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2

Evidence Based SpO2 Monitoring: Targeting in Preterm Infants

Augusto Sola

President of Ibero-American Society of Neonatology (Siben), USA

Oxygen is a neonatal health hazard. Three randomized clinical trials (RCT’s) studied SpO2 targeting in

infants 28 weeks gestation using signal extraction technology oximeters (SET, Masimo, Irvine, Ca.). Two

SpO2 targets were compared (85-89% vs 91-95%). In two RCT’s SpO2 85-89% was associated with

increased mortality and SpO2 91%-95% with a higher incidence of severe retinopathy of prematurity (ROP).

The other RCT revealed no differences in mortality or ROP between the two SpO2 targets.

SpO2 of 85-89% cannot be recommended. SpO2 of 91-95% is a narrow target that can be associated with

hyperoxia.

Wider intermediate targets may be safer than 85-89% and 91-95%.

3

Universal CCHD Screening Saves Lives: International Update in CCHD Screening

Anne de-Wahl Granelli

Heriot-Watt University, India

30% of the babies with critical congenital heart disease (CCHD) leave the newborn nurseries without a

diagnosis. Five percent of them will die without a diagnosis, and 25% return with a circulatory collapse. In

2011, the US secretary of health recommended to add CCHD screening with pulse oximetry to the

mandatory newborn tests. Several multicenter studies have concluded that this simple test reduces the risk

significantly.

The international progress of CCHD screening with pulse oximetry in USA, Europe and Asia will be shared

with you.

4

Clinical Matters and Discernment on Neonatal SpO2 Monitoring

Augusto Sola

President of Ibero-American Society of Neonatology (Siben), USA

SpO2 in daily clinical practice will be presented to provide bedside neonatal care providers with tools to

improve monitoring, clinical decision making and avoid undesired hazardous hypoxia and hyperoxia. There

are many SpO2 monitors in the market. Signal extraction technology oximeters (SET, Masimo, Irvine, Ca)

measure through motion and low perfusion and provide perfusion index. For resuscitation and continuous

care of ill neonates several technical issues are of importance, including types of sensors used and their

placement and other. SpO2 targets of 85-89% or of 91-95% are not ideal. Wider intermediate targets may be

safer than both of them.

5

Evidence Based Medicine: Advantages and Implementation of Screening for

Critical Congenital Heart Disease

Anne de-Wahl Granelli

Heriot-Watt University, India

The strategies for implementing CCHD screening with pulse oximetry were endorsed by AAP, ACC and

AHA in 2011, and based on European research. The journey from identifying the problem, finding evidence

based solution and implementing CCHD screening across Sweden will be shared. Pitfalls, obstacles and

answers to the most common questions about implementing a CCHD screening program will be shared with

you.

6

Effect of Therapeutic Hypothermia on DNA Damage and Neurodevelopmental Outcome among Term

Neonates with Perinatal Asphyxia: a Randomised Controlled Trial

Bahubali Gane1, Vishnu Bhat

1, Nandakumar S

2, Ramachandra Rao

2, Ramachandra Rao,

Harichandrakumar K T3

1Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), India

2Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), India

3Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), India

Background: One of the mechanism by which therapeutic hypothermia acts is by reduction in oxidative

stress-induced DNA damage. We studied the effect of therapeutic hypothermia on DNA damage with the

help of comet assay (Olive tail moment) and oxidative stress by serum 8-hydroxy2-deoxyguanosine(8-

OHdG).

Objective: To study the effect of therapeutic hypothermia on oxidative stress-induced DNA damage and

neuro developmental outcome in term babies with perinatal asphyxia.

Methods: Babies were randomized into hypothermia and control group. Babies in the hypothermia group

were cooled for the first 72 h after birth using cloth-covered gel packs.

Target rectal temperature of 33–340C was maintained for 72hours. Blood sample was collected before, at 36

h and after completion of therapeutic hypothermia (at 72 h) for DNA damage and oxidative stress

assessment using comet assay & 8-hydroxy2-deoxyguanosine. Infants were followed up to 18 months and

neurodevelopmental assessment was done using Developmental Assessment Scale for Indian Infants

(DASII), Indian adoption of Bayley Scale

Results: There were no significant differences in baseline parameters. After 72 h, the hypothermia group

showed lower olive tail moment (12.88±2.14 arbitrary units) than the control group (22.16±5.26) (p0.05). 8-

OHdG levels increased drastically in control group (1252.87±357.07) than the hypothermia group

(757.03±198.49) (p0.05).

Neurodevelopmental assessment at 18 months showed significantly low motor and mental developmental

quotient in control than the hypothermia group.

Conclusion: Therapeutic hypothermia reduces oxidative stress-induced DNA damage and improves

neurodevelopmental outcome at 18 months in perinatal asphyxia.

7

Neonatal Resuscitation- An All Wales Survey on Training of Junior Doctors

Jaya Parasuraman

Wales Deanery, UK

Introduction: All junior doctors undertaking pediatrics rotation are expected to attend deliveries and

provide at least the basic level of neonatal resuscitation. This is quite daunting especially to junior doctors at

the foundation level. This survey looked into the training available to the junior doctors in neonatal

resuscitation prior to and during their pediatrics rotation in the Welsh hospitals.

Methods: Junior doctors doing their first pediatrics rotation requiring neonatal resuscitation were included

in the survey. They include foundation level doctors (F1/F2), GP trainees, junior pediatric trainees

(ST1/ST2) and trust grade doctors. The online-based survey was sent to them through Wales Deanery, local

postgraduate centers, pediatric secretaries and WRCPCH Facebook page. The survey was conducted from

December 2012 to April 2013.

Results: 26 doctors responded to the survey from hospitals all over Wales. 26.9% of doctors were not aware

that they had to provide neonatal resuscitation in their rotation. 88.5% of them have not attended Neonatal

Life Support course. 24% of doctors did not receive formal training in neonatal resuscitation prior to

attending deliveries.

40% of doctors attended 5 deliveries under supervision initially. A concerning 40% of juniors doctors have

been put in a situation where they felt not competent in attending neonatal resuscitation independently.

Conclusion: This survey has identified a gap in the neonatal resuscitation training provided to junior

doctors. In response to this, a study day focusing on basic neonatal resuscitation is being set up for the junior

doctors.

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Preferential Cephalic Redistribution of Left Ventricular Cardiac Output during Therapeutic

Hypothermia for Perinatal Hypoxic-Ischemic Encephalopathy

Ori Hochwald1, Mohammed Jabr

2, Horacio Osiovich

2, Steven Miller

3, Patrick

McNamara3, Pascal Lavoie

2

1Rambam Medical Center, Israel

2University of British Columbia, Canada

3Hospital for Sick Children and the University of Toronto, Canada

Background: Therapeutic hypothermia (TH) improves outcomes in newborns with perinatal hypoxic-

ischemic encephalopathy (HIE) and is now the standard of care in neonatology. However, data

are lacking on the hemodynamic effects of TH on the systemic and cerebral blood circulations in newborns.

Objective: To determine the relationship between left ventricular cardiac output (LVCO), superior vena

cava (SVC) flow and brain injury during whole-body TH. Study design: Sixteen newborns with moderate or

severe hypoxic ischemic encephalopathy were studied using echocardiography during and immediately after

TH. Measures were also compared with twelve healthy control newborns of similar post-natal age.

Newborns undergoing TH also had a cerebral magnetic resonance imaging (MRI) as part of routine clinical

care on post-natal day 3 to 4.

Results: LVCO was markedly reduced (mean+/-SD: 126+/-38 mL/kg/min) during TH, whereas SVC flow

was maintained within expected normal values (88+/- 27 mL/kg/min) such that SVC flow represented 70%

of the LVCO. This reduction in LVCO during TH was mainly accounted by a reduction in heart rate (99 +/-

13 BPM versus 123 +/- 17 BPM; p0.001) compared to immediately post-warming in the context of

myocardial dysfunction. Neonates with documented brain injury on MRI showed higher SVC flow pre-

rewarming, compared to new borns without brain injury(p=0.013).

Conclusion: Newborns with perinatal hypoxic-ischemic encephalopathy showed a preferential systemic-to-

cerebral redistribution of cardiac blood flow during whole-body TH, which may reflect a lack of cerebral

vascular adaptation in newborns with more severe brain injury.

9

Incidence and Outcomes of Asphyxia in Term and Near-Term Infants Born in Public Hospital from a

Low-Middle-Income Country

Sithembiso Velaphi

University of Witwatersrand, South Africa

Background: Birth asphyxia is one of the common causes of mortality in neonates. Asphyxia

incidence and outcomes in developing countries are not commonly reported.

Objectives: To determine the incidence and outcomes of asphyxia at hospital discharge in a public hospital

from a low-middle-income-country.

Methods: This was a retrospective descriptive study. Records of neonates weighing ≥2000g who were

admitted or died in delivery-room with a primary diagnosis of asphyxia (defined as need for bag mask

ventilation and admission to NICU) were reviewed for maternal/infant characteristics, resuscitation and

outcomes at hospital-discharge.

Results: Among the 23035 total live-births per year, 21086 weighed ≥2000g of which 357 had a diagnosis of

asphyxia, giving an incidence of 16.9/1000 live-births. Using other criteria to define asphyxia the incidence

varied from 2.5 to 12.1/1000 live births. Resuscitation required was bag mask-ventilation only in 90%,

while 7% and 3% also required chest-compressions and adrenalin respectively. Hypoxic-ischaemic-

encephalopathy (HIE) Stage-I occurred in 131 (47%), Stage-II in 122 (43%) and Stage-III in 28 (10%) with

mortality rates of 1.5%, 5.7% and 57% respectively. Infants who had Apgar score 5 at 10 minutes, required

adrenalin or took more than 20 minutes to spontaneous breathing were more likely to die or have moderate to

severe HIE with odds ratio of 19.13 (95% CI;5.66-66.89); 81.2 (95% CI; 13.17-647.7) and 27.9 (95% CI;

6.89-117.3) respectively.

Conclusion: Incidence of asphyxia is high. Severe HIE is associated with high mortality. Apgar score 5 at

10 minutes, use of adrenalin and time-to-spontaneous-respiration may be useful in decision making where

resources are limited.

10

Helping Babies Breathe (HBB) Training in Remote Areas of China: Educational Impact of a Pilot

Training Workshop

Qing Yue1, Tao Xu

1, Huishan Wang

1, Linmin Gong

1, Danhua Wang

2, Lixin Wang

3,

Mei Jiang4, Shiwen Xia

5, Tong Zhang

1

1National Center for Women and Children's Health,China CDC, China

2Peking Union Medical Colledge Hospital, China

3Global Care Women and Children's Hosipital, China 4Beijing Obstetrics and Gynecology Hosipital, China

5Hubei Province Women and Children's Health Care Hospital, China

Background: Helping Babies Breathe (HBB) is an evidence-based educational program which teaches the

simple and essential steps that effectively resuscitate the majority of infants not breathing at birth, aiming to

reduce mortality from birth asphyxia. HBB could extend resuscitation training in resource-limited settings.

Objective: To evaluate the training effectiveness of HBB program in remote areas of China, providing

proposal and reference for expanding HBB program in future. Based on the HBB educational materials of

American Academy of Pediatrics (APP), a two-day intensive training work was carried out by sufficient

master trainers among 73 healthcare providers from county level hospitals of Tibet and Sichuan province in

2013. The neonatal resuscitation (NR) knowledge of trainees and their self-confidence to complete NR were

evaluated and compared before and after training. Bag and mask ventilation skills and objective structured

clinical examination (OSCE) Station A and Station B were assessed after the training.

Methods: NR knowledge score improved from 12.43±3.50 to 15.86±1.60 after HBB training, with

statistically significant difference (t=7.42, P0.001). NR confidence score improved from 2.15±1.01 to

3.38±0.80, with statistically significant difference (t=7.72, P0.001). 72.2% of 73 trainees mastered the whole

7 items on bag and mask ventilation skill after training, and 16.7% of trainees mastered 6 items of the skill.

92.3% of trainees passed the OSCE A assessment, 83.9% passed the OSCE B assessment, and 77.4% passed

both assessments.

Conclusions: Healthcare providers participating the HBB training can significantly improve their NR

knowledge and confidence. More simulation trainings are needed for healthcare providers to master the

practical bag and mask ventilation skills, and deal with complex clinical cases correctly.

11

Egyptian Neonatal Network, Four-Year’s Experience

Mohamed Reda Bassiouny, William Keenan, Amr Elshahed

Egyptian Neonatal Network, Egypt

The field of neonatology has been dramatically changed during the past decade. With these changes, it was

not always clear what was the "best" practice. Evidence of this is seen in the wide variations in outcome and

process indicators in the network database. There are many Neonatal networks all over the world e.g.

Vermont Oxford Network, National Institute of Child Health and Human Development, Canadian Neonatal

Network and European Neonatal Network. Egypt showed advancement in neonatal care provided in many

NICUs. For evidence based neonatal care, continuous collaboration should be established between these

Units. An Egyptian Neonatal Network (EGNN) is established 2010 in Egypt supported by Tempus Grant

from EU to study our local problems . EGNN is not-for-profit organization whose mission is to improve the

quality and safety of medical care for newborns and their families through a co-ordinated program of

research, education and quality improvement projects. This can be achieved through: creating databases,

conducting outcomes research, clinical trials and collaborative quality improvement. Since then 38 neonatal

units have joined. They add more than 10,000 patient's records.

The data were defined in advance. Also data has been verified and passed three phases of validation before

analysis. A centre participating in EGNN can receive important benefits including: reports with feedback

about its performance, opportunities to participate in collaborative quality improvement projects, research

projects and clinical trials, the Network’s newsletter and notifications of annual meetings. This will facilitate

audit – outcomes and resource use, research – clinical trials, health services, population health, translational

research, quality improvement, professional guidelines, education and training, policy and resource

allocation decisions, advocacy and international collaborations. The activities of EGNN will be displayed.

All neonatal associations and Funding agents are invited to share and support EGNN and to extend their

work to regional and international network.

12

Comparison of Two Natural Surfactants for Pulmonary Hemorrhage in Very Low Birthweight

Infants: a Randomised Controlled Trial

Dilek Dilli, Şenol Bozdağ, Tülin Gökmen, Uğur Dilmen

Zekai Tahir Burak Maternity and Teaching Hospital, Turkey

Objective: To compare the efficacy of two natural surfactants for pulmonary hemorrhage in very low

birthweight (VLBW) infants. Study design: A prospective randomised controlled trial were conducted on 42

infants who were divided into two groups; poractant alfa (n=21) and beractant (n=21). Primary outcome

measure was oxygenation index (OI) calculated before and after surfactant.

Results: In groups, the mean (SD) birthweight and gestational age were similar [1051g (236) vs 1074g

(242), P=0.33] and [27.9 (2.3) vs 27.2 (2.3), P=0.89]. Although the mean OI increased after pulmonary

hemorrhage compared to baseline value and decreased after surfactant in both groups, variations in OI were

more prominent in poractant alfa group [before pulmonary hemorrhage: 11.9, after pulmonary hemorrhage:

22.7, after surfactant: 14.6, P=0.003 vs before pulmonary hemorrhage:11.1, after pulmonary hemorrhage:

17.9, after surfactant: 12.8, P=0.02]. There was no significant difference between the groups for after

surfactant OI values (P=0.59). The rates of bronchopulmonary dysplasia (BPD) and mortality related to

pulmonary hemorrhage were similar in groups.

Conclusion: Both natural surfactants improved oxygenation when administered for pulmonary hemorrhage

in VLBW infants. The type of surfactant seems to have no effect on BPD and mortality rates in

these patients.

13

Volume Guarantee Pressure Support Ventilation in Extremely Preterm Infants and

Neurodevelopmental Outcome at 18 Months

Beatrice Stefanescu1, Naima Frewan

2, Chris Slaughter

1, Michael O'Shea

2

1Vanderbilt University School of Medicine, USA

2Wake Forest University School of Medicine, USA

Background: Compared to pressure-controlled ventilation, volume targeted ventilation is associated with

decreased neonatal complications including the combined outcome of death or bronchopulmonary dysplasia.

However, little is known about its effect on neurodevelopmental outcomes.

Objective: We evaluated the hypothesis that as compared to pressure-controlled ventilation, volume

targeted ventilation, increases survival without neurodevelopmental impairment in extremely preterm

infants.

Methods: We studied a cohort of extremely preterm infants (birth weight ≤ 1250 grams) managed with

either volume guarantee pressure support ventilation (VGPSV; n=135) or pressure controlled ventilation

(PCV; n=135). Infants were evaluated at 18 months adjusted age with a standardized neurological

examination and the Bayley Scales of Infant Development-Third Edition (Figure

1).

Logistic regression models were used to evaluate the association of ventilation mode and

neurodevelopmental outcomes.

Results: Infants in the VGPSV group had a shorter time on mechanical ventilation than infants in the PCV

group (median time on mechanical ventilation was 11, and 23 days, respectively; log rank p value 0.01;

Figure 2).

14

Rates of pulmonary interstitial emphysema (OR 0.6, [0.4, 0.8]; p = 0.006), hypotension (OR 0.7, [0.5, 0.9]; p

= 0.01), and mortality were lower among infants treated with VGPSV (OR 1.7, [1.01, 2.9]; p = 0.03).

Seventy percent (155/221) of survivors were evaluated at 18 months adjusted age. No difference was found

in the risk of the combined outcome of death or neurodevelopmental impairment (Table 1).

15

Conclusion: Although VGPSV was associated with lower mortality and improved short-term outcomes, it

was not associated with improved neurodevelopmental outcome. The lack of improvement in

neurodevelopmental outcome among infants treated with volume ventilation might be attributable to

improved survival of infants at particularly high risk of impairment.

16

Surfactant replacement therapies; Poractant versus Beractant; 5 Years’ Experience of Ankara

Training Research Hospital

Hatice Tatar Aksoy1, Serçin Taşar

2, İnci Arıkan

2, Yıldız Dallar Bilge

2

1Ankara Training and Research Hospital, Turkey

2Ankara Training and Research Hospital, Turkey

Background: Surfactant replacement in preterm infants with respiratory distress syndrome (RDS) has been

a major therapeutic breakthrough. Surfactant also can be used in other.

Objective: To evaluate indications of surfactant replacement therapies in a NICU of a research hospital and

compare the outcomes of the usage of two different form (poractant vs beractant).

