Iranian Journal of Neonatology
Volume:11 Issue: 1, Winter 2020

Sepsis is one of the most important causes of death in infants. The pattern of bacterial agents responsible for neonatal septicemia changes over time. The main aim of the present study was to provide a clinical guideline adapted for treatment of neonatal sepsis based on the frequency of microbial agents in the Neonatal Intensive Care Unit of Alzahra Hospital, Tabriz, Iran. The clinical guideline adaptation is conducted based on the ADAPTE Resource Toolkit for Guideline Adaptation (version 2.0) from December 2016 to January 2018. For data collection, the specialized websites were identified, then an internet search method was used for gaining clinical guidelines and medical literature databases. A panel was established with members of multi-specialties and the obtained guidelines were examined and evaluated. In the end, the final guideline was selected and translated. Regarding the guideline, employing antibiotics should start when the neonate is < 35 weeks and premature rupture of membrane (PROM) happened < 18 h. Moreover, it could be employed when the neonate did not receive antibiotics, the gestational age (GA) is < 35 weeks with a PROM < 18 h or a GA < 37 weeks with a PROM ≥ 18 h. Implementation of the neonatal sepsis treatment guideline leads to a unified method of treatment, reduces the risk of antibiotic resistance, and decreases the mortality and morbidity associated with sepsis.

Stress in preterm neonates is associated with morbidity and mortality. Preterm newborns who are in need of special care are at risk of experiencing stress because of separation from the mother, ambient noises, lighting intensity, and medical procedures. Massage is believed to reduce stress through touch stimulation, and the cortisol is one of the indicators of the stress response. This study aimed to identify the effects of touch stimulation in the form of massage on salivary cortisol in preterm neonates. This study was conducted based on a quasi-experimental design. The neonates were divided into intervention and control groups who received massage and standard therapy (n=19) and only the standard therapy (n=20), respectively. The massage was given to the infants three times daily for 15 min. Salivary cortisol was measured after 10 days of intervention. According to the results, the mean salivary cortisol concentration of the control group was higher (0.53±0.73 μg/dL) than that in the intervention group (0.05±0.32 μg/dL). Moreover, there was a significant difference between the groups regarding the salivary cortisol level at pre- and post-test (P=0.001). Based on the pre-test and post-test results, there was a significant decrease in salivary cortisol levels in the intervention group, compared to the control group (P=0.03 versus P=0.53). It should be noted that there were no observable side effects during the intervention. Based on a decrease in salivary cortisol levels, this study suggests that touch stimulation given as a massage may reduce the level of stress in preterm neonates.

The aim of this study was to describe the prevalence of neonatal urinary tract infection (UTI), demographics, and clinical characteristics in a single referral tertiary neonatal intensive care unit.

The medical records of 118 neonates diagnosed with neonatal UTI were reviewed over a 7-year period.

The prevalence of neonatal UTI was 1.5%. The male to female ratio was 1.6:1. In this study, 61% of the neonates were preterm babies. The mean age of diagnosis was 19.55±19.5 days. Pyuria was observed in 20% of the cases, and Escherichia coli was the most common pathogen. Hospital-acquired UTI was observed in 76% of the cases, and community-acquired UTI was noticed in 24% of the subjects. Prolonged jaundice was the most common presenting symptom of UTI followed by sepsis. An abnormal ultrasound was found in 29% of the neonates with hydronephrosis as the most associated anomaly. There was a high rate of extended spectrum-beta lactamase organisms and a high rate of antimicrobial resistance.

The occurrence of neonatal UTI was rare in the study population. In addition, hydronephrosis was the most common anomaly. Proper antibiotic stewardship is needed to halt the increasing antimicrobial resistance of uropathogens.

