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Hypoxic ischemic encephalopathy (HIE) is associated with acute kidney injury (AKI) in neonates with birth asphyxia. This study aimed to utilize urinary biomarkers to characterize AKI in an established neonatal rat model of HIE. Day 7 Sprague–Dawley rat pups underwent HIE using the Rice–Vannucci model (unilateral carotid ligation followed by 120 mins of 8% oxygen). Controls included no surgery and sham surgery. Weights and urine for biomarkers (NGAL, osteopontin, KIM‐1, albumin) were collected the day prior, daily for 3 days post‐intervention, and at sacrifice day 14. Kidneys and brains were processed for histology. HIE pups displayed histological evidence of kidney injury including damage to the proximal tubules, consistent with resolving acute tubular necrosis, and had significantly elevated urinary levels of NGAL and albumin compared to sham or controls 1‐day post‐insult that elevated for 3 days. KIM‐1 significantly increased for 2 days post‐HIE. HIE did not significantly alter osteopontin levels. Seven days post‐start of experiment, controls were 81.2% above starting weight compared to 52.1% in HIE pups. NGAL and albumin levels inversely correlated with body weight following HIE injury. The AKI produced by the Rice–Vannucci HIE model is detectable by urinary biomarkers, which can be used for future studies of treatments to reduce kidney injury. Although animal models of brain injury resulting from HIE are well established, the kidney injury that occurs is not well studied. This study aims to characterize AKI in an established rat model of HIE and track injury progression using sensitive urinary biomarkers. This provides an experimental approach utilizable for testing effectiveness of therapies that treat AKI.

ObjectiveNeonates requiring Non-InVasive respiratory Support (NIVS) are at high risk of device-related pressure injury (DRPI), with incidence rates of 20%–60% in extremely premature infants. Over a 4-year period, our team undertook a Quality Improvement Project to review aspects of the clinical management of NIVS: types of interfaces, introduction of hydrocolloid dressing and the development and implementation of nasal injury care plan (NICP) to reduce DRPI in high-risk neonates.DesignA prospective descriptive study was completed in three stages: trial of nCPAP interfaces, preintroduction NICP (2016–2018), post-NICP (2018–2020) and (2021–2022) to measure sustainability of implementation. Data included: gestational age (GA), birth weight, NIVS days, incidence, grade and day of DRPI. Statistical analysis of incidence rate ratio was completed between pre and postgroups.SettingAustralian neonatal intensive care unit.PatientsAll neonates ≤32 weeks requiring nCPAP.InterventionsEvaluation of types of interfaces, introduction of hydrocolloid dressing and the development and implementation of NICPMain outcome measures: incidence and severity of DRPI.ResultsTotal DRPI recorded in all CPAP babies pre/post NICP were (59/659 (9.0%), 26/574 (4.5%), p=0.0032, respectively). Analysis showed DRPI incidence rates per 1000 NIVS days ((10.6, 5.5), p=0.0001, respectively). 75 (88%) of DRPI occurred in the ≤32 week group of neonates requiring NIVS. Review of babies ≤32 weeks across the three intervals showed significant improvement with time (55 (19%); 27 (13%); 19 (9%), p=0.0001).ConclusionsPreferred nCPAP interface, nasal dressing and NICP have reduced the incidence and severity of DRPI in the NICU.

Neonatal hypertension occurs in up to 2% of neonatal intensive care survivors and in up to 3% of all neonates. Normal blood pressure (BP) measurements are required to diagnose and manage appropriately both hypotension and hypertension in the neonate and infant. The aim of this study was to provide normative BP measurements during the first year of life of healthy infants born at term, using an oscillometric method. Neonates were enrolled from August 2003 to August 2005. Exclusion criteria included: infants of mothers with hypertension or diabetes of any type, use of illicit substances, congenital or chromosomal anomaly, admission to the neonatal intensive care unit or possible sepsis. There were 406 infants enrolled, with 150 children followed at 6 months of age and 118 children at 12 months of age. There were no differences in BP measurements at 6 months or 12 months of age by gender, weight or height. A BP measurement above the 90th percentile on day 2 or at 6 months was not predictive of a BP above the 90th percentile at 12 months of age. Higher systolic and diastolic measurements at 6 months and 12 months were found, in comparison to those in previous studies using ultrasonic devices. The findings of this study provide normative BP values for infants during their first year of life, using the oscillometric method, the most frequently used method in paediatric, neonatal intensive care and emergency departments.

