Respiratory Care of the Neonate

The respiratory distress is a very common condition both in term and in preterm neonates and the most frequent reason for admission to the neonatal intensive care unit (NICU). The aetiology greatly depends on the maturation of neonate’s organs and perinatal events. The clinical picture is sometimes scarce and very nonspecific for the etiologic determination. Treatment of neonatal RD begins first with the application of a mixture of oxygen and air, then with different modes of non-invasive respiratory support methods. Non-invasive respiratory support can be sustained with nasal continuous positive airway pressure, bi-level positive airway pressure and high-flow nasal cannula ventilation. Non-invasive ventilation with high-frequency oscillations through nasal cannula or masks is also possible with some respiratory devices. Non-invasive ventilation is usually combined with the application of natural surfactant and other therapeutic means, like methylxanthine therapy, prevention and closure of patent ductus arteriosus, and control of infection. In the case of non-invasive ventilation failure, different kinds of invasive ventilation methods are available and being practiced in NICUs. The invasive respiratory support can be maintained by controlled or intermittent mandatory ventilation combined with different supportive synchronous positive inspiratory ventilation, offered by modern respirators

Hemodynamic Monitoring in Neonates

Sick neonates are often hemodynamically unstable, hence their organs are inadequately supplied with oxygen. In order to maintain blood flow to vital organs, a number of compensatory mechanisms divert the blood flow away from the non‐vital organs. If hemodynamic changes are detected early, the cardiovascular compromise can be recognized in compensated phase and thereby the escalation to decompensated phase of low cardiac output syndrome might be prevented. In the treatment of hemodynamically unstable neonate venous filling, contractility of the heart muscle, blood pressure in the aorta, systemic blood flow, and regional distribution of blood flow should be evaluated. There are many evaluation and measurement methods based on different physical basis, each of them having their advantages and disadvantages. For most of them, it has not been demonstrated that they improve outcomes of sick neonates. Using these methods, useful hemodynamic data for the treatment of sick neonates can be obtained. Using new techniques will clarify the pathophysiology of cardiovascular failure in sick neonates, assess the effects of drugs on blood pressure and perfusion of the heart and other organs

Non‐Pulmonary Management of Newborns with Respiratory Distress

Due to the developmental immaturity of the lungs and other organs, the premature newborns are more prone to develop respiratory distress syndrome (RDS) and other problems of prematurity. The prevention of heat and water loses improves survival. Intolerance to excessive fluids and electrolytes in the transitional period may affect urine and sodium excretion together with maladaptation of cardiovascular system, the development of heart failure, and deterioration of RDS due to patent ductus arteriosus (PDA) and further development of bronchopulmonary dysplasia (BPD). Closure of PDA is frequently needed. The “trophic feeding” and intensive nutrition as soon as possible prevent weight loss and further growth restriction. Greater sensitivity to pain, short‐ and long‐term effects of inappropriately treated pain, use of opioids and sedatives are of concern in the short‐ and long‐term outcomes. Cardiovascular stability and adequate perfusion of the brain both affect the neurological outcome. Delayed cord clamping and erythropoietin help maintaining adequate levels of circulating hemoglobin which might affect later cognitive outcomes. In the following sections, detailed descriptions of non‐pulmonary management will be presented. We conducted electronic searches of articles on supportive (non‐pulmonary) management of newborns with RDS. Consensus guidelines on newborns with respiratory distress have been reviewed

Ob 90. letniku izhajanja Zdravniškega vestnika: Zgodovinski pregled od leta 1929 do leta 2021

Zdravniški vestnik je odigral pomembno vlogo v razvoju sodobne slovenske medicine in slovenskega medicinskega jezika, zlasti terminologije. Namen članka je na kratko prikazati razvoj Zdravniškega vestnika od njegove ustanovitve 1929 do danes

A case report of short-chain acyl-CoA dehydrogenase deficiency (SCADD)

Background: Short-chain acyl-CoA dehydrogenase deficiency (SCADD) is a rare inherited mitochondrial fatty acid oxidation disorder associated with variations in the ACADS (Acyl-CoA dehydrogenase, C-2 to C-3 short chain) gene. SCADD has highly variable biochemical, genetic and clinical characteristics. Phenotypes vary from fatal metabolic decompensation to asymptomatic individuals. Subject and methods: A Romani boy presented at 3 days after birth with hypoglycaemia, hypotonia and respiratory pauses with brief generalized seizures. Afterwards the failure to thrive and developmental delay were present. Organic acids analysis with gas chromatography-mass spectrometry (GS/MS) in urine and acylcarnitines analysis with liquid chromatography-tandem mass spectrometry (LC-MS/MS) in dried blood spot were measured. Deoxyribonucleic acid (DNA) was isolated from blood and polymerase chain reactions (PCRs) were performed for all exons. Sequence analysis of all exons and flanking intron sequences of ACADS gene was performed. Results: Organic acids analysis revealed increased concentration of ethylmalonic acid. Acylcarnitines analysis showed increase of butyrylcarnitine, C4-carnitine. C4-carnitine was 3.5 times above the reference range (<0.68 µmol/L). Confirmation analysis for organic acids and acylcarnitine profile was performed on the second independent sample and showed the same pattern of increased metabolites. Sequence analysis revealed 3-bp deletion at position 310-312 in homozygous state (c.310_312delGAG). Mutation was previously described as pathogenic in heterozygous state, while it is in homozygous state in our patient. Conclusions: In our case clinical features of a patient, biochemical parameters and genetic data were consistent and showed definitely SCAD deficiency

Longitudinal strain vs. conventional echocardiographic parameters in the first week of life in healthy term newborns