The present study aimed to determine the mean blood glucose during the first 24 h post-surgery and its relation with the source of calorie intake. The data of the current observational retrospective study was collected from hospital medical records. A total of 45 neonates suffering from atresia in different parts of the gastrointestinal tract, who were candidates for open abdominal surgery from September to October 2016 were selected. Blood glucose within 24 h after the surgery were taken four times using a glucometer. Moreover, the mean blood glucose during this period was calculated. Independent Student's t-test, chi-square test, and logistic regression model were performed to assess the association of post-operative blood glucose with calorie and macronutrient intakes. In one third of neonates, the mean blood glucose of the samples during the first day after the surgery was ≥180 mg/dl and the rest of them had mean blood glucose of 40-179 mg/dl. There was a significant relationship between blood glucose BG≥180 mg/dl and calorie (P=0.001), macronutrient (carbohydrate (P<0.001), and fat (P=0.04)) intakes. After adjustment of confounding variables, carbohydrate intake was found as an independent factor in increasing BG≥180 mg/dl during the first 24 h after the surgery (P=0.01). In addition, fat intake was observed as an effective factor in decreasing BG≥180 mg/dl during this time (P=0.04). The present study revealed that there was a significant relationship between mean blood glucose during the first 24 h after the surgery and intake of macronutrients (carbohydrate and fat).

Standard medical treatments for patent ductus arteriosus (PDA) closure are, including indomethacin/ibuprofen and surgical ligation. Nowadays, a new strategy to close PDA is the use of paracetamol. The present study aimed to describe the use of intravenous (IV) paracetamol for PDA closure in neonates who present a contraindication to ibuprofen or ibuprofen failure with no possibility to perform surgical ligation due to major instability. The present study was conducted from January to December 2017 in the neonatal intensive care unit of Dr. Zainoel Abidin Hospital and Harapan Bunda Hospital, Banda Aceh, Indonesia, on neonates with hemodynamic significant PDA (hsPDA). All the subjects received IV paracetamol (15 mg/kg every 6 h) for 3 days. Thereafter, the ductus was evaluated by echocardiography on the 5th day after the regiment. A total of 72 neonates were diagnosed with hsPDA and their average of gestational age was 34.26 weeks and their average of birth weight was 1945.69 g for 39 (54.2%) female neonates, 33 (45.8%) male neonates, 45 (62.5%) premature infants, and 27 (37.5%) full-term infants. About 26 (36.1%) infants had a closed PDAs on the 5th days of evaluation, 11 (15.3%) infants had regiment twice for closed PDA at the 10th days of evaluation, and 35 (48.6%) neonates had more closed PDA after three or four regiments. Successful closure with paracetamol was achieved in 51(70.8%) neonates, while 21 (29.2%) neonates failed the PDA closure. Based on the findings of the present study, IV paracetamol appears to be reasonably effective for PDA closure in both preterm and term infants. This should be the first-line of therapy choice when there are contraindications for the treatment with ibuprofen.

Predictive value of the umbilical nucleated red blood cells (NRBCs) at birth for neonatal outcomes has been assessed. Hence, the present study was conducted to compare NRBC between discharged and dead neonates. This cross-sectional study was performed on preterm newborns with a birth weight of < 1,500 g admitted to the Neonatal Intensive Care Unit of Ghaem Hospital, Mashhad, Iran, within 2012-2018. The subjects were divided into two groups of discharged and dead. Data collection tool was a researcher-made questionnaire containing three sections, namely maternal demographic information, neonatal data, and blood tests (measuring white blood cell [WBC], absolute NRBC, NRBC/100 WBC and blood gas). The collected data were analyzed in SPSS software (version 20), using t-test, Chi-square test, receiver operating characteristic curve, and regression models. A total of 205 neonates, including 136 discharged neonates (66.03%) and 69 dead neonates (33.7%), were examined in the present study. The results demonstrated a significant difference between the two groups in terms of the first minute Apgar score (P=0.023), fifth minute Apgar score (P=0.010), gestational age (P=0.000), birth weight (P=0.000), WBC (P=0.020), absolute NRBC (P=0.004), NRBC percentage (P=0.001), duration of mechanical ventilation (P=0.029), duration of oxygen therapy (P=0.012).Moreover, mechanical ventilation (P=0.036), type of oxygen therapy (P=0.000), NRBC percentage (P=0.001), and absolute NRBC count (P=0.001) showed a statistically significant relationship with neonatal survival rate. As the findings indicated, mechanical ventilation, type of oxygen therapy, absolute NRBC count, and NRBC percentage can be used as markers for predicting neonatal mortality rate.

