European Journal of Pediatrics最新文献

Delayed cord clamping (DCC) is now the standard of care in singleton vigorous neonates. But consensus is lacking on the appropriate approach to placental transfusion in multifetal gestational births. In this study, we tried to determine the effect of cut umbilical cord milking (C-UCM) as compared to early cord clamping (ECC) on hematological and clinical hemodynamic parameters in preterm twin neonates of 30-37 weeks gestation. The primary outcome assessed was venous hematocrit (Hct) at 48 (± 4) h of postnatal age. Venous Hct at 6 weeks of age, mean blood pressure during the transitional period, significant neonatal morbidities, and possible sequelae were the significant secondary outcomes evaluated. In this single-center stratified randomized controlled trial, 84 pairs of twin births of 30-37 weeks gestation were allocated in a 1:1 ratio to either C-UCM (n = 84) or ECC (n = 84). For statistical analysis, unpaired Student t and Chi square or Fisher's exact test were used. The C-UCM group had a higher mean Hct at 48 h than the control group, 49.74 (4.463) vs. 41.11 (4.898), p < 0.0001. The mean Hct at 12 h and 6 weeks was also significantly greater in the milked group (p < .0001). Additionally, the milked arm had significantly higher mean blood pressure at 1, 6, and 48 h of life. Similar statistically significant differences were also observed in subgroup analysis (stratified according to gestational age of 30-34 weeks, 34-37 weeks). The groups did not differ significantly in terms of potential complications.

Conclusion: C-UCM raises the venous hematocrit and stabilizes initial blood pressure. For twin preterm neonates born between 30 and 37 weeks of gestation, it may be a useful placental transfusion technique. Further large multicentric studies are needed to fully establish its efficacy and safety.

Trial registration: CTRI/2024/01/061865; registration date January 25, 2024.

What is known: • DCC is the standard of care for singleton vigorous neonates, but no consensus exist for multifetal gestation. • C-UCM is feasible, but studies are lacking in the preterm multifetal population.

What is new: • C-UCM is an effective placental transfusion strategy in preterm neonates of 30-37 weeks born out of twin gestation. • C-UCM can serve as a substitute for DCC in multifetal gestation especially in low resource settings.

The purpose of this study is to evaluate the impact of DCC (> 30 s) compared to immediate cord clamping (ICC) or umbilical cord milking (UCM) on early cardiac and cerebral hemodynamics, mortality, and severe intraventricular hemorrhage (IVH) in very preterm infants. We searched Ovid Medline, EMBASE, and Cochrane CENTRAL from inception to September 28, 2023, and included randomized controlled trials (RCTs) comparing preterm infants < 32 weeks who received DCC to ICC or UCM. The results were obtained using the Mantel-Haenszel and pooled with a random-effects model. Fifteen articles (2967 patients) were selected, comparing DCC to ICC (10), DCC to UCM (4), and one three-arm study. DCC resulted in a slight increase in superior vena cava (SVC) flow compared to ICC (MD 16.09 ml/kg/min, 95% CI = 4.03 to 28.15, I² = 20%; low-certainty evidence). There was little to no difference in right ventricular output (RVO) after DCC compared to ICC (MD - 2.09 ml/kg/min, 95% CI = - 26.20 to 22.02, I² = 17%; low-certainty evidence). DCC resulted in a large reduction in mortality compared to ICC (RR 0.64, 95% CI = 0.47 to 0.88) but was very uncertain compared to UCM. DCC may reduce severe IVH compared to UCM (RR 0.54, 95% CI = 0.28 to 1.06).

Conclusion: DCC improves outcomes in preterm infants < 32 weeks when compared with ICC, as indicated by an increase in SVC flow and regional cerebral oxygenation (rSO2) (moderate- and low-certainty evidence) and reduced mortality. There is low- and very-low-certainty evidence to suggest little to no difference in mortality and cardiac and cerebral hemodynamics after DCC compared to UCM.

What is known: • DCC or UCM assists the physiological transition from intrauterine to extra-uterine life by increasing the amount of circulating blood at birth in preterm neonates. • In comparison to ICC, DCC or UCM were shown to reduce mortality, NEC, and infection in preterm infants < 32 weeks; however, a higher incidence of severe IVH was a concern in the UCM group.

What is new: • Although DCC has been associated with a large reduction in mortality for preterm infants < 32 weeks compared to ICC, the current evidence is of moderate certainty. However, there appears to be little or no difference in early cardiac hemodynamic parameters and cerebral near-infrared spectroscopy parameters (low or very-low certainty evidence). • Current evidence, which is of low and very low certainty, suggests that there is little or no difference in cardiac and cerebral hemodynamics, mortality, and severe IVH with DCC compared to UCM.