Methods: In this retrospective trial, we evaluated the outcomes of 137 infants treated with surfactant in 5

Years period. 23 infants were treated with poractant, 114 infants were treated with beractant.

Results: Mean gestational age and birth weight was not different between the groups (32 vs 32

weeks, 1972g vs 2000g, p=0.76 and p=0.9 respectively). The primary diagnosis was MAS in 27 patients and

pneumonia in 4 patients and RDS in 82 patients in beractant group. In poractant group 4 patients had MAS,

18 patients had RDS and 1 had pneumonia. Median hospitalization time of the patients was shorter in

poractant group but the difference was not statistically different (21,3 vs 23,9 days p=0.6). Median duration

of mechanical respiratory support was not different between the groups (1,54 vs 3,12, p=0.3). Three patients

had pneumothorax, four patients had pulmonary hemorrhage in beractant group. Mortality rate did not differ

between the groups (%12 vs %22 p=0.43).

Conclusion: Pneumothorax and pulmonary hemorrhage were not detected with poractant group. Median

hospitalization time of the patients was shorter in poractant group but it is not statistically significant, this

can be a result of the small sample size of the poractant group.

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Reference Ranges of Tidal Volume in Preterm Infants Supported with Continuous Positive Airway

Pressure

Qaasim Mian1,2

, Gerhard Pichler1,2,3

, Corinna Binder3, Megan O'Reilly

1,2, Khalid Aziz

1,2,

Berndt Urlesberger3, Po-Yin Cheung

1,2, Georg Schmolzer

1,2,3

1Royal Alexandra Hospital, Canada 2University of Alberta, Cambodia

3Medical University, Austria

Objective: To describe changes in tidal volume (VT) and their correlation to changes in oxygen saturation

and heart rate in spontaneously breathing preterm infants immediately after birth.

Study design: In this prospective observational two-center study a flow sensor was attached to the facemask

of spontaneously breathing infants born at 37 weeks gestational age who received continuous positive airway

pressure (CPAP) immediately after birth. Respiratory function, heart rate, and oxygen saturation were

continuously recorded during spontaneous breathing

Results: Fifty-five infants receiving mask CPAP in the delivery room with a mean (SD) gestational age 31

(3) weeks and birth weight 1647 (500) grams were included. CPAP was started at a median (IQR) 103 (56-

186) seconds after birth and was delivered for 269 (205-379) seconds. Median VT ranged between 4.2-5.8

mL/kg with the individual VT varied between 0.9 and 19.8 mL/kg. Overall, VT increased over the first few

minutes after birth and decreased thereafter. The rise in saturation after birth lagged the published normal

ranges for spontaneously breathing preterm infants without CPAP.

Conclusions: The 50th

centile for spontaneous VT in preterm infants during mask CPAP ranged from 4.2 to

5.8 mL/kg with wide individual variation in the first minutes after birth. Preterm babies requiring CPAP

after birth may take longer to achieve so-called “normal” saturation targets.

18

Using Mesenchymal Stem Cells to Treat Lung Injury: Effects in a Rat Model of Bronchopulmonary

Dysplasia

Megan O'Reilly1, Marius Moebius

1, Farah Eaton

1, Lavinia Ionescu

1, Saima Rajabali

1,

Rajesh Anthuvan1, Arul Vadivel

2, Bernard Thebaud

2

1University of Alberta, Canada

2Ottawa Hospital Research Institute, Canada

Background: Many preterm infants develop a chronic lung disease known as bronchopulmonary dysplasia

(BPD), which interrupts lung development and results in long-term pulmonary complications that reach into

adulthood. Mesenchymal stem cells (MSCs) prevent lung injury in experimental BPD in newborn rats.

Whether MSCs can restore normal lung growth after established lung injury is clinically relevant,

but unknown.

Aim: Determine if administration of MSCs offers any therapeutic benefit to the adult BPD lung.

Methods: Experimental BPD was achieved by exposing newborn rats to 95%O2 from postnatal day 4-14.

Animals were then housed in room air (RA) until adulthood. Controls were exposed to RA. MSCs were

isolated from human umbilical cord and intratracheally administered to rats (1x106cells/kg). Three time-

points were investigated: MSC-treatment at 1, 3, and 6 months (mo) followed by harvest at 2, 5, and 8mo

respectively. -exposed rats exhibited persistent lung injury characterized by arrested alveolar growth with

airspace

Results: Adult O2enlargement. MSC-treatment at 1 and 3mo partially attenuated injury, but not at 6mo.

Lung function parameters were not significantly different between treatment groups at all ages. O2-

exposed rats ran a shorter distance at 1 and 6mo, demonstrating lower exercise capacity, but not at 3mo.

Exercise capacity was not significantly different after MSC treatment.

Conclusions: Treatment of the adult BPD lung with MSCs has the potential to improve lung injury if

administered at an early stage of adulthood. Further studies are required to determine if cell-based strategies

can be optimized to achieve therapeutic benefit later in adulthood.

19

Does Increasing Blood Sample Volume Improve the Yield of Blood Cultures in the Neonatal Intensive

Care Unit? - A Prospective Controlled Trial

Ruben Bromiker1, Nurit Yakobi

2, Maskit Bar Meir

3

1Shaare Zedek Medical Center, Israel

2Shaare Zedek Medical Center, Israel

3Shaare Zedek Medical Center, Israel

Background: Bacteremia is a frequent complication in neonatal intensive care units (NICU). Blood cultures

are the gold standard for the diagnosis. It is a common practice to draw small blood volumes for culture from

neonates in order to prevent anemia, however this might compromise the sensitivity of the test. We examined

whether using 1 ml of blood in an single aerobic bottle would improve the yield as compared to the current

practice of obtaining two samples of 0.5 ml of blood (aerobic and anerobic bottles).

Methods: A prospective controlled study was conducted between December 2009 and September 2010 at

the NICU of Shaare Zedek Medical Center, Jerusalem, Israel. Study samples were 1ml blood cultures in

single aerobic bottle, while control samples (paired) were as described above in our current practice. Culture

bottles were weighed before and after blood inoculation. Time to positivity (TTP) was also recorded

Results: We obtained 706 complete culture sets from 519 patients. Pathogens grew in 72 cultures from 37

patients. From these 72 cases, isolation of organisms was significantly higher in the control group (94.4%

versus 77.7%, McNemar's test, p = 0.012). TTP in 0.5ml and 1ml aerobic bottles was similar and

significantly shorter compared with anaerobic bottles.

Conclusions: Contrary to our hypothesis, increasing the blood culture volume to 1ml in a single aerobic

bottle did not improve the yield of the test, nor did it shorten the time to positivity. The current NICU

practice for obtaining cultures is validated.

20

Usefulness of Pulse Oximetry Screening in the Newborns for Detecting Critical Congenital Heart

Disease in Rural Hospital

Amar Taksande

Jawaharlal Nehru Medical College, Sawangi Meghe, Wardha, India

Background: Congenital cardiovascular malformations are the most common category of birth defects and

responsible for more deaths in the first twelve month of life. Critical congenital heart disease (CCHD) will

be present in approximately one quarter of these children, which requires catheter or surgery intervention in

the first year of life.

Aim: To determine the accuracy of pulse oximetry screening for detecting clinically unrecognized CCHD in

the newborns.

Methods: Pulse oximetry was performed on clinically normal newborns at within 4hour of first day of life.

If screening oxygen saturation (SpO2) was below 90%, echocardiography was then performed. Inclusion

criteria: All newborns who wasadmitted in postnatal ward & NICU. Exclusion criteria: Out born babies and

babies with a prenatal diagnosis of duct dependent circulation.

Results: Pulse-oximetric screening was performed on 2100 clinically normal newborns. Low SpO2 (90%)

was found in eight babies seven of them had CCHD, including three patient with TGA, two with tricuspid

atresia, one with tetralogy of fallot and one with transposition of great vessels. A pulse oximetry cut-off

value of below 90% for detecting CCHD showed 100% sensitivity, 99.95% specificity, 87.50% positive

predictive value, 100% negative predictive value.

Conclusions: Pulse oximetry is a safe, feasible test in addition to routine examination of newborn to

improve the early diagnosis of CCHD in the newborn. If oxygen saturation in clinically normal newborns is

below 90% at 4 hours of age, urgent echocardiography is suggested to rule out CCHD.

21

Treatment Outcomes of Infants with Cyanotic Congenital Heart Disease Treated with Synbiotics

Dilek Dilli, Banu Aydın, Aysegül Zenciroğlu, Elif Özyazıcı, Serdar Beken, Nurullah

Okumuş

Dr Sami Ulus Maternity and Children Research and Training Hospital, Turkey

Objectives: The goal was to investigate the effect of orally administered synbiotics on outcome of infants

with cyanotic congenital heart disease (CCHD).

Methods: A prospective, blinded, randomized controlled trial was conducted to evaluate the effect of

synbiotics on outcome of infants with CCHD. The infants with CCHD were assigned randomly to 2 groups.

Infants in the study group were given synbiotic (Bifidobacterium lactis plus inulin) added to breast milk or

mixed feeding until discharge or death. Infants in the placebo group were fed with breast milk or mixed

feeding. The outcome measurements were nosocomial sepsis, necrotizing enterocolitis (NEC; Bell stage =2),

length of NICU stay, and death.

Results: A total of 100 infants were enrolled in the trial: 50 in each arm. There were 9 cases of culture-

proven sepsis (18%) in the placebo group and 2 cases (4%) in the synbiotic group (P = .03). Length of NICU

stay did not differ between the groups (26 [14–36] vs 32 days [20–44], P =.07]. There were 5 cases of NEC

(10%) in the placebo group and none in the synbiotic group (P = .03). The incidence of death was lower in

synbiotic group (5 [10%] of 50 vs 14 [28.0%] of 50, respectively; P = .04).

Conculsions: Synbiotics administered enterally to infants with CCHD might reduce the incidence of

nosocomial sepsis, NEC, and death.

22

The Effect of a Ductus Arteriosus on Left Ventricular wall Shortening, Size and Volume Changes

Measured with Speckle Tracking Echocardiography

Koert de Waal1,2

, Anil Lakkundi1,2

, Farrah Othman1

1John Hunter Children's Hospital, Australia

2Hunter Medical Research Institute, Australia

Background: A ductus arteriosus causes increased preload to the left ventricle and can increase stroke

volume (SV). Preload and contractility determine myocardial wall shortening, and wall shortening and left

ventricular size determine SV. We explored the interaction between wall shortening and left ventricular size

in preterm infants with a range of ductal diameters.

Methods: Ductal diameter (DAd), left ventricular output (LVO) and apical 4 chamber clips were imaged and

analysed using TomTec software. Global longitudinal strain (GLS) and strain rate (GLSR) as measurements

of wall shortening normalised for the length of the wall are provided by the software. The software uses

Simpson’s rule to calculate parameters of left ventricular size, such as end systolic volume (ESV) and end

diastolic volume (EDV).

Results: 124 measurements in 56 infants (median 28 weeks) were analysed. A ductus arteriosus was found

in 88 measurements (median DAd 1.5 mm, range 0.5 to 3.2mm). With 0.5 mm increments in DAd, a gradual

increase in GLS (-17.7 to -19.6%, p 0.01) and GLSR (-1.64 to -1.84s-1

, p 0.01) with a decrease in EDV (2.38

to 1.91ml, p 0.05) and ESV (0.71 to 0.56ml, p 0.05) and no significant change in SV (1.68 to 1.35ml, p 0.12)

and LVO (337 to 363 ml/kg/min, p 0.37) was seen up to a DAd of 1.5 mm. With further increase in DAd,

GLS and GLSR decreased (to -17.7% and -1.62s-1

, p 0.05) with an increase in EDV (to 3.21ml, p 0.05) and

SV (to 2.62ml, p 0.05).

Conclusions: Wall shortening increases and left ventricular size decreases with small increases in preload.

With increasing preload, increased left ventricular size and decreased wall shortening was seen. A decrease

in GLS and GLSR might be used as marker to indicate volume overload in infants with a ductus arteriosus.

23

Life Threatening Signs and Treatment Interventions of Critical Congenital Heart Defects in Newborns

Mary Wyckoff, Sandra Ellingson

University of California Davis Medical Center, USA

Understanding and identifying congenital heart disease can save the newborn infant’s life. Prenatal

ultrasound technology may facilitate identification of underlying disease, but some infants may still present

without this critical prenatal information. Without screening, some newborns with critical congenital heart

defects (CCHDs) might be missed since the life-threatening signs of CCHD might not be evident before an

infant is discharged from the hospital. Infants with CCHDs are at risk for significant morbidity or mortality

early in life due to the closing of the ductus arteriosus and other physiologic changes.

The CDC has implemented a newborn screening using pulse oximetry, which can identify some infants with

critical congenital heart defects (CCHDs). CCHDs are structural heart defects that are generally associated

with hypoxemia and may require cardiac catheterization and early surgical intervention to decrease mortality

and morbidity. CCHDs represent about 25% of all congenital heart defects and the diagnostics screen for 7

primary targets including hypoplastic left heart syndrome, pulmonary atresia with intact septum, tetralogy of

Fallot, total anomalous pulmonary venous return, transposition of the great arteries, tricuspid atresia, and

truncus arteriosus and 5 secondary targets coarctation of the aorta, double outlet right ventricle, Ebstein

anomaly, interrupted aortic arch, and single ventricle.

Treatment protocols will be discussed and case based scenarios will be used to present individual case

identification. The guidelines and use of the bedside Near Infrared Spectroscopy (NIRS) for Infant Cerebral

Function Monitoring will be provided including treatment protocols and interventions for monitoring.

24

Growth Velocity and Early Brain Maturation in Extremely Preterm Infants after Exposure to

Maternal Sounds

Amir Lahav

Brigham and Women's Hospital, Harvard Medical School, USA

Preterm infants in the NICU are often deprived of language exposure that may be crucial for the initial

wiring of their brain. Here we report several studies from our lab examining the effects of maternal speech

sounds on early growth and postnatal brain development. Seventy six (N=76) preterm infants (25-33 wks

GA) were randomly assigned to receive daily exposure to either biological recordings of their own mother's

voice and heartbeat (treatment group) or routine hospital sounds (control group) throughout their hospital

stay. Infants in the treatment group showed significantly improved weight gain velocity (p=0.001) and

increased auditory cortex volume (p=0.05) at one month of age compared to control infants matched for sex,

birth GA, birth weight, and illness severity scores. In addition, we show that exposure to maternal sounds

significantly reduced the number of apnea and bradycardia episodes (p=0.03), suggesting the role of soothing

maternal stimulation in improving cardiorespiratory stability and autonomic self-regulation. These results

suggest that exposing preterm infants to maternal auditory stimulation soon after birth may improve growth

and neurodevelopment in the early postnatal period. Further studies are needed to determine the development

cascade of these effects on subsequent neurodevelopment.

25

Continuous Glucose Monitoring in Preterm Newborns

Enrico Zecca, Eloisa Tiberi, Alessandro Perri, Mirta Corsello, Francesco Cota,

Costantino Romagnoli

Catholic University of the Sacred heart, Italy

We assessed feasibility and reliability of a new continuous glucose monitoring system (CGMS) in 20

preterm newborns with a mean gestational age of 32 weeks and a mean birth weight of 1350 g. A

subcutaneous sensor connected to the CGMS was inserted within 24h of delivery. Data collected from

CGMS were compared with those obtained by a glucometer. Therapeutic management followed the usual

standards protocols. The mean duration of CGMS recordings was 137 h, with a total of 449 paired glucose

measurements. The Bland Altman Analyses showed a mean (95% CI) difference of -6,8 (-37,4 to 23,8)

mg/dl. The Clarke Error Grid (CEG) criteria for clinical significance were met (98% in zone A and B).

Because zones in the CEG were defined for the management of adult or paediatric patients with diabetes, we

then modified the CEG to adapt it to a population of newborns. Again, the CGMS performance met the

criteria for clinical accuracy because we did not find any increase of measurements in zones C, D, and E

which involve an inadequate management of hyperglycaemia or hypoglycaemia. Our experience shows that

the new CGMS is a safe and clinically adequate method to estimate glucose levels in preterm infants. The

new sensor was well tolerated and the wireless connection to the monitor allowed an easy nursing of the

neonates. This CGMS can be useful to check glycemic trends and to detect episodes of hypo- or hyper-

glycaemia that cannot be valuated with a standard glucose monitoring.

26

Monitoring the Oxygen Status in Infants receiving Mechanical Ventilation by means of Transcranial

Cerebral Oximetry

Anna Simonova, Estrin Vladimir

Research Institute of Obstetrics and Pediatrics, Russia

Purpose: To investigate the efficacy of transcranial cerebral oximetry for the diagnosis and prevention of

oxidative stress in newborns on mechanical ventilation.Methods: In step 1 examined 24 healthy infants born

at 38-40 weeks of gestation , with Apgar 7-10 points , with birth weight 2500-3900 , in a state of sleep after

feeding. All children measured oxygen saturation of cerebral tissue (SctL, SctR) at 1, 3 and 5 days after

birth. In the future, the study included two groups of newborns on mechanical ventilation. Group 1 patients

(n = 38) modes of ventilation and FiO2 were established under the control of cerebral oximetry. Group 2

patients (n =37) selection modes of mechanical ventilation and FiO2 was carried out under the control of

pulse oximetry and oxygen tension in capillary blood ( pO2 ) ,excluding cerebral oximetry . All patients

underwent determination of peroxides and protein oxidation products (AORR) in serum at 1, 5, 10 day.

Results: The age norm of cerebral oximetry in healthy infants was in the left hemisphere of the brain 79,2 ±

4,06% (p 0,01), in the right hemisphere 84,89 ± 5,1% (p0,01 ) . In 1group of patients the mean respirable

FiO2 of the blend was 21% in contrast to 55 % for group 2 patients. In group 1 was significantly ( p0,01)

decreased the length of stay on mechanical ventilation ( from 9.4 to 5.6 days ) compared with group 2

patients .In group 1, the content of peroxides reduced 2 times, and oxidation products ofproteins (AORR) 3

fold compared to group 2 ( p 0.05).

Conclusions: Monitoring the oxygen status using transcranial cerebral oximetry decreases FiO2 in

the inspired mixture and does not cause the development of oxidative stress in newborns.

27

Incidence of Neonatal Hypoglycemia in Babies Identified as at Risk and Hospitalized, in a Secondary

Hospital

Montse Pons1, A Bordoy

1, M Garcia

2, E Alemany

1

1Hospital Manacor, Spain

2Hospital Manacor, Spain

Objectives: To determine the incidence of hypoglycemia in babies identified as being at risk , and

hospitalized for any reason ; and also to study the differences and characteristics between each group of

patients.

