Coşkun Armağan

Objectives: Very low birth weight (VLBW) infants are at disproportionately high risk for neonatal seizures, yet optimal first-line antiseizure medication (ASM) strategies in this vulnerable population remain a matter of debate. Over the past decade, levetiracetam (LEV) has emerged as a promising alternative to phenobarbital (PB), driven by growing concerns over PB’s limited efficacy and potential neurotoxic effects. Methods: This retrospective cohort study analyzed medical records of VLBW infants treated for seizures at our Neonatal Intensive Care Unit from 2013 to 2023. We compared the efficacy and safety of LEV and PB as initial antiepileptic treatments. Data on gestational age, birth weight, type of seizures, electroencephalogram findings, and treatment outcomes were meticulously collected and analyzed. Results: The study included 103 VLBW infants (mean gestational age 26.17±2.31 weeks); 27 received LEV and 76 received PB. Baseline demographic and clinical characteristics were comparable between the two groups. Although the LEV group had a higher proportion of infants with severe intraventricular hemorrhage and necrotizing enterocolitis indicating a potentially more critical baseline, these differences were not statistically significant. The primary outcome revealed that significantly fewer infants in the LEV group were unresponsive to initial treatment compared to the PB group (14.8 vs. 56.6 %; p<0.001). Furthermore, lower gestational age was identified as a significant risk factor for PB unresponsiveness. Conclusions: This study supports that LEV is more successful in clinical seizure control compared to PB as the first choice in ASM selection in VLBW. If our study results are supported by randomized controlled prospective studies, LEV, with its potentially fewer side effects, could be included in clinical algorithms as the first-choice ASM especially for VLBW.

Introduction: Autophagy is a crucial cellular degradation pathway that maintains homeostasis during stress. Preterm infants are exposed to significant oxidative and metabolic stress during the perinatal transition. This study aimed to evaluate the levels of autophagy markers (Beclin-1, LC3B-I and LC3B-II) in the umbilical cord blood of preterm infants and investigate their association with neonatal morbidities and mortality. Material and methods: This prospective multicentre cohort study included 60 preterm infants. Umbilical cord blood samples were analysed for Beclin-1, LC3B-I and LC3B-II levels using Western blot. The LC3B-I/LC3B-II ratio was calculated as an indicator of autophagic flux. The relationship between these markers and major neonatal outcomes (respiratory distress syndrome (RDS), intraventricular haemorrhage (IVH), haemodynamically significant patent ductus arteriosus (hsPDA), early neonatal sepsis (ENS) and mortality) was evaluated using Mann-Whitney U tests and multivariable logistic regression adjusted for gestational age. Results: A significant positive correlation was observed between gestational age and Beclin-1 levels (r=0.406, p=0.005). In subgroup analyses, non-survivors exhibited significantly lower median Beclin-1 levels (0.45 vs 0.92, p=0.047) and a depressed LC3B-I/LC3B-II ratio (0.48 vs 1.90, p=0.018) compared with survivors. Similarly, infants with IVH had significantly lower LC3B-I levels (0.07 vs 0.65, p=0.011). However, in multivariable logistic regression analyses adjusted for gestational age, the independent statistical significance of these markers was attenuated, suggesting that the observed autophagic impairment is closely linked to gestational immaturity. No significant associations were found for RDS, hsPDA or ENS. Discussion: This study identifies lower cord blood Beclin-1 levels and an altered LC3B ratio as potential markers of vulnerability in preterm infants, particularly for mortality and IVH. The findings suggest that autophagic capacity at birth is developmentally regulated, with more immature infants displaying compromised autophagy initiation.

The study aimed to compare the effects of individualized nasal continuous positive airway pressure (nCPAP) therapy using different positive end-expiratory pressure (PEEP) levels on heart rate, SpO₂, and surfactant requirement in very preterm infants at birth. This multicenter, randomized controlled trial is designed in the settings of delivery room and level 3–4 neonatal intensive care units of two hospitals. Infants < 31 weeks of gestation were randomized to receive initial nCPAP pressures of 6 cmH₂O for the standard and 8 cmH₂O for the open CPAP groups. Unless the target heart rate and SpO₂ were met, the pressures were increased to 8 for the standard group and 10 for the open CPAP group. FiO₂ was titrated if the targets were not achieved. NIPPV and surfactant therapy indicated if FiO₂ > 40%. The primary outcomes were SpO₂/FiO₂ ratio and Oxygen Saturation Index (OSI) at 5 and 10 min, as well as the need for surfactant within 72 h. A total of 145 infants were enrolled (standard CPAP, n = 76; open CPAP, n = 69). The need for PEEP adjustment to the upper limit was higher in the standard CPAP group. Although there was no difference in the S/F ratio after 5 or 10 min, the OSI was higher in the open CPAP group due to the higher pressure. There was no difference between the groups in terms of the other primary outcomes. Conclusion: This randomized clinical trial evaluated the effects of different PEEP levels in the delivery room management of very preterm infants. Initiating CPAP support at 6 cmH₂O, as commonly practiced, required escalation to higher pressures in nearly half of very preterm infants to achieve target oxygen saturation levels. These findings suggest that an individualized approach using higher initial pressures may facilitate more effective lung recruitment and warrant further investigation in the delivery room setting. Trial registration: Open lung strategy during non-invasive respiratory support of very preterm infants in the delivery room (OpenCPAP-DR), NCT05031650, 26 August 2021 https://clinicaltrials.gov/study/NCT05031650?term=Nuray%20duman&rank=1, deidentified individual participant data will not be made available. What is Known: • There is no specific evidence-based pressure level for early nCPAP recommended in the delivery room for very preterm infants. What is New: • When stabilizing very preterm infants in the delivery room, it has been found prudent to increase pressure rather than increase oxygen first when using nCPAP if the target oxygen saturation is not reached.

