Purpose We evaluated the diagnostic utility of abdominal ultrasound (AUS), an adjunct to abdominal X-ray (AXR), for necrotizing enterocolitis (NEC) in congenital heart disease (CHD) patients. Methods 86 patients with suspected NEC from 2009 to 2018 were classified as with CHD (n = 18) if they required cardiac intervention versus without CHD (n = 68). Clinical and radiological data were collected, including AXR and AUS concordance. Wilcoxon rank-sum test and Fisher's exact test were performed. Results CHD patients had higher birth weights (p < 0.001) and gestational ages (p < 0.001) than non-CHD patients. CHD patients presented more frequently with hypotension (p = 0.041) and less frequently with bilious emesis (p < 0.001). Overall, CHD patients were less likely to have AUS findings of pneumatosis (33.3 vs. 72.1%; p = 0.005) and decreased mural flow (0 vs. 20.6%; p = 0.035) compared to non-CHD patients. On concordance analysis, CHD patients had 3.9-fold more discordant studies with pneumatosis on AXR but not on AUS (33.3 vs. 8.8%; p = 0.016) compared to non-CHD patients. Urgent surgery was required in 5.6% of CHD patients versus 16.2% of non-CHD patients. Conclusion CHD patients with suspected NEC represent a distinct clinical population. AUS has particular utility in assessing findings of bowel viability in the CHD NEC population, reflecting reduced rates of surgical NEC.

BACKGROUND:Abdominal ultrasound (AUS) is a promising adjunct to abdominal x-ray (AXR) for evaluating necrotizing enterocolitis (NEC). We developed a multivariable risk score incorporating AUS to predict surgical NEC.METHODS:83 patients were evaluated by AXR and AUS for suspected NEC. A subset had surgical NEC. Multivariate logistic regression determined predictors of surgical NEC, which were incorporated into a risk score.RESULTS:14/83 patients (16.9%) had surgical NEC. 10/83 (12.0%) patients required acute intervention, while 4/83 (4.8%) patients only required delayed surgery. Four predictors of surgical NEC were identified: abdominal wall erythema (OR: 8.2, p = 0.048), portal venous gas on AXR (OR: 29.8, p = 0.014), and echogenic free fluid (OR: 17.2, p = 0.027) and bowel wall thickening (OR: 12.5, p = 0.030) on AUS. A multivariable risk score incorporating these predictors had excellent area-under-the-curve of 0.937 (95% CI: 0.879-0.994).CONCLUSIONS:AUS, as an adjunct to physical exam and AXR, has utility for predicting surgical NEC.