Critical congenital heart diseases (CCHDs) are among the most common birth malformations. This study aimed to determine the cardiac and noncardiac diseases in the Iranian healthy newborns using pulse oximetry (POX) as a suggested screening method. In this cross-sectional study, healthy term and near term neonates who were born from October 2017 to March 2018 were evaluated. Preductal and postductal POX was performed in all asymptomatic healthy newborns after 24 hours of life or at any time before discharge from the nursery. Oxygen saturation (SPO2) was considered normal if SPO2 was  95%, and the difference between preductal O2 saturation and postductal POX was obtained at ≤ 3%. The POX was repeated after 2 hours for abnormal patients. In the case of the same results in both repeated measures, echocardiography, chest X-ray, sepsis screening, and blood glucose were conducted. A total of 413 asymptomatic healthy term and near term neonates underwent the pulse oximetry screening (POX). The mean birth weight and gestational age of the neonates were 3256.31±509.62 gr and 38.2 weeks, respectively. The POX was performed averagely 19.5 hours after birth. Finally, a total of 10 cases were detected with abnormal POX. Among these 10 patients, three cases had cardiac diseases (i.e., transposition of the great arteries, ventricular septal defect/pulmonary atresia, and ventricular septal defect/pulmonary hypertension), three cases had noncardiac diseases (i.e., esophageal stenosis, hypoglycemia, and persistent pulmonary hypertension/sepsis), and four subjects were healthy. The obtained findings showed that routine pox, along with clinical examinations could be applied, especially in developing countries for the early detection of cardiac and noncardiac diseases in asymptomatic newborns.

Spiritual health is one of the important factors predicting human health. This study aimed to determine the relationship between mothers’ spiritual health with newborns’ physical development indices and other physiologic parameters. In this cross-sectional study, 155 mothers giving birth to newborns were selected from Hazrat Zeinab hospital during 2017-2018. The data were gathered through a checklist containing all mothers’ and babies’ demographic information. Moreover, we used Palutzian and Ellison’s scale to measure the mothers’ spiritual health score. To analyze the data, we used SPSS software (version 18). The mothers’ mean age was reported as 27.84±6.67 years. Moreover, 71.6% of the mothers’ educational level was under diploma, and 65.2% of them were not employed (did not have any jobs). The mean score of the mothers’ spiritual health was 75.96±8.75. In this regard, 97.4% of the subjects had a moderate level of spiritual health, and 2.6% of them had a high level of spiritual health. There was a significant negative correlation between the mothers’ spiritual health score and neonates’ physical development scores. However, this correlation was significant (height: r=-0.1, P=0.21; weight r=-0.058, P=0.47; size of head: r=-0.033, P=0.6; size of belly: r=0.047, P=0.56), and there were positive correlations between the mothers’ spiritual health scores (heart beats: r=-0.034, P=0.66; percentage of saturated oxygen: r=-0.034, P=0.90; degree of heat: r=0.047, P=0.96). However, none of these correlations were statistically significant. In general, the results of this study showed that most of the mothers had a normal and high level of spiritual health, but a higher percentage of moderate level of spiritual health was observed in mothers, compared to those of other levels. Moreover, no significant correlations were found between mothers’ spiritual health scores with newborns’ physical development indices and other physiologic factors.

