Journal of Pediatric and Neonatal Individualized Medicine (JPNIM)

Hyperosmolar therapy in pediatric traumatic brain injury: a systematic review

Marta Rodrigues — 2023-08-30

Background: Traumatic brain injury (TBI) is a prominent reason for morbidity and mortality in children. The use of hyperosmolar therapy to manage increased intracranial pressure (ICP) is portrayed in pediatric guidelines; however, there still remains some debate regarding which option to select. The aim of this systematic review was to assess which hyperosmolar therapy – mannitol or hypertonic saline (HTS) – is more effective in terms of lowering ICP and having better outcomes in treating children with TBI.

Methods: A literature search was conducted using MEDLINE (through PubMed), Scopus, and Web of Science. This review included 6 retrospective and prospective studies comparing the use of mannitol and HTS in pediatric patients with TBI.

Results: HTS was the most frequently described hyperosmolar agent, obtaining better results in managing ICP, cerebral perfusion pressure and osmolarity. It also showed to be effective in refractory intracranial hypertension, in situations where mannitol fails to lower ICP. Mannitol was less studied but demonstrated a higher incidence of mortality than HTS. There were several studies that did not report monitoring outcomes associated with serum osmolarity, despite the use of hyperosmolar therapies. Discrepancies were noticed between the studies in the overall study design in addition to reported monitoring parameters and length of stay.

Conclusions: HTS seems to be safe and efficient in the treatment of severe TBI in children. The reduced existing studies regarding the use of mannitol do not permit a strong decision to be made concerning its practice. For the time being, the choice of hyperosmolar therapy in this context must be individualized and based on clinical practice and experience, not disregarding the latest guidelines that recommend the use of HTS.

The clinical role of probiotic and prebiotic supplementations during and after maternal gestation

Giulio Perrotta — 2023-09-04

Background: For over two decades we have been trying to study and demonstrate the role of the gut microbiota in the onset of cardiovascular, autoimmune, infectious and neurobiological diseases, and more generally the clinical efficacy.

Materials and methods: All clinical trials and randomized controlled trials were selected up to March 30, 2023, for a useful total of 45 studies.

Results: Significant evidence emerges in the literature that supports the therapeutic use for clinical purposes of prebiotics and probiotics even during gestation and within the first 2 years of life, of specific bacterial strains of Lactobacillus and Bifidobacterium (with almost no definite evidence for S. boulardii) to promote proper intestinal eubiosis, slow down inflammatory and infectious processes, including those of an allergic nature, and prevent or ameliorate disease states such as that of gestational diabetes mellitus, sepsis, necrosis, and preeclampsia. In addition, the use of high-fat polyunsaturated fatty acid (HF-PUFA) blends from fish oil, fermented milk supplemented with probiotic strains, and galactooligosaccharides/polydextrose (GOS/PDX) seems useful.

Conclusions: There emerges, therefore, the need, in such a varied and contradictory landscape, to design a research project that takes into account, first of all, a significant and representative population sample, but above all, one that does not underestimate the critical issues mentioned above, to address with a scientific method the proper and functional use of prebiotics and probiotics in the neonatal and obstetrical fields in general; further studies that can confirm and expand scientific knowledge in this particular field are therefore needed.

Vomiting in neonates

Íris Santos Silva — 2023-08-28

Vomiting is a common clinical sign in the paediatric age group, including neonates. It is the forced expulsion of gastric content through the mouth and must be differentiated from gastro-oesophageal reflux. Vomiting in neonates is usually a non-specific clinical sign and may correspond to gastrointestinal abnormalities, but it can also signal systemic disorders such as infectious pathologies, intracranial injuries with intracranial hypertension, and endocrine and metabolic diseases. Physicians should be able to recognize life-threatening causes of vomiting in order to avoid serious complications. This review considers congenital gastrointestinal malformations, infections and other less common causes of vomiting in neonates.

Multisystemic inflammatory syndrome in children post-COVID-19: clinical-biological characteristics of patients in the first year of the pandemic

Luminita Goicea (Spatariu) — 2023-09-07

Introduction: Initially considered the “hidden victims” of the pandemic, children have come into the spotlight regarding the impact of COVID-19 since spring 2020. Against this background, a new entity of multisystemic hyperinflammatory syndrome in the pediatric population with manifestations that overlap with Kawasaki disease has become an increasing focus of attention.