BACKGROUND: Abdominal sonography (AUS) is emerging as a potentially valuable adjunct to conventional abdominal radiography (AXR) in the setting of suspected necrotizing enterocolitis (NEC). We sought to evaluate concordance between AUS and AXR for signs of NEC to better understand the potential advantages and disadvantages of AUS. As a secondary aim, we characterized AUS-specific findings and evaluated the association of imaging results with clinical outcomes. STUDY DESIGN: Hospitalized infants with clinical concern for NEC from 2009 to 2018 were included in this multicenter retrospective review. All infant patients had at least 1 paired AXR followed by an AUS within 24 hours. Findings were abstracted from written radiology reports. Cohen's k, nonparametric Mann-Whitney U test, and quantile regression were used to evaluate chance-corrected levels of agreement for concordance analyses and associations with clinical outcomes. RESULTS: In total, 66 patients and 96 paired studies were evaluated. Agreement between the 2 imaging modalities was 61 of 96 (63.5%) for pneumatosis (kappa = 0.29; 95% CI, 0.10 to 0.48), 79 of 96 (82.3%) for portal venous gas (kappa = 0.07; 95% CI, 0.00 to 0.47), and 91 of 96 (94.8%) for pneumoperitoneum (kappa = 0.52; 95% CI, 0.11 to 0.93). Each finding was present more frequently on AUS than AXR. On AUS, pneumatosis and focal fluid collection were independently associated with a longer antibiotic course (4.1 days longer; p = 0.03 and 21.3 days longer; p < 0.001, respectively). CONCLUSIONS: AUS holds promise as a useful adjunct to radiography for neonates with possible NEC. It might be more sensitive for the presence or absence of bowel ischemia and can reveal findings not detectable by radiography, which can aid provider decision-making. (C) 2020 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Introduction: We implemented a bundle of respiratory care practices and optimized delivery of continuous positive airway pressure (CPAP) to reduce the incidence of chronic lung disease (CLD) among very low birth weight (VLBW) infants born before 33 weeks gestation. Methods: Our multidisciplinary task force utilized 6 plan-do-study-act cycles to test our interventions. The primary outcome was the quarterly percentage of infants diagnosed with CLD; other outcomes included the percentage of infants initially managed with CPAP, intubation <72 hours of age, use of a nasal cannula, and days of ventilation, oxygen, and/or CPAP. Process measures included compliance with each of the 5 components of the bundle; balancing measures included mortality and complications of prematurity. Results: Demographics were similar in the 55 infants born before and 76 infants born after the task force interventions, except for gestational age, which was lower before. CLD decreased by 55.5% (from 37.5% to 16.7%). Quarterly percentage of infants requiring intubation decreased from 87.5% to 40.8%. Quarterly average days of ventilation decreased from 11.2 to 6.1, and days of supplemental oxygen declined from 44.1 to 25.4, while the use of CPAP increased. There were no differences in adverse events including mortality, pneumothorax, use of postnatal steroids, or any retinopathy of prematurity. The incidence of patent ductus arteriosus declined from 60% to 33% (P < 0.01). Conclusions: We reduced the incidence of CLD among our very low birth weight infants born before 33 weeks gestation by over 50% without increasing any measured adverse outcomes. The incidence of patent ductus arteriosus declined.

OBJECTIVE:To determine whether the restriction of young sibling (<13 years) visitation in the neonatal intensive care unit (NICU) during the respiratory syncytial virus (RSV) season was associated with a reduction in the rate of RSV infection among NICU patients.STUDY DESIGN:A retrospective chart review of all RSV positive infants from the 2001-2010 RSV seasons. The 2001-2006 RSV seasons (group 1) contained 639 admissions and the 2007-2010 (group 2, with sibling restriction) contained 461 admissions. Groups were compared by using the Fisher's Exact Test.RESULTS:There was a reduction of RSV positive infants from 6.7% in Group 1 to 1.7% in Group 2 (P<0.0001). There was a reduction of symptomatic infants from the number of infants with symptomatic RSV infection from 23/639 infants with young sibling visitation to 2/461 (P<0.001).CONCLUSION:Exclusion of young sibling visitors <13 years of age during RSV season was associated with a significant reduction in the number of RSV positive infants in the NICU.

Myelination is essential for proper functioning of the CNS. In this study, we have identified a mouse mutation, designated furue, which causes tremors and hypomyelination in the CNS, particularly in the spinal cord, but not in the sciatic nerve of the PNS. In the spinal cord of the furue mice, myelination of small-diameter axons was dramatically reduced, and differentiation of oligodendrocytes, the myelin-forming cells in the CNS, was inhibited. We subsequently found that the furue mutation was associated with a transgene insertion into the teneurin-4 (Ten-4, Ten-m4/Odz4) gene, encoding a transmembrane protein of unknown function. Ten-4 was strongly expressed in the spinal cord of wild-type mice and was induced during normal oligodendrocyte differentiation. In contrast, in the furue mice, the expression of Ten-4 was absent. Differentiation and cellular process formation of oligodendrocytes were inhibited in primary cell culture from the furue mice. Cell differentiation and process formation were also inhibited in the oligodendrocyte progenitor cell line CG-4 after suppression of Ten-4 expression by shRNA. Furthermore, Ten-4 positively regulated focal adhesion kinase, an essential signaling molecule for oligodendrocyte process formation and myelination of small-diameter axons. These findings suggest that Ten-4 is a novel regulator of oligodendrocyte differentiation and that it plays a critical role in the myelination of small-diameter axons in the CNS.

