Melina Winkler

Objective Non-invasive respiratory support during immediate postnatal transition is common in caesarean-delivered late preterm and term neonates yet distinguishing those, who will require neonatal intensive care unit (NICU) admission and those who will stabilise with initial respiratory support, remains challenging. This exploratory study assessed whether clinical parameters obtained within the first 15 min after birth are associated with NICU admission for ongoing respiratory support lasting beyond 60 min.Design and setting Post hoc analysis of prospectively collected data from three observational studies (2018–2024) conducted at a single tertiary NICU (Medical University Graz).Patients A total of 105 neonates with a gestational age (GA) ≥34 weeks delivered by caesarean section and requiring non-invasive respiratory support within 15 min after birth were eligible.Results Neonates admitted to the NICU for ongoing respiratory support (NICU group, n=30, GA 35 4/7 (344/7–380/7)) were compared with those who stabilised in the delivery room (non-NICU group, n = 75, GA 384/7 (374/7–390/7)). Neonates in the NICU group were significantly more often male, had lower GA, birth weight, 10 min Apgar scores, peripheral arterial oxygen saturation (SpO2), SpO2/fraction of inspired oxygen ratio (S/F ratio) and higher heart rates 15 min after birth. In multivariable regression, lower GA (p = 0.010) and a lower S/F ratio at 15 min (p < 0.001) were independently associated with NICU admission.Conclusion Among this cohort of caesarean-delivered late preterm and term neonates requiring non-invasive respiratory support in the first 15 min after birth, lower GA and a lower S/F ratio at 15 min were independently associated with subsequent NICU admission. These findings identify candidate early clinical indicators; larger prospective studies are needed to validate their predictive value and determine their role in clinical decision-making.

Introduction: Immediate postnatal transition is a vulnerable phase, especially in preterm neonates. Arterial blood pressure (ABP) modulates cerebral perfusion and may contribute to intraventricular haemorrhage (IVH) when autoregulation is impaired. Evidence for its role during transition remains limited. We investigated associations between ABP and IVH. Methods: We conducted a retrospective matched case-control study at the Medical University of Graz including neonates born <32 weeks’ gestation between 2009 and 2025. Cases with IVH grade ≥II during the first week of life and an oscillometric ABP measurement at 15 min after birth were matched 1:1 to controls without IVH by gestational age (±3 days), birth weight (±70 g), sex, and cord clamping strategy. Systolic, mean, and diastolic ABP (SABP, MABP, DABP) were compared using paired analyses. Subgroup analyses were performed according to infection status and physiological-based cord clamping (PBCC). Results: Forty-four neonates with IVH grade ≥II (median GA 25 weeks; BW 755 g) were matched to 44 controls. Baseline characteristics were similar. At 15 min after birth, IVH cases had lower SABP, MABP, and DABP (Holm-adjusted p = 0.018, 0.012, 0.018, respectively), consistently below the 10th percentile. Infection occurred only among IVH cases. The association remained consistent across infection-stratified analyses, but no significant difference was detected in the exploratory PBCC subgroup. Conclusion: Reduced ABP at 15 min after birth is strongly associated with IVH ≥ grade II. Values below the 10th percentile may indicate circulatory compromise. Early ABP assessment may improve risk stratification and monitoring.