Study design: Retrospective study. We revised nurse chart of all the babies hospitalized for any reason in

our hospital during 2012 and all babies identified as at risk for hypoglycemia (small, large, infant of a

diabetic mother, late-preterm...) during 2012.

Background: In clinical practice in Neonates Units, we routinely perform blood glucose screening in risk

neonates; but the incidence is not well established in asymptomatic neonates, and there is no evidence that

asymptomatic hypoglycemia has any relevant consequence in psychomotor development (2). The

clinical management of babies at risk of hypoglycemia has also changed over the last decades, with

improved methods for diagnosis, and a greater focus on early feeding and glucose monitoring.

However, there are few recent data on the effects of these changes on the incidence of

neonatal hypoglycemia.

Our hypothesis is that we have very low incidence of neonatal hypoglycemia in our population (secondary

hospital) compared with the results of incidence published in a recent paper (3), but it could be either

because of the population (tertiary hospital) or depending on the definition of neonatal hypoglycemia is used.

We present the results of the review of 348 patients, discuss the results and make recommendations based on

our population characteristics.

28

Analysis of Mortinatality Causes in Almaty in 2008-2011

Nyshangul Bozhbanbayeva, Tykaz Mustaphasade, Saule Dikanbayeva, Guljan

Baigazieva, Indira Suleimenova

Kazakh National Medical University named after S.D. Asfendiyarov, Kazakhstan

The aim of the study was to conduct a perinatal audit with regards to the rate level and causes as a basis for

the development of measures focused on reduction of perinatal and neonatal mortality. We conducted a

retrospective analysis of 2760 mortality cases in Almaty during the period of 2008-2011.

During the study of direct neonatal mortality cases (anatomopathological diagnosis) it was found that the

leading position belongs to asphyxia (31.1%), second position to intrauterine pneumonia (27.5%), respiratory

distress syndrome (20.5%), congenital malformations (14.9%), other (6.1%).

The studies revealed that 1139 newborns died in the juvenile neonatal period and it amounted to 41.3% out

of the whole number of mortality cases of 0-27 days old infants and stillborns. Out of the total number of

stillborns and infants who died within the first 27 days, 605 newborns died within the late neonatal period

which amounts to 21.9%. 1016 cases (36.8%) of stillbirths were registered.

Of all cases of mortality in neonatal period there were 82.6% of preterm infants, 15.5% of full-term infants

and 1.9% of post-term infants.

Only 32.1% of infants with birth weight between 500 and 999 and 24.4% of infants with birth weight

between 1000 and 1499 grams died. Among all stillbirths the majority of infants (74.4%) died in antenatal

period, and 25.3 died in intranatal period. Thus, the analysis of postnatal deaths causes and risk factors

(social and domestic conditions, woman's health, peculiarities of pregnancy and labors) has shown that all

these factors in varying degree influence the state of a newborn child.

29

Early Term: Are They Really Term?

Bahubali Gane, Vishnu Bhat

Jawaharlal Institute of Postgraduate Medical Education & Research, India

Background: The babies born between 37 weeks (260 days) of gestation up to 38 completed weeks (274

days) are called early terms. We focus attention on a subcategory of term because there are increasing data

that these births have higher morbidity and mortality.

Aims: To study morbidity and mortality among early term babies during neonatal period.

Methods: Total 400 babies were included in the study, 200 were early term and 200 full term. Single live

born babies between 37 0/7 weeks to 38 6/7weeks wereincluded as cases after assessing the gestational age

at birth based on maternal history and Extended Ballard’s score. The course of hospital stay and progress

were monitored and recorded. One fullterm (39-42 weeks) baby of the same sex born immediately after the

birth of earlyterms baby was taken as control. The babies were followed up till 28 days.

Results: Early term babies had higher neonatal mortality than full term babies [Relative risk 5(CI: 1.1-22),

P=0.03]. Early term babies had 13% higher mortality than term babies. Early term babies had significantly

higher incidence of perinatal asphyxia [RR-3.7, P0.05], sepsis [RR-4, P0.05], transient tachypnea of

newborn, necrotizing enterocolitis, neonatal hyperbilirubinemia. Mean duration of hospital stay was longer

in early term babies. Early term babies had significantly higher readmission rate during neonatal period.

Conclusion: Early term babies have higher mortality and morbidity when compared to term babies.

30

Outcome for Newborn Babies in Regional Neonatal Intensive Care Unit in Iraq

Raid Umran, Mayumi Iwakawa

Al Zahra Teaching hospital, Iraq

Objective: To document the number, disease pattern and outcome of patients admitted to a neonatal

intensive care unit (NICU) at a high workload receiving requests from maternity units with 24,000 deliveries

yearly.

Design: Descriptive study

Method: The study was conducted at a level II Care NICU at Al Zahra teaching hospital at Najaf, in Iraq,

from January 2011 to August 2013. The data of all the admitted neonates were analyzed, delivery type,

weight at the time of admission, sex, cause of admission and outcome.

Results: Four thousands two hundreds seventy seven neonates were admitted during the study period,

Neonatal mortality was 969 cases. Eighty-six % of death cases were premature (less than 2500g birth

weight). The most common cause of death was respiratory distress syndrome, prematurity followed by

Sepsis and birth asphyxia.

Conclusions: This study identified overloads by maternity case volumes contributes high neonatal mortality,

and mortality rate among infants with low birth weight was high. Attempts to prolong the pregnancy might

improve the neonatal outcome considerably. Shortage of trained nursing staff and ethical issue for maternity

would be discussed.

31

A Divisive Set-up: the Problems Caused by the Separation of Medical and Surgical Neonatal Services

Andrews Hannah

University of Birmingham Medical School, UK

Aims: This paper explores the impact of transferring neonates for surgery by using a sample from

Birmingham, UK. The Women’s Hospital (BWH), houses a level 3 NICU but is 5.5 miles from the

Birmingham Children’s Hospital (BCH) where surgery is carried out but there is no NICU. The separation of

surgical and intensive care services is perceived to be having a negative impact.

Method: Semi-structured parent interviews were carried out at BWH, between May and June 2013. The

interviewees were a convenience sample of parents of preterm surgical neonates (mean birth weight 1293g

(range: 890g-1910g)).

Results: The interviews revealed that the separation of these services is detrimental to parental experiences

and is compromising the consistency and level of neonatal care. Qualitative analysis of the interview

transcripts has identified problem areas for improvement: neonatal nursing care, hygiene, equipment, breast

milk, the NICU/PICU environment, communication, ownership and transport. Some of the suggestions for

improvement were: surgeons to visit the NICU more frequently (where surgery could be performed), the

(re)training of nurses with neonates and the need for clearer transfer/care plans including neonatal

preferences (lighting, touching, noise) and parental needs (emotional and psychological).

Conclusion: The ‘Birmingham-type’ set-up causes additional burden for parents and neonates. Listening to

the parent feedback in this study could lay the groundwork for improving the situation at sites where surgery

and NICU are not co-located. (This project was carried out by a fourth year medical student at the University

of Birmingham Medical School)

32

Solar Powered Portable Culture Incubator

Vasantha Thavaraj1, Brijesh Vashishth

1, Arti Kapil

2, Neeraj Kapur

3

1Indian concil Of Medical research,, India

2All India Institute of Medical Scxiences, India

3Widsons Scientific works Lid, India

Background: The current rate of infant mortality in India is 47/1000, two thirds of which is due to

neonatal mortality1. Neonatal sepsis accounts for more than 50% of the neonatal mortality in India. Ideally

the prompt culture of specimens –The results of the lab tests will help clinicians to institute. This will

culminate in an overall decrease in morbidity and mortality related to sepsis/infections.

In resource-limited countries, in rural communities, there is a distinct lack of (functional) culture facilities;

therefore, these specimens would require to be transported to the nearest well-equipped culture laboratory for

culturing causative organism, and its sensitivity to antimicrobials. Our main aim was to fabricate a portable

culture incubator which could run on solar energy.

Methods: Solar Powered Portable Culture Incubator has been fabricated .It has a culture compartment and

the battery compartment. The Solar Powered Portable Culture Incubator is made of wood and can maintain a

temperature of 35 ± 2º C on a dual system i.e. a battery which is charged through a solar module during

daytime, and switches to normal electric power in the night time . During transportation the temperature

within the incubator is maintained with a solar module installed on the rooftop of the vehicle.

Findings: Sample of pus from an inpatient’s infected wound at a district hospital has been cultured. Blinded

Blood agar plates streaked with bacteria and a control plate were cultured in the Solar Powered Portable

Culture Incubator. The experiment plate grew bacterial colonies but the control plate did not grow any

colonies.

Interpretation: The Solar Powered Portable Culture Incubator will help in establishing mobile culture

facilities at the district level or the sub-district level; therefore, there is a tremendous scope for this product in

our health system in rural as well as urban settings.

33

Neonatal Care without Ventilators: What is the Yield?

Subhashchandra Daga

MIMER Medical College, India

Background: Basic neonatal care, administered through simple interventions, has potential to prevent a

large number of newborn deaths in limited resource setting.

Methods: First, we strengthened following interventions: provision of warmth, enteralfeeding and oxygen

administration for babies with respiratory distress and antibiotics for babies at risk of sepsis.Soon inotropes

and pulmonary vasodilators were introduced. Later, CPAP delivery was started using locally assembled

unit. We “compared with self” the following outcome variables: Weight-wise mortality, excluding babies

less than 1000 g, bed occupancy and hospital stay.

Results: Change in mortality was as follows- 1000-1499 g: 54% to 26.6%,1500-1999 g: 13.6% to 12.2%,

2001-2500g: 2.8% to 3.4% and 2500g: 3% to 2.5%.

Average bed occupancy changed from 13.7 to 14.5 per day and average hospital stay changed from 10.3 to

11.26 days per baby. Survivals in less than 1000 g category are negligible.

Conclusions: A non-ventilatory care can substantially reduce neonatal mortality in all weight categories

except 1000 g.

34

Quality of Neonatal Health care in Kilimanjaro Region, Northeast Tanzania: Learning from Mothers'

Experiences

Bernard Mbwele

Christian Social Service Commission, Tanzania, United Republic of

Background: Neonatal mortality has remained stagnant 26 to 28 deaths per 1,000 live births in the last 3

years. The aim of the study was to assess mothers’ involvement, experiences, perception and satisfaction of

neonatal care in the hospitals of Kilimanjaro region of Tanzania.

Methods: A cross sectional study using qualitative and quantitative approaches in 112 semi-structured

interviews from 14 health facilities. By Purposive sampling, mothers from Peripheral facilities

and Referral Hospital were interviewed for detection of illness, care given to the baby and time spent by the

health worker for care and treatment were studied.

Results: 80 mothers were interviewed from 13 peripheral facilities and 32 mothers were interviewed at a

zonal referral hospital of Kilimanjaro region. Majority of mothers 28 (87.5%) at the referral hospital were

referred from the periphery with critical neonatal condition. From these 28, 12 of them (37.5%) assisted in

raising a concern for further investigations. From the peripheral hospitals of the region 59 mothers (73.8%)

noted neonatal problems and they assisted for attaining diagnosis after a showing a concern for a request for

further investigations. 11 mothers (13.8%) were able to identify the baby’s diagnosis directly without any

assistance, followed by 7 mothers (8.7%) who were told by a relative, and 3 mothers (3.7%) who were told

of the problem by the doctor that their babies needed medical attention. 24 times mothers in the peripheral

hospitals reported bad language like “I don’t have time to listen to you every day and every time.” 77

mothers in the periphery (90.6%) were not satisfied with the amount of time spent by doctors for their

babies.

Conclusion: Mothers of the neonates play great roles in identifying the illness of the newborn. Their

involvement in Health care delivery and evaluation is of paramount importance.

35

A Complete Model of Rural Newborn Care in a Developing Country

Subhashchandra Daga

MIMER Medical College, India

State government of Maharashtra, started Rural Newborn care project in a tribal block. Newborn care had

two components, the home care and the hospital care. Most births took place at home and deliveries were

conducted by traditional birth attendants. Home care revolved around training of birth attendants in thermal

care, resuscitation of a depressed baby, identification of a small baby and its safe transportation. The chain of

caregivers included, birth attendant, link worker and nurse midwife. At community hospital, the doctors and

nurses were trained to deliver special care to referred babies by fine tuning thermal protection, enteral

feeding and administration of antibiotics and oxygen, when indicated. Guidelines for management were

prepared in graphic form for easy understanding. Principles of newborn care may not be new but adaptation

to local situation for the delivery of care was the key to success. Reduction in perinatal mortality, still-birth

rate and early neonatal mortality at primary health center area, and weight-wise mortality at community

hospital are testimony to it.

36

Efficacy and Safety of Right Internal Jugular Vein Access Guided by Ultrasound in Low Birthweight

Neonates

Fernando Montes1, Antonio Rodríguez-Taméz

1, Itzel Barreto-Arroyo

1, Adolfo

Hernández-Garduño1, Isaías Rodríguez-Balderrama

1, José Quero

2, Manuel de la O-

Cavazos1

1Hospital Universitario/ Universidad Autónoma de Nuevo León, Mexico

2Universidad Autónoma de Madrid, Spain

Introduction: The placement of an intravascular catheter is the most frequently invasive procedure

performed in the NICU.The options include peripheral lines, umbilical catheters and PICC. Success in

achieving these accesses depends on the size of the vessel and the skill of the person performing the

procedure. Once you have exhausted these venous accesses, a central venous line is considered.

Objective: Evaluate the efficacy and safety of right internal jugular vein (RIJV) access guided by ultrasound

in low birthweight neonates.

Material and Methods: We carried out a prospective, comparative, longitudinal study in patients less than

2500 g that required placement of a central venous catheter (CVC) by ultrasound in the RIJV. The study was

developed in the NICU of the University Hospital in Monterrey, México. In all patients a vascular access had

been ordered after having attempted the usual accesses without successfully entering a vein. The population

was divided into three groups: low (LBWN, 1500-2500g), very low (VLBWN, 1000-1499g), and extremely

low (ELBWN, 1000g) birthweight newborns.

During a period of 29 months we included 100 neonates: 39% LBW, 33% VLBW, and 28% ELBW. Of

these 53% were female. Mean weight 1352 g. An average of two attempts to puncture RIJV were made and

mean duration of the procedure was 16.8 ± 6.7 minutes. A 4 Fr catheter was used. Success of the procedure

was 94%. To accomplish this, one puncture was required in 50% of the population, and five in 95.7%.

Success was 97% in VLWN, 92.9% ELWN, and 92.3% in LWN. Cannulation was not successful in 6%

of cases with a hematoma being present in the puncture area in 5% of cases. Puncture of the carotid artery

did not occur.

Conclusions: Catherization of the RIJV guided by ultrasound is an effective procedure in different low

birthweight neonate populations.

37

Use of Tegaderm TM Dressing for Prevention of Hypernatremic Dehydration in ≤ 30 Weeks Preterm

Newborns. Controlled Randomized Trial: Preliminary Results

Valentina Cardiello, Valentina Cardiello, Mirta Corsello, Mirta Corsello, Simonetta

Costa, Simonetta Costa, Francesco Cota, Francesco Cota, Teresa Pianini, Luca Maggio,

Costantino Romagnoli, Enrico Zecca

, "A. Gemelli" University Hospital , Catholic University of Rome School of Medicine,, Italy

Hypernatremic dehydration is a severe complication of preterm newborn with reportedly highmorbility. The

use of Tegaderm dressings, a polyurethane semi-permeable film, is useful in reducing transepidermal water

loss.

Aim of the Study: Early use of Tegaderm dressing in preterm newborns is useful in reducing incidence of

hypernatremicdehydration?

Materials and Methods: A controlled randomized trial was designed. All ≤ 30 weeks preterms who were

born at our institution from September 1st 2012 to Agoust 10th 2013 were included. Babies with

chromosomal syndromes, major malformations and congenital infectious diseases were excluded.Babies in

group T received Tegaderm dressing, babies in group noT did notreceive Tegaderm. Hypernatremia was

defined as serum Na 145 mEq/l and it wasthe primary endpoint for the study. The sample size to observe a

reduction ofthe incidence of hypernatremia from 35% to 15% was 83 babies per group. Secondary outcomes

were weight loss, time to regain neonatal weight, IVH, PDA, ROP, NEC,sepsis, and duration of hospital

stay.

Results: Thirty babies have been included in the T group and 31 babiesin the noT group. No

significant differences have been observed in baseline demographics among the two groups. Incidence of

hypernatremia in the T group is 26.7% vs 45.2% for the noT group (p 0.18); the maximum weight loss is

10.6% in the T group vs 14.7% (p 0.00191) and occurred on average at 4.4 ± 1.6 days in the T group vs 5.2 ±

1.5 days for the noT group (p 0.046); regain of neonatal weight occurred at 12 ± 3.8 days in the T group vs

14.9 ± 4 days for noT group (p 0.01729).

Conclusions: Our results are preliminary. Tegaderm dressing is useful for reducing incidence of

hypernatremic dehydrationand maximum weight loss in ≤ 30 weeks’ preterm newborns.

38

Spectrum of Clinical Manifestations of Amniotic Band Syndrome- A 20 years of Experience

Krishna Gopagondanahalli Revanna, Suresh Chandran

KK Women's and Children's Hospital, Singapore

Amniotic band syndrome (ABS) is a spectrum of asymmetrical congenital malformations causing defects in

the limbs, head, faceand rarely in the trunk. Spectrum of clinical manifestations varies from simple

constriction bands affecting the distal limbsto lethal malformations involving craniofacial and visceral

organs. The aetiology of ABS is unclear. In 1930, Streeter described his intrinsic defect of germ plasm

theory which fails to explain the variety and asymmetry of lesions involving structures formed

embryologically at very different times and derived from different germ layers. Torpin’s theory (1968) of

early amnion rupture sequence, leading to development of multiple mesoblastic fibrous strands from

chorionic side of the amnion could explain most of the manifestations of ABS. The development of fibrous

strands appear to cause damage to the foetus through malformation, deformation and disruption. The clinical

manifestations vary from asymmetric annular bands typically causing constriction bands, syndactyly and

amputation of limb/digits in severe forms. The multiple, polymorphic, and asymmetrical facial

malformations may be due to swallowing of amniotic bands by the fetus. The more lethal malformations

involving cranial and facial structures are acrania, anencephaly, and acalvaria. Limb-body wall complex is

an example of severe ABS affecting the trunk and extremities. Antenatal diagnosis of most of the cranial

vault anomalies seen in ABS can be made as early as 12 weeks with accuracy using high resolution

ultrasonography, whereas constriction rings and digital often go undiagnosed. We report a case series with

clinical manifestations of ABS of varying severity due to malformation, deformation and disruption studied

over the past 20 years.

