Wolfgang Raith

Systolic Right Ventricular Function in Preterm and Term Neonates: Reference Values of the Tricuspid Annular Plane Systolic Excursion (TAPSE) in 258 Patients and Calculation of Z-Score Values

Background: The tricuspid annular plane systolic excursion (TAPSE) is an echocardiographic measurement to assess right ventricular systolic function in adults and children. Objective: We determined growth- and birth weight-related changes of TAPSE to establish reference values in preterm and term neonates. Methods: A prospective study was conducted in a group of 258 preterm and term neonates (age: 25+0 to 40+6 weeks of gestation, birth weight: 530–4,200 g). Results: The TAPSE ranged from a mean of 0.44 cm (Z-score ±2: 0.30–0.59 cm) in preterm neonates in the 26th week of gestation to 1.03 cm (Z-score ±2: 0.85–1.21 cm) in term neonates in the 41st week of gestation. The TAPSE values increased in a linear way from the 26th to 41st week of gestation. TAPSE, week of gestation and weight are strongly correlated: Pearson’s correlation coefficient was 0.93 for week of gestation – TAPSE (p < 0.001), 0.93 for week of gestation – birth weight (p < 0.001), and 0.89 for birth weight – TAPSE (p < 0.001). There was no statistically significant difference of normal TAPSE values between female and male patients (p = 0.987). Conclusion: Z-scores of TAPSE values were calculated and percentile charts were established to serve as reference data for ready application in preterm and term neonates with structurally normal hearts and with congenital heart disease in the future.

Plasma Concentrations after Intravenous Administration of Phylloquinone (vitamin K1) in Preterm and Sick Neonates

Vitamin K prophylaxis usually is administered orally or intramuscularly, but in neonatal intensive care oral administration might not be feasible and intramuscular administration is not general practice in very small infants. No data are available about plasma levels after intravenous administration of vitamin K to neonates. Therefore, we investigated plasma levels in 18 infants: 14 preterms with a birthweight of 1785+/-648 g and 4 sick newborns with a birth-weight of 3167+/-510 g after administration of a single dose of 0.3+/-0.1 mg/kg phylloquinone (vitamin K(1)) (Konakion MM((R)), Roche) intravenously after birth. Blood was collected 22.9+/-18.4 hours after intravenous administration of vitamin K(1). In 10 neonates a second sample was obtained 111.8+/-49.1 hours after the first vitamin K(1) administration. Gas chromatography-mass spectrometry (GC-MS) was used as the method for determination of vitamin K(1). The measured plasma concentration after intravenous administration of vitamin K(1) was 191.3+/-102.6 ng vitamin K in the first sample /mL in the first sample and 98.7+/-75.2 ng vitamin K(1)/mL in the second samples. These results are similar to those described in newborns after oral administration of 3 mg vitamin K(1) and after intramuscular administration of 1.5 mg vitamin K(1). In conclusion, the recommendation of the producer to give 0.4 mg/kg of vitamin K intravenously to neonates, in whom oral or intramuscular administration is not feasible, seems to be rational.

Efficacy and Safety of Acupuncture in Preterm and Term Infants

The aim of the paper was to review the literature about safety and efficiency of acupuncture therapy in term and preterm infants. We searched Medline, EMBASE, and Cochrane Central Register of Controlled Trials using a predefined algorithm, reviewed abstracts from the Pediatric Academic Society annual meetings (2000–2012), and performed a manual search of references in narrative and systematic reviews. A total of 26 studies identified met our search criteria. Only 6 of these studies met our inclusion criteria; however, two studies had to be excluded because the manuscripts were published in Chinese. Hence, only four studies were included in our analysis. Three of the four studies evaluated the effects of acupuncture on infantile colic, and one assessed pain reduction during minor painful procedures in preterm babies. The limited data available suggests that acupuncture could be a safe nonpharmacologic treatment option for pain reduction in term and preterm infants and could also be a non-pharmacologic treatment option to treat infantile colic. Currently acupuncture in infants should be limited to clinical trials and studies evaluating short- and long-term effects and should be performed only by practitioners with adequate training and experience in neonatal/pediatric acupuncture.