We examined superior mesenteric artery blood flow velocity in response to feeding in infants randomized to trophic feeds (n = 16) or nil per os (n = 18) during previous treatment for patent ductus arteriosus. Blood flow velocity increased earlier in the fed infants, but was similar in the 2 groups at 30 minutes after feeding.

OBJECTIVE:Concern regarding the magnitude and consequences of diagnostic radiation exposure in premature infants in neonatal intensive care units (NICUs) has increased as survival of premature infants has improved. Radiation exposure is not often rigorously monitored in NICU patients. The purpose of this observational study was to quantify the amount of ionizing radiation exposure in infants <33 weeks gestational age and to identify the indications for diagnostic imaging. STUDY DESIGN:We conducted a retrospective review of 215 premature infants who were <33 weeks gestation and who received central venous line (CVL) placement during their NICU stay during the period from 2006 to 2011. Absorbed ionizing radiation was estimated using the method of Puch-Kapst and colleagues (2009) and compared with recommended radiation exposure limits. All infants were 29.2±2.3 weeks (mean±s.d.) and 1262±433 g birth weight. RESULT:Subjects received 15±15 radiographs (4.4±2.9 for CVL placement, 5.7±9.8 for gastrointestinal (GI) evaluations and 5.2±9.3 for respiratory indications). Eleven infants (5.1%) received more than the maximum recommended radiation from radiographs (>1000 μSv). Inclusion of fluoroscopic procedures increased to 26 the number of infants (12.1%) who received more than the maximum recommended 1000 μSv. CONCLUSION:Ionizing radiation exposure that exceeded the recommended maximum in premature infants at high risk for long-term sequelae occurred in 12.1% of infants who were <33 weeks gestation and who were cared for in our NICU over the past 5 years. CVL placement accounted for 22% of this radiation exposure. GI evaluations accounted for the greatest amount of ionizing radiation exposure. We suggest that the increased use of other imaging strategies may reduce total ionizing radiation exposure in this vulnerable population.

Neonatal Respiratory Distress Syndrome (RDS), caused by surfactant deficiency, is a primary cause of neonatal morbidity and mortality in premature infants in the United States.The pathophysiology of RDS, however, involves more than surfactant deficiency and decreased pulmonary compliance.There is an intricate interaction of pulmonary and cardiovascular contributors to the pathophysiology.The consequences of the treatment of RDS and its associated morbidities may increase the risk for additional morbidities.The purpose of this review is to describe the cardiovascular responses to RDS and its treatment in preterm infants.Topics include the significance of the cardiovascular system in the natural history and treatment of RDS, from antenatal care through the evolution of chronic lung disease.The discussion reviews what is known, what needs to be known, and how neonatologists may increase their awareness of these underappreciated consequences in the future.

Objective To test the hypothesis that infants who are just being introduced to enteral feedings will advance to full enteral nutrition at a faster rate if they receive "trophic" (15 mL/kg/d) enteral feedings while receiving indomethacin or ibuprofen treatment for patent ductus arteriosus.Study design Infants were eligible for the study if they were 23(1/7) -30(6/7) weeks' gestation, weighed 401-1250 g at birth, received maximum enteral volumes <= 60 mL/kg/d, and were about to be treated with indomethacin or ibuprofen. A standardized "feeding advance regimen" and guidelines for managing feeding intolerance were followed at each site (N = 13).Results Infants (N = 177, 26.3 +/- 1.9 weeks' mean +/- SD gestation) were randomized at 6.5 +/- 3.9 days to receive "trophic" feeds ("feeding" group, n = 81: indomethacin 80%, ibuprofen 20%) or no feeds ("fasting [ nil per os]" group, n = 96: indomethacin 75%, ibuprofen 25%) during the drug administration period. Maximum daily enteral volumes before study entry were 14 +/- 15 mL/kg/d. After drug treatment, infants randomized to the "feeding" arm required fewer days to reach the study's feeding volume end point (120 mL/kg/d). Although the enteral feeding end point was reached at an earlier postnatal age, the age at which central venous lines were removed did not differ between the 2 groups. There were no differences between the 2 groups in the incidence of infection, necrotizing enterocolitis, spontaneous intestinal perforation, or other neonatal morbidities.Conclusion Infants required less time to reach the feeding volume end point if they were given "trophic" enteral feedings when they received indomethacin or ibuprofen treatments.