39

A Retrospective Cohort Study of Infants Born with Meconium Peritonitis in a Tertiary Hospital in

Singapore

Chandran Suresh, Lee Samanta, Bhavani Sriram, Victor Samuel Rajadurai

KK Women's and Children's Hospital, Singapore

Meconium peritonitis (MP) is a rare prenatal condition defined as sterile chemical peritonitis resulting from

intestinal perforation with leakage of meconium into the peritoneal cavity that may occur in-utero or soon

after birth. A retrospective cohort study of fourteen infants with antenatal diagnosis of MP during the period

from January 2004 to June 2013 was enrolled. The median gestational age and birth weight were 36 weeks

and 2858 grams. Eight were premature infants (57%) ranging from 24 to 36 weeks. The earliest antenatal

ultrasonographic (US) diagnosis was made at 19 weeks of pregnancy. Prenatal US findingswere fetal ascites

(86%), intraperitoneal calcifications (43%), polyhydramnios (29%), echogenic bowel (21%), meconium

pseudocyst (14%) and hydrops fetalis (7%). Two of our infants had normal fetal scan. Meconium pseudocyst

was detected postnatally in 50% infants. In the neonatal period, abdominal distension (67%) and bilious

aspirates (33%) were the most common manifestations. One infant in the study group remained

asymptomatic and was managed conservatively. Plain X-ray of the abdomen showed intraperitoneal

calcifications (93%), meconium pseudocyst (33%) and pneumoperitoneum (14%). Nine of the 14

infants(64%) underwent surgery while the rest of them were managed conservatively. Per-operatively ileal

atresia and volvulus was found in43% and 14% of babies respectively. All the infants were tested negative

for congenital infections and cystic fibrosis. Survival rate was 86% with no long-term morbidities. Two

babies in study group died at 3 months of age following pneumonia and enterocolitis.

Conclusion: Fetal ascites is the commonest antenatal US finding identified in this cohort of MP infants.

Hence fetal ascites when detected as an isolated abnormality in the US scans, it is imperative to look for

other radiographic features of MP. In babies with antenatal diagnosis of MP, management should be planned

in a tertiary hospital for better survival and reduced morbidity.

40

Neonatal Abstinence Syndrome Due To Dependency-Inducing Drugs- Our Experience With

Methadone Treatment

Vasiliki Sideri, Christiana Vliora, Anna Daskalaki, Panagioula Mexi-Bourna, Kleanthis

Kleanthous, Soulioti Maria, Kyrkou Gianna, Nikos Bournas, Vasiliki Papaevangelou

Attikon Hospital, Greece

Aim: Our aim was to study methadone substitution-treatment of NAS caused by dependency-inducing

substances.

Method: We retrospectively studied NICU hospitalization charts of infants with NAS, during 2008-2013.

Results: We admitted, over a five year period, 7 neonates (5 girls, 2 boys), born to mothers using

dependency-inducing medications, during pregnancy. Three had been accepted in a rehab methadone

program, while the rest were active drug-users, most of them abusing more than one substance. Hepatitis C

was present in 71.5% of mothers. Delivery was through natural labor in 57%. Median pregnancy length was

39.2±1.7weeks, median birth weight 2765.7±516.12gr and median head circumference 33.5±1.7cm, while 2

neonates had IUGR. All of the aforementioned infants presented with NAS and were treated with oral

methadone (except one, who was treated with phenobarbital). The majority (5/7) began substitution therapy

on the 2nd

day of life, with a modified Finnegan Neonatal Abstinence Score ranging from 9-15. The median

length of methadone administration was 37.5±8.9days (29-56 days), while median hospitalization length was

49.6±7.2days (42-156 days). Maximum methadone dose was given between the 10th

- 15th

day of life, and

once treatment was over no relapse occur.

Excepting the case in which phenobarbital was administered and who subsequently developed seizures on

the 13th

day of life, there were no other complications either from NAS or the methadone administration.

Brain ultrasound, auditory brainstem responses and otoacoustic emissions were normal in the entirety of

patients. One infant was initially given TPN, while the rest received enteral feeding exhibiting adequate

weight gain. Upon discharge all of the infants had normal growth and development.

Conclusions: Methadone administration for treating NAS seems to be effective and safe. Of course a larger

cohort needs to be studied.

41

Solar Powered Baby/radiant warmer Installed at Neonatal Intensive Care Unit at Lok Nayak

Hospital,New Delhi

Vasantha Thavaraj1, Sankara Sastry

2, Nav Nidhi Sharma

3, Siddharth Ramji

4

1Indian council of Medical Research, India

2Solar Energy Centre, 9th Milestone, Institutional Area, Gurgaon- Faridabad Road,

Gwalpahari,, India 3Indian council of Medical research, India

4Maulan Azad Medical College, India

Background: The important health challenges before India is that India has a high Neonatal mortality (death

within 28 days after birth), Infant mortality (death within one year).

The Open care system of baby radiant warmer is presently being used in our health system in Level I

(tertiary care hospitals) and Level II in Special care newborn unit (SCNU) , Neonatal stabilization Unit, New

born care corner.

Methods: A single open care system of infant radiant warmer with 400 watts of infra red heating element

and an energy meter, with baby bassinet was installed in the NICU, in Lok Nayak Hospita. The radiant

warmer was kept near the window so that the connection can be made easily with the panel in the roof. The

Thermostatic skin servo control device regulates radiant heat. Details of the power plant used: 400W is the

peak power during its full load operation. Accordingly the present PV system is designed for about 10 hours

of working, the system consumes about 4kWh (or 4units) in a day. Therefore, the designed PV system is for

approximate generation of 4 kWh of energy per day.

Findings: The Solar powered Radiant warmer has been successfully installed Neonatal nursery, Lok Nayak

Hospital and fully functional since 10-12-2012. The preliminary energy consumption study shows that PV

panels of 1.2kWp can be connected to 2-3 radiant warmers.

Interpretation: The Solar powered baby warmer is environment friendly. It can be used in Tertiary care

hospitals and also in rural areas where power supply is erratic and where there is plenty of sunshine this

product will help in the care of high risk infants in Level II.

42

Non-invasive Study of the Gut Microbiota Profiles and Mucosal Cells Gene Expression Changes

Caused byNeonatal Sepsis in Very Low Birth Weight (VLBW) Twins

Maria Carmen Collado1, Christine Bäuerl

1, Maria Cernada

3,4, Eva Serna

2, Maximo

Vento3,4

, Gaspar Perez-Martinez1

1IATA-CSIC, Spain

2University of Valencia, Spain

3Polytechnic University Hospital La Fe, Spain

4Polytechnic University Hospital La Fe, Spain

Neonatal sepsis is a major cause of morbidity and mortality in preterm infants. The role of prenatal microbial

contact and its role on health remains elusive. Distortions in the establishment of microbiota might increase

the risk of infections. Understanding microbial colonization of the gut in prematurity status and host

response may predict risk of late onset sepsis to guide future strategies. Then, our aim was to evaluate the

impact of neonatal sepsis on microbiota composition by 16S pyrosequencing and also, the host response by

whole genome microarray analysis of exfoliated epithelial cells in very low birth weight (VLBW) preterm

twins and likely identification of biomarkers for early diagnostic through non-invasive techniques.Important

differences were found in the fecal microbiota and transcriptomic response from exfoliated intestinal

epithelial cells in preterm infants who developed sepsis compared their matched healthy twins. Lower levels

of Bifidobacterium spp and higher levels of Enterobacteriaceae where found in sepsis than controls. By

pyrosequencing, Proteobacteria phylum (Enterobacteriaceae family) was predominant in sepsis. PCoAs

showed differences between sepsis and control groups and profiles were twin-pair and neonate-dependent.

Transcriptomic analysis of epithelial cells rendered clearly different profiles in infants with sepsis than in

their healthy twins. We identified 820 probe sets to be differentially expressed among septic infants and

healthy controls.

Our data show specific shifts on microbiome and gene expression genes which differentially separate the

VLBW premature twins suffering sepsis from their matched control twins. The intestinal transcriptome

in response to sepsis measured by the recovery of exfoliated cells in fecal samples represents a non-invasive

tool which particularly in VLBW preterm infants minimizes any discomfort to the subject. Our research

suggests the potential of microbiota modulation by use of probiotics and prebiotics in order to reduce

the risk of sepsis.

43

Regional Prospective Review Study of the Neonatal Infection Screening Methods Within the East of

England Neonatal Network.

Maria Chalia1, Michele Upton

2

1Mid Essex Hospital NHS Trust, UK

2East of England, UK

Aim: To monitor the adaptation of the regional neonatal infection screening policy in clinical practice

amongst the neonatal units in the East of England region.

Background: Based on the existing policy, all babies should have surface swabs taken, following admission

or transfer to a neonatal unit. Additionally, all babies on the unit should be screened on a weekly basis

in order to detect the presence of Methicillin Resistant Staphylococcus Aureus and other resistant

organisms. METHODS: The study period was between September 2012 and May 2013. All 17 neonatal

units (level 1to 3) in the region were asked to participate. There was random selection of at least 10 neonates

from each unit with a minimal length of stay of 10 days. RESULT: 15 neonatal units participated in the

study. Data from 149 babies were selected. The mean gestational age at birth was 32+3 weeks. The mean

birth weight was 1.8 kilograms. The median of their stay on the unit was

3 weeks.

Pie 1-Origin of

Admission

44

Graph 1-Admission

swabs

45

Pie 2-Surface swabs

46

Graph

2

47

Graph 3

Conclusions: This study demonstrates that the regional infection screening policy has been well adapted,

with 89% of cases having both admission and weekly swabs obtained. This positive and unified practice

facilitates communication between units, especially when a neonatal transfer is required. In addition, it

reinforces the significance of strong affiliation bonds required between level 1, 2 and referring, level 3

neonatal units within a geographically challenging region.

48

Electrical Inhibition (EI) Of Human Preterm Uterine Contractions: Just Another Pretty Smooth

Muscle

Jeffrey Karsdon1, William M Huang

2, Graham Gaylord Ashmead

3

1Unaffiliated, USA

2New York Presbyterian Lower Manhattan Hospital, USA

3St. Luke’s-Roosevelt Hospital Center, USA

Background: Drugs controlling preterm uterine smooth muscle contractions are inefficient with systemic

side effects.

Objective: Use a weak electrical current to inhibit human preterm uterine smooth muscle contractions.

Study Design: Rabbits and rats had intrauterine pressure (IUP) and/or electromyographic (EMG) activity

measured. An electrical device gave EI via electrodes to the uteri. Other rats got EI via an electrode

transvaginal catheter (TVC) placed near the cervix. EI was a bipolar constant current square wave. EI effect

was determined by IUP values or rat, pup birth interval (BI). Women in preterm labor at 24-34 weeks

gestation got EI via TVC while monitoring fetal heart rate (FHR). A fetal monitor (toco) measured

contraction tension and frequency. Contraction frequency or peaks (P-P), were measured for 3 20 minute

periods. A mixed-model analysis of variance estimated mean P-P for C1, E1, and C2 with the level of

significance at 0.05.

Results: Animal EI decreased IUP only in the study horn (fig. plate A, bottom), IUP and EMG (fig. plate B)

and increased rat BI either directly or by TVC. Human EI decreased toco (fig. plate C, bottom) with P-P 23%

slower than controls (p=0.0134) and no FHR changes (fig. plate C, top). In all species EI decreased smooth

muscle tone (solid line fig. plates B and C).

Conclusions: Comparing studies of the first human's and animals show EI may control preterm uterine

smooth muscle and birth. EI may decease resting smooth muscle tone in certain neonatal pathologies e.g.

ductus arteriosis and persistent pulmonary hypertension.

49

Surfactant replacement therapies; Poractant versus Beractant; 5 Years’ Experience of Ankara

Training Research Hospital

Hatice Tatar Aksoy1, Serçin Taşar

2, İnci Arıkan

2, Yıldız Dallar Bilge

2

1Ankara Training and Research Hospital, Turkey

2Ankara Training and Research Hospital, Turkey

Background: Surfactant replacement in preterm infants with respiratory distress syndrome (RDS) has been

a major therapeutic breakthrough. Surfactant also can be used in other.

Objective: To evaluate indications of surfactant replacement therapies in a NICU of a research hospital and

compare the outcomes of the usage of two different form (poractant vs beractant).

Methods: In this retrospective trial, we evaluated the outcomes of 137 infants treated with surfactant in 5

years period. 23 infants were treated with poractant, 114 infants were treated with beractant.

Results: Mean gestational age and birth weight was not different between the groups (32 vs 32 weeks, 1972g

vs 2000g, p=0.76 and p=0.9 respectively). The primary diagnosis was MAS in 27 patients and pneumonia in

4 patients and RDS in 82 patients in beractant group. In poractant group 4 patients had MAS, 18 patients had

RDS and 1 had pneumonia. Median hospitalization time of the patients was shorter in poractant group but

the difference was not statistically different (21,3 vs 23,9 days p=0.6). Median duration of mechanical

respiratory support was not different between the groups (1,54 vs 3,12, p=0.3). poractant group. Three

patients had pneumothorax, four patients had pulmonary hemorrhage in beractant group. Mortality rate did

not differ between the groups (%12 vs %22 p=0.43).

Conclusion: Pneumothorax and pulmonary hemorrhage were not detected with poractant group. Median

hospitalization time of the patients was shorter in poractant group but it is not statistically significant, this

can be a result of the small sample size of the poractant group.

50

Maternal Speech Sounds Elicits Sustained Heart Rate Response in Preterm Newborns in the First

Month of Life

Amir Lahav, Katherine Rand

Brigham and Women's Hospital, Harvard Medical School, USA

Background: The preferential response to mother’s voice is well documented in the fetus and term newborn.

However, the response of preterm neonates is much less understood and more difficult to interpret due to the

intensive clinical care and range of medical complications that characterize this population.

Aim: This study examined the physiological response to mother’s voice and its sustainability in the first

month of life in extremely preterm infants.

Methods: Heart rate changes were monitored over a period of three weeks in 20 preterm infants born

between 25-32 weeks gestation. Using innovative bedside technology, heart rate data were obtained daily

from the infant’s cardiac monitor during short periods of exposure to recorded maternal speech sounds

played inside the incubator.

Results: Exposure to mother’s voice elicited sustained changes in heart rate. During exposure periods,

infants had significantly lower heart rate compared to matched periods of care without exposure on the same

day (p.0001). This effect was demonstrated exclusively by all infants, irrespective of gestational age at birth,

birth weight, age at testing, Apgar score, caffeine therapy, and respiratory support.

Conclusion: Exposure to mother’s voice induced distinct physiological changes in heart rate in hospitalized

preterm infants in first month of life. It is possible that mother’s voice may improve autonomic stability and

promote relaxation in this population of newborns. Further studies are needed to illuminate the inner

workings of the preterm response to mother’s voice and to determine its therapeutic implications for

optimizing care practices and developmental outcomes.

51

The Hemodynamic of Bichorionic Biamniotic Twins in Early Neonatal Period

Olena Riga, Anastasia Senatorova, Margaret Gonchar, Alena Boychenko, Iryna

Vasilyeva, Iryna Vasilyeva, Iryna Vasilyeva

Kharkiv National Medical University, Ukraine

Background: The multiple pregnancies are associated with placental dysfunction and pathology of early

neonatal period. The objectives of study was to investigate central and cerebral hemodynamic in early

neonatal period in bichorionic biamniotic twins.

Material: Prospective case-control investigation of central and cerebral hemodynamic was performed in 62

twins (37 without intrauterine growth retardation (IGR) and 25 with IGR), and 48 singletons (25 without

IGR and 23 with IGR). The routine sings of hemodynamic were investigated (PhilipsHD7 XEunit,

the Netherlands).For comparison of multiple groups, Kruskal-Wallis ANOVA on program STATISTICA 7.

Results: The pregnancy course in women with twins and singletons was not difference except increase rate

of in vitro fertilization (p=0.0006), and cesarean section (p=0.001) multiple pregnancy. The third twins ware

“near term infants”. There were significant difference in decreasing of Vmin (11 cm/s) at third day of life in

twins with IGR comparing singletons and twins without IGR in medium cerebral artery. At this time

registration of decreasing cardiac output (60±2.7%) was present with correlation on Vmin (r=0.68, p0.05).

The twins and singletons had no difference in central hemodynamic regimen: 53.2% twins and 56.2%

normokinetic, p=0.7547; 35.4% twins and 41.6% singletons hyperkinetic, p=0.5208; and 11.4% and 2.2%

hypokinetic respectively, p=0.0706. There was correlation between resistance index in anterior cerebral

artery and ductus arteriosus diameter (r=0.5, p0.05); systolic index and ductus arteriosus diameter (r=-0.45,

p0.05), and ductus arteriosus functional period in days (r=-0.48, p0.05).

Conclusions: We speculate about risk of brain ischemia in bichorionicbi amniotic twins with IGR on third

day of life due to decrease of cardiac output (hypokinetic hemodynamic regimen) on decrease catecholamine

labor stress in “near term” infants with premature brain autoregulation. The regimen of central hemodynamic

depends on the diameter and its functional period.

52

Infant Driven Feeding Protocol

Robyn Foo1, Woei Bing Poon

2

1Singapore General Hospital, Singapore

2Singapore General Hospital, Singapore

Feeding practices for preterm babies are often inconsistent amongst clinicians and based on historical

practice rather than evidence. There is increasing evidence that Infant Driven Feeding (IDF) may result in

improved neurodevelopmental outcome, earlier attainment of full oral feeding and shorter hospital stay.

Barriers to providing such care include perceptions of increased workload as well as increased length of stay.

The purpose of this study was to determine whether oral feeds that are systematically advanced based on an

IDF protocol would (1) result in greater nursing satisfaction, and (2) was non-inferior in length of stay.