Objectives: The current study was intended to identify some indicators of the severity of pediatric inflammatory multisystem syndrome, temporally associated with SARS-CoV-2/multisystemic inflammatory syndrome in children post-COVID-19 (PIMS-C/MIS-C) and factors predictive of its prognosis, paying attention to both already established factors (cardiac injury markers) and less used parameters (neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR]) that could provide valuable information for predicting severe disease development.

Materials and methods: This study was based on a descriptive observational analysis of a group of pediatric patients (0-18 years) in whom the following were identified: persistent fever, the presence of single/multiple-organ dysfunction, a significant biological inflammatory syndrome, a temporal association with SARS-CoV-2 infection (infection/exposure 2-6 weeks previously), and an absence of other conditions that could explain this pattern.

Results: The patients who met the criteria for inclusion in the study during the analyzed period were children aged between 4 months and 17 years and 10 months, with a median age of 5 years (IQR, 3-8.75). All enrolled patients presented fever (with a maximum duration of 9 days) at admission, which was associated at varying rates with digestive, neurological, and skin-mucosal changes, and cardiac manifestations. Three main phenotypes of the condition were outlined (Kawasaki-like, shock-like, and a non-specific form). In the evaluated patients classified into the Kawasaki-like phenotype, higher median values of NLR but lower values of PLR were observed compared with those in the other forms of PIMS-C/MIS-C.

Conclusions: The current study outlines the spectrum of PIMS-C/MIS-C while also emphasizing the importance of establishing certain correlations between biological markers and the evolution of the disease. The use of certain parameters easily obtained from the blood count (NLR, PLR) as well as determining their correlation with disease severity could offer new directions to treat this condition.

Early time to positivity in blood cultures as an indicator of mortality in very low birth weight neonates – A retrospective observational cohort study

Sidharth Nayyar — 2023-08-17

Introduction: Neonatal sepsis is an important cause of mortality. Blood culture is the gold standard for the diagnosis. Time to positivity (TTP) in blood cultures may help in early optimization of treatment in sick neonates.

Methods: This was an observational study. Data records were collected for all neonates who were screened for both early- and late-onset sepsis. BacT/Alert system was used for culture detection. For every positive culture, TTP was calculated as the difference between loading time and detection time. Primary outcome was correlation of TTP with mortality due to culture-proven sepsis in gestational age ≤ 34 weeks.

Results: 151 VLBW neonates with culture-proven sepsis were included in the study over a period of 22 months. Gram-negative organisms were the predominant isolates, with Klebsiella pneumoniae being the commonest organism. Median TTP was significantly lower in the mortality group (9 hours, IQR 5-24) versus the survivor group (20 hours, IQR 9-78) with a p-value < 0.001. Early-onset sepsis was significantly higher in the mortality group (60%) versus the no-mortality group (27.9%). On multivariate analysis, TTP was the only factor significant in the neonatal mortality amongst the cohort with a p-value < 0.001 and AOR 1.54, 95% CI 1.22-1.93, indicating higher odds of death in neonates with a shorter duration of TTP.

Conclusions: TTP is an important predictor of neonatal mortality. Neonates with shorter TTP had higher odds of neonatal mortality due to sepsis. Thus, TTP can be used as a guide for optimal and judicious treatment in neonatal sepsis.

Neonatal encephalopathy beyond hypoxic-ischemic etiology: experience of a Level III Neonatal Intensive Care Unit in the last decade

Rita Gomes — 2023-09-06

Neonatal encephalopathy (NE) is a condition of neurologic dysfunction with heterogeneous severity. The terms hypoxic-ischemic encephalopathy (HIE) and NE are often used interchangeably, although the differential diagnosis is vast. We aimed to evaluate the etiologies behind NE in newborns (NB) treated with therapeutic hypothermia (TH) for a presumed diagnosis of HIE.