The accurate differentiation of perinatal torsioned ovarian cysts (PTOCs) in neonates is of utmost importance. This importance is due to the fact that if PTOCs are diagnosed properly, minimally invasive or conservative management approaches can be offered. The present study aimed to describe the ultrasound findings of PTOCs and compare the results with pathological findings. This prospective cross-sectional study was conducted in Mashhad University of Medical Sciences, Mashhad, Iran, within 2014-2019. All infants with an intra-peritoneal cyst underwent meticulous ultrasound examination. Patients were followed up until reaching the final diagnosis. In surgically approved PTOCs, the correlation between sonographic and pathologic findings was examined. Twenty two cases (aged 2 days to 6 months, mean age = 6 weeks) with PTOC were diagnosed during this time. Cysts were mainly on the right side (86%) with mean diameter of 51 mm (27-73mm). The ultrasonogrphic signs of fluid debris level, triple-layer wall and wrinkled inner layer were observed in almost all of patients.The pathologic triple-layer of perinatal torsioned ovarian cysts included necrotic content with granulation, stroma, and epithelium layers was observed by ultrasound as a uni-locular cyst containing fluid debris level with an echogenic wrinkled inner layer, a hypoechoic uneven non-uniform middle layer and echogenic outer epithelial surface. Sonographically detected triple-layered pattern for PTOCs was completely in agreement with pathologic results. Then, this specific ultrasound pattern is pathognomonic for PTOC.

Considering the importance of job satisfaction and occupational burnout among nurses, the present study aimed to determine the prevalence of occupational burnout and the degree of job satisfaction among neonatal intensive care unit (NICU) nurses. The current research was a cross-sectional study in which the Job Descriptive Index and Maslach Burnout Inventory were distributed among the NICU nurses. The collected data were analyzed using SPSS software. A total of 30 NICU nurses working in two public and private hospitals participated in the present study. The mean age of the participants was measured at 37.46±6.93 years, most of them (73.3%) held a Bachelor’s degree and more than 60% were married. No significant relationship between job satisfaction and burnout was observed among the nurses. Both variables were moderate among the NICU nurses as representatives of the staff working in special units. It is widely believed that people who are exposed to extreme stress for a long time are more likely to suffer from occupational burnout. Moreover, considering the importance of this issue in healthcare environments for the provision of services that physically and mentally affect patients, it is recommended to pay greater attention to employee satisfaction and burnout process in hospital settings.

The current study aimed to investigate the effect of enteral Granulocyte-Colony Stimulating G-CSF(Factor) on feeding tolerance in very low birth weight (VLBW) and extremely low birth weight (ELBW) neonates. This historical-controlled clinical trial was conducted on VLBW and ELBW neonates admitted to MahdiehHospital, affiliated to Shahid Beheshti University of Medical Sciences, Tehran, Iran, between July 2016 and March 2017.In the intervention group, 81 neonates with birth weights of 710-1480 were given enteral 5 μg/kg/day of G-CSF (whichhas been approved by the US FDA) for 7 consecutive days. On the other hand, the control group included 191 neonateswho did not receive G-CSF with birth weights of 600-1490 admitted during 24 months prior to the study. The twogroups were compared in terms of adverse effects of treatment, primary and secondary outcomes. The mean of gestational age and birth weight in the G-CSF group were reported as 29.96±2.47 weeks and1204.81±201.68 grams, and these values in the control group were measured at 29.77±2.13 weeks and1189.47±207.89 grams, respectively. Neonates who received G-CSF demonstrated better feeding tolerance, asreflected by the earlier achievement of 50, 75, 100, full enteral feeding of 150, and maximal enteral feeding of 180mL/kg/day (p < 0.05), with earlier weight gain and a shorter hospital stay. The rate of necrotizing enteroc olitis(NEC) in the G-CSF group was measured at 3.7% that was significantly lower, as compared to the control group(P=0.005). Approximately 8.9% of the neonates in the control group expired which was higher than the G-CSFgroup (P=0.06). All neonates tolerated the treatment and there was no statistically significant difference betweenthe two groups. As evidenced by the obtained results, the enteral administration of G-CSF to VLBW and ELBW neonatesimproved feeding tolerance and it was well tolerated without any associated side effects.

