsy (78.6% versus 81.4 %, P = .467) that are in accordance with Hamrick et al, but significantly reduced rates of mental retardation (61.2% versus 30.5%, P < .0001) were revealed. The latter seems

Do wet diapers induce arousals in sleeping infants

Aim: To find out whether simulated bladder voiding was able to induce arousals in sleeping infants.

Prematurity: Influence on mother's locus of control

ZusammenfassungIn der vorliegenden Arbeit wurde erstmals die Kontrollüberzeugung von Krankheit und Gesundheit bei Müttern von Frühgeborenen untersucht und mit jener von Müttern Reifgeborener verglichen. Die mütterlichen Einschätzungen wurden auf drei Ebenen erhoben: Internale Ebene (der Krankheits- bzw. Gesundheitszustand ist von der Person selbst abhängig), sozial-externale Ebene (der Krankheits- bzw. Gesundheitszustand ist von anderen Personen abhängig) und sozial-fatalistische Ebene (der Krankheits- bzw. Gesundheitszustand ist von äußeren unkontrollierbaren Faktoren abhängig: Schicksal, Glück, Religion, … ). In der Studie nahmen 35 Mütter von Frühgeborenen (<32 SSW) und 35 Mütter von Reifgeborenen (≥37 SSW) teil, wobei die Datenerhebung innerhalb der ersten drei Tage nach der Geburt durchgeführt wurde. In der Kontrollüberzeugung von Krankheit und Gesundheit zeigte sich ein signifikanter Unterschied zwischen den Müttern von Früh- und Reifgeborenen im Bereich der sozial-fatalistische Ebene, während in den Bereichen der internalen und sozial-externalen Ebene keine signifikanten Unterschiede nachgewiesen werden konnten. Diese Einschätzung des Krankheits- bzw. Gesundheitszustandes von Müttern Frühgeborener, sollte in der mütterlichen Behandlung und Elternbetreuung miteinbezogen und berücksichtigt werden, um sowohl den unmittelbaren Kontaktaufbau zwischen Mutter und Kind zu unterstützen, als auch in weiterer Folge die zukünftige psychosoziale Entwicklung des zu früh geborenen Kindes zu gewährleisten.SummaryThe aim of the present study was to compare the beliefs of mothers of term infants with the beliefs of mothers of preterm infants in regards to their locus of control mainly influencing their personal health and well-being. Mothers beliefs regarding the level of internal (self), social external (other individuals) and fatalistic external control (e.g. chance, destiny, and religion) were assessed while mothers were admitted to hospital postnatally. Thirty-five mothers of preterm infants under 32 weeks of gestation, and 35 mothers of term infants (≥37weeks of gestation) were included and participated within the first three days after delivery. Between the group of mothers of term infants and the group of mothers of preterm infants there was a significant difference in the level of fatalistic external control of health and disease they experienced. Mothers beliefs regarding internal and social external control did not differ between the two groups. When dealing with the mothers of preterm infants one should consider their strong beliefs that health and disease are largely dependent on fatalistic external factors. This might help to improve mother-child interaction and as a consequence also neurobehavioral development of the preterm infant.

Endoscopic laser posterior cordectomy in a newborn with bilateral vocal fold paralysis and cerebro-oculo-facio-skeletal (Pena-Shokeir II) syndrome

A newborn term infant showed typical signs of a cerebro-oculo-facio-skeletal syndrome (COFS, Pena-Shokeir II): muscular hypotonia, microcephaly, blepharophimosis, bilateral cataract, hypertelorism, low-set dysplastic ears, micrognathia, prominent nasal bridge, camptodactyly, flexion contractures of the lower extremities, rocker bottom feet and bilateral syndactyly of the second and third toes. Family history was inconspicuous. COFS is an autosomal recessive disorder. The diagnosis was made clinically, since the gene locus of the disease is as yet unknown [6]. Our patient developed a severe inspiratory stridor with increasing oxygen requirement. A bilateral vocal fold paralysis (BVFP) was detected on flexible bronchoscopy. Mechanical ventilation was necessary after the 3rd week. Two days later, endoscopic laser posterior cordectomy was performed [2]. With superimposed high frequency jet ventilation there were no problems during the surgical procedure [4]. At the age of 5 weeks he was discharged from the hospital without a need of oxygen support. At the age of 3 months seizures were treated with valproic acid. Psychomotor retardation was severe. Social contact and vocalism were possible, but there was no motor development. The parents were supported in daily care by a nurse for 30 min three times a week. The boy remained at home without severe respiratory problems until he died at the age of 15 months as a result of neurological degeneration. Since children with a COFS syndrome die within the first 3 years of life and severe psychomotor retardation is unavoidable [6], we decided to use endoscopic laser posterior cordectomy in the 3rd week of life to enable home care by his parents without the difficulties of tracheotomy. The release into home care in the 5th week of life would not have been possible without cordectomy. Recently, endoscopic laser posterior cordectomy has become an accepted therapy for BVFP after the age of 4 years [1, 2,3]. A triangular wedge of one posterior vocal fold is excised from the free border of the membranous cord (Fig. 1). In children, most cases of BVFP are abductor palsies with the folds close to one another [1]. BVFP in the neonatal period is a potentially life-threatening condition. Presenting symptoms in infants include stridor and feeding difficulties [1].The dilemma faced by the paediatrician and the surgeon is that any procedure that improves the airway is likely to permanently affect the quality and volume of the voice. Of children with BVFP, 15%–60% will regain some degree of vocal fold function [3,5]. Recovery from BVFP is even described up to 11 years after birth [1]. Therefore a definite surgical procedure is usually not recommended until at least 6 to 12 months after diagnosis and until the patients are 4 years of age [1, 3,5]. Nevertheless, early endoscopic laser posterior cordectomy in an infant with a severe disease like the COFS syndrome is a procedure that can enable Fig 1 Schematic of a posterior cordectomy of the left vocal fold, modified after [2] Eur J Pediatr (2004) 163: 120–121 DOI 10.1007/s00431-003-1374-9