Introduction: Physiological postnatal changes in fetal hemoglobin fraction (FHbF) may affect neonatal tissue oxygenation through shifts in the oxyhemoglobin dissociation curve. We examined cross-sectional associations between FHbF and near-infrared spectroscopy (NIRS)-derived tissue oxygenation, and longitudinal associations between within-infant changes in FHbF and cerebral tissue oxygenation (cStO2) and oxygen extraction (cFTOE) during the first 3 postnatal weeks in neonates without red blood cell transfusions. Methods: This prospective observational study included 25 preterm (median [IQR] gestational age 33.6 [1.6] weeks) and 25 term (39.9 [1.4] weeks) neonates in a tertiary-center neonatal unit. Measurements were performed at T1 (days 2–3), T2 (days 5–10), and T3 (days 12–18). cStO2 was assessed by time-resolved NIRS, peripheral tissue oxygenation by spatially resolved NIRS and peripheral fractional oxygen extraction by venous occlusion. cFTOE was calculated. Total hemoglobin (Hb) and FHbF were measured by co-oximetry. Cross-sectional associations were assessed using Spearman’s rho correlations. Longitudinal trajectories and gestational age-adjusted within-infant change-on-change associations were analyzed using linear mixed-effects models. Results: No significant cross-sectional correlations were identified between FHbF and cerebral or peripheral NIRS-derived variables at any time point. Over time, Hb and cStO2 declined, cFTOE increased, while peripheral oxygenation and extraction remained stable. Within-infant Hb changes were not associated with concurrent cerebral NIRS changes. In contrast, FHbF change was associated with change in cStO2 (T2–T1: β per 1% FHbF, −0.19; 95% CI −0.33 to −0.05) and cFTOE (β 0.22; 95% CI 0.06–0.38). Conclusion: Within-infant FHbF decline was associated with increased cStO2 and decreased cFTOE, independent of total Hb.

Background: Conjugated hyperbilirubinemia in early infancy is a critical indicator of hepatobiliary dysfunction. Prompt and accurate identification is essential to diagnose cholestatic liver disease (CLD), particularly biliary atresia. Current guidelines define conjugated bilirubin (CB) ≥ 1 mg/dL as abnormal, irrespective of total bilirubin (TB). This study aimed to evaluate whether combining absolute and relative CB thresholds improves diagnostic performance for CLD. Methods: We retrospectively analyzed all infants aged ≤6 months of chronological age with CB ≥ 1 mg/dL admitted to the Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Austria, between January 2004 and February 2025. During that period, 116,104 infants were born at our hospital catchment area; 3119 of these underwent bilirubin fractionation, and 257 infants (0.2% of total births) had a CB ≥ 1 mg/dL and were included in the analysis. Clinical and biochemical data were extracted. Diagnostic performance of the absolute (CB ≥ 1 mg/dL) and in combination with the relative (CB ≥ 20% of TB) thresholds was assessed using receiver operating characteristic (ROC) analysis for the detection of CLD. Results: Among 257 infants, 47 (18%) were diagnosed with CLD. The median age at the time of blood sampling was 18 days (IQR 9–31). The combined criterion (CB ≥ 1 mg/dL and ≥20% of TB) achieved 100% sensitivity and 61.2% specificity (AUC = 0.82, 95% CI 0.79–0.92; p < 0.001). Implementation of the combined cut-off reduced the number needed to screen from 5.5 to 2.7, representing nearly a twofold improvement in diagnostic efficiency. Conclusions: Applying both absolute (≥1 mg/dL) and relative (≥20% of total bilirubin) CB thresholds substantially improves detection of neonatal CLD in early infancy. This combined approach maintains full sensitivity while reducing false positives and unnecessary investigations, thereby enhancing diagnostic efficiency in early infancy.

Background: The surveillance of athletes with congenital heart disease remains challenging despite recent recommendations. Stress echocardiography as a diagnostic tool is not yet part of the routine follow-up but has emerged as an innovative approach to assess cardiac reserve and exercise capacity. It can unmask cardiac exercise pathophysiology and hence inform decision making for repeat interventions in athletes with complex congenital heart disease. Case summary: This case report describes two athletes with Tetralogy of Fallot who, despite similar conditions, exhibit different cardiovascular risks. Their above average exercise capacity masks early cardiac deterioration, underscoring the limitations of cardiopulmonary exercise testing in assessing myocardial function. Stress echocardiography revealed severe biventricular dyssynchrony in one athlete, playing a major role in decision-making to perform a pulmonary valve replacement (PVR). Post transcatheter PVR, improved left ventricular–right ventricular synchrony was seen at rest and during exercise stress echocardiography. Conclusion: In athletes with congenital heart disease (CHD), disease worsening might be masked by above-normal exercise capacity, and detailed assessment, including cardiopulmonary exercise testing and exercise echocardiography, might be needed to detect underlying pathophysiology and hence guide the therapeutic approach. Two-strain during exercise echocardiography can be used to quantify cardiac function but also decipher interventricular dyssynchrony in CHD.