Handan Bezirganoglu

Objective: There is an ongoing debate about the best and comfortable way to administer surfactant. We hypothesized that uninterrupted respiratory support and continuous PEEP implementation while instilling surfactant via endotracheal tube (ETT) with side port will result in higher regional cerebral tissue oxygenation (rcSO2) and the alterations in cerebral hemodynamics will be minimal. Methods: Preterm infants who required intubation in the delivery room and/or in the first 24 hours of life with gestational age <32 were enrolled. Patients were intubated either via conventional ETT or ETT with side port (Vygon®) with appropriate sizes. Following NICU admission a NIRS probe placed on the forehead and each infant were monitored with NIRS.In conventional ETT group, patients separated from the ventilator while surfactant was instilled. In ETT with side port group respiratory support was not interrupted during instillation. Heart rate, oxygen saturations, rcSO2, cerebral fractional tissue oxygen extraction (cFTOE) and blood pressures were recorded. Results: A total of 46 infants analyzed. Surfactant was instilled with conventional ETT in 23 and ETT with side port in 23 infants. Birthweights (1037±238 vs 1152±277g) and gestational ages (28±2.3 vs 29±1.6weeks) did not differ between groups. During instillation of surfactant, rcSO2 levels [61.5 (49-90) vs 70 (48-85)] and cFTOE levels 0.28 (0.10-0.44) vs 0.23 (0.03-0.44)] were similar (p=0.58 and 0.82 respectively). Conclusion: Interruption of respiratory support during surfactant instillation did not significantly alter the cerebral tissue oxygenation. These results did not support our hypothesis possibly due to small sample size and should be confirmed with further studies.

BACKGROUND: The role of platelet function in the development of intraventricular hemorrhage is still a subject of debate. In this study, we aimed to determine whether there is an association between platelet indices in the first week of life and severity of intraventricular hemorrhage in very preterm infants. MATERIALS AND METHODS: Preterm infants born < 30 weeks of gestation in our hospital were retrospectively evaluated. Platelet parameters, including platelet counts, mean platelet volume, platelet distribution width, and platelet mass were retrieved at two different time points: the initial value on the first day of life and the value closest to the end of the first week of life. The infants were categorized according to the findings of cranial ultrasonography as; no intraventricular hemorrhage, mild or severe intraventricular hemorrhage. RESULTS: Totally, 1051 infants were evaluated. The mean gestational age and birth weight for the entire cohort were 27.9±1.6 weeks and 1058±247 g, respectively. Infants in the severe intraventricular hemorrhage group had significantly lower gestational age ( p < 0.001) and birthweight ( p < 0.001) compared to other two groups. Furthermore, there were significant differences in platelet count and platelet mass between the groups at two time intervals. However, logistic regression analysis revealed that only platelet count of < 100×10⁹/L on the first postnatal day was independently associated with the severity of intraventricular hemorrhage. CONCLUSION: There is an association between platelet count of < 100×10⁹/L on the first postnatal day and severe intraventricular hemorrhage in very preterm infants.

Glycogen storage disease type IV (GSD IV) (OMIM #232500) is an autosomal recessive disorder caused by deficiency of the glycogen-branching enzyme. Here, we report a patient presenting with prematurity and severe hypotonia resulting from a complicated pregnancy with polyhydramnios. During her stay in the neonatal unit, the infant remained dependent on a ventilator, and her movements were mostly absent, except for occasional small movements of her fingers. A spontaneous fracture of femur shaft occurred in the postnatal fourth week. Whole-exome sequencing of DNA from the patient revealed a homozygous missense variant in the GBE1 gene (c.1693C>T, p.Arg565Trp). The variation detected in the index case was also confirmed by Sanger sequencing in the patient and respective parents. This study showed that the neuromuscular subtypes of GSD-IV should be considered as a possible differential diagnosis in severe neonatal hypotonia cases.

Infants who undergo cardiac surgery frequently have complications that may advance to multiple organ failure and result in mortality. This study aims to compare three different multiple organ dysfunction scoring systems: the Neonatal Multiple Organ Dysfunction (NEOMOD) score, the modified NEOMOD score, and the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score in predicting postoperative 30-day mortality in neonates undergoing cardiac surgery. This retrospective cohort study was conducted between January 2019 and February 2021 in a single unit on neonates operated on due to congenital heart disease in the first 28 days of life. Patients who underwent off-pump surgeries were excluded from the study. The NEOMOD, modified NEOMOD, and PELOD-2 scores were calculated for each of the first 3 days following surgery. A total of 138 patients were included. All scores had satisfactory goodness-of-fit and at least good discriminative ability on each day. The modified NEOMOD score consistently demonstrated the best prediction among these three scores after the first day, reaching its peak performance on day 2 (area under curve: 0.824, CI: 0.75–0.89). Our findings suggest that NEOMOD and modified NEOMOD scores in the first 72 h could potentially serve as a predictor of mortality in this population.