Neonatal hypertension is an uncommon but important complication of intensive care management. The aims of this study were to identify in neonates with hypertension: antenatal and postnatal risk factors; aldosterone and renin levels; and report on outcome in early infancy. The study involved a retrospective review of neonates diagnosed with systemic hypertension from January 2001 to December 2005. Demographic data, risk factors, laboratory investigation, and follow-up data at 3-6 months of age were collected. Of the 2,572 newborn infants included, 34 (1.3%) had neonatal hypertension. Gestational age and birth weight and length were significantly lower in infants with hypertension. The median postnatal age at diagnosis of systemic hypertension was 5.0 days. Antenatal steroid administration, maternal hypertension, umbilical arterial catheter, postnatal acute renal failure, patent ductus arteriosus, indomethacin treatment and chronic lung disease were associated with the development of neonatal hypertension [odds ratios (OR) 8.7, 3.8, 10.0, 51.8, 5.9, 5.7 and 7.7, respectively]. Elevated aldosterone and renin levels occurred in 60% and 33% but had normalised in the majority by 6 months of age. The majority of infants do not require treatment for hypertension by 6 months of age.

Hypertension is encountered in up to 3% of neonates and occurs more frequently in neonates requiring hospitalization in the neonatal intensive care unit (NICU) than in neonates in newborn nurseries or outpatient clinics. Former NICU neonates are at higher risk of hypertension secondary to invasive procedures and disease-related comorbidities. Accurate measurement of blood pressure (BP) remains challenging, but new standardized methods result in less measurement error. Multiple factors contribute to the rapidly changing BP of a neonate: gestational age, postmenstrual age (PMA), birth weight, and maternal factors are the most significant contributors. Given the natural evolution of BP as neonates mature, a percentile cutoff of 95% for PMA has been the most common definition used; however, this is not based on outcome data. Common causes of neonatal hypertension are congenital and acquired renal disease, history of umbilical arterial catheter placement, and bronchopulmonary dysplasia. The treatment of neonatal hypertension has mostly been off-label, but as evidence accumulates, the safety of medical management has increased. The prognosis of neonatal hypertension remains largely unknown and thankfully most often resolves unless secondary to renovascular disease, but further research is needed. This review discusses important factors related to neonatal hypertension including BP measurement, determinants of BP, and management of neonatal hypertension.

IntroductionHyperglycemia in pregnancy (HIP, including gestational diabetes and pre-existing type 1 and type 2 diabetes) is increasing, with associated risks to the health of women and their babies. Strategies to manage and prevent this condition are contested. Dynamic simulation models (DSM) can test policy and program scenarios before implementation in the real world. This paper reports the development and use of an advanced DSM exploring the impact of maternal weight status interventions on incidence of HIP.MethodsA consortium of experts collaboratively developed a hybrid DSM of HIP, comprising system dynamics, agent-based and discrete event model components. The structure and parameterization drew on a range of evidence and data sources. Scenarios comparing population-level and targeted prevention interventions were simulated from 2018 to identify the intervention combination that would deliver the greatest impact.ResultsPopulation interventions promoting weight loss in early adulthood were found to be effective, reducing the population incidence of HIP by 17.3% by 2030 (baseline (‘business as usual’ scenario)=16.1%, 95% CI 15.8 to 16.4; population intervention=13.3%, 95% CI 13.0 to 13.6), more than targeted prepregnancy (5.2% reduction; incidence=15.3%, 95% CI 15.0 to 15.6) and interpregnancy (4.2% reduction; incidence=15.5%, 95% CI 15.2 to 15.8) interventions. Combining targeted interventions for high-risk groups with population interventions promoting healthy weight was most effective in reducing HIP incidence (28.8% reduction by 2030; incidence=11.5, 95% CI 11.2 to 11.8). Scenarios exploring the effect of childhood weight status on entry to adulthood demonstrated significant impact in the selected outcome measure for glycemic regulation, insulin sensitivity in the short term and HIP in the long term.DiscussionPopulation-level weight reduction interventions will be necessary to ‘turn the tide’ on HIP. Weight reduction interventions targeting high-risk individuals, while beneficial for those individuals, did not significantly impact forecasted HIP incidence rates. The importance of maintaining interventions promoting healthy weight in childhood was demonstrated.