Laser Acupuncture for Neonatal Abstinence Syndrome: A Randomized Controlled Trial

BACKGROUND: Neonatal abstinence syndrome (NAS) is usually treated with opiate derivatives and supported with nonpharmacological treatment. METHODS: This prospective, randomized, controlled, blinded, single-center study was carried out between March 2009 and November 2014. Newborn infants diagnosed with NAS after maternal opioid substitution therapy were eligible for inclusion. Infants were randomly allocated to the acupuncture group (combining laser acupuncture and pharmacological therapy of morphine and phenobarbital) or control group (pharmacological therapy alone). Laser acupuncture was performed with a LABpen MED 10 (675 nm/10 mW) at 5 ear and 4 body acupuncture points, bilaterally, and sessions were repeated every day. The primary outcome measure was duration of oral morphine therapy for NAS. Secondary outcomes included highest single Finnegan score, time to highest single Finnegan score, maximum amount of oral morphine solution (in milliliters per kilogram and milligrams per kilogram), time to maximum amount of oral morphine solution, and length of hospital stay. RESULTS: Twenty-eight newborns (14 in each group) were eligible for analysis. Duration of oral morphine therapy was significantly reduced in the acupuncture group compared with the control group (28 vs 39 days, respectively, P = .019). In addition, we observed a significantly reduced length of hospital stay in the acupuncture group compared with the control group (35 days [interquartile range 25 to 47] vs 50 days [36 to 66], P = .048). CONCLUSIONS: Adjunctive laser acupuncture significantly reduced the duration of morphine therapy in newborns with NAS.

Thermographical Measuring of the Skin Temperature Using Laser Needle Acupuncture in Preterm Neonates

In children, laser acupuncture is used more often than needle acupuncture in Western countries, due to their aversion to needles. When applying laser acupuncture to premature babies and neonates, firstly the degree of the thermal increase to the skin has to be evaluated so as to guarantee safe application. The patients were premature neonates before their discharge from hospital. The measurements were carried out by means of a polygraphy while they were asleep shortly. The large intestine 4 acupoint (LI4, Hegu) was stimulated by a microlaser needle (10 mW, 685 nm) twice (5 and 10 min). Local thermographic pictures were taken with a thermal camera (Flir i5, Flir Systems Inc., Portland, USA), and the warmest point was determined and subsequently compared. The study included 10 premature neonates (7 male, 3 female). The measurements were carried out on the 33rd day of life (weight 2030 g, gestational age 36 + 3 weeks of pregnancy). In comparison to the initial temperature (32.9°C), after 5 minutes of stimulation (33.9°C) (P = 0.025) and also after 10 minutes of stimulation (34.0°C) (P = 0.01), there was found to be a significant increase in the skin temperature. The singular maximum value of 37.9°C bears a potential danger; however, compared to the local temperatures reached in transcutaneous blood gas measurements it appears not to entail any risks.

Active Ear Acupuncture Points in Neonates with Neonatal Abstinence Syndrome (NAS)

The aim of the study was to determine the presence of acupuncture ear points in neonates with Neonatal Abstinence Syndrome (NAS). NAS occurs in the first days of life in neonates whose mothers have a history of drug abuse, and may also occur in neonates whose mothers are currently following substitution therapy. The patients are neonates with NAS admitted over one year to the Division of Neonatology at the University Hospital Graz. The examination took place on the third day after delivery (mean value 70.3 hours) and was performed by a neuronal pen (PS 3

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.

Near-infrared spectroscopy for objectifying cerebral effects of laser acupuncture in term and preterm neonates.