Amaç: Antenatal magnezyum sülfat uygulamasının uzun dönemde nöroprotektif etkisi kanıtlansa da pretermlerde doğum sonrası erken dönem yan etkilerine dair yapılan çalışma sonuçları çelişkilidir. Bu çalışmada nöroprotektif amaçlı antenatal magnezyum sülfat tedavisinin prematüre bebeklerde erken dönemde kardiyopulmoner fonksiyonlar ve serum elektrolitleri üzerine etkisi araştırılmıştır. Gereçler ve Yöntem: Ocak 2015- Aralık 2018 yılları arasında ≤ 32 gestasyon haftası doğan, ünitemizde takip edilen ve postnatal ilk 48 saati içinde serum magnezyum düzeyi alınan yenidoğanlar dahil edildi. Major konjenital malformasyonu, kromozom anomalisi olanlar, dosya bilgileri eksik olanlar dışlandı. Preeklampsi ve eklampsi için magnezyum sülfat anne bebekleri çalışmaya dahil edilmedi. Erken doğum riski nedeniyle antenatal dönemde nöroprotektif amaçla magnezyum sülfat tedavisi uygulanan anne bebekleri vaka grubunu oluşturdu. Gestasyon haftasına göre bire bir eşleştirme yapılarak kontrol grubu belirlendi. Hasta dosyalarından demografik veriler, doğum salonunda resüsitasyon ihtiyacı, sürfaktan ihtiyacı, ilk gün solunum desteği, kalp tepe atımı (KTA), kan basıncı ,ilk 48 saatte elektrolit değerleri, tam enteral beslenme süresi, eşlik eden major morbiditeler ve erken dönem mortalite kayıt edildi. Bulgular: Toplamda 156 hasta çalışmaya dahil edildi. Nöroprotektif amaçlı antenatal magnezyum alan 78 prematüre, antenatal magnezyum almayan 78 kontrol ile karşılaştırıldı. Gestasyon yaşları ve doğum ağırlıkları (sırasıyla 28.3(±1.8) hafta ve 28.4 (±2.4) hafta; 1113 (±301) gr ve 1160 (±329) gr benzerdi (p=0,41, p=0,54)). Anne magnezyum düzeyi ve bebek ilk magnezyum düzeyi , antenatal magnezyum alan grupta daha yüksekti. Doğumda entübasyon ihtiyacı, hipotansiyon varlığı, ilk 24 saat mekanik ventilasyon desteği, ilk 24 saat oksijen ihtiyacı ve mortalite oranı arasında iki grup arasında anlamlı fark yoktu. Antenatal magnezyum alan grupta ilk 24 saat ortalama KTA daha düşüktü ancak ortalama >120/dk idi. Sonuç: Nöroprotektif amaçlı antenatal magnezyum sülfat kullanımı prematüre bebekte postnatal erken dönemde güvenilirdir

Hypoxic ischemic encephalopathy (HIE) is an important cause of mortality and morbidity in newborns. Our study aimed to determine the neurodevelopmental outcomes, risk factors, and the relationship between risk factors and prognosis of cases followed up with HIE diagnosis and who were treated with hypothermia treatment. Medical records of 23 patients who were followed up with HIE diagnosis in the pediatric neurology outpatient clinic between January 1, 2018, and December 31, 2021, and treated with therapeutic hypothermia in the newborn period were retrospectively reviewed. Denver Developmental Screening Test II was used in the developmental evaluation. Neurodevelopment was normal in 12 (52.2%) of 23 cases and retarded for age in 11 (47.8%) cases. Variables such as Sarnat encephalopathy score in the neonatal period, need for prolonged ventilation, presence of severe acidosis at birth, Apgar scores at the 1st and 5th minutes, and abnormal cranial magnetic resonance (Mrg) findings were determined to be major factors in determining neurodevelopmental prognosis in asphyxic cases. The male gender was found to be riskier in terms of prognosis. Of the patients with HIE, retardation was determined for fine motor skills in 52.2%, speaking in 39.1%, gross motor skills in 26.1%, and personal development in 21.7%. Epilepsy, cerebral palsy, and speech disorders were the most common chronic period problems in patients with HIE. Despite therapeutic hypothermia treatment, neurodevelopmental problems are still observed in newborns with HIE. We found that male gender, low Apgar score, severe acidosis, and abnormal cranial Mrg findings in the neonatal period are risk factors in determining the neurodevelopmental prognosis of newborns with HIE. Monitoring and supporting the development of HIE cases with risk factors from the first months of life and intervening in developmental problems promptly are crucial in order to improve long-term outcomes.