Blood pressure (BP) measurements have been increasingly used across neonatal intensive care units to determine and monitor hemodynamic status in neonates. A number of studies have attempted to derive normative blood pressure data in both preterm and term infants. However, this still remains a complex process, as several maternal and neonatal factors influence neonatal blood pressure. Maternal conditions, including hypertension and preeclampsia, seem to have some impact on neonatal BP, while maternal drugs, in particular antenatal steroids, seem to have a strong influence. Among the neonatal factors, gestational age, post-conceptual age and weight seem to have the strongest influence. The paucity of data on the short and long term effects of maternal conditions and medication on neonatal BP requires further research.

Extremely preterm neonates are at risk of morbidity and mortality related to their underdeveloped skin barrier. Humidified incubators are typically used in their care, but there is a paucity of literature to inform the standardization of specific evidence-based humidification practices in the NICU. A brief, voluntary, anonymous survey was distributed to our home institution and numerous national and international external institutions. Survey questions pertained to institutional humidification guidelines and were qualitatively analyzed. We received 89 responses from the home institution and 42 responses from the external institutions. Within the home institution, despite the presence of a guideline, individual practitioners reported varying practices in the starting levels of humidity and length of time spent in humidity. The results also demonstrated significant variability in individual humidification practices between the external institutions. There is no standard humidification guideline for extremely preterm neonates being cared for in the NICU. Further research is required to provide appropriate evidence on which to base clinical guidelines for the management of extremely preterm neonates to prevent morbidity and mortality in this population.

BackgroundHypertension occurs in up to 3% of neonates admitted to the Neonatal Intensive Care Unit (NICU), and is a potentially under-recognized condition. The aim of this study was to examine the incidence of documented and undiagnosed hypertension from the 24-center Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) database, and to assess risk factors for hypertension according to gestational age.MethodsDiagnosed hypertension was documented if an infant had a discharge diagnosis of hypertension and/or discharged on antihypertensive medications. Undiagnosed hypertension was defined when infants did not have a diagnosis of hypertension, but >50% of the lowest mean, diastolic and systolic blood pressure recordings were >95th percentile for gestational age.ResultsOf the 2162 neonates enrolled in the study, hypertension was documented in 1.8%. An additional 3.7% were defined as having undiagnosed hypertension. There was a significant correlation with neonatal hypertension and acute kidney injury (AKI). Additional risk factors for neonatal hypertension were hyperbilirubinaemia, Caucasian race, outborn, vaginal delivery, and congenital heart disease. Protective factors were small for gestational age, multiple gestations, and steroids for fetal maturation.ConclusionsNeonatal hypertension may be an under-recognized condition. AKI and other risk factors predispose infants to hypertension.

BackgroundPhotobiomodulation by 670 nm red light in animal models reduced severity of ROP and improved survival. This pilot randomised controlled trial aimed to provide data on 670 nm red light exposure for prevention of ROP and survival for a larger randomised trial.MethodsNeonates <30 weeks gestation or <1150 g at birth were randomised to receive 670 nm for 15 min (9 J/cm2) daily until 34 weeks corrected age. Data collected: placental pathology, growth, days of respiratory support and oxygen, bronchopulmonary dysplasia, patent ductus arteriosus, necrotising enterocolitis, sepsis, worst stage of ROP, need for laser treatment, and survival.ResultsEighty-six neonates enrolled—45 no red light; 41 red light. There was no difference in severity of ROP (<27 weeks—p = 0.463; ≥27 weeks—p = 0.558) or requirement for laser treatment (<27 weeks—p = 1.00; ≥27 weeks—no laser treatment in either group). Survival in 670 nm red light treatment group was 100% (41/41) vs 89% (40/45) in untreated infants (p = 0.057).ConclusionRandomisation to receive 670 nm red light within 24–48 h after birth is feasible. Although no improvement in ROP or survivability was observed, further testing into the dosage and delivery for this potential therapy are required.