A retrospective analysis between January 2012 and July 2020 was conducted. Demographic data, information regarding pre- and perinatal factors, systemic dysfunction parameters, neuroimaging and neurologic sequelae were collected. A comparative analysis between the group considered with hypoxic-ischemic versus non-hypoxic-ischemic NE was performed.

Forty-six NB were included. HIE was confirmed in 29 (63.0%) patients (group 1). There was no evidence of perinatal asphyxia in 17 (37.0%) patients (group 2). In the latter group, intracranial hemorrhage was the most frequent etiology (7; 15.2%), followed by infection (5; 10.9%). In group 1, there was a higher prevalence of emergency cesarean section (p = 0.013), clinical seizures at admission (p = 0.048) and a higher encephalopathy severity (p = 0.027). In this group, amplitude-integrated electroencephalogram improvement at 48 hours of TH was less frequent (p = 0.027) and major neurologic sequelae were more prevalent at 12 (p = 0.006) and 24 months (p = 0.041).

HIE was the main cause of NE. Despite the clinical overlap, clinicians should recognize other etiologic factors beyond anoxic events. Our findings might help to prospectively differentiate between HIE and NE from different etiologies early after birth, ideally prior to initiation of TH, in the future.

The effect of white noise on sucking success and infant comfort in premature babies: a paired randomized controlled trial

Esra Tanrıverdi — 2023-08-22

Purpose: This study was conducted in a paired randomized controlled trial manner to determine the effect of white noise on sucking success and infant comfort in premature babies.

Methods: Sixty-six preterm babies were randomized into two groups (33 newborns in the white noise group and 33 newborns in the control group). In the white noise group, preterm babies were exposed to white noise during breastfeeding. Patient identification form, application registration form, Premature Infant Comfort Scale (PICS), and LATCH Breastfeeding Assessment Tool were used in the study.

Results: There was no significant difference between the pre- and post-procedure LATCH scores of the babies in the white noise and control groups (p > 0.05). However, in the comparison within the groups, a statistical difference was found between the pre- and post-procedure scores of the newborns in the white noise and control groups (p < 0.05). The breastfeeding success scores of the newborns in the white noise group were found to be higher than that of the control group (white noise group Cohen d value = 0.45, control group Cohen d value = 0.17). While there was no significant difference between the groups in terms of pre-procedure PICS scores (p = 0.114), a significant difference was found in the post-procedure PICS scores (p = 0.031). The increase in the comfort levels of newborns in the white noise group was found to be significant.

Conclusion: The white noise played to premature babies during breastfeeding was effective on the sucking success and the comfort level.

Stress levels in parents of neonates: an underrated aspect of neonatal intensive care?

Hemakrishnasai Mallapu — 2023-08-29

Aim: A neonate requiring admission to the Neonatal Intensive Care Unit (NICU) can cause significant stress and anxiety for parents. To evaluate this, a validated questionnaire was used to assess parents’ perceptions of stressors within the physical and psychosocial environment of the NICU. Furthermore, the questionnaire aimed to identify socio-demographic factors that play a role in influencing stress levels.

Methods: A validated questionnaire known as the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU), developed by Miles et al., was employed to evaluate parents’ stress levels across 4 domains encompassing a total of 34 items. Parental stress levels were classified based on Likert scale points as low (1-2.9), medium (3-3.9), and high (4-5).

Results: The study involved a total of 55 participating parents, with the majority (54.5%) experiencing a medium level of stress. Analysis of socio-demographic factors revealed that mothers with lower levels of education, as well as parents of term neonates and female neonates, exhibited higher stress levels. However, no significant correlations were observed between parental stress levels and factors such as the father’s education, parental age, family income, birth order, weight of the neonate, and mode of delivery.

Conclusion: The use of the PSS:NICU in every NICU can aid in identifying parental stress levels and relevant socio-demographic and neonatal factors. This valuable information can be used to provide optimal care for the parents of neonates. By incorporating this approach, we can effectively promote Family-Centered Developmental Care (FCDC) in the NICU setting.

