Neonatology最新文献

Background: Several interventions provided to newborns at birth or within 24 h after birth have been proven critical in improving neonatal survival and other birth outcomes. We aimed to provide an update on the effectiveness and safety of these interventions in low- and middle-income countries (LMICs).

Summary: Following a comprehensive scoping of the literature, we updated or re-analyzed the LMIC-specific evidence for included topics. Ninety-four LMIC studies were identified. Delayed cord clamping with immediate neonatal care after cord clamping resulted in a lower risk of blood transfusion in newborns <32-34 gestational weeks and a lower occurrence of anemia in term newborns but did not have significant effect on neonatal mortality or other common morbidities both in preterm and term newborns. Immediate thermal care using plastic wrap/bag led to a 38% lower risk of hypothermia and a higher axillary temperature in preterm newborns without increasing the risk of hyperthermia. Kangaroo mother care initiated immediately (iKMC) or early after birth (eKMC, within 24 h) significantly reduced neonatal mortality and the occurrence of hypothermia in preterm or low-birth-weight neonates. For delayed first bath in newborns, no pooled estimate was generated due to high heterogeneity of included studies. Trials from high-income countries demonstrated anti-D's effectiveness in lowering the incidence of Rhesus D alloimmunization in subsequent pregnancy if given within 72 h postpartum.

Key messages: We generated the most updated LMIC evidence for several immediate newborn care interventions. Despite their effectiveness and safety in improving some of the neonatal outcomes, further high-quality trials are necessary.

Introduction: We present a robust and up-to-date synthesis of evidence on the effectiveness of interventions to prevent and treat newborn infections in low- and middle-income countries (LMICs). Newborn infection prevention interventions included strategies to reduce antimicrobial resistance (AMR), prevention of healthcare-associated infections (HAIs), clean birth kits (CBKs), chlorhexidine cleansing, topical emollients, and probiotic and synbiotic supplementation. Interventions to treat suspected neonatal infections included prophylactic systemic antifungal agents and community-based antibiotic delivery for possible serious bacterial infections (PSBIs).

Methods: A descriptive review combining different methodological approaches was conducted. To provide the most suitable recommendations for real-world implementation, our analyses considered the impact of these interventions within three distinct health settings: facility, mixed, and community.

Results: In facility settings, the strongest evidence supported the implementation of multimodal stewardship interventions for AMR reduction and device-associated infection prevention bundles for HAI prevention. Emollients in preterm newborns reduced the risk of invasive infection compared to routine skin care. Probiotics in preterm newborns reduced neonatal mortality, invasive infection, and necrotizing enterocolitis (NEC) risks compared to standard care or placebo. There was insufficient evidence for synbiotics and prophylactic systemic antifungals in LMICs. In mixed settings, CBKs reduced neonatal mortality risk compared to standard care. In community settings, chlorhexidine umbilical cord cleansing reduced omphalitis risk compared to dry cord care. For the treatment of PSBIs, purely domiciliary-based antibiotic delivery reduced the risk of all-cause neonatal mortality when compared to the standard hospital referral.

Conclusion: Strategies for preventing HAIs and reducing AMR in healthcare facilities should be multimodal, and strategy selection should consider the feasibility of integration within existing newborn care programs. Probiotics are effective for facility-based use in preterm newborns; however, the establishment of high-quality, cost-effective mass production of standardized formulations is needed. Chlorhexidine cord cleansing is effective in community settings to prevent omphalitis in contexts where unhygienic cord applications are prevalent. Community-based antibiotic delivery of simplified regimens for PSBIs is a safe alternative when hospital-based care in LMICs is not possible or is declined by parents. More randomized trial evidence is needed to establish the effectiveness of CBKs, emollients, synbiotics, and prophylactic systemic antifungals in LMICs.

Introduction: Chimeric antigen receptor T cells (CAR-Ts) targeting CD19 represent a significant advance in treatment for patients with relapsed/refractory B-cell malignancies. Although a significant minority of recipients are women during their reproductive years, there is a paucity of data regarding pregnancy and neonatal outcomes in women previously treated with CAR-T. This is important as maternal T cells are known to cross the placenta and into breastmilk during pregnancy and breastfeeding, respectively.