33 infants, less than 34 weeks gestation formed the intervention group. These infants were given early non-

nutritive sucking stimulation and commenced on oral feeds only after showing consistent signs of alertness

during scheduled 3 hourly gavage feeds. Feed advancement, managed by trained nurses, was based on the

protocol. Nurses were also trained on feeding techniques and infant behavioural cues.

A retrospective cohort of infants (n=293) formed the control group. These infants had feedings advanced

according to standard, schedule-driven feeding. Qualitative information from nurses regarding perceived

standard of care and competence with feeding were collected. Nurses surveyed felt the new protocol allowed

them to provide better care. They also felt more competent in feeding and more confident of the infants’

feeding abilities before discharge. Infants in the intervention group (median gestation at discharge=37.9

weeks) did not differ significantly from controls (median 37.3 weeks) in the length of stay. No adverse

outcomes such as aspiration pneumonia or feeding related NICU re-admission were found during the

implementation period.

IDF did not increase the length of stay, or increase adverse health outcomes. It also allows individualized,

developmentally appropriate progression of feeds that is safe, with greater nursing satisfaction.

53

“Eating’s not as important as Breathing!” – Multidisciplinary Collaborative Decision-Making in

Infant Feeding Disorders

Andrea Fourie

University of the Witwatersrand, South Africa

Infant feeding disorders have far reaching negative health, nutritional and respiratory consequences. Feeding

also influences bonding, family participation and quality of life. Balance between these factors is crucial for

appropriate feeding and reiterates the need for multidisciplinary collaborative decision-making in infants

with disordered feeding. In South Africa, many health professionals are moving to the private-sector due

to higher salaries and the lack of resources in state facilities. The influence of this on the standard of care is

unknown. Two in-patient infant feeding teams were compared. Team A, a multi-disciplinary team, works in

an under-resourced state hospital. Team B, a multidisciplinary team, works in a well-resourced private

hospital. The frequency and nature of team discussions related to infants with feeding conditions was

evaluated. This will be illustrated through the use of case studies. Team A met daily with at least 4 team

members and the infant’s family present. Decision-making was collaborative with all opinions considered.

The family’s focus was typically related to discharge and the social aspects of feeding, this was therefore

prioritized when possible. Daily ward-rounds; team members employed by the hospital and the need for

problem-solving due to lack of resources facilitated this decision-making process. Team B did not meet as

a team and decisions were made unilaterally by the paediatrician/otolaryngologist without the team or

family’s involvement. Management priorities were typically related to health considerations with less

emphasis on social and quality of life factors. Team members rely on private payment and were not

employed by the hospital resulting in logistical challenges in holding discussions. The under-resourced

state-based team appeared to be adopting a balanced multidisciplinary, family-centered collaborative-

decision making approach when managing infants with feeding problems, unlike the private hospital. This

highlights that privatization in developed countries may not necessarily result in improved quality of care

particularly with regards to infant feeding disorders.

54

Comparison of Conventional Phototherapy with the Adjunct Use of Reflecting Surfaces (Aluminum

Foil Curtains and White Cloth Curtains) in Reducing Bilirubin Levels among Term Neonates – a

Single-Blind RCT

Rumar Magaspi, Lucila M. Perez

Ospital ng Makati, Philippines

Objective: This study aims to determine the effectiveness of conventional phototherapy, conventional with

aluminum foil curtains versus conventional with white cloth curtains with aluminum foil versus with white

cloth curtains in lowering bilirubin among term neonates with hyperbilirubinemia.

Design: Single blind randomized controlled trial.

Setting: Ospital ng Makati – Tertiary Hospital

Participants: Three hundred two term neonates (7 days old) with indirect hyperbilirubinemia and total

serum bilirubin (TSB) levels 75th percentile were included.

Interventions: Subjects were randomized into 3 groups: conventional phototherapy (control), with

aluminum foil curtains (AF), and with white cloth (WC). TSB levels were taken every 24 hours until it

eached low risk levels (75th percentile for age).

Main Outcome Measures: The rate of decline of TSB from baseline after 24 hours phototherapy and

duration of phototherapy needed to reach the low risk level. Two-tailed z test and post hoc Scheffe test were

used with Intention to Treat Analysis.

Results: The rate of decline in TSB levels after 24 hours of phototherapy was significantly higher in

aluminum foil (12%) compared with white cloth (5%) and control (3%). The mean duration of phototherapy

was significantly shorter with phototherapy using aluminum foil at 3.13+0.84 days compared with white

cloth at 4.49 + 0.53 days, and conventional phototherapy alone at 6.70 + 0.59 days (p=0.000). No adverse

effect was noted.

Conclusion: Reflecting surfaces used with phototherapy are effective and safe. Aluminum foil curtains

produced more significant benefits than white cloth curtains.

Keywords: Aluminum foil curtains, white cloth curtains, phototherapy, total serum bilirubin

55

Vaccination Pain Management and Effect of Breast Feeding, Sucking the Pacifier and Mother's Hug:

a Randomized Control Trial

Simin Taavoni1, Shadab Shahali

2, Hamid Haghani

3

1Tehran University of Medical Sciences, Iran 2Iran University of Medical Sciences, Iran

3Iran University of Medical Sciences, Iran

Infants’ vaccination pain management is very important and must be managed, with lowest side effect

methods. The aim of this study was to examine pain relieving effect of breast-feeding, sucking pacifier or

being in mother's hug during DPT vaccination.

Methods: This controlled trial study, was performed on 152 (38 in each group) healthy term infants with 2-

4 months years old, whom was brought to the health centers in west of Tehran for DPT vaccination, their

parents filled in informed consent. (Year 2008- 2010) By randomized collection infants divided to three

intervention group (Breast feeding, Sucking pacifier and being in mothers hug, and each group

had intervention 2 minutes before, during, and 15 seconds after the injection) and

control group, whom lied on the examining bed as routine of clinics (38 infants in each group). Objective

changes in appearance of Neonates were assessed by Modified Behavioral Pain Scale (MBPS) during 5

second before immunization to 15 second after it. Descriptive and inferential statistics (ANOVA and

paired sample T test) were used. All ethical points were considered and approved by Research ethics

committee of IUMS and registered in Iranian Registry of

Clinical Trials (IRCT).

Result: Equality of age, gender and the time of feeding prior to vaccination were controlled and there were

no significant difference between 4 groups. There were significant differences in Behavioral Pain Scores of

four groups. (P 0.0001) and routine group had highest pain score.

Conclusions: Breast feeding is more analgesic than pacifier use with maternal holding and maternal holding

with breast feeding or pacifier use is more analgesic than being in mother's hug. These three interventions

are more analgesic than lying on the examining table. It is suggested to use these simple interventions during

immunization injection.

Acknowledgment: Received grant by Research department of Iran University of Medical Sciences.

56

Predictors of Death in Neonates with Coagulase Negative Staph Infections

Mohammad Khassawneh1, Abdulrahman Almatari

2

1United Arab Emerate university, United Arab Emirates

2King Fahad Medical city, Saudi Arabia

Background: Neonatal sepsis is a major cause of mortality and morbidity in this population. Predictors of

outcome in neonatal sepsis are helpful for physician for counseling and setting expectation. We aimed to

compare clinical characteristics of patients with Coagulase-negative staphylococci (Cons) sepsis who died

with those who survived their Neonatal Intensive Care Unit (NICU) hospitalization. Methods:

Retrospectively all infants admitted to NICU with neonatal sepsis proven by blood culture with Cons during

stay in the NICU of King Fahad Medical City, Saudi Arabia in 4 year period between January 2009-January

2012 were included.

Demographic data and other clinical characteristics were used as predictor of survival. The chi-squared test

or the Fisher's exact test will be used for categorical variables comparison. A p-value 0.05 was considered

statistically significant. Results: Death was recorded in 5 of 13 (38.4%) infants with gastrointestinal

perforation and versus 10 of 58 (17.2%) without GI perforation, p value 0.043, In 10 of 32 (31.3%) with low

platelet compared with 5 of 49 (10.2%) in patients with normal platelet, p value 0.017. Death was recorded

in 8 of 10 (80%) of infants who needed High Frequency ventilator (HFV) versus 7 out of 71(9.9%) of infants

who did not require this respiratory support, p value was less than 0.001. Birth weight and being infected by

methicillin resistant Cons were not predictive of death in this population. Conclusion: Needing HFV,

presence of low platelet, GI perforation are predictor of death in patients with neonatal sepsis caused by

Cons.

57

Predictive Risk Factors for Infection of The Fetus and Newborn.

Nyshangul Bozhbanbayeva, Tykaz Mustaphasade, Guljan Baigazieva, Indira

Suleimenova, Maral Amantayeva

Kazakh National Medical University named after S.D. Asfendiyarov, Kazakhstan

The aim of the research was to investigate the prognostically significant risk factors for intrauterine infection

of the fetus and newborn. We observed 462 infected children and their mothers admitted to the clinics in

Almaty during the period of 2005-2010 years. The average age of mothers was equal to 30,6 ± 0,7 years. The

control group consisted of 55 non-infected children and their mothers. There’s a coupling force between the

examined factor and infection. High risk factors with the greatest coupling force (bonding force of 10 to 15)

are: missed abortion in maternal history (15), premature birth (15), the stimulation generic activity (14.6) ,

pre-eclampsia (11.5) , premature rupture of membranes (11.5), the threat of miscarriage ( 8.0), chronical

intrauterine hypoxia of fetus by ultrasound (8.0). Acute respiratory viral infection during the current

pregnancy (6.6), pseudo erosion of vesical cervix (6.5), somatic pathology of the mother in the form of

chronic bronchitis (6.5), chronical adnexitis (6.5), acute of chronical pyelonephritis (6.5), allergic diseases of

the mother (6.5), weighed down obstetrical history in the form of spontaneous miscarriages (6.0),

pathological course of pregnancy in the form of late gestosis (6.0), dark green color of the amniotic fluid

(5.8) were included in the medium risk factors . The coupling force between infection and disease states such

as chronic coleitis (4.5) over the mother, a chronic disease of the gastrointestinal tract (4.5), cardiovascular

disease 4.4 ), and endocrine pathology (4.3) over the mother, uterine (3.5), a history of abortion (3.5), and

premature detachment of the placenta (3.0) composed a group of low-risk factors. Thus, the identification of

the above mentioned risk - factors should guide clinicians on the directional survey of women and their

children against persistent infections.

58

Reduction in Late-onset Sepsis Associated with the Implementation of a Package of Infection

Prevention and Control Interventions

Roopali Soni

Leeds General Infirmary, UK

Aims: This study was undertaken to compare the rate and type of late-onset blood stream infections before

and after the introduction of a package of infection prevention and control interventions introduced in

November 2009.

Methods: A retrospective study of all patients with culture proven late-onset sepsis over a period of 12

months pre (1st November 2008 to 31st October 2009) and post (1st January 2010 to 31st December 2010)

intervention was undertaken. The infection rates for the five years prior to and 1 year following the study

period were also analysed.

Results: A total of 101 patients met the study criteria. There was a significant (P0.05) reduction in infection

rates following the interventions when comparison was made based on the episodes of infection (5.0% vs.

3.6%). Although not statistically significant, there was also a reduction in the number of infants with

infection (5.5% vs. 4.0%) and the rate of catheter related sepsis (9.8 vs. 7.6). There was an elimination

of MRSA, Candida and Pseudomonas infections following the interventions. This effect was however not

sustained for more than 12-18 months following the interventions. VLBW (1.5Kg) infants, those born at or

25 weeks and those with central venous catheters were the most susceptible.

Conclusions: There was a significant reduction in the episodes of late onset sepsis associated with the

implementation of infection prevention strategies. This study adds to the increasing evidence to support

infection prevention care packages on neonatal units. There is a need for continued efforts to maintain these

practices.

59

Non-invasive Study of the Gut Microbiota Profiles and Mucosal Cells Gene Expression Changes

Caused byNeonatal Sepsis in Very Low Birth Weight (VLBW) Twins

Maria Carmen Collado1, Christine Bäuerl

1, Maria Cernada

3,4, Eva Serna

2, Maximo

Vento3,4

, Gaspar Perez-Martinez1

1IATA-CSIC, Spain

2University of Valencia, Spain

3Polytechnic University Hospital La Fe, Spain

4Polytechnic University Hospital La Fe, Spain

Neonatal sepsis is a major cause of morbidity and mortality in preterm infants. The role of prenatal microbial

contact and its role on health remains elusive. Distortions in the establishment of microbiota might increase

the risk of infections. Understanding microbial colonization of the gut in prematurity status and host

response may predict risk of late onset sepsis to guide future strategies. Then, our aim was to evaluate the

impact of neonatal sepsis on microbiota composition by 16S pyrosequencing and also, the host response by

whole genome microarray analysis of exfoliated epithelial cells in very low birth weight (VLBW) preterm

twins and likely identification of biomarkers for early diagnostic through non-invasive techniques. Important

differences were found in the fecal microbiota and transcriptomic response from exfoliated intestinal

epithelial cells in preterm infants who developed sepsis compared their matched healthy twins. Lower levels

of Bifidobacterium spp and higher levels of Enterobacteriaceae where found in sepsis than controls. By

pyrosequencing, Proteobacteria phylum (Enterobacteriaceae family) was predominant in sepsis. PCoAs

showed differences between sepsis and control groups and profiles were twin-pair and neonate-dependent.

Transcriptomic analysis of epithelial cells rendered clearly different profiles in infants with sepsis than in

their healthy twins. We identified 820 probe sets to be differentially expressed among septic infants and

healthy controls.

Our data show specific shifts on microbiome and gene expression genes which differentially separate the

VLBW premature twins suffering sepsis from their matched control twins. The intestinal transcriptome

in response to sepsis measured by the recovery of exfoliated cells in fecal samples represents a non-invasive

tool which particularly in VLBW preterm infants minimizes any discomfort to the subject. Our research

suggests the potential of microbiota modulation by use of probiotics and prebiotics in order to reduce the risk

of sepsis.

60

Clabsi Reduction With Strict Maintenance Care Bundle

Junaid Khan, Junaid Khan, Junaid Khan

Al-Rahba Hospital, United Arab Emirates

Background: Central line-associated bloodstream infections (CLABSIs) cause substantial morbidity and

incur excess costs. 80,000 CVC-related BSIs occur in U.S. hospital ICUs causing an estimated 28,000 deaths

annually. Annual cost to the healthcare system $296 million-$2.3 billion (U.S.).The use of a central line

insertion bundle has been shown to reduce the incidence of CLABSI. Maintenance care has been included in

some studies of CLABSI, but this has not been studied independently of other interventions.

Objective: Getting to zero CLABSI, a believable goal.

Methods: Maintenance care was conducted by trained infection controlpersonals using device-day

measurement methods. During the intervention period,

nursing staff used a post insertion maintenance bundle consisting of

—Daily

assessment of catheter need

—Review

dressing integrity & cleanliness

—Use

closed system for infusion, blood sampling & medication administration

—Assemble

& connect infusion tubing using aseptic or sterile technique.

—Use

consistent tubing configuration

—Disinfect

injection port (Hub) with 2 % chlorhexidine or 70% alcohol for 15 seconds &

allow to dry for 30 sec to 1 min.

—Hand

hygiene performed & clean gloves worn for catheter entry

—Use

prefilled, flush containing syringes

—Staff

empowered to stop the line in non-emergent procedure if sterility breached

Results: During the pre-intervention period, there were 450 documented catheter-days and 2 CLABSIs ( Oct

2011-Oct 2012), for an incidence density of 5.9 CLABSIs per 1000 catheter-days. After implementation of

the interventions, there were 400 catheter-days and 0 CLABSIs (Nov 2012-Oct 2013), for an incidence

density of 0 per 1000 catheter-days. Our target is also 0 CLABSI catheter days/1000.

Conclusion: This study demonstrates that implementation of a central venous catheter maintenance care

bundle with CLABSI bundle of care was associated with a significant reduction in CLABSI. It is important

to stress on maintenance care bundle and strict surveillance by trained personals needed. Maintenance care

bundle can be modified according to the need.

Key Words: Bacteremia; central venous catheterization; infection control; catheter-related infections;

maintenance care bundle.

61

Language Assessment and Outcomes of Very Premature Infants

Betty Vohr

Alpert Medical School of Brown University, USA

Preterm infants are at increased risk for language delays that may persist to school age and adolescence.

They have early delays in expressive and receptive language and delays in grammatical awareness,

vocabulary acquisition and phonological awareness at school age. Factors related to speech & language

delay including the immature brain, the injured brain, neonatal morbidities, the NICU environment and

social and environmental risk factors will be presented. Both short term and long term language

outcome studies and their relationship with brain volume and MRI findings along with evidence for recovery

of language skills with increasing age will be reviewed. Outcomes of a very preterm cohort using a new

tool, Language Environment Analysis digital language processor (LENA™), to assess the natural language

environment in the NICU and at home will be presented. Our studies have shown that preterm infant 1250g

have reciprocal vocalizations (conversation turns) 8 and 4 weeks prior to their due date and are significantly

more likely to have conversation turns with their mother than with another adult (Pediatrics 2009).

In addition, increased amount of parent talk with preterm infants in the NICU was associated with higher 7-

and 18-month Bayley-III language and cognitive scores (Pediatrics 2014). These findings offer an

opportunity for language intervention for preterm infants starting in the NICU.

62

Mortality and Long-Term Sequelae from Childhood to Adulthood of Extremely Preterm or Tiny

Survivors

Lex Doyle

Royal Women's Hospital, Australia

University of Melbourne, Australia

Murdoch Childrens Research Institute, Australia

Survival rates for extremely preterm (28 weeks’ gestational age) or extremely low birthweight (birthweight

1000 g) infants have increased dramatically with the advent of successful techniques for assisting ventilation

from the 1970s. However survivors remain at significant risk for a wide array of long-term morbidities,

which are mostly inversely related to gestational age, and occur at much higher rates than in non-preterm

controls. Neurodevelopmental impairments obvious in the early years include cerebral palsy, developmental

delay, and sensory impairments such as visual and auditory deficits. Approximately 1-in-4 extremely

preterm or very tiny survivors have substantial problems with thinking, hearing, walking, talking or seeing.

Although the rates appear high, 4% of normal birthweight, non-preterm controls also have substantial

neurodevelopmental disability.

At young adulthood, extremely preterm subjects have only slightly lower rates of educational achievement,

employment and independent living. Despite the high rates of neurodevelopmental disabilities, and

educational and behavioural problems encountered during their early years, most subjects adapt to roles of

adult functioning and do better than might have been anticipated.