Advances in the medical care of Very Low Birth Weight (VLBW) infants have led to decreased mortality rates.Unfortunately, this has not been accompanied by a similar decline in the rate of Bronchopulmonary dysplasia (BPD).In fact, while severity of lung disease at many gestational ages has decreased, the improved survival of the most premature of infants has led to survival with significant respiratory morbidity.So while improvements in care have reduced the risk for severe lung disease in larger, more mature preterm infants, BPD continues to be a major cause of mortality and morbidity in extremely premature infants.For the subset of infants with most severe BPD, who still require ventilator support at 36 weeks post-conception, management remains a significant challenge.No standardized protocols exist to optimally treat severe BPD.Current available strategies include optimization of adequate gas exchange, including prolonged oxygen therapy or ventilator support, utilization of systemic steroid therapy, minimization of ongoing insults like aspiration, and treatment of other sequelae, including pulmonary hypertension.Each of these treatment strategies carries significant toxicities of their own, but individualized evaluation of risk/ benefit and appropriate use of such strategies may improve pulmonary outcomes.

Copyright: © 2012 Fujii AM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Neonatology is a relatively new, age and size determined subspeciality involved in the care acute care of sick and premature newborns. Neonates are in transition from the aquatic, intrauterine environment to an aerobic, pulmonary dependent, environment. The interaction between pulmonary and cardiovascular systems in ill neonates is more complex than at any other time in the spectrum of life. Conventional evaluation of disturbances in these interactions by oxygen saturation, heart rate, respiratory rate, and physical examination are inadequate. Bedside Ultrasound Imaging (BUSI) in the Neonatal Intensive Care Unit (NICU) provides a rapid, non-invasive, real-time window into disturbances in these cardiopulmonary interactions. Traditionally, in the NICU, control of the ultrasound is managed by experts in pediatric cardiology and radiology. Whether the neonatologists themselves should perform ‘point of care’ ultrasound, is controversial. In reality, 24 hour presence of specialists to provide ultrasound services in the NICU is not achievable. Overall, use of ultrasound in the NICU by neonatologists has lagged behind other specialists in adult intensive care, emergency room medicine and obstetrics where use of ultrasound by the primary care giver is routine. The purpose of this editorial is to discuss the usefulness of BUSI in enhancing clinical care, indications for usage, barriers to implementation and development of training programs that teach use of BUSI in the NICU.

Correction to: Journal of Perinatology (2010) 30, 665–670; doi:10.1038/jp.2010.20; published online 25 March 2010 In the 'Results' section of the abstract, the last sentence reads that rates of death are (2/15 vs 5/27). Here the first number should be 2/25 not 2/15.

Objective: To determine whether type and timing of surfactant preparation affect cerebral blood flow (CBF) hemody- namics differently. Study design: Two sites monitoring cerebral hemodynamics during surfactant administration. Beractant (4.0 ml/kg) and poractant (2.5 ml/kg first dose, 1.25 ml/kg subsequent doses) were administered according to the manufacturer. CBF velocity (CBFv) was assessed before and after the first (Site A) and second (Site B) doses of beractant and poractant. Results: At Site A, 10 infants (birth weight 690 ± 133 g) were studied. CBFv decreased 28.9 ± 5.1% following the first dose of surfactant; there were no differences between beractant and poractant. At Site B, 16 infants (birth weight 896 ± 311 g) were studied. CBFv increased 47.4 ± 35.7% after the second dose of beractant and did not change after the second dose of poractant. Conclusion: This is a preliminary report of two related trials examining CBFv responses to beractant and poractant. CBFv decreased similarly after the first dose of beractant and poractant. CBFv increased after the second dose of beractant, but not after poractant. Cerebral hemodynamic responses between the first and second doses may be due to differences in quantities of airway fluid, while second dose differences between beractant and poractant may be due to differences in dose-volume.

