Hyperammonemia and perinatal asphyxia association in newborns
Neonatal hyperammonemia is a life-threatening condition, caused by inherited metabolic disorders or perinatal complications. Neonatal asphyxia is one of the factors leading to transient hyperammonemia in newborns that can cause the hypoxic or toxic-metabolic central nervous system damage.
Objective. To determine the hyperammonemia in newborns with birth asphyxia frequency and to identify the clinically significant outcomes of this condition.
Material and methods. The study included 78 children with moderate or severe birth asphyxia. Newborns were divided into groups depending on the hypoxic-ischemic encephalopathy severity and the hyperammonemia presence. Children had complex clinical, laboratory and instrumental examinations, and had neurological follow-up after discharge.
Results. Hyperammonemia was detected in 28 (35.8%) patients. The frequency was comparable in children with various hypoxic-ischemic encephalopathy degrees (p>0.05), however no correlation between the level of ammonia, gender, gestational age, birth weight and Apgar score was observed (p>0.05). In the first three days of life, patients with hyperammonemia did not show specific changes in the neurological status (p>0.05). With a later manifestation, hyperammonemia led to a deterioration in the child’s condition as neurological symptoms. In the long-term period, the presence of hyperammonemia did not affect the cerebral palsy, epilepsy, and psychomotor retardation incidence. However, a significantly higher incidence of neurological disorders, such as dyspraxia and delayed expressive speech development of varying severity signs, was revealed (p<0.05).
Conclusion. Ammonia blood test in newborns with birth asphyxia can determine the neurological prognosis of such children and thus, it is of great clinical importance.
Clinical experience of peritoneal dialysis in newborns and infants in maternity clinics and hospitals without special renal replacement therapy units
Critically ill newborns are at high risk of developing acute kidney injury (AKI), which greatly increases the number of adverse outcomes. In patients with AKI, peritoneal dialysis (PD) could be a life-saving therapy. The article analyzes the experience of PD, performed by the specialists of the Center for Neonatal Nephrology and Dialysis of the Children’s City Clinical Hospital No. 9 named after G.N. Speransky (Moscow) in 100 newborn patients, born in clinics without special dialysis departments.
The aim of the study was to generalize and analyze the experience of peritoneal dialysis in children, born full-term and premature, with acute kidney injury and congenital renal failure in maternity hospitals and pediatric clinics without dialysis departments.
Material and methods. A retrospective analysis of 100 clinical cases of patients, treated with renal replacement therapy (RRT) – PD was carried out. Clinical characteristics included: medical institution, age, sex, birth weight, weight gain, creatinine level, indications for the dialysis, type, duration, and complications of RRT, main diagnosis, and outcome. The gestational age ranged from 23 weeks + 2 days to 41 weeks + 2 days (mean 33.2±6.1 weeks). 44% of children (n=44) were full-term newborns. 45 infants (45.0%) were girls and 55 (55.0%) – were boys. Birth weight ranged from 470 to 5550 g (average 2290±1153 g).
The main diagnosis for 50 patients was neonatal sepsis, 15 had severe asphyxia at birth, 8 had a combination of sepsis and asphyxia, 8 – fetal hydrops, 5 – congenital renal failure, 4 – orphan diseases (citrullinemia, galactosemia, 2 cases were unspecified), 4 – AKI, assosiated with neonatal shock (of various origin), 3 – AKI due to hypernatraemic dehydration, 1 – severe birth asphyxia, associated with placental abruption, 2 – Edwards syndrome. The majority of patients at the start of dialysis were in serious or extremely serious condition. 91% (n=91) received cardiotonic and vasopressor support, and 46% (n=46) required vasoactive therapy (adrenaline, norepinephrine, dobutamine/dopamine).
Results and discussion. Depending on the birth weight and gestation, various methods of PD were used: classical modification or flow peritoneal dialysis. The duration of RRT ranged from 1 to 60 days (7±6.9 days). The incidence of complications was 35%: catheter block in 12 (12%), local hemorrhage – 10 (10%), dialysate leakage around the catheter – 9 (9%), dialysis peritonitis – 5 (5%), intestinal perforation – 3 (3%). In 1 (1%) case, catheter loss was noted when using Blake drainage, in 1 (1%) case ultrafiltration was insufficient.
Conclusion. Dialysis technologies are increasingly being used in neonatal practice, although so far most publications contain a small number of cases. The accumulation of clinical experience contributes to the early and timely start of RRT in critically ill neonates, which can significantly reduce mortality and improve outcomes in patients with AKI.
Necrotizing enterocolitis in extremely low birth weight infants and associated risk factors: a retrospective analysis
Necrotizing enterocolitis (NEC) is the leading cause of morbidity and mortality in infants with extremely low birth weight (ELBW).
Objective: to determine the risk factors of NEC in ELBW infants.