Case presentation: Here we present two successful pregnancies following CAR-T therapy where both neonates were initially breastfed. These represent the first cases of neonates born following CAR-T therapy comprehensively described in medical literature.

Conclusion: Pregnancy following CAR-T therapy does not appear to be associated with adverse neonatal outcomes. Further work is required to delineate the outcomes in this population.

Introduction: While a patent ductus arteriosus (PDA) helps offload the right ventricle in the acute congenital diaphragmatic hernia (CDH)-associated pulmonary hypertension, its role on long-term outcomes in CDH has not been investigated. Our objective was to examine associations of the PDA with long-term clinical outcomes in CDH.

Methods: A single-center retrospective descriptive study of 122 CDH patients dichotomized by duration with PDA, as ≤14 versus >14 postnatal days (PND) and ≤30 versus >30 PND. Fisher's exact test, Wilcoxon rank-sum test, and multiple linear and logistic regression analyses were used for analyses.

Results: In unadjusted and adjusted for CDH severity comparisons, patients with PDA >14 PND and >30 PND had a higher risk of death, longer length of stay, mechanical ventilation duration, and need for tracheostomy, diuretics, and PH medications at discharge.

Conclusion: A PDA beyond the newborn period is associated with adverse outcomes in infants with CDH.

Introduction: Neonatal sequential organ failure assessment (nSOFA) score predicts mortality in preterm newborns. The aim of the study was to assess whether nSOFA score could predict respiratory outcomes in preterm infants with late-onset sepsis (LOS).

Methods: This retrospective, observational, single-center study enrolled infants with gestational age <32 weeks born between January 2016 and June 2023 who experienced an episode of LOS during NICU stay. The primary outcome was death or bronchopulmonary dysplasia (BPD); secondary outcomes were BPD, death or mechanical ventilation (MV) on day 5 after the onset of LOS, and MV on day 5 after the onset of LOS. The nSOFA score was assessed at the onset of LOS and after 6 ± 1, 12 ± 3, and 24 ± 3 h.

Results: Neonatal SOFA score was significantly higher in patients who developed each outcome versus those who did not at all timings. Maximal nSOFA score during the first 24 h after onset of LOS was an independent predictive factor for death or BPD (p = 0.007), BPD (p = 0.009), and death or MV on day 5 (p = 0.009), areas under the curve (AUC) were 0.740 (95% CI: 0.656-0.828), 0.700 (95% CI: 0.602-0.800), and 0.800 (95% CI: 0.710-0.889), respectively. Maximal nSOFA score also predicted moderate to severe BPD (p = 0.019) and death or moderate to severe BPD (p < 0.001). Maximal nSOFA ≥4 was associated with odds ratio (OR) of 7.37 (95% CI: 2.42-22.44) for death or BPD, 4.86 (95% CI: 1.54-15.28) for BPD, and 7.99 (95% CI: 3.47-18.36) for death or MV on day 5. AUC of the predicting model was 0.895 (95% CI: 0.801-0.928) for BPD, 0.897 (95% CI: 0.830-0.939) for death or BPD, 0.904 (95% CI: 0.851-0.956) for MV on day 5, 0.923 (95% CI: 0.892-0.973) for death or MV on day 5.

Conclusion: Maximal nSOFA score during the first 24 h after the onset of LOS predicts respiratory outcomes and allows identification of patients who may crucially benefit from lung-protective measures.

Introduction: Normative blood pressure (BP) values on preterm infants exist but are based on small cohorts of infants. Utilizing electronic medical records (EMR), we can explore earlier gestational ages (GA) and follow their progression to 40 weeks corrected gestational age (CGA).

Methods: A retrospective cohort study of infants within the SSM Health System from July 1, 2013 through June 30, 2023. Infants born at >22 0/7 weeks but <41 weeks GA were included if any BP measurements existed (n = 29,323 infants, 1.4 million BPs). Data were extracted electronically from EMR using Microsoft SQL. Systolic BP (SBP), mean arterial pressures (MAP), and diastolic BP (DBP) were determined for each week of life from birth and percentile ranges (1st to 99th) for infants alive at CGA, and BP patterns for GA determined.