The first week of life is characterized by substantial alterations in hemodynamic conditions. Changes in myocardial contractility will reflect these changes. We aimed to assess right and left ventricular function on the third and seventh days of life in 50 healthy term newborns. To assess myocardial function, we used speckle tracking echocardiography. Pulsed-wave tissue Doppler imaging, M-mode, Doppler and pulsed-wave Doppler were also used to assess ventricular function. We found a significant increase in both right and left longitudinal strain and an increase in systolic and diastolic tissue Doppler velocities, whereas most other parameters remained unchanged. At both time points, the measured parameters were significantly greater for the right ventricle, but the changes with time were similar for both ventricles. We also found an increase in right ventricular outflow tract acceleration time as an indirect sign of decreasing pulmonary vascular resistance and an increase in systolic blood pressure, pointing to increasing systemic vascular resistance. Together with a decreasing proportion of patients with patent ductus arteriosus, the estimated left ventricular cardiac output decreased and right ventricular cardiac output increased but not to a statistically significant degree. In conclusion, the results of our study show how different echocardiographic techniques capture hemodynamic changes and changes in myocardial contractility and compliance. Both longitudinal strain and tissue Doppler imaging parameters seem to offer greater sensitivity in comparison with conventional echocardiographic parameters

Bilateral adrenal bleeding: the cause of high early jaundice and acute primary adrenal insufficiency in the neonate

Adrenal bleeding in a newborn is rare. The cause of bleeding is unknown, most likely due to several factors. Bleeding may be minimal with no clinical signs or fulminant with acute adrenal insufficiency, which is a life-threatening situation that requires immediate detection and treatment. In this paper we represent a clinical case of a term neonate born to the mother with gestational diabetes, who was hospitalised due to high early hyperbilirubinemia. Significant bleeding in both adrenal glands was identified by ultrasound and primary adrenal insufficiency diagnosed. We discuss possible causes, the diagnostic clues, the treatment of disease and its prognosis

The prevalence and pattern of pharmaceutical and excipient exposure in a neonatal unit in Slovenia

<div><p></p><p><i>Objective</i>: Because of the restraints on conducting studies on pharmaceutical use in sick newborns, many drugs are used off-label in this population. Moreover, industrially manufactured pharmaceuticals may contain different excipients, which may be either untested or not licensed for use in neonates. The aim of our study was to determine the prevalence and pattern of pharmaceutical and excipient exposure in newborns hospitalized at the Department of Neonatology, Ljubljana, Slovenia.</p><p><i>Methods</i>: A longitudinal prospective cross-sectional study was performed during a one-month period and included all hospitalized neonates. Route of administration, site of action, type of manufacture, licensing status, type and concentrations of excipients for all pharmaceuticals given to the neonates were determined.</p><p><i>Results</i>: Twenty seven different pharmaceutical preparations were prescribed to a total of 48 hospitalized newborns. In most cases, newborns were prescribed various pharmaceuticals that were not approved for use in this population. Newborns were exposed to 60 different excipients in industrially manufactured pharmaceutical preparations. More than half of the received pharmaceuticals contained potentially harmful and harmful excipients.</p><p><i>Conclusions</i>: Two-thirds of pharmaceutical preparations for neonates were used off-label. Newborns receive more auxiliary substances, which may be unsuitable for this age group and may even be toxic to them, via industrially manufactured pharmaceuticals.</p></div

Invasive neonatal Streptococcus agalactiae infection in Slovenia, 2003–2013

Background: Streptococcus agalactiae (group B streptococcus, GBS) is the leading cause of invasive neonatal infections in the developed world. We present epidemiological and clinical characteristics of invasive GBS disease among Slovenian neonates between 2003 and 2013. Methods: A retrospective cohort study was performed. Children aged 0–90 days with invasive GBS disease, born in Slovenia and hospitalized in the University Medical Centre Ljubljana were included. Cases were identified concurrently from (i) hospital and (ii) microbiological databases. Medical records from mothers and children were reviewed and relevant data extracted. The incidence rate was calculated based on the national vital statistics data and expressed per 1000 live births. Results: Altogether, 144 children were included in the analysis, 72.9 % (n = 105) based on hospital database and 27.1 % (n = 39) based on microbiological database. Among them, 47.9 % (n = 69) were girls and 52.1 % (n = 75) boys. Among the cases with available data, 54.5 % (n = 73) were born at term and 45.5 % (n = 61) were preterm. Early-onset disease (0–6 days) was present in 74.3 % (n = 107) of patients; 95.3 % (n = 102) of them became ill during the first 3 days of life. Late-onset disease (7–90 days) was present in 25.7 % (n = 37) of patients. Outcome data was available for 134 children. Neonatal mortality rate was 4.5 % (n = 6). Periventricular leukomalacia (PVL) or intraventricular haemorrhages Grade III/IV (IVH 3/4) were detected in 17.9 % (n = 24). Severe outcomes (death or PVL or IVH 3/4) were detected in 22.4 % (n = 30) children. Cumulative incidence rate was 0.72/1000 live births; 0.53/1000 for early-onset and 0.18/1000 for late-onset disease. Risk factors for early-onset disease were present in 47.9 % (n = 68) mothers in labour. Intrapartum antibiotic prophylaxis was delivered to 16.9 % (n = 24) of mothers. Conclusions: High incidence of invasive neonatal GBS disease was detected in Slovenia. Although low mortality was observed, brain pathology concordant with long-term adverse outcome was confirmed in a high proportion of patients. The application of intrapartum antibiotic prophylaxis in cases of known risk factors was suboptimal, especially among preterm deliveries. Approximately half of the patients were born to mothers without any risk factors. A comprehensive national strategy for the prevention of invasive GBS disease is warranted in Slovenia