Other areas of ill-health for ex-preterm children into adulthood included more abnormalities in respiratory

function, with variables reflecting airflow being substantially diminished compared with controls,

particularly in those who had bronchopulmonary dysplasia in the newborn period. The blood pressure of

preterm subjects is significantly higher than controls, which is not related to intrauterine growth restriction.

Despite their small size at birth very tiny or preterm survivors tend to achieve adult heights consistent with

their genetic potential.

As mortality rates have fallen, the focus for perinatal interventions must be to develop strategies to reduce

long-term morbidity. In addition, follow-up to middle age and later adulthood is warranted to determine the

risks, especially for cardiovascular, respiratory and metabolic problems, and other lifestyle issues likely to be

confronted by very preterm or tiny survivors.

63

Neuroprotection for Very Preterm Babies – Are We Making any Progress?

Lex Doyle

Royal Women's Hospital, Australia

University of Melbourne, Australia

Murdoch Childrens Research Institute, Australia

Survival rates for extremely preterm or tiny babies have increased dramatically with advances in perinatal

and neonatal intensive care. However the rates of neurological impairments and disabilities are too high in

survivors relative to term controls; major neurological disability rates in those 1000 g or 28 weeks are 4-5

times higher than in term controls. There are some recent advances, however, that improve the outcome, both

short-term and long-term, for extremely preterm or tiny babies.

Magnesium sulphate given to the mother just prior very preterm birth reduces the rate of cerebral palsy in

survivors. Caffeine given to very tiny babies not only reduces several short term morbidities, such as a patent

ductus arteriosus and bronchopulmonary dysplasia, it also reduces the rates of death or disability, cerebral

palsy, and cognitive delay. Docosahexanoic acid, an omega-3 fatty acid important in brain function, given as

a supplement to feeds in very preterm babies improves cognitive function, but mostly in girls and in those

1250 g birthweight. Avoidance of corticosteroids to prevent or treat bronchopulmonary dysplasia may

improve long-term outcome. Developmental interventions after discharge home designed to improve baby

cognitive and motor development have been shown to increase cognitive development over the pre-school

years, however, the effect is no longer evident after the children start school.

In summary, several recent interventions look promising in improving long-term outcomes for very preterm

infants; however their effects when implemented into usual clinical practice must be determined.

64

Grapple with Ethical Puzzles in the Critical Care: A Neonatologist Prospective

Sulaiman Alsaad

State of Kuwait, Kuwait

Progress in neonatal care has significantly improved the prognosis and chances of survival of critically ill or

extremely preterm neonates. However, in some situations, when the neonate’s death can only be briefly

postponed at the price of severe suffering, or when survival is associated with unexpected disabilities and an

intolerable life for the child and his/her parents, the application of the full support of recent

neonatal intensive care may not be appropriate. In such circumstances the limitation of intensive treatments

(withholding or withdrawing) and shift towards palliative

care, can represent a more humane and reasonable alternative. Conflicts in values regarding life and death

and our understanding about “quality of life” influence our opinions about what is happening with many

babies in our NICUs. We must recognize that our values and opinions are our own, and are not necessarily

held by others. We should also remember that our images of disabilities might be overly negative. A study of

former extremely low birth-weight infants who are now in adulthood noted that even though they

acknowledged limitations in cognitive and physical abilities, they did not report a lower health-related

quality of life than their more healthy counterparts. It is difficult to watch parents who want “everything

done” for an infant that we know is not going to survive. How do we support the parents and also

advocate for the best interests of our patient? This is one of the most difficult situations we find ourselves in

and one that is not easily resolved. What we consider futile treatment may not be so in the eyes of the

parents.

In presentation I will address the following:

The role of communication and information exchange between the NICU team and parents

·Strategies for withdrawal/withholding of life support among neonate

·Influence of culture/religion and believes on difficult decisions with the NICU (In my culture parents want)

·The rights of an NICU kid (THE KARATE KID)

65

Newborn Care in the Tamale Teaching Hospital, Northern Ghana- a 6 month Review

Alhassan Abdul-mumin1,2

, Peter Kwarteng1, Gladys Ponpuo

1

1Tamale Teaching Hospital, Ghana

2University for Development Studies, Ghana

Under- 5 mortality rate in Ghana is unacceptably high at 82/1000 live births. A neonatal mortality rate of

32/1000 live births, contribute substantially to about 40% of all under-5 deaths in the country. A wide

regional variation is observed for both vital statistics with the Northern region of the country recording the

highest deaths. Fortunately or unfortunately, many of these deaths are due to preventable causes.

Driven by the herculean task of meeting the MDG 4 target of reducing under-5 mortality to 40/1000 live

births by 2015, the country has rolled out many neonatal interventions recently but it is unlikely that the

target will be met at the current pace of progress.

Six month review of sick neonates admitted to the NICU of the Tamale Teaching Hospital in Northern

Ghana, where new born care is in infantile stage, is presented.

A total of 757 patients were admitted to the ward in the period under review. Out of these 74% were

delivered in our hospital, 18% were from other health facilities and 12% were delivered at home. The most

common diagnoses were prematurity/low birth weight (LBW) (36%), neonatal sepsis (25%) and birth

asphyxia (17%). 136 deaths were recorded, 64%, 21% and 13% due to prematurity/LBW, birth asphyxia and

sepsis respectively. These diagnoses together constituted 78% of all admissions and contributed to 98% of

deaths. The mortality was 18% of admissions.

In conclusion, neonatal deaths due largely to preventable conditions, contribute substantially to U-5

mortality and significant gains could be made towards reduction of these deaths if the right neonatal

interventions are implemented appropriately. The disproportionately high premature/LBW deaths highlights

the challenges faced in care of this group of neonates.

66

2 years Follow Up of Intra-Abdominal Extravasation of TPN Causing Liver Necrosis in a Preterm

Infant

Rana Alia, Haytham Ali

Leeds Teaching Hospitals NHS Trust, UK

To our knowledge, this is the first case report describing the outcome of liver necrosis following TPN

extravasation in a preterm infant.

A 26 weeks gestation preterm boy was born spontaneously with a birth weight of 1.0 kg. As part of routine

stabilization he had a UVC inserted soon after birth and it was used to infuse TPN from day 2. The tip of the

UVC was at the junction of the left portal vein. On day 6 of life the baby deteriorated with abdominal

distension, renal impairment and abnormal liver function. Initial clinical diagnosis was necrotising

enterocolitis. Plain abdominal radiograph showed an area of translucency overlying the liver Figure [1]. An

ultrasound scan showed moderate ascites and a cystic lesion overlying the liver containing debris Figure [2].

Chemical analysis and the physical appearance of the ascetic fluid confirmed TPN leak.

The UVC was not faulty when it was examined by the manufacturer. However and given the position of the

UVC tip on x rays, the possible explanation was of chemical erosion of the liver by TPN with subsequent

rupture of the liver capsule and leak inside the peritoneal cavity. Acute rupture of the portal vessels by the tip

of UVC was unlikely because of the insidious onset of symptoms over days and lack of clinical signs of

acute blood loss.

The baby was managed conservatively and he made quick recovery. Regular liver ultrasound scans showed

cyst calcification and then regression in size Figure [3]. It disappeared by the age of 2 years. There was no

portal hypertension.

67

Assessment of Labial Angle via Goniometer and Oral Motor Reflexes in Preterm Infants: Comparison

with Term Infants

Deniz Anuk Ince1, Ulas Tugcu

1, Ayse Ecevit

1, Abdullah Kurt

1, Aslıhan Abbasoglu

1,

Mustafa Agah Tekindal2, Aylin Tarcan

1

1Baskent University Faculty of Medicine, Turkey

2Baskent University Faculty of Medicine, Turkey

Introduction: Oral feeding is complex sensorimotor process that differs preterm and term infants.

Our objective was to evaluate labial angle via goniometer (an instrument for measuring angles) and oral

motor reflexes in preterm and healthy term infants.

Methodology: Seventy-eight preterm infants between 27 and 36 weeks gestational age and 45 healthy full-

term infants were investigated. Term infants were evaluated once during the first week of life, and preterm

infants were evaluated weekly until they reached independent oral feeding at 38-40 weeks postmenstrual age

(PMA). The exclusion criteria were major congenital abnormalities, craniofacial malformation, intracranial

hemorrhage. Labial angle was measured via goniometer and volume of milk ingested and oral motor reflexes

(sucking, rooting, transverse tounge) were evaluated. APGAR score at 1st and 5th minute, full enteral

nutrition time, hospitalization duration and weight at discharge were recorded. Dependency of variables on

postmenstrual age is investigated by independent t tests and Mann-Whitney U tests.

Results: Assessment of labial angle in preterm infants compared to term, significant differences were

observed in both right and left labial angle. Oral motor reflexes showed significant differences in preterm

infants compared to term. Also preterm group presented significant differences when comparing first to the

other evaluations on sucking, rooting and transverse tongue reflexes.

Conclusions: The development of feeding skills requires sensorimotor integration of swallowing and

respiration, normal muscle tone, posture and normal oral-motor development. This was the first study

evaluating labial angle via goniometer in preterm infants. The use of goniometer may help to show

performance of oral motor capacity and may be used in preterm infants during evaluation of feeding skills.

68

Non-invasive Evaluation of Feeding Maturation via Swallowing Sound Recording in Preterm Infants:

Comparison to Findings in Term Infants

Deniz Anuk Ince1, Ayse Ecevit

1, Banu Oskay Acar

2, Ahmet Saracoglu

2, Abdullah Kurt

1,

Mustafa Agah Tekindal3, Aylin Tarcan

1

1Baskent University Faculty of Medicine, Turkey

2Kuartis Technology and Consulting, Turkey

3Baskent University Faculty of Medicine, Turkey

Aim: Our objective was to evaluate maturation of sucking and swallowing in preterm infants using a non-

invasive method: assessment of swallowing sounds.

Methodology: Fifty-two preterm infants between 27 and 36 weeks’ gestational age and 42 healthy full-term

infants were investigated. Feeding performance was assessed based on swallowing data collected during 2-

minute audio recordings that were captured via a digital stethoscope placed at the hyoid region. Term infants

were evaluated once during the first week of life, and preterm infants were evaluated weekly until they

reached independent oral feeding at 38-40 weeks postmenstrual age (PMA). A software program is

implemented in order to automatically generate the following variables for each evaluation: total number of

swallows (S), total number of rhythmic swallows (RS), total number of resting intervals (RI), average time

between resting intervals (ATRI), average time between swallows (ATS), average time between rhythmic

swallows (ATRS), maximum number of rhythmic swallows (MRS), and volume of milk ingested.

Dependency of variables on postmenstrual age is investigated by independent t tests and Mann-Whitney U

tests.

Results: The preterm infants' VM and MRS reached 10th percentile at postmenstrual 34-35 weeks. In the

preterm group, VM and MRS (p0.001) were positively correlated with PMA. At 38-40 weeks PMA, MRS

for preterm infants was not significantly different from the term infants’ MRS.

Conclusion: We have demonstrated that swallowing function improve with advancing postmenstrual age

and reach term infants' reference values. Swallowing sound analysis may be used to assess feeding

maturation in preterm infants during NICU follow-up.

69

Effect of Facilities in Decreasing the Perinatal Mortality Rate in Misurata Teaching Hospital –LIBYA

Bashir Ashur, Salima Alburke, Muktar Sadi, Ali Rajab

Misrata Hospital, Libyan Arab

Objectives: To measure the perinatal mortality rate (PNMR) , to identify risk factors of perinatal death and

to compare it with previous results in misurata hospital.

Patient and methods: A descriptive, retrospective study of hospital files records. From January 2012to

December 2012, information was collected from admitted newborn in neonatal unit and the registration book

at labour room including operating theatre. The information collected include, history, clinical examination,

investigation, treatment and outcome.

Results: The total number of delivery in misurata hospital were6520 births, include 36 stillbirth and 6474

were live births .48 babies died in the first week of life and 70% (34) of the first week death died in the first

24hours. The main reasons of admission to neonatal unit were preterm delivery, sepsis, meconium delivery,

birth asphyxia, and congenital malformation. Perinatal mortality rate was 13/1000 total births (57% death in

the first week of life and 43% still birth). The main causes of early neonatal deaths were RDS 45%,

congenital malformation 18%, birth asphyxia 12.5%, CHD 10% and sepsis 6%. 12(25%) of death were full

term and 36(75%) were PT, of these PT , 35% between 32- 36weeks gestation, 20% between 24- 28 weeks

and 18% between 28- 32 weeks gestation.

70

Customized Bubble Continuous Positive Airway Pressure at the National Hospital Abuja for the

Treatment of Respiratory Distress Syndrome

Lamidi Audu, Adekunle Otuneye, Mairami Amsa, Mariya Mukhtar-Yola, Lauretta

Mshelia, Mercy Garu

National Hospital Abuja, Nigeria

Background: Prematurity accounts for 25% of neonatal mortality in Nigeria and respiratory distress

syndrome is responsible for half of these deaths. Introducing continuous positive airway pressure for the

treatment of RDS in Nigeria where health care financing is predominantly out-of-pocket is quite challenging.

Objectives: To construct an affordable, easy and effective bubble cpap device for the treatment of

Respiratory Distress Syndrome

Method: At the neonatal unit of the National hospital, Abuja we assembled a circuit of tubing connecting a

gas source (oxygen concentrator/cylinder) through an interface (nasal prongs) to the baby and this was

further connected through an expiratory tube to an under-water-seal bottle to generate bubble CPAP.

Result: The resultant device when activated by turning on the gas source results in an immediate and

sustained improvement in tissue oxygenation (SPO2) and reduction in work of breathing (respiratory rate,

chest recessions and grunting). The respiratory rate dropped from a mean (sd) value of 64.5(19.2)/min before

commencement of CPAP to 54.9(11.6)/min one hour after. (p0.05).The corresponding values for mean SPO2

were 84(12)% and 95(6)% respectively (P0.05).

Conclusion: This devise is inexpensive ($15/unit), requires minimal training to assemble and apply and can

be used in both secondary and tertiary institutions. Its adoption nation-wide will ultimately reduce deaths

from premature deliveries in Nigeria.

Authors: Audu L I, Otuneye AT, Mukhtar MY, Mairami AB, Mshelia LJ, Garu M

71

Clinical Approach to Cerebral Sinovenous Thrombosis in Newborn: Case Report

Iva Bilic Cace1, Irena Barbaric

2, Izidora Holjar Erlic

3, Branimir Peter

1

1University Hospital Centre Rijeka, Croatia

2University Hospital Centre Rijeka, Croatia

3University Hospital Centre Rijeka, Croatia

Cerebral Sinovenous Thrombosis (CSVT) in the neonatal population is a relatively uncommon disorder.

However, its current morbidity, mortality, and adverse neurodevelopmental sequelae emphasize the

importance of establishing an early diagnosis and a proper therapeutic plan. Early signs and symptoms are

often vague and unrecognized by the clinician. Cranial imaging study is often requested for reasons other

than suspected CSVT and the finding of this condition is accidental. The active treatment of any underlying

cause of CSVT is undoubtedly necessary; however, one must be prudent when commencing antithrombotic

therapy. Question of treatment strategy of CSVT remains controversial. We present a case of CSVT in a

term newborn with birth asphyxia, meconium aspiration syndrome and sepsis. Cranial magnetic resonance

imaging (MRI) was requested due to the above mentioned diagnosis, and it revealed thrombosis of right

transverse and sigmoid sinus. At that time, the child was in a good clinical condition, with normal

neurological status. We decided not to introduce any medication and the expectative treatment was

commenced. Seven days later second MRI was performed and previously noted CSVT confirmed. Since

the child condition had not deteriorated he was discharged from the hospital. Six weeks later third and final

MRI was performed and the result was astonishing- there were no signs of CSVT, and the finding was

normal. This case of CSVT in a newborn previously suffering from birth asphyxia and neonatal sepsis

emphasize the importance of proper clinical examination as a part of decision making process regarding

treatment modalities.

72

Potential Fatal Complication of a Percutaneous Central Venous Catheter with Long Term Sequelae in

a Premature Neonate

Maria Chalia, Maria Chalia, Ahmed Hassan

Mid Essex Hospital NHS Trust, UK

Background: Cardiac tamponade is a well recognized complication of percutaneous central venous catheters

with high mortality rates. In that respect specific policies have been implemented regarding the insertion and

care of such catheters.

Objective: To alert clinicians for prompt recognition of a rare but not obsolete complication. To emphasize

that long term sequelae can be expected.

Methods: We present a case of premature male infant, 27+4 weeks of gestation at birth, with rapid clinical

deterioration on day 12 of life after a previously uneventful course.

Progressive pallor, tachycardia and increasing requirement for respiratory support were noted. There was

subsequent unrecordable saturations and blood pressure which led to the prompt recognition of cardiogenic

shock with possible correlation to the existing central catheter in the right upper limb, used for parenteral

nutrition.

[Chest X ray]

Results: The infant was intubated and the infusion was discontinued. On site Echocardiogram confirmed the

diagnosis of cardiac tamponade, following which a pericardiocentesis was

performed.

73

[Echocardiogram] 27 mls of fluid were aspirated and immediate clinical improvement was noted. On

readmission to the paediatric ward at the corrected age of 2 months with an acute respiratory illness, a clot

was identified at the superior vena cava to the right atrial junction on Echocardiogram. Still at the age of 6

months the clot persists and has not diminished in size. The baby is on aspirin, close paediatric and cardiac

follow up.

Conclusions: Prompt recognition of cardiac tamponade is crucial. Long term follow up is required and

repeat Echocardiogram should be considered.

74

Regional Prospective Review Study of the Neonatal Infection Screening Methods Within the East of

England Neonatal Network.

Maria Chalia1, Michele Upton

2

1Mid Essex Hospital NHS Trust, UK

2East of England, UK

Aim: To monitor the adaptation of the regional neonatal infection screening policy in clinical practice

amongst the neonatal units in the East of England region.

Background: Based on the existing policy, all babies should have surface swabs taken, following admission

or transfer to a neonatal unit. Additionally, all babies on the unit should be screened on a weekly basis

in order to detect the presence of Methicillin Resistant Staphylococcus Aureus and other resistant

organisms.

Methods: The study period was between September 2012 and May 2013. All 17 neonatal units (level 1to 3)

in the region were asked to participate. There was random selection of at least 10 neonates from each

unit with a minimal length of stay of 10 days.