To analyze the impact of placental histological findings on the development of bronchopulmonary dysplasia (BPD) in preterm infants, this prospective, observational, single-center study included infants born before 32 weeks of gestation between 2012 and 2023. Perinatal variables were collected and correlated with mortality at hospital discharge and the diagnosis of grade 2-3 BPD at 36 weeks postmenstrual age (PMA). Placental histology was categorized into three groups: inflammatory pathology, vascular malperfusion, and no pathology. A total of 1128 preterm infants were enrolled, with placental histology results available for 899 cases. Inflammatory placental pathology was associated with a lower gestational age (GA) at birth (- 1.4 weeks, 95% CI - 1.74 to - 1.11). The increased mortality linked to placental inflammation was no longer significant after adjusting for GA. In preterm infants born at 27 weeks' GA or later, the effect of vascular malperfusion on BPD showed sexual dimorphism. In males, placental malperfusion was associated with a 2.25-fold increased risk of developing BPD (95% CI 1.10 to 4.57), independent of GA and exposure to mechanical ventilation. No significant differences were observed in females born at 27 weeks or later.

Conclusions: The impact of placental histological abnormalities on BPD development is influenced by gestational age and sex. While placental inflammation increases mortality by triggering extremely preterm birth, it does not appear to increase respiratory morbidity compared to cases with normal placental histology at similar GAs. In males, however, placental malperfusion appears to affect lung development and contributes to BPD independently of GA and exposure to mechanical ventilation.

What is known: • Bronchopulmonary dysplasia (BPD) is a common respiratory complication among preterm infants, strongly influenced by prenatal events. • The placenta plays a crucial role in fetal lung development, and its analysis provides objective insight into antenatal conditions.

What is new: • Placental malperfusion affects lung development in a sex-specific manner, with male infants born at or after 27 weeks of gestation being more specifically affected and showing a higher susceptibility to BPD, independent of gestational age or mechanical ventilation. • These findings highlight the importance of considering sex differences in BPD pathophysiology and the role of placental pathology.

Vincristine, a chemotherapy drug primarily used in pediatric cancer treatments like acute lymphoblastic leukemia and Wilms' tumor, is known for neurotoxic side effects, including a rare but under-discussed manifestation-vincristine-induced ptosis. This systematic review (PROSPERO: CRD42024617946) analyzed data from three databases, identifying 379 articles. Of these, 28 articles encompassing 31 unique pediatric cases were included, with Turkey contributing the highest number of cases (9 cases, 29.03%). The median age was 3 years (IQR: 2 - 5.5), with 58.06% male (18 cases) and 41.93% female (13 cases). Ptosis appeared bilaterally in 61.29% (19 cases) and unilaterally in 38.71% (12 cases), showing a left-side predominance in unilateral cases. The median time to symptom onset after the last vincristine dose was 6 days (IQR: 2 - 12). Treatment protocols varied; 74.19% (23 cases) adjusted or discontinued vincristine, with 34.78% (8 cases) restarting after skipping doses. Pyridoxine with or without pyridostigmine was used in 70% (14 of 20 treated cases), and recovery was generally favorable, with symptoms resolving within 28 days (IQR: 22.75 - 42) in most cases. Mild residual ptosis was noted in 9.67% (3 cases). Our review shows the significant variability inherent to management approaches in this patient demographic and highlights the need for standardized documentation and treatment approaches, proposing "VINTOSIS-3" as a practical treatment protocol. Furthermore, the VICTORIA (Vincristine-InduCed pTOsis cRIteriA) Grading is introduced to standardize ptosis severity evaluation. We further emphasize the importance of early detection, vigilant monitoring, and tailored interventions to balance neurotoxicity management with chemotherapy efficacy. What is Known: • Vincristine, a widely used chemotherapeutic agent in pediatric oncology, is associated with toxic side effects, primarily peripheral neuropathy. • Ocular complications of vincristine, including ptosis, have been reported but remain under-recognized. What is New: • Vincristine-induced ptosis is predominantly bilateral, but when unilateral, it shows a left-sided predominance and typically appears after a median of four doses. • The proposed VICTORIA Grading standardizes severity assessment, and the VINTOSIS-3 protocol provides a structured approach to management.