Germinal matrix hemorrhage and intraventricular hemorrhage (GMH-IVH) are among the causes of morbidity and mortality in very low birth weight (VLBW) neonates. The aim of this study was to determine the postnatal prophylactic effect of magnesium sulfate on GMH-IVH. In this double-blind clinical trial, 140 VLBW newborns were selected. The babies with birth weight ≤ 1500 g and gestational age ≤ 32 weeks were included. The babies with major malformation, infection, hemostatic disorders, severe cardio-respiratory failure, as well as asphyxia and resuscitation in the delivery room were excluded. They were randomly divided into two groups using a coin. The case group received 50% magnesium sulfate 4 mg/kg/day as a single dose via intravenous injection over 15-20 min for 3 days. All babies had a head ultrasound (HUS) in 24 to 48 h after birth, and if it was normal they were included in the study. The HUS was repeated in 1, 2, and 3 weeks after birth by a radiologist who did not know about the intervention. The control group received placebo sterile water in a dose similar to magnesium sulfate. The magnesium level was measured on day 4 at the end of the treatment. Although GMH-IVH was two times more in the control group, the difference was not statistically significant between the two groups (P>0.05). The difference in the grading of IVH was not also significant between the two groups (P=0.25). The level of magnesium sulfate was significantly higher in the case group (P=0.04). The results of this study showed that the postnatal administration of magnesium sulfate has no effect on the prevention of IVH.

Invasive candidiasis infection is one of the main life-threatening problems for extremely low birth weight (ELBW) neonates who are in the neonatal intensive care unit (NICU). Candidiasis can cause mortality, short-term morbidity, and long-term neurodevelopmental outcome in infected infants who survive. Therefore, since several years ago fluconazole prophylaxis has begun for premature newborns who were admitted to NICUs in some parts of the world. In this retrospective cohort, the population study was all the infants of less than 1,000 gram admitted to Valiasr Hospital during the years 2011-2016. The subjects were divided into two groups of control and intervention. The control group did not receive any fluconazole prophylaxis, while for the test group, intravenous fluconazole was administered. Finally, we compared the incidence of candidiasis between the two groups. Fluconazole was administered to 70 out of 167 neonates. Our findings showed that two infants of the prophylaxis group (2.9%) and two (1.2%) of the non-prophylaxis group were infected with Candida species. The difference between the two groups was not statistically significant (P=0.501). Among the risk factors, bacterial sepsis, the duration of central catheter installation, total parenteral nutrition, meropenem or vancomycin administration, and hospitalization costs were significantly related to the incidence of invasive candidiasis infection. The incidence of candidiasis in our study was 2.39% and fluconazole prophylaxis has not been effective in reducing fungal infections. Consequently, further investigations in larger sample sizes with different study settings and a variety of methodologies are needed to evaluate the efficacy of fluconazole prophylaxis on invasive candidiasis infection in ELBW neonates.

Arrhythmias in neonates are not common and usually affect newborns with a normal heart or those that suffer from structural heart disease. A malignant type of arrhythmias is supraventricular tachycardia. Meanwhile, one uncommon type of supraventricular arrhythmias is atrial flutter (AFL), which is founded upon reentry mechanisms in the atrium. The AFL may result in heart failure or even death, but the majority of its cases have revealed favorable prognosis in the event of early prenatal diagnosis and immediate treatment.

A four-day term male newborn with a birth weight of 4,560 g born to a 43-year-old multiparous mother was delivered through cesarean section. The patient’s admission to the hospital was on account of her poor feeding and tachypnea. The results of physical checkup exhibited tachycardia with 210 beats/min, and electrocardiogram (ECG) indicated a narrow QRS complex tachycardia with P-waves in the leads II and III that showed AFL. The adenosine injection revealed atrioventricular conduction 2.1. Therefore, oral propranolol therapy with a dosage of 3 mg/kg/day was prescribed for the patient. Given the recurrence of AFL, cardioversion was conducted with 0.25 joule/kg until the rhythm was restored to normal. Later, the normal sinus rhythm was observed on ECG. Fifteen days after birth, the patient was discharged with a perfect general state. The results of a 6-month follow-up did not show any AFL.

Despite its rare occurrence, AFL must be considered in the differential diagnosis of newborns with poor feeding with tachypnea and tachycardia.