Laser acupuncture (LA) becomes more and more relevant in neonates and infants. With near-infrared spectroscopy (NIRS), a continuous and noninvasive measurement of tissue oxygenation is possible. Aim was to investigate, whether the application of LA was associated with any changes in regional cerebral oxygen saturation (rcSO2) in term and preterm neonates. The study included 20 neonates (12 males, 8 females). The Large Intestine 4 acupuncture point (LI 4, Hegu) was stimulated by a microlaser needle (10 mW, 685 nm laser needle EG GmbH, Germany) for 5 minutes, bilaterally. All neonates underwent polygraphic recording during undisturbed daytime sleep, including heart rate (HR), peripheral oxygen saturation (SpO2), and measurement of nasal flow. Using NIRS, rcSO2 was measured continuously. Cerebral fractional tissue oxygen extraction (cFTOE) was calculated. We did not observe any significant changes in SpO2 and HR values during the whole observation period. However, there was a significant decrease in rcSO2 (P = 0.003) within postintervention period, accompanied by a significant increase in cFTOE (P = 0.010) in postintervention period.

Changes of Locoregional Skin Temperature in Neonates Undergoing Laser Needle Acupuncture at the Acupuncture Point Large Intestine 4

Laser acupuncture bears a potential risk for the skin surface, especially in neonates whose skin has histological and physiological peculiarities. We evaluated thermal changes of skin temperature in neonates during laser acupuncture by using a thermal camera (Flir i5, Flir Systems Inc., Portland, USA). Laserneedles (Laserneedle GmbH, Glienicke/Nordbahn, Germany) were fixed to the skin at Large Intestine 4 (LI 4, Hegu), bilaterally. Before application of laser acupuncture (685 nm, 15 mW, 500 μm), as well as after 1, 5, and 10 min, thermographic pictures of both hands were taken. The measuring was carried out on the 23rd day after birth (20 neonates, mean postmenstrual gestational age 38 + 2, mean weight 2604 g). Compared to the initial temperature of 34.2°C on the right hand, the skin temperature had increased to 35.3°C (P < 0.05) after 5 min and up to 36.1°C (P < 0.05) after 10 min of stimulation. Equally, on the left hand, an increase of the skin temperature from 34.5°C to 35.9°C (P < 0.05) and 35.9°C (P < 0.05) was measured. The highest measured skin temperature after 10 min of stimulation amounted to 38.7°C, without any clinically visible changes on the skin surface.

Laseracupuncture – a possible alternative treatment for agitation and pain in neonates?

malformation seen on cranial magnetic resonance imaging, called the molar tooth sign. Clinically important for the anesthetist are mental retardation of variable degree, hypotonia in infancy, disturbance in breathing pattern, ataxia, and abnormal eye movements (2). So far to our knowledge, there are only reports about inhalational anesthesia or regional anesthesia with or without sedation in pediatric patients with JBS (3–5). We report about a propofol–remifentanil-based anesthesia for a dental procedure. The patient was 18 years of age, 170 cm, 60 kg, mentally retarded, and wheelchair bound. Anamnestically she had episodes of hypoand hyperventilation. There was no premedication given, except for EMLA patch. Anesthesia was induced with an effect-site target-controlled infusion system of propofol (first 4 mcg/ml, then increased to 6 mcg/ml) and remifentanil (3 ng/ml). Mask ventilation was uneventful. Without administering muscle relaxation, the patient’s trachea was nasally intubated. The dental procedure lasted for 80 minutes, and anesthesia was maintained using bispectral index control (BIS; 40–60), varying propofol between 2 and 3 mcg/ml and remifentanil between 2 and 6 ng/ml effect site concentration. Low blood pressure was once treated by 5 mg of epinephrine IV. At the end of the procedure, the dentist installed local anesthesia, and the patient received 75 mg diclofenac IV. For PONV prophylaxis, ondansetron 4 mg IV was given. With effect site concentrations of propofol 0.8 mcg/ml and remifentanil 0.8 ng/ml, resulting in a BIS value of 77, the patient spontaneously opened her eyes at the end of the procedure, and her trachea was extubated. Postoperative standard monitoring showed absolutely no abnormalities, so that after 4 hours the patient was discharged to her nursing home. In conclusion, we found total intravenous anesthesia in combination with local anesthetic, without neuromuscular blockage and without long-lasting opioids, to be a safe and reliable method of anesthesia for a patient with JBS.