Material and methods. A retrospective case-control study conducted at the neonatal intensive care unit of the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation in the period from 2017 to 2019. 71 preterm infants were enrolled. The newborns were divided into 2 groups: group 1 (infants with NEC) – NEC group (n=26), and group 2 (infants without NEC) – no-NEC group (n=45). The clinical characteristics of both groups were evaluated. Logistic regression analyses were conducted to assess the risk factors of NEC in ELBW infants.
Results. There were statistically significant differences in abnormal antenatal umbilical artery flow (AAUF) frequency. It was defined as the absence or reversed end of the diastolic velocity obtained from the umbilical artery. In the 1st group – 6 (23.1%) cases, and in the 2nd group – 4 (8.9) (p=0.039). The frequency of birth of infants small for gestational age (OR 1.1, 95% CI 0.84–75.93) and patent ductus arteriosus (OR 3.3, 95% CI 0.73–15.31) did not differ significantly between NEC and no-NEC groups. The mortality (OR 23.3, 95% CI 2.74–198.08) and acute renal injury (AKI) (OR 9.5, 95% CI 1.85–49.47) were higher in the NEC group compared to the no-NEC group. There were statistically significant differences in the frequency of anemia and multiple red blood cells (RBC) transfusions between the 1st group and the 2nd group (p<0.05). Multiple RBC transfusions were more common in the NEC group. Colonization of the gut by the association of Malassezia furfur and Gram-negative bacteria was more common in the NEC group (OR 6.5, 95% CI 1.20–34.82). Meanwhile, breastfeeding was the protective factor for NEC in ELBW infants (OR 0.322, 95% CI 0.113–0.917).
Conclusion. The incidence of NEC in ELBW is high. It is affected by many antenatal and postnatal factors (AAUF, severe anemia, gut colonization with M. furfur, and Gram-negative bacteria). Breastfeeding significantly reduces the risk of NEC in ELBW infants.
Development of the gut microbiota of term and late preterm newborn infants
The gut microbiota affects the physiological processes and the maintenance of homeostasis of the human body. Violation of the composition of the microbiota, including at an early age, can lead to various diseases. The formation of the microbiota of newborns, especially preterm infants, depends on numerous factors and it is not well studied.
Aim. To assess the dynamics of the gut microbiota composition during the first month of life in full-term and late preterm newborns born spontaneously and by caesarean section.
Material and methods. 100 full-term newborns (49 children were born spontaneously, 51 – by caesarean section) and 51 late preterm newborns (25 children were born spontaneously, 26 – by caesarean section) were examined. Fecal samples of children obtained on the 1st, 7th and 30th days of life were studied by culture methods with the identification of microorganisms by the MALDI-TOF mass spectrometry and 16S rRNA gene sequencing. The Mann-Whitney test, median and interquartile distance were used for statistical analysis.
Results. During the 1st month of life in newborns of the compared groups, a significant difference in the indicators of the qualitative and quantitative composition of the gut microbiota was found. Newborns born spontaneously, already on the 1st day of life, had an advantage: microorganisms from the commensal group (lactobacilli, bifidobacteria and bacteroids) were isolated in the microbiota, unlike newborns born by caesarean section. On the 7th day of life in children of all groups, strict anaerobes prevailed over facultative anaerobes in the composition of the gut microbiota, but this process was slower in preterm newborns and full-term infants born by caesarean section. By the end of the 1st month of life, newborns born by caesarean section, lagged more than 5 times behind newborns born spontaneously, in terms of the level of colonization with bacteroids. Preterm newborns born spontaneously approached full-term newborns born spontaneously, in terms of the level of colonization with bifidobacteria and bacteroids. In groups of preterm newborns, the titer of lactobacilli remained consistently high, mainly due to probiotic species (Lactobacillus fermentum and Lactobacillus plantarum).
Conclusion. Gestational age is the most significant factor in the formation of the gut microbiota of newborns. However, caesarean section hinders the normal development of the gut microbiota. The use of probiotics for the treatment of preterm newborns helps to speed up the process of microbiota formation.
Medical care for newborns with epidermolysis bullosa
The article presents the experience of organizing medical care for newborns with the congenital epidermolysis bullosa at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov, Ministry of Health of the Russian Federation, in cooperation with the Charitable Foundation “BELA. Butterfly children”. As part of a joint project, a system of staged care for newborns with epidermolysis bullosa has been developed and implemented in all regions of the Russian Federation. The capabilities of the National Center make it possible to combine high-quality medical care for patients with epidermolysis bullosa with scientific research.
During the period of the newborn’s stay in the hospital, an individual treatment plan is developed. Comprehensive examination, molecular genetic diagnosis, symptomatic treatment of epidermolysis bullosa, and treatment of concomitant diseases are carried out.
Teaching the mothers basic care, accompanying the patient by a doctor-expert of the Butterfly Children Charitable Foundation, to providing versatile charitable assistance, and informational support will be an additional positive psychological factor for the family. Early onset of proper care and treatment improves skin condition, reduces the risk of complications, and improves quality of life.