Results: Percentiles for SBP, DBP, and MAP are provided. There is a rapid increase in BP at all gestations during the first 2 weeks, thus BP values are higher at any CGA in infants born at an earlier GA than infants born at that GA. For MAP values between the 5th and 10th percentile, the GA is appropriate for first week and then use CGA + 5 mm Hg. After the first week, 2.8 X CGA is between 90 and 95 percentile for SBP.

Conclusions: The BP is dependent on the GA at birth and the CGA when it is measured. SBP, MAP, and DBP all increase rapidly in the 2 weeks of life prior to a gradual increase over time.

Introduction: Congenital anomalies are one of the major causes of the global burden of diseases, and low- and middle-income countries (LMICs) are disproportionately affected. This review assesses the prenatal and postnatal screening methods and compares the prevalence of major congenital anomalies in LMICs.

Methodology: We conducted a systematic search in MEDLINE/PubMed, CINAHL, Cochrane databases of systematic reviews, clinical trials.gov for relevant studies using Medical Subject Headings and keywords. We categorized the studies into different systems and screening methods depending on the time the tests were conducted (prenatal or postnatal). The studies were then subjected to detailed descriptive analysis.

Results: A total of 59 studies were selected for analysis; these focused on screening methods for congenital anomalies and compared their prevalence with regards to different systems. The most common screening techniques both prenatal and postnatal included antenatal ultrasound, fetal echocardiography, pulse oximetry, and clinical examination. The most common congenital abnormalities involved the central nervous system (neural tube defects) and musculoskeletal (clubfoot), followed by gastrointestinal (omphalocele and gastroschisis) and cardiovascular (structural heart defect). Overall, different systems had varying prevalences of different birth defects, ranging from 0.28 to 8.5%. In contrast, the prevalence of musculoskeletal system disorders varied from 1.01% to 3.96%, in the cardiovascular system from 0.57% to 10.4%, and in the urogenital group from 0.83% to 5.9%.

Conclusion: The review highlights the lack of screening programs and studies, especially in the primary and secondary care settings in LMICs, and limited studies do indicate a high burden of various congenital anomalies. There is a need for guidelines and programs in global maternal and child health programs to include timely screening and management of common birth defects in LMICs.

Introduction: Hypoxic-ischemic encephalopathy (HIE) affects 1-2 per 1,000 births and is associated with mortality and long-term neurodevelopmental challenges. At present, therapeutic hypothermia (TH) is the only neuroprotective intervention for these infants. This study examines whether HIE severity, clinical management during TH, and post-rewarming outcomes have changed since its introduction 15 years ago.

Methods: Neonatal characteristics, HIE severity, management during TH, and post-rewarming MRI of all infants with HIE undergoing TH between 2008 and 2023 were compared across three five-year epochs. Linear regression was used to estimate annual changes over time.

Results: In total, 252 infants underwent TH. Median gestational age (39.5 weeks), birth weight (3,376 g), and time to start TH (4.25 h) remained stable over time. Apgar score at 5 min (p = 0.031) and lowest pH <1 h postpartum (p = 0.020) increased over time. Thompson score at 1-3 h decreased across epochs (p = 0.046). There was an increase in percentage with normal-mild aEEG background patterns on admission (p = 0.041) and a decrease in aEEG-confirmed seizures (p < 0.001) and antiseizure medication (p < 0.001). Inotropic support decreased (p = 0.007), and use of invasive mechanical ventilation decreased over the last 5 years. Mortality (28.6%) and post-rewarming composite adverse outcome (i.e., neonatal mortality and/or adverse MRI score) (37.9%) remained unchanged. Number of infants seen at 2-year follow-up increased (p < 0.001).

Conclusion: Over the last 15 years, we treated more infants with milder HIE, as indicated by lower Thompson and milder aEEG scores, and the need for invasive cardiorespiratory support declined. However, there were no improvements in composite adverse outcome (mortality and/or adverse MRI score).