Results: 15 neonatal units participated in the study. Data from 149 babies were selected. The mean

gestational age at birth was 32+3 weeks. The mean birth weight was 1.8 kilograms. The median of their stay

on the unit was

3 weeks.

Pie 1-Origin of

Admission

75

Graph 1-Admission

swabs

76

Pie 2-Surface swabs

77

Graph

2

78

Graph 3

Conclusions: This study demonstrates that the regional infection screening policy has been well adapted,

with 89% of cases having both admission and weekly swabs obtained. This positive and unified practice

facilitates communication between units, especially when a neonatal transfer is required. In addition, it

reinforces the significance of strong affiliation bonds required between level 1, 2 and referring, level 3

neonatal units within a geographically challenging region.

79

The Efficacy of Table Sugar Solution as Snalgesia During Intradermal Injection of BCG Vaccine in

healthy term Neonates

Frances Jane Dago -Oc

Background: Large numbers of studies have shown that orally administered sweet tasting solutions result

in a significant reduction in behavioral pain responses during or following painful procedures compared with

placebo in term neonates.

Objective: To evaluate the efficacy and safety of table sugar solution as analgesia during intradermal

injection of BCG vaccine in healthy term neonates.

Setting: Private tertiary hospital in Cebu City.

Methods: A total of 72 subjects were included in this randomized, double-blind, prospective study. Eligible

neonates received either 2ml of table sugar solution or placebo given orally two minutes prior to intradermal

injection. Neonates were observed for 30 seconds and assessed using the Neonatal Infant Pain Scale (NIPS).

Scores of 0-3 indicate minimal or no pain. Scores 4 and above indicate moderate to severe pain.

Result: There was no statistically significant difference on the demographic information of the neonates with

regards to sex (P value 0.815= NS) age of gestation (P value 0.735 =NS) and birthweight (mean =

2,882.38±427.56, P value 0.439=NS). The mean NIPS of neonates treated with table sugar was 2.095 (SD

±1.872) and 4.5 (SD ±1.196) for neonates treated with placebo. There was statistically significant difference

noted on NIPS between the two groups (p value 0.0000=S).

Conclusion: There was a significant decrease in pain intensity based on NIPS score of newborns who

underwent intradermal injection treated with sugar compared to those treated with placebo. This study

showed that table sugar solution is a safe and effective analgesia during intradermal injection of BCG

vaccine.

80

The Influence of Fish-oil Lipid Emulsions on Retinopathy of Prematurity in Very Low Birthweight

Infants: A Randomized Controlled Trial

Serdar Beken1, Dilek Dilli

1, Nurdan Dinlen Fettah

1, Emrah Utku Kabataş

2, Aysegül

Zenciroğlu1, Nurullah Okumuş

1

1Dr Sami Ulus Maternity and Children Research and Training Hospital, Turkey

2Dr Sami Ulus Maternity and Children Research and Training Hospital, Turkey

Objective: To compare the effect of two lipid emulsions on the development of retinopathy of prematurity

in very low birth weight infants.

Design: Randomized controlled study.

Patients and methods: Eighty very low birth weight infants receiving parenteral nutrition from the first day

of life were evaluated. One of the two lipid emulsions were used in the study infants: Group 1 (n = 40)

received soybean oil based lipid emulsion (Intralipid®) and Group 2 (n = 40) fish-oil based lipid

emulsion (SmofLipid®).

Main outcome measures: Development of retinopathy of prematurity and the need for laser

photocoagulation were assessed.

Results: The maternal and perinatal characteristics were similar in both groups. The median (range) duration

of parenteral nutrition [14 days (10-28) vs 14 (10-21)] and hospitalization [30 days (10-28) vs 34 (21-53)]

did not differ between the groups. Laboratory data including complete blood count, triglyceride level, liver

and kidney function tests recorded before and parenteral nutrition also did not differ between the two groups.

In Group 1, two patients (5.0%) and in Group 2, 13 patients (32.5%) were diagnosed with retinopathy of

prematurity (p=0.001). One patient in each group needed laser photocoagulation, without significant

difference. Multivariate analysis showed that only receiving fish-oil emulsion in parenteral nutrition

decreased the risk of development of retinopathy of prematurity.

Conclusions: Fish-oil lipid emulsions may be preventive for development of retinopathy of prematurity in

preterm infants requiring parenteral nutrition.

81

Precision and Accuracy of Integrated Incubator Scale Versus Stand-Alone Scale

Shaul Dollberg, Inbal Yarkoni, Laurence Mangel, Margarita Shlifer

Tel Aviv Medical Center, Israel

Background: Body weight is an important variable to follow preterm infants. The need to weigh the

unstable preterm infant outside of the incubator have prompted incubator manufacturers to integrate weight

scales to incubators.

Objective: As a part of a patient safety evaluation we aimed to compare accuracy and precision of stand-

alone weight scale to integrated scale.

Design / Methods: Six stand-alone weight scales (Shekel LTD, Israel) and 11 integrated to Isolette 8000

(Drager, Germany) weight scales were used. We used a 1KG standard metal weight and stable infants

weighting 1000 to 2500 g. Precision was evaluated by repeated weighting of the standard and of infants in

each of the scales (triplicates). Accuracy was evaluated by comparing weight measurements of infants and

standard in the stand alone and integrated scales. Data are mean of differences weight ± SD. Comparison of

weights was by the Wilcoxon test.

Results: Using the standard 1KG weight, as well as weighing infants, stand alone scales were very accurate

and precise compared to the integrated scales. The stand alone scales were subsequently used as the gold

standard. There were large discrepancies in weight measurements in both within integrated scales and

between the integrated and the stand alone scales, with a difference if up to 9% of the infants' weight, a

clinically significant difference. The mean difference between stand alone and integrated scales was also

statistically significant (p=0.022)

Conclusion: Stand-alone weight scales were more accurate and precise compared with integrated scales. We

suggest to use caution and clinical judgment when using integrated scales for clinical decision making.

82

The Crisis of PAN Resistant Bacteria: How to Know What to Prescribe

Sandra Ellingson, Mary Wyckoff

University of California Davis Medical Center, USA

According to the WHO, high percentage of hospital-acquired infections is caused by highly resistant bacteria

such as methicillin-resistant Staphylococcus aureus (MRSA). Inappropriate and irrational use of

antimicrobial medicines provides favorable conditions for resistant microorganisms to emerge, spread and

persist.

This presentation will provide an overview of the epidemiology of antimicrobial resistance on a global scale.

Multi-drug resistant organisms are prevalent worldwide and these infections cause severe illness, especially

in acute and chronically ill neonatal intensive care patient populations. Choosing appropriate antimicrobial

therapy has become increasingly complex as more choices become available and resistant bacteria continue

to evolve. Multiple factors affect the choice of agent, and resistance forces vary widely between clinical

settings, patient populations, and geographic areas. This bacterial culture specific data will be used to

demonstrate how to implement antibiograms into everyday prescriptive practice.

Facilitating the understanding of the cellular mechanisms through which bacteria become resistant is vital for

healthcare providers. Individual patient care practices affect resistance within patients and clinical

environments. This research-based information and recommendations on how to manage the use of

antimicrobial agents, minimize iatrogenic infections in the acutely-ill neonatal population, and responsibly

care for patients, in an age of widespread bacterial resistance will enhance the individual’s knowledge base.

Recommendations will include description of evidence-based guidelines from professional societies, as well

as provision of multiple resources through which participants may further gain knowledge of the state of the

science of this important topic.

83

Cyclic Sleep Organization and Melatonin Production in Full Term Newborns with Intrauterine

Growth Retardation

Inna Evsyukova, Ol'ga Koval'chuk-Kovalevskaya, Natalia Maslyanyuk

Ott Research Institute of Obstetrics and Gynecology RAMS, Russia

The number of newborns with intrauterine growth retardation (IUGR) due to the unfavorable impact

of chronic hypoxia in a pregnancy complicated by placental insufficiency has been on the rise in recent

years. They are characterized by a high rate of neurological disorders not only in the perinatal period

but also in subsequent years of life.

Objective: to study cyclic sleep organization and melatonin production in full termnewborns with IUGR.

Methods: Electropolygraphic sleep studies (EEG, ECG, EOG, respiration, motor activity) were conducted in

25 newborns: 15 with IUGR and 10 healthy (control group) on the fifth and sixthday of life. Melatonin (M)

production was studied by determining the urinary level of the 6 sulfateoxymelatonin (6-SOMT) in the

daytime and nighttime by means of ELISA (DRG Instruments,Germany).

Results: In IUGR newborns duration of the sleep cycle was shortened (37.7 ± 1.5 min versus63.4 ±3.9 min;

Р= 0.0003) at the expense of the orthodoxical phase (14.0 ±1.9 min versus 27.3 ± 1.7 min; Р= 0.04) and the

paradoxical phase (23.6 ± 1.9 min versus 36.1 ± 2.3 minР= 0.0004).The disorder of the formation of cyclic

sleep organization was in 10 IUGR newborns and associated with a considerable delay in the development of

tonic and congenital reflex reactions. The urinary content of 6-SOMT in the infants with IUGR was

considerably lower than in healthy newborns (14,1 versus 4,5±1,1ng/ml; Р 0.001).

Conclusions: The sleep in IUGR newborns indicates the degree of intrauterine brain damage as a result of

chronic hypoxia. The absence of cyclic sleep organization, the impaired formation of the paradoxical phase

combined with retarded development of tonic and reflex reactions and low melatonin production give

evidence of severe brain damage, which warrants combined therapy aimed at restoring and improving the

impaired functions in the early neonatal period of infant life.

84

Necrotizing Enterocolitis in Neonates Monitored by INVOS

Olariu Gabriela, Olariu Laura2, Tunescu Mihaela

Clinical Unversitary Children Hospital Louis Turcanu, Romania

Introduction: Congenital heart malformation is a risk factor for the development of necrotisingent rocolitis.

Objective: Non-invasive monitoring by regional cerebral and somatic oximetry performed early in the

newborn have led to identification of severe affections

Material and Method: Regional somatic and cerebral oximetry monitoring by using INVOS device can be

an indicator of regional ischemia. The first case is a term newborn, with birth weight 2850g. at 6 days of life

develop neonatal shock, but cerebral and somatic oximetry monitoring had detected severe mesenteric

ischemia Echocardiography reveals an congenital heart malformation-interrupted aortic arch type. The ratio

between mesenteric and cerebral circulation was 0.38/ 0.24 predictive for necrotisingent erocolitis,witch had

developed at 14 days of age. The second case is a premature with birth weight 820g, GA=26 weeks and

monitored trough regional somatic / brain oximetry, with a lower ratio of 0.22 / 0.19, which has developed

necrotizing enterocolitis in 4th day of life. Doppler cardiac ultrasound detected a tight aortic stenosis with a

hypoplastic left ventricle, Discussion indicator of regional ischemia when is developing an

ecrotisingenterocolitis, this report is predictive to a value below 0.75% is early detection of necrotising

enterocolitisin

Conclusion: Somatic / brain oxigenation below 0.75) is a predictive factor for to detect in the early stages

necrotizingenterocolitis.

Key Words: Necrotizing enterocolitis, INVOS, mesenteric ischemia

85

Cerebral Doppler Flowmetry Changes At a Premature Newborn

Olariu Gabriela1, Olariu Sebastian

1, Tunescu Mihaela

1, Botiz Alina

2

1Clinic Hospital Municipal, Romania

2Clinical Universytary Children Hospital Louis Turcanu, Romania

Introduction: In premature infants with idiopathic respiratory distress syndrome has significant

hemodynamic changes occur in the cerebral circulation, at birth and during the first three days of life

Objective: The aim of the study was to assess early postnatal changes of Doppler sonographic parameters of

blood flow in the cerebral artery occurring, during the first three days of life at a premature newborn whit

severe RDS versus a healthy premature newborn.

Material and Methods: Two premature newborn were enrolled into the study, one presenting severe

idiopathic RDS, the other clinically healthy. Cerebral blood flow velocities (CBFV) in the cerebral were

obtained at age of 2, 12, 24, 48 and 72 hours after birth. Measured parameters included the peak systolic

velocity (PSV), end-diastolic velocity (EDV), time-averaged mean velocity (TAMV). Doppler indices (DI) -

resistance index (RI) and pulsatility index (PI). Each newborn required continuous monitoring of blood

gases, Sat O2, HR, BP, temperature and weight.

Discussion: In premature infants with severe RDS who need surfactant replacement therapy and mechanical

ventilation, changes in blood pressure and patent ductus arteriosus (PDA), reveal brain changes related to

ischemia and then reperfusion processes, there are changes of the values of IR and IP.

Conclusion: Cerebral Doppler flowmetry provides a noninvasive method of cerebral circulation monitoring

and establishing future therapeutic approach.

Key Words: Cerebral doppler flowmetry, severe respiratory distress syndrome

86

Abruptio Placentae Reflection Towards Neonatal Blood Components

Snezhana Janchevska, Emilija Badeva Gajdova

University Clinics of Gynecology and Obstetrics, Macedonia

Abruptio placentae is a premature separation of the placenta from the uterus. Women with placental

abruption, typically present with bleeding, uterine contractions, and fetal distress.

Objective: Relationships between fetal distress provocated by abruptio placentae and neonates’ peripheral

blood components dynamic in the start of postnatal life.

Study design: Cohort collected 20 months, contents 93 neonates with mothers’ abruptio placentae and fetal

distress. Babies were born by Cesarean Section in the University Clinics of Gynecology and Obstetrics.

Premature newborns formed a first group, and near to term newborns second group. Blood components were

determinated with a blood counter, immediately after birth, in the end of the first day and second day.

Results: All pregnancies finished by Cesarean Section. 67,7% of newborns were with Apgar score more than

7. Others neonates were asphictic. The prevalence of anemia after birth was 15% (14/93). The prevalence of

the neonatal neutrophilia was 62,3% (58/93), range 74%-86%, with out of significant diferences between

two groups. The first control showed descending of neutrophils values, and second control confirmed

normalizing, with out of antibiotics therapy. 11/93 babies had conatal infection.

Conclusions: The presence of placental abruption has been associated with selected labor and fetal distress.

Vaginal bleeding in placental abruption is follows to neonatal anemia. Neonatal neutrophilia a postpartum

event which result from oxygen stress by placental abruption, what can produce a placental insufficient and

fetus oxygen stress too. The baby’s answer is high number of neutrophils in peripheral blood. Poststress

neutrophilia occurs rapidly and disappears shortly.

87

A Severe Hemolytic Disease of the Newborn Caused by Anti-E Antibodies : A Case Report

Mathew Kripail, Mohammed Abdel Latif, Asad Ur Rahman

Sultan Qaboos University Hospital, Oman

With the implementation of Rhesus D immunoprophylaxis, there has been a relative increase in non -Rh(D)

alloimmunization causing Hemolytic Disease of Fetus and Newborn. We report a rare case of severe

hemolytic disease of newborn in a neonate due to anti-E alloantibodies ,born to a mother who was Group B

Rh positive. The mother 27 years old , gravida 2 para 1 at 38 weeks of gestation delivered vaginally a

male baby with apgars 8 and 8 at 1 and 5 mins with a birth weight of 2.3 kg. She was an unbooked case in

our hospital and her antenatal scans were normal. This baby was admitted for respiratory distress and pallor,

developed hypotension, needed inotropic support and high frequency ventilation. Echocardiography revealed

severe cardiac dysfunction with severe tricuspid regurgitation with evidence of near systemic pulmonary

hypertension.

Lab investigations demonstrated a severe anemia Hb 5.2 gm/dL, a severe hyperbilirubinemia total S. ilirubin

192 umols/L (11.3 mg/dL), reticulocytes 35%,and a positive Direct Antglobulin test . As there was no

apparent cause of the hemolytic disease, antibody testing in mother showed the presence of Rh E

antibodies. A double volume exchange transfusion was performed with anti Rh E negative cross matched

blood, along with intensive phototherapy. The baby recovered fully and was discharged in a healthy

condition on postnatal day nine.

This case highlight the importance of routine antibody screening and if necessary antibody identification

even in Rh (D) positive females. This is necessary to ensure timely availability of Antigen negative blood

and reduce the effects on the newborn.

88

Hypoplasia of Right Ventricle with Tricuspid Stenosis and Atrial Septal Defect

Svetlana Krstevska Blazevska, Svetlana Krstevska Blazevska1, Radica Muratovska

2,

Svetlana Krstevska Blazevska 1Clinical Hospital Acibadem Sistina, Macedonia

2University Hospital for pediatric desease, Macedonia

Background: Hypoplasia of the right ventricle (RV) is part of malformation such as pulmonary and

tricuspid atresia and very rare is associated with atrial septal defect (ASD), tricuspid stenosis and/or other

congenital heart disease. A few cases with isolated hypoplastic RV and ASD have been reported.

Objective: To show the case of a female newborn with very severe form of small right ventricle with ASD

and tricuspid stenosis, but normal pulmonary valve. The newborn was one day old, with generalized

cyanosis and swelling, especially of the head and neck. The baby was oxygen-depending, with increased

liver of 4 cm. The patient was on mechanical ventilation. Palliative surgery was not made; because of very

sever general condition. The baby died when it was 40 days old. Diagnosis of congenital heart disease was

made by echocardiogram and confirmed at autopsy.

Methods: Diagnosis was confirmed by two-dimensional transthoracic echocardiography, chest x-ray,

computed tomography and autopsy findings.

Conclusion: Right ventricular hypoplasia with ASD and tricuspid stenosis is an uncommon abnormality.

Severe forms of hypoplasia, usually presenting in early newborn period. Surgery for symptomatic patient

should be palliative during first days of life. Without palliative surgery the newborn with hypoplastic right

ventricle have no chance of survival. Screening for critical congenital disease is the most important in case of

critical congenital heart disease.

89

Improving Quality of Care and Patient Satisfaction by Better Communication between Neonatal Unit

and Primary Care

Uday Kumar

Evelina London, UK

Aim: To examine the quality of communication between the neonatal unit and primary care for babies

transferred from neonatal unit to postnatal ward and subsequently home. To improve the quality of discharge

summaries and by doing so decrease the re-admission rate and improve the level of patient satisfaction.

Method: It was a retrospective study of all babies admitted to the neonatal unit in January 2013 who were

transferred to postnatal ward and subsequently discharged home. Data was collection from SEND

(Standardized Electronic Neonatal database) summaries, clinical notes and postnatal discharge

summaries. Results: 17 babies were included in the study. 47% (8) babies needed significant input from the

pediatric team in the post natal ward. 35 %( 6) babies were found to have inadequate communication with

primary care about the care they had received during their hospital stay.