Late prematurity in the zone of the increased attention. Literature review. Part 2. Features of the morbidity of late premature newborns
Late premature newborns are a group of special attention from neonatologists and pediatricians over the world. Observation of the group of children with a gestational age of 340–366 weeks is often associated with an underestimation of the clinical condition of infants that have clinical and anthropometric data comparable to full-term newborns.
Recent studies revealed the understanding of the problem of infants born on the “verge of full term”. This group of newborns has higher morbidity rates than those born at term, both in the early neonatal period and the long-term outcome.
Data on the frequency and severity of morbidity of late premature infants in various conditions preceding the onset of pregnancy, and complications of pregnancy, with various methods of delivery, are contradictory and have a large variability.
The review highlights the etiological factors of premature delivery, problems that arise during the early neonatal period, and long-term complications of newborns of late premature gestational age in the focus of attention of neonatologists and pediatricians and the ways to prevent and reduce adverse outcomes.
Caffeine citrate in neonatology: history, pharmacodynamics and pharmacokinetics, clinical effects, dosage regimens: a review
Caffeine citrate is the most common prescribed drug for apnea of prematurity. This review briefly highlights the issues of the history of the use of caffeine citrate, provides up-to-date information on the short-term and long-term effects of caffeine citrate, its effectiveness, safety and dosage regimens in premature infants. We analyzed relevant studies published over the last 50 years. Literature searches were conducted using PubMed, Cochrane Library, EMBASE, Web of Science, Chinese Biomedical Literature databases. This review makes it possible to highlight the perspective of further studies.
Clinical guidelines and real clinical practice in diagnosis and treatment of cytomegalovirus infection in pregnant patients and newborns
Cytomegalovirus infection (CMVI) is the leading causes of intrauterine disease and can lead to severe problems in physical, psychoneurological and intellectual development in newborns and infants. The following article discusses the diagnostic and treatment approach to acute and secondary CMVI in pregnant women, newborns and infants using the real-life clinical examples. An analysis of approaches to solving these issues was presented in a number of Russian Clinical Recommendations. Indications for prescribing anti-cytomegalovirus immunoglobulin, high-dose valacyclovir, ganciclovir, valganciclovir in pregnant, new-born and young children are discussed.
Interaction of medical personnel with legal representatives of patients: complexities of legal relations. Part 1
The article is devoted to the difficulties of establishing contact with the legal representatives of minor patients, determining the legality of the several demands made by legal representatives.
The palliative status of the children and the communication with parents in the aggressive stage
The article is devoted to the peculiarities of the communication with the parents of palliative children, which is in the aggressive stage. Special attention is focused on the characteristic angry manifestations, depending on the type of parent personality.
Guidelines for the skin care of premature infants (project)
The article presents a draft of guidelines for the care of the skin of premature newborns. This topic is a difficult task, since the barrier function of the skin in preterm infants, due to immaturity and severe diseases, is significantly impaired. The skin functions as the first barrier of defense against pathogens, preventing fluid loss and maintaining electrolyte balance. The consistency of the barrier and other functions of the skin depends on the maturity of the newborn. Therefore, recommendations for the care of the skin of a full-term baby may not be sufficient for a very preterm newborn.
Immunization of preterm infants: current evidence and future strategies to individualized approaches
Preterm infants are at particularly high risk for infectious diseases. As this vulnerability extends beyond the neonatal period into childhood and adolescence, preterm infants benefit greatly from infection-preventive measures such as immunizations. However, there is an ongoing discussion about vaccine safety and efficacy due to preterm infants’ distinct immunological features. A significant proportion of infants remains un- or under-immunized when discharged from primary hospital stay. Educating health care professionals and parents, promoting maternal immunization and evaluating the potential of new vaccination tools are important means to reduce the overall burden from infectious diseases in preterm infants. In this narrative review, we summarize the current knowledge about vaccinations in premature infants. We discuss the specificities of early life immunity and memory function, including the role of polyreactive B cells, restricted B cell receptor diversity and heterologous immunity mediated by a cross-reactive T cell repertoire. Recently, mechanistic studies indicated that tissue-resident memory (Trm) cell populations including T cells, B cells and macrophages are already established in the fetus. Their role in human early life immunity, however, is not yet understood. Tissue-resident memory T cells, for example, are diminished in airway tissues in neonates as compared to older children or adults. Hence, the ability to make specific recall responses after secondary infectious stimulus is hampered, a phenomenon that is transcriptionally regulated by enhanced expression of T-bet. Furthermore, the microbiome establishment is a dominant factor to shape resident immunity at mucosal surfaces, but it is often disturbed in the context of preterm birth. The proposed function of Trm T cells to remember benign interactions with the microbiome might therefore be reduced which would contribute to an increased risk for sustained inflammation. An improved understanding of Trm interactions may determine novel targets of vaccination, e.g., modulation of T-bet responses and facilitate more individualized approaches to protect preterm babies in the future.