This study aimed to analyze the clinical and electroencephalogram (EEG) data of a cohort of children diagnosed with Febrile Infection-Related Epilepsy Syndrome (FIRES) to provide a comprehensive evaluation of the acute and chronic phases of the disease and their associated clinical outcomes. A retrospective cohort study involved 19 pediatric patients admitted to two tertiary centers in Egypt. Data collection encompassed clinical manifestations, laboratory investigations, brain magnetic resonance imaging (MRI), and EEG findings. The study included 19 children with FIRES, with a median age at onset of 7 years, and 68.4% were male. All patients presented with fever before the onset of illness, followed by early convulsions that rapidly progressed to status epilepticus (SE). Seizures began 2-9 days after fever onset, with the acute phase lasting a median of 29 days and SE lasting a median of 20 days. Seizure types were primarily focal (52.6%). Abnormal MRI findings were observed in 84.2% of cases. During the acute phase, EEG showed a complete loss of normal background activity in all patients. In the chronic phase, EEG background activity gradually normalized, and epileptiform activity remained prevalent in all patients, with multifocal spikes and slow waves in 94.7% and extreme delta brush noted in 36.8% of patients. FIRES in children is associated with significant morbidity and mortality, characterized by prolonged refractory seizures and enduring neurological impairments. Early recognition and aggressive management are crucial in improving clinical outcomes. What is Known: • Febrile Infection-Related Epilepsy Syndrome (FIRES) is a rare, severe, and often fatal form of epileptic encephalopathy that has been a focus of significant attention in medical literature over the past two decades.  What is New: • This study provides a detailed analysis of clinical and EEG data in children with FIRES, highlighting distinct characteristics of the acute and chronic phases. •The findings underscore the critical need for early recognition and aggressive management to address prolonged refractory seizures and mitigate enduring neurological impairments.

To test the hypothesis that thoracic fluid content (TFC) by thoracic electrical bioimpedance would be higher in preterm infants with respiratory distress syndrome (RDS) both at birth and in the first 48 h of life than in those without RDS and that TFC measured at birth would be associated with RDS diagnosis and need for surfactant. Cross-sectional exploratory observational study including infants ≤ 34 weeks of gestation admitted to two level three NICUs. TFC, clinical, and respiratory data were recorded at 5 timepoints: within the first 2 h of life, before surfactant therapy, and at 4, 12, 24, and 48 h of life. TFC was compared between infants with and without RDS. A ROC curve was calculated to assess the association between TFC at birth and the need for surfactant. TFC was higher in infants with RDS than in infants without RDS at all timepoints. The ROC AUC of TFC measured at birth for the need for surfactant was 0.817 (95% CI 0.64-0.93, p < 0.001); a TFC cut-off of 20.4 1/KOhm/Kg yielded a sensitivity of 83% and specificity of 80% for the need for surfactant. Conclusion: TFC in the first 48 h of life was higher in preterm infants with RDS than in infants without RDS. TFC measured within the first 2 h of life had a good association with the need for surfactant. What is known: • Thoracic electrical bioimpedance can be used to measure thoracic fluid content (TFC) non invasively in newborns What is new: • TFC was higher in premature newborns with respiratory distress syndrome (RDS) that in those without RDS in the first 48 h of life. A high TFC in the first 2 h was associated with the need for surfactant.

To compare NHFOV in decreasing the need for mechanical ventilation in the first 7 days of randomization in preterm infants born before 34 weeks of gestational age having nCPAP failure when used as rescue mode compared to NIMV. All eligible neonates were randomized and allocated to either NHFOV or NIMV group after taking the consent from the parents. Standardized protocol was followed on initiation, titration, weaning, and optimization of all the respiratory supports. In this study, a total of 45 neonates were eligible; among them, 20 neonates were randomized to NIMV group and 20 neonates to NHFOV group remaining 5 infants were missed due to the non-availability of a machine (n = 4) and missed randomization (n = 1). The primary outcome was need for mechanical ventilation within first 7 days of randomization in NIMV and NHFOV group was 45% and 40% (p = 0.85, OR = 1.22 (CI 0.35-4.3)). The secondary outcome was a duration of ventilation within 72 h of randomization was 40% vs. 31.6% in NIMV and NHFOV group (p = 0.58). Bronchopulmonary dysplasia was 5% and 10% in NIMV and NHFOV group with p = 0.548, OR = 0.47 (CI 0.39-5.6), and mortality was one infant in NIMV and 3 infants in NHFOV group (p = 0.568, OR = 0.29 (CI 0.02-3.1)).

Conclusion: NIMV and NHFOV are comparable in reducing the rates of mechanical ventilation within 72 h and within 7 days of post-randomization. Multi-centric trials with large sample sizes are required to prove the hypothesis.

Trial registration: www.ctri.nic.in id CTRI/2021/10/037681, registered on October 29, 2021.