Exogenous surfactant treatment of premature infants with respiratory distress syndrome (RDS) has been the standard of care for the past two decades. There are many studies comparing various surfactant preparations. Data are clear that the synthetic surfactants without surfactant proteins are inferior to animal-derived surfactant preparations. Less compelling are the data regarding the relative efficacy of the various animal-derived surfactants available, but a pattern has evolved favoring surfactant preparations with higher concentrations of phospholipids and surfactant proteins. A higher initial dose of phospholipids may also be important, especially for preterm infants less than 32 weeks of gestation. Development has begun of new synthetic surfactants with surfactant protein analogs or recombinant surfactant proteins, which are not yet available in the United States. Synthetic surfactants hold the possibility of surfactant treatments without potential animal-born infectious agents or animal proteins that could induce an immune response in fragile premature infants with multiple medical problems. The goal of this review is to assess the comparison of available animal-derived surfactants and what is known of their comparison. with the newer synthetic surfactants. In addition, the possible direct and indirect effects of surfactant administration on regional blood flow are discussed, with their potential relationship to the volume of surfactant administered.

A multicystic pneumatocele progressively enlarged when the patient required positive pressure ventilation for an intercurrent respiratory syncytial virus infection. Video Assisted Thoracoscopic Surgery was used to visualize the pneumatocele for cannulation. One chamber of the pneumatocele was cannulated with a pigtail catheter and another large chamber ruptured, without cannulation. The multicystic pneumatocele resolved with this therapy.

Progression of pulmonary interstitial emphysema (PIE) to single or multiple pneumatoceles is uncommon, but may be seen in extremely premature infants with respiratory distress syndrome (RDS) on mechanical ventilation, after bacterial pneumonia and after suction catheter-induced airway trauma. While most premature infants with pneumatoceles are managed conservatively, mechanical decompression may be necessary.1–3 Prior descriptions of neonatal intensive-care management of pneumatoceles in premature infants are individual case reports. We report the case of a 1-month-old extremely premature infant with RDS and respiratory failure from superimposed respiratory syncytial viral pneumonitis, PIE, and an enlarging pneumatocele, which was successfully managed with a percutaneously placed pigtail catheter.

Survival of extremely premature infants (<27 weeks' gestational age) has improved over the past two decades. Indomethacin prophylaxis was used in these infants, who have the highest mortality and morbidity rates, to reduce the incidence of intraventricular hemorrhage and patent ductus arteriosus (PDA). Medical records of 65 extremely premature infants born at our institution between 1995 and 2001 were reviewed retrospectively to determine whether treatment of PDA with indomethacin in the first 48 hours of life reduces the need for PDA ligation or increases neonatal morbidity, when compared to treatment begun later. Thirty infants in the early treatment group (ETG) were treated during the first 48 hours after birth, and 32 infants in the standard treatment group (STG) were managed expectantly for PDA. Three infants died in the first hours of life and were eliminated from further analysis. ETG infants were 24.9±1.1 (mean±SD) weeks' gestation with a birth weight of 678±143 g. STG infants were 25.3±1.1 weeks (NS) and 730±125 g (NS). Hemodynamically significant PDA was diagnosed or confirmed by echocardiography in 19 ETG patients and 17 STG patients. Of the patients with hemodynamically significant PDA, 1 (5%) ETG patient and 6 (35%) STG patients underwent surgical ligation (p=0.033). Necrotizing enterocolitis (NEC) with intestinal perforation was the most serious morbidity and occurred in 20% of infants in the ETG, but in no STG infant (p=0.011). Four of the six infants in the ETG with NEC and intestinal perforation died. The overall mortality rate for all infants studied was 28%. We conclude that in extremely premature infants, use of indomethacin during the first 48 hours of life was associated with a reduced need for PDA ligation, but an increased risk of NEC with intestinal perforation.