Objective: This study aims to evaluate the long-term neurological outcomes of neonates diagnosed with mild hypoxic-ischemic encephalopathy (HIE) and compare them with moderate/ severe cases, hypothesizing that a significant proportion of mild HIE cases may experience adverse neurodevelopmental sequelae. Materials and Methods: This was a cross-sectional observational study evaluating the neurodevelopmental outcomes of neonates with mild versus moderate/severe HIE. Maternal, perinatal, and neonatal characteristics along with treatments were documented. Neurological outcomes were assessed via brain MRI, the Ankara Developmental Screening Inventory (ADSI), and developmental milestones. Results: The study included 42 infants, 20 (47.6%) were classified as having mild HIE and 22 (52.4%) as moderate/severe HIE. Baseline characteristics were similar except that moderate/ severe cases had lower 1-minute Apgar scores (median 4 vs. 6; P = .02) and more frequent need for advanced resuscitation (68% vs. 25%; P = .006). All moderate/severe infants received TH vs. none in the mild group. Invasive mechanical ventilation and adjuvant neuroprotective agents were also more frequently used in the moderate/severe group. Magnetic resonance imaging abnormalities consistent with HIE were present in 2/12 mild cases (16.7%) vs. 8/19 (42.1) in moderate/severe cases. There were no significant differences in HIE injury pattern between the 2 groups (P = .197). On ADSI screening, 8/12 (66.7%) mild HIE survivors showed gross motor delay compared with 5/7 (71.4%) moderate/severe survivors. Conclusion: Even infants with mild HIE are at risk of adverse neurological outcomes. The development of more sensitive diagnostic tools could improve treatment strategies and early interventions, ultimately impacting prognosis. With proper recognition, tailored follow-up, and appropriate therapeutic approaches, potential neurodevelopmental impairments in mild HIE cases could be mitigated. Cite this article as: Canbeldek M, Armağan C, Şenol HB, et al. Challenging mild hypoxic–ischemic encephalopathy: insights into neurological outcomes.Turk Arch Pediatr. 2025;60(5):507-514.

Beyond the Expected: Importance of Recognizing Intussusception in Diabetic Ketoacidosis - Journal of Pediatric Emergency and Intensive Care Medicine

Managing acute abdomen in very low birth weight (VLBW) and premature infants presents a diagnostic challenge, often necessitating a thorough assessment to discern underlying causes. Umbilical venous catheters (UVCs), commonly used in neonatal intensive care, are essential but not without risks. A 29-week premature male infant, born to a 23-year-old mother, was referred to our clinic on the 16^th day of life with a suspected diagnosis of necrotizing enterocolitis (NEC). The infant had spent the first day intubated and received non-invasive respiratory support for 15 days. A 5 French UVC was inserted at the 2^nd hour of life, and by the 3^rd day of life, the infant transitioned to minimal enteral feeding. Between the 12^th and 16^th days of life, the infant initially diagnosed with NEC due to symptoms such as decreased stool passage and abdominal distension. The patient had been on a continuous course of antibiotic treatment throughout the entirety of his life, commencing on the very first day due to suspected early neonatal sepsis, followed by nosocomial sepsis during the hospitalization, and persisting with antibiotic therapy for suspected NEC. The case took a unique turn upon further evaluation after being referred to our unit. Despite a preliminary NEC diagnosis, further evaluation revealed umbilical catheter complications, leading to total parenteral nutrition extravasation. Removal of the catheter, drainage, and antibiotic adjustment resulted in improved clinical outcomes. In neonatal care, cautious management is vital when dealing with infants exhibiting abdominal symptoms. A nuanced approach, including differential diagnosis and careful antibiotic use, is essential. Received: 12 January 2024 Accepted: 15 March 2024 Article published online: 06 May 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Introduction and methods: Thanks to developments in perinatal and neonatal care, the survival rate of premature babies has increased. Depending on the development level of countries and units, some of the morbidity rates may increase, while others may decrease. In this retrospective cross-sectional study; the morbidity and mortality results of very low birth weight (VLBW) infants were evaluated by comparing the results of the infants in our previous study and the data of developed countries. Results: 203 infants were included in the last group. The mean birth weight of these babies was 976±308 g and the mean gestational age was 27.8±2.5 weeks. The rate of babies with a gestational age of 28 weeks and above were significantly lower than the first group containing 173 infants. Regarding major morbidities, the rates of bronchopulmonary dysplasia (moderate to severe) and necrotizing enterocolitis (>stage 2) were significantly higher in the last group; while the rates of retinopathy of prematurity (>grade 2), intraventricular hemorrhage (>grade 2) and periventricular leukomalacia were also similar among the two groups. While survival rates were found to be similar, the survival rate without major morbidity was significantly lower in the last group. Conclusion: While the survival rates remained unchanged despite the observation of smaller babies in terms of birth weight and gestational age in the last period when mortality and morbidity data were compared with developed countries, the study demonstrated a need for improvement in mortality rates especially in small gestational weeks, while major morbidity rates were generally encouraging.

A case representing neonatal jaundice that includes direct and indirect hyperbilirubinemia was diagnosed with classical galactosemia. Even though she was initially approached as a neonatal sepsis case, after the cessation of her milk consumption, jaundice resolved, and the diagnosis was made and supported by additional diagnostic tools. It has been shared to emphasize the importance of assessment and urgent management of the disease during the neonatal period.