Severe neonatal anemia: looking at the whole picture

Maria Sousa Dias — 2023-08-24

Neonatal anemia is an important cause of newborn morbimortality. Its causes fall into three categories: hemorrhagic, hemolytic or hypoplastic. Prompt recognition and acute care are crucial for good outcomes. Its etiological investigation is also essential to prevent further complications for the newborn and its mother.

We report a case of a full-term neonate born after an uneventful pregnancy of a mother with a significant medical history of ulcerative colitis under mesalazine treatment. He was delivered by an emergency c-section for a non-reassuring fetal status with an Apgar score of 5-8-9. Investigation revealed severe neonatal anemia with high reticulocyte count and a positive Kleihauer-Betke test. After an effective blood transfusion, he was discharged home under iron supplementation and later reevaluations showed normalization of blood parameters and regular growth and neurodevelopment.

Many causes of neonatal anemia have been described. The presence of fetal erythrocytes in maternal blood occurs in nearly all term pregnancies, but massive fetomaternal hemorrhage occurs only in 0.5% of cases. Active inflammatory bowel disease is also associated with adverse pregnancy outcomes and, in recent years, mesalazine, one of its main treatments, has been linked to neonatal anemia and hydrops fetalis. Regardless of the patient’s clinical presentation and predicted anemia etiology, we highlight the importance of identifying and acting on further possible causes.

Nursing interventions and assessment tool for neonatal abstinence syndrome (NAS): a case report

Lorenzo Righi — 2023-08-24

A newborn female was admitted to the Neonatal Intensive Care Unit 2 days after birth with neonatal abstinence syndrome (NAS). The patient displayed withdrawal symptoms from substance misuse, which was passively absorbed in utero via the placenta. This clinical scenario analysis aims to investigate which nursing interventions are dedicated to restoring normal vital functions in NAS patients and which assessment tool is most commonly used to monitor withdrawal symptoms. NAS is a medical condition that affects newborns of drug-abusing mothers. The clinical presentation can involve different organ systems: the central nervous system (CNS), autonomic nervous system (ANS), gastrointestinal (GI) system, and respiratory system. Possible symptoms include excessive or high-pitched crying, agitation, fever, tremors, sleep disturbance, vomiting, weight loss, seizures, sweating, yawning, sneezing, tight muscle tone, tachypnoea, poor feeding, and uncoordinated suction. A NAS diagnosis can be confirmed by verifying the presence of drugs using biological tests and assessment tools to classify and manage the condition. Several biological tests are available to confirm exposure to a misused substance: urine testing, meconium testing, cord blood testing, and baby hair testing. The most commonly used assessment tool is the Finnegan Score. Treatment for an infant with NAS involves both non-pharmacological and pharmacological interventions and a multidisciplinary team. This team works with the parents, particularly the mother, who must be part of the newborn’s healing process.

Patching persistent pneumothorax in a neonate

Sumona Bose — 2023-09-11

Introduction: Though autologous blood patch (ABP) pleurodesis is widely used in adults, its use in children is uncommon, with only one reported in a neonate thus far. Here, we report a late-preterm neonate with persistent air leak and concurrent Aspergillus infection, who was successfully treated with ABP, and we review the literature on pleurodesis.

Case report: A late-preterm baby girl born at 35 weeks of gestation was referred with respiratory distress since birth. She required intubation and high-frequency oscillatory ventilation (HFOV) as she did not respond to conventional ventilation. On day 2 of life (D2), she developed left pneumothorax and, on D3, right pneumothorax, requiring intercostal chest tube drains (ICDs). The child was extubated on D14, and the right ICD was removed on D18. However, the left pneumothorax persisted. Computerized tomography revealed right-sided consolidation and pneumatoceles, and persistent left pneumothorax. ABP was done on D23 and D25, with resolution of pneumothorax and removal of ICD on D27. Concurrently, pleural fluid cultures done on D16, D23 and D25 grew Aspergillus terreus, which was treated with voriconazole. The child is well at 3 months follow-up.

Conclusion: ABP for persistent pneumothorax is a safe, easy and inexpensive bedside procedure. Though its therapeutic role is well established in adults and older children, its use in neonates, especially in preemies, is less explored. The results are satisfactory, and it may be a feasible alternative to surgery when used in select neonates.