Objectives This study aimed to compare the effects of volume guarantee (VG) combined with assist/control (AC) ventilation to AC alone on hypocarbia episodes and extubation success in infants born at or near term. Methods In this prospective cohort study, infants >34 weeks of gestation at birth, who were born in our hospital supported by synchronized, time-cycled, pressure limited, assist/control ventilation (AC) or assist-controlled VG mechanical ventilation (AC + VG) were included. After admission, infants received either AC or VG + AC using by Leoni Plus ventilator. The ventilation mode was left to the clinician. In the AC group, peak airway pressure was set clinically. In the VG + AC group, desired tidal volume was set at 5 mL/kg, with the ventilator adjusting peak inspiratory pressure to deliver this volume. The study was completed once the patient extubated. Results There were 35 patients in each group. Incidence of hypocarbia was lower in the VG + AC compared with AC (%17.1 and 22.8%, respectively) but statistically not significant. Out-of-range partial pressure of carbon dioxide (PCO2) levels were lower in the VG + AC group and it reached borderline statistical significance (p = 0.06). The median extubation time was 70 (42–110) hours in the VG + AC group, 89.5 (48.5–115.5) hours in the AC group, and it did not differ between groups (p = 0.47). Conclusion We found combining AC and VG ventilation compared with AC ventilation alone yielded similar hypocarbia episodes and extubation time for infants of >34 gestational weeks with borderline significance lower out-of-range PCO2 incidence. Key Points

Background: Urticaria frequently causes pediatric emergency department (PED) admissions. Children with urticaria may unnecessarily avoid suspected allergens. We aimed to investigate the possible and exact triggers of urticaria in children admitted to the PED.Methods: Medical records of children admitted to the PED within a 1‐year period were evaluated for the International Classification of Diseases 10 (ICD‐10) L50 urticaria code, noting symptoms, and possible triggers of urticaria. We performed telephone interviews to complete the missing data and further diagnostic tests for IgE‐mediated allergies to identify the exact triggers of urticaria.Results: Among 60,142 children, 462 (0.8%) with the L50 code were evaluated. Possible triggers based on the history and physical examination could be identified in 46%: infections (18%), drugs (11%), foods (8%), infections and drugs (3%), insects (3%), pollen (1%), blood products (0.4%), and vaccines (0.4%). The most frequent infections related to urticaria were upper respiratory tract infections (74.5%), urinary tract infections (13.2%), gastroenteritis (8.2%), and otitis media (4.1%). After a diagnostic workup, IgE‐mediated allergic diseases were diagnosed in 6% of patients. Twenty‐two percent of the patients had multiple PED admission for the same urticaria flare. Urticaria severity was found to be the most important risk factor for readmissions to the PED (odds ratio: 3.86; 95% confidence interval: 2.39–6.23; p < .001). No relationship between urticaria severity, duration, and the triggers was present.Conclusions: Despite detailed diagnostic tests, IgE‐mediated allergic triggers were rarely the cause of urticaria in children admitted to the PED. Infections are the most frequent trigger. Severe urticaria causes more frequent readmissions to the PED.

Objective There is an ongoing debate about the best and comfortable way to administer surfactant. We hypothesized that uninterrupted respiratory support and continuous PEEP implementation while instilling surfactant via endotracheal tube (ETT) with side port will result in higher regional cerebral tissue oxygenation (rcSO2) and the alterations in cerebral hemodynamics will be minimal. Study Design Preterm infants who required intubation in the delivery room and/or in the first 24 hours of life with gestational age <32 were enrolled. Patients were intubated either via conventional ETT or ETT with side port (Vygon) with appropriate sizes. Following neonatal intensive care unit admission a near-infrared spectroscopy (NIRS) probe was placed on the forehead and each infant was started to be monitored with NIRS. In conventional ETT group, patients separated from the ventilator while surfactant was instilled. In ETT with side port group, respiratory support was not interrupted during instillation. Heart rate, oxygen saturation, rcSO2, cerebral fractional tissue oxygen extraction (cFTOE), and blood pressures were recorded. Results A total of 46 infants were analyzed. Surfactant was instilled with conventional ETT in 23 and ETT with side port in 23 infants. Birth weights (1,037 ± 238 vs. 1,152 ± 277 g) and gestational ages (28 ± 2.3 vs. 29 ± 1.6 weeks) did not differ between groups. During instillation of surfactant, rcSO2 levels [61.5 (49–90) vs. 70 (48–85)] and cFTOE levels 0.28 (0.10–0.44) vs. 0.23 (0.03–0.44)] were similar (p = 0.58 and 0.82, respectively). Conclusion Interruption of respiratory support during surfactant instillation did not significantly alter the cerebral tissue oxygenation. These results did not support our hypothesis and should be confirmed with further studies. Key Points