What is known: • NIMV or nHFOV being used as primary as well as post extubation respiratory support in neonates. • NIMV and nHFOV has shown better clinical outcomes than nCPAP when used as primary and post extubation respiratory support.

What is new: • NIMV and nHFOV can be used as rescue mode after CPAP failure to prevent need for mechanical ventilation. • nHFOV appears promising as rescue mode in neonates who meets CPAP failure criteria.

Perimenstrual attacks have been reported in up to 15% of patients with FMF, suggesting that menstruation may be a trigger for FMF attacks. The aim of this study was to investigate menstrual period patterns and dysmenorrhea in adolescents with FMF in comparison to their healthy peers. This cross-sectional case-control study included 73 FMF patients and 70 age- and body mass index-matched controls. A structured questionnaire was designed to assess menstrual history, the frequency and severity of dysmenorrhea, symptoms related to dysmenorrhea, and the clinical features of FMF attacks. Dysmenorrhea was present in 90.4% of patients and 95.7% of controls (p = 0.32). Pain was reported during every cycle or every two cycles by 83.3% of patients versus 65.6% of controls (p = 0.02). Fever (27.4% vs. 10.3%, p = 0.01) was significantly more frequent in patients, while musculoskeletal symptoms (46.6% vs. 66.2%, p = 0.02), fatigue (53.4% vs. 83.8%, p < 0.001), and sleep disturbances (19.2% vs. 50.7%, p < 0.001) were more common in controls. Notably, FMF patients reported heavier bleeding episodes with higher number of sanitary pads used during menstruation (p = 0.001). Menstruation-associated FMF attacks were reported by 37% of patients, with 14.8% experiencing them every cycle. Exon 10 variants were present in 86.3% of cases, with 23.3% being homozygous. The frequency and character of dysmenorrhea did not differ significantly according to genetic profiles.

Conclusions: This study is the first to investigate menstrual patterns and dysmenorrhea symptoms in adolescent FMF patients compared to their healthy peers. Dysmenorrhea is prevalent in FMF patients with distinct menstrual characteristics, including more frequent fever and heavier bleeding.

What is known: • Menstruation may trigger Familial Mediterranean Fever (FMF) attacks in a subset of patients, but the relationship between FMF and dysmenorrhea remains unclear. • Some studies suggest that inflammation associated with FMF could contribute to menstrual pain and abnormalities, but comprehensive data in adolescents are limited.

What is new: • This study is the first to compare menstrual patterns and dysmenorrhea characteristics between adolescent FMF patients and healthy controls, highlighting distinct menstrual symptoms in FMF patients. • FMF patients experience more frequent febrile episodes and heavier menstrual bleeding compared to their healthy peers, but dysmenorrhea characteristics are not influenced by specific MEFV gene mutations.

Crying by healthcare professionals in the medical setting is a common but understudied phenomenon. We aimed to develop a questionnaire which measures the attitudes of parent towards crying pediatricians and pediatric nurses. We assessed reliability and validity in a group of parents of children who are living with, have died from or survived a life-limiting or life-threatening-condition. The development of the PACPN was based on modification of an existing questionnaire and expert input. In a cross-sectional-design, we assessed reliability and validity for both pediatricians and pediatric nurses. Dimensionality was assessed using principal component analysis (PCA). Cronbach's alphas were calculated for each subscale. For construct validity, participants were asked to rate an additional question regarding the goal to measure parents' attitudes towards crying pediatricians/pediatric nurses. We hypothesized that a higher score would have a strong positive correlation with the total score of the PACPN. At the end of the questionnaire, participants were asked to rate and comment the completeness. The developed 25-item questionnaire was completed by 116 parents. The PCA revealed two dimensions: (1) family's circumstances; (2) personal circumstances of the pediatrician/pediatric nurse. Internal consistency was good (pediatricians, .81-.93; pediatric nurses, .83-.93). The hypothesis regarding construct validity was confirmed (Spearman's rho = .71-.75). The completeness score was 7.7 (min-max 1-10, SD = 1.51).

Conclusion: The PACPN showed good internal consistency and some degree of construct validity. We assume that by adding some items with nuance to the situation and the degree of crying the completeness of the questionnaire will improve.

What is known: • Crying by HCPs in the medical setting, such as the hospital is common but HCPs have different attitudes towards this. • A questionnaire on crying physicians and nurses is available for assessing HCPs attitudes.

What is new: • The PACPN questionnaire is a simple tool for assessing parents' attitudes towards crying pediatricians and pediatric nurses. • The PACPN showed good internal consistency and some degree of construct validity.