Conclusion: Two separate discharge summaries were being generated for each baby for a single episode of

care. Neither of these discharge summaries contained full information about the whole episode of care in

hospital and there was a significant risk of important information getting missed.

Recommendations: All babies transferred from neonatal unit to postnatal ward should be kept on the SEND

database as transitional care babies until they are discharged home from postnatal ward. Discharge

summaries will be initiated by the neonatal team and edited by the postnatal doctor at the time of discharge

from postnatal ward. A single final summary will be sent to primary care.

90

Islam and Resuscitation (D.N.R. Islamic Perspective)

Bader Kurdi

NICU, Hamad Medical Corporation, DOHA, Qatar

Introduction: Religious and cultural issues often play a more vital role in decision making by parents and

physicians than economic considerations, especially in Arab nations. Physicians are often reluctant to even

broach the subject of DNR with parents, believing it will not be accepted, may cause a loss of trust in the

physician, or “it is unfair to ask parents to be involved in the decision making process involving life and

death”. This has led to a significant increase in the number of handicapped survivors, and to a shortage of

intensive care beds

Method: 2 Types of facilitation of death (DNR):1-Active facilitation of death: (Withdrawal of the therapy)

when the doctor takes effective action to facilitate the death of the patient, such as stop mechanical

ventilation 2-Passive facilitation of death: (No escalation of therapy) Where the doctor doesn’t take any

effective steps to facilitate the death of the patient, but leaves the disease to take its occurs without any extra

support if the patient deteriorated.

We offer both ways of DNR for parent of 25 cases in the last 12 months.

Result: After we explain to the parents about the prognosis of those cases and supply them with multiple

Islamic fatwa regarding Islam and resuscitation 12 of them agreed to not be aggressive in the resuscitation if

the condition of the patient deteriorated.

Conclusion: The majority of scholars said that the treatment of patients is desirable (not a must) where there

is a recovery.

91

Incidence of Neural Tube Defects in a Highly Endogamous Society: Community Based Study

Bader Kurdi, Abdulbari Bener

HMC, Qatar

Background: The incidence rates of Neural Tube Defects (NTD) in the Arabian region have been attributed

to environmental, dietary and genetic factors. No previous study has been conducted in the State of Qatar to

document the incidence and trends of NTD.

Objective: The aim of this study is to determine the incidence of NTD over a 25 years period in the State of

Qatar.

Subject and methods: The study was based on study from 1985 to 2009 with a total of 285,008 newborns at

Women’s Hospital in Qatar were screened for NTD. The study included was age, gender, ethnicity, parental

consanguinity, and residential area.

Results: The overall prevalence of neural tube defects and anencephaly were 28 and 12 per 10000 births,

respectively. The prevalence of anencephaly was 11 and 12 per 10000 births in male and female newborns,

respectively. There were 131 (42.1%) males and 180 (57.9%) female newborns. The rate of NTD was 8.99

per 10,000 and 12, 89 per 10.000 in male and female newborns respectively. This difference was significant

(p0.001). The prevalence of anencephaly was 13.1/10000 in newborns with mothers aged 35 years.

Consanguinity was seen in 36.7% of the parents. . The prevalence of NTD (total Meningomyelocele,

M+hydrocephalus and Anencephaly) during the 25 years period was 10.9 per 10,000 births.

Conclusion: The present study revealed that Qatar has a high incidence of NTD. High rates of consanguinity

and lack of per conceptual folic acid intake among mothers were the main factors contributing to NTD

incidence rates in Qatar.

92

Creation of Follow-up System in Ukraine in Frame of National Project "New Life: New Quality of

Maternity and Childhood Protection

Tetiana Znamenska1, Tetiana Kurilina

1, Olena Riga

2, Andrey Penkov

3

1SI "Institute of Paediatrics, Obstetrics & Gynaecology NAMS of Ukraine", Ukraine

2Kharkiv National Medical University, Ukraine

3Kharkiv Regional Specialized Orphanage 1, Ukraine

Actions in frame of National project (2011-2014)

-the audit of medical care for mother & newborns in region (different state of follow-up system)

- Planning & financial substantiation in new perinatal center (27 regions –now 12 centers opened)

- Reconstruction (follow-up unit) & purchase of equipment

- Education & training of medical personnel (telecommunication – on-line training, training cycle in-site)

Our investment of capital (the main target of new project)

The manpower

- Highly skilled medical staff (postgraduate pre-attestation cycle, guest training, national manual, national

standards & guidelines)

- Medical care oriented on patient

- International standard of “friendly hospital” as mandatory conditions

- Professional support: clinic-twin, training for administration

Material resources

- Up-to-date equipment

- Innovation technology

- comfort conditions for mother-child joint station

- Assured & free provision with medicine and materials, instructions for early discharge, effective

development

Information support

- The approaching of availability of medical care for population

- The application of the best world practice in maternity & childhood protection

- The formation of the motivation of healthy mode of life in population

- The approaching of population with print information materials

Prospects for follow-up and early intervention system as a standard care for preterm &sick infants

- The creation of training center for follow-up units personnel

- Revision of orders of Health ministry

- Unification of psychological-medical tracking

- Inclusion of follow-up program in medical education

Expectation results

- Creation of national electronic register of preterm & sick infants

- decreasing of child abandonment

- Standardization of follow-up system and program of early intervention

- decreasing of the rate of all consequences of aggressive intensive care

93

The Pharmacogenetic Approach in Prognosis of Dopamine Dose in the Neonatal Intensive Care Unit

Svitlana Kyriachenko, Gorovenko Natalia, Rossokha Zoia

State Institute of Genetic and Regenerative Medicine National Academy of Medical Sciences

of Ukraine, Ukraine

Introduction: Molecular medicine is the foundation in the development of new approaches to the

determination of an individual dose of the drug in the patient’s treatment. This is particularly important in

neonatology to avoid side effects. T-786C polymorphism of the eNOS gene influences on the production of

the protein.

Aim: The aim of this study was to evaluate the effect of T-786C polymorphism on the dose of dopamine

required for therapeutic effect.

Material and methods: We conducted study of 51 newborns (27 full-term and 24 premature newborns)

with perinatal pathologies (perinatal hypoxic damage, respiratory failures, necrotizing enterocolitis, etc.). It

was obtained the informed consent of the parents for the participation in this study. For the genotyping was

used polymerase chain reaction followed by visualization on 2% agarose gels.

Results: The dose of dopamine for newborns in the intensive care unit was 5,0-9,0 mcg/kg/min to achieve a

therapeutic effect. The frequency of -786TT genotype in investigated newborns was 27,45%, -786CT –

52,94% -786CC – 19,60%, respectively. The average dose of dopamine depending on the genotype is shown

in Table 1.

Table 1. Drug hemodynamic support in newborns depending on the C-786T polymorphism

Patients with -786CC genotype treated significantly lower dose of dopamine to achieve a therapeutic effect

compared with -786CT (p0,05) and -786TT (p0,05) genotypes patients.

Conclusion: Genetic testing is promising to determine the therapeutic dose of dopamine in patients of

neonatal intensive care unit.

-786TT

Dopamine

dose, mcg/kg/min

5,30+0,12

7,80+0,06

8,50+0,13

94

New Approach to Prognosis of Development Risk of Severe Perinatal Pathology in the Newborns

Svetlana Kyriachenko, Zoia Rossokha, Natalia Gorovenko, Gorovenko Natalia

State Institute of Genetic and Regenerative Medicine National Academy of Medical Sciences

of Ukraine, Ukraine

Introduction: Genetic characteristics of newborns have an impact on the risk of perinatal pathologies and

neonatal syndromes.

Aim: This work was to evaluate the role of gene-gene interaction in the development of critical conditions

in newborns.

Material and Methods: We conducted case-control study included 245 newborns (116 full-term and 119

premature newborns) with perinatal pathologies (perinatal hypoxic damage,

respira

tory failures, necrotizing enterocolitis, neonatal jaundice, etc.) and 110 healthy full-term newborns. There

were used polymerase chain reaction with further restriction fragments length polymorphism analyses.

Statistical analysis of the results was performed using SPSS 17.0 and R-Studio. To visualize the obtained

results we used classification and regression trees (CART) and ID3 algorithm.

Results: We determined the association between DD, ID genotypes of ACE gene, 1166AC, 1166CC

genotypes of AT2R1 gene, 308AG, 308GG of TNF-a gene, with increased development risk of perinatal

pathology, perinatal hypoxic damage, RDS, NEC, neonatal jaundice. 677TT genotype of MTHFR gene was

associated with reduced gestational age (prematurity) and the development risk of severe perinatal

pathology. The statistical model with 83,2% predictive value was elaborated. The best model included ACE,

AT2R1, TNF-a genes (fig.1). Figure 1. Gene-gene interaction for individual prognosis in newborns.

Conclusion: It was shown that genetic analysis is promising approach for using in clinical practice. It may

help to allocate the risk of perinatal pathologies and critical states.

95

Arterial Blood Gas Sampling in Neonatal Intensive Care, King Faisal Hospital

Ingabire Magera, Nambayisa Schadrack1

King Faisal Hospital, Rwanda

An arterial blood gas (ABG) is a blood test that is performed using blood from an artery. It involves

puncturing an artery with a thin needle and syringe and drawing a small volume of blood. ABG sampling

provides valuable information on the acid-base balance at a specific point in the course of a patient's illness.

It is the only reliable determination of ventilation success as evidenced by CO2 content. The purpose of the

project was to improve the quality of health care by ensuring the skill and accuracy in

ABG sampling; improve the accuracy of results in order to monitor the severity and progression of a

documented disease process and to control the risks related to the ABG sampling technique. The population

of this project consists of all nurses and doctors (GP) working in NICU. The data was obtained using a

checklist for a period of three months (March to May 2012). The results showed that the performance of

checking oxygen concentration, hand washing, and use of gloves during the procedure are decreased

respectively to +21.8, +6.4 and +5.2%. ABG sampling technique improved.

However, the performance related to the use of aseptic technique decreased to -1.9%.

96

Nosocomial Infection in Neonatal Intensive Care, King Faisal Hospital

Ingabire Magera, Kamagaju Josephine2

King Faisal Hospital, Rwanda

Nosocomial infections are defined as those “Occurring in a patient during the process of care in a hospital or

other health-care facility which was not present or incubating at the time of admission and is manifested at

least two (2) days post admission and within one (1) week post discharge. In King Faisal Hospital, Kigali

(KFH, K) NICU, out of 60 neonates admitted between January to June 2009, 12 (20%) had Nosocomial

infections as confirmed by blood culture. Out of 12 (100%) neonates with NI, 5 (42%) died due to NI

during that period.

97

The Safety and Effectiveness of Therapeutic Hypothermia in Neonates with Hypoxic Ischaemic

Encephalopathy

Jennifer Miah

University of Liverpool, UK

Background: Cooling has been used traditionally in many aspects of medical care. However the role of

Hypothermia in neuro protection for neonatal Hypoxic Ischemic Encephalopathy has emerged as a more

novel and non-invasive approach. Hypoxic Ischemic Encephalopathy is a syndrome consisting of debilitating

neurological symptoms of which asphyxia is a common cause. Oxygen deprivation in the brain results in a

cascade of biochemical events which leads to cell necrosis. The use of therapeutic hypothermia however has

been shown to alter these biochemical processes. Clinically this may improve the outcome in newborn

infants with HIE by reducing the extent of neurological damage and mortality.

Objective: The purpose of this literature review was to ascertain the safety and effectiveness of therapeutic

hypothermia in neonates with Hypoxic Ischaemic Encephalopathy.

Method: A literature review was undertaken on randomised controlled trials which were obtained through

electronic databases such as science direct and pubmed. Nine studies were critically appraised using the

critical appraisal skills programme. Outcome measures included mortality, neurodevelopment defects and

adverse effects.

Results: All studies revealed that there were greater numbers of deaths or disability in neonates provided

with conventional care compared to those given cooling. Adverse effects of therapeutic cooling were low.

Importantly, neonates given therapeutic hypothermia suffered less neurodevelopment impairments.

Conclusion: Neonates less than 6 hours of age with Hypoxic Ischemic Encephalopathy demonstrate greater

clinical benefits from therapeutic hypothermia in contrast to standard treatment. Hypothermia has shown to

be a safe technique in improving survival and neurodevelopment impairments among neonates meeting

strict selection criteria. Therefore therapeutic hypothermia should be considered more strongly as part of the

clinical care to newborns with HIE.

98

The Impact of the Baby Friendly Hospital Initiative in Saudi Arabia

Cynthia Mosher, Cynthia Mosher, Abdurahman Alhamdani, Asma Alhoulan, Reem

Hamadah, Tehreem Khan, Yosra Almakadma, Alaa AbouBakr Hashem, Abdullah Sarkar,

Abiola Senok

Alfaisal University, Saudi Arabia

Background: The Baby Friendly Hospital Initiative (BFHI) launched by the World Health Organization

(WHO) is a global effort aimed at promoting and supporting breastfeeding and has been shown to be

effective in increasing breastfeeding rates. The WHO recommends exclusive breastfeeding for six months.

Although Saudi Arabia has one of the highest breastfeeding initiation rates (92%), this falls rapidly to only

10% within six months.

Aim: To identify the factors that shape breastfeeding trends and assess the effectiveness of BFHI

implementation in Saudi Arabia.

Methodology: This prospective, longitudinal study was carried out at two-matched healthcare facilities in

Riyadh (BFHI-practicing versus BFHI-non-practicing). Randomly selected women at 38-40 weeks gestation,

of all education, nationalities and ages, were enrolled. Known contraindications to breastfeeding were

excluded. Pre-tested questionnaires administered prenatally, one, three and six months postnatal collected

data on demographics, infant feeding practices, breastfeeding education and support. Maternity staff

practices were surveyed. Data was analyzed using SPSS software.

Results: preliminary data analyses showed a significantly higher incidence of women receive breastfeeding

education at the BFHI hospital (93.3% vs 48.2%). Formula marketing targeting non-BFHI hospital patients

was found to be 24.1% vs 4.8% despite national policies restricting such activities. Hospital policies

regarding visitation times were identified as a risk factor. More BFHI-hospital patients were exclusively

breastfeeding at discharge (51.0% vs 30.1%)

Conclusion: While BFHI implementation is demonstrating success, there are weaknesses. Improved

compliance with BFHI practices and addressing hospital policies may have an even larger impact on

breastfeeding rates.

Implications: An extensive research of the literature has found no study published assessing the

effectiveness of BFHI implementation in increasing breastfeeding rates in Saudi Arabia. Our study will be

the first to make this assessment and will be the first source of information to the local and global scientific

community and the public.

99

Effects of Surfactant Replacement Therapy in Preterm Baby with Neonatal Respiratory Distress

Syndrome

Vesna Novakovic, Stojislav Konjevic, Veroslava Milosevic, Ana Blagojevic

Pediatric Clinic,Clinical Center, Bosnia and Herzegovina

Introduction: Respiratory distress syndrome (RDS) is a pulmonary insufficiency mostly premature

newborns, caused pulmonary surfactant deficiency. As many as 50% of all neonatal deaths is the result of

RDS. A revolution in the treatment of RDS entered is application of surfactant, which is the gold standard in

the treatment, with significant reduction mortality and complications.

Objective: The objective of this study was to investigate the effect of surfactant replacement therapy,

survival rate, and mortality risk factors in premature neonates with RDS in the clinic.

Methods: This study included 105 preterm infants with RDS, between 24 and 37 weeks gestation, were

admitted in the Neonatal Intensive Care Unit (NICU) and received surfactant during 2010 -2013.

Results: Overall, 62% (83/134) neonates who received surfactant survived. The higher efficacy of surfactant

therapy was observed in neonates with gestational age of more than 28 weeks 82,8% (58/70), in those who

received the surfactant during the first 2 hours of life (58.3%),in a dose greater than 100mg/kg (63,4%), and

whose mother received steroid therapy before labor (42.3%).The highest mortality 60,9% (39/64) was the

neonates gestational age below 28, and Apgar score of less than 5/7 (53.1%), and birth weight of less than

1000 g 67.9% (36/53).Significantly higher risk of dying was observed in neonates with one or more risk

factor, prenatal asphyxia, air-leak say and pulmonary hemorrhage, intracranial hemorrhage gr III i IV and

early et late sepsis.

Conclusion: Early treatment with surfactant, in doses higher than 100 mg/kg body weight significantly

reduces mortality of RDS Prevention of risk factors and antenatal administration steroids increases the

efficiency of surfactant replacement therapy.

100

Treatment Breathing Disorders of Infants with Respiratory Distress Syndrome

Fayziev Otabek, Anvar Yusupov

Taskent pediatric medical institute, Uzbekistan

Aim: The study was to evaluate the effectiveness of the drug Surfactant composite in the treatment of acute

respiratory disorders in the newborn respiratory distress syndrome.

Materials and methods: We observed 30 children: 15 children a basic group and 15 control groups. All

infants were treated with the treatment of RDS (antibiotic, infusion and symptomatic therapy, enteral or

parenteral nutrition). In the study group received the drug, as well as Surfactant composite premature 1st day

of life, with a gestational age ≤ 36 weeks, body weight ≥ 900g at birth. The drug is used pulmonary, every 12

hours for 2 days. Hemodynamic monitoring, chest x-ray pulse oximetry (HR, A / D and SpO2):

Results: The results showed that the main group of children during treatment with the drug Surfactant

composite were quickly reduce the value of the maximum inspiratory pressure (Pin) and frequency –

controlled ventilation (VR), and the significant difference was noted already from 2 days up to and transfer

of children at weaning. Baby’s core group quickly noted the positive dynamics in the clinical picture, and in

some patients in the first, 3 - minutes after administration of the drug improved chest and holding of breath

in the lungs, skin color, or disappear minimum marbling. On changes in children can also judge the

dynamics parameters of mechanical ventilation, including the duration of mechanical ventilation and

ventilation with the use of hyperoxic mixtures (FIO2 ≥ 0,3).

Conclusion: Use of the drug Surfactant composite in the treatment of respiratory distress syndrome leads to

a more dynamic performance improvement respiratory biomechanics allows faster start falling Pin, VR and 2

times quickly reach the level of nontoxic FIO2.

101

Recurrent Air Leakage in Preterm Newborn Infants: When Surgical Approach Could be Decisive. A

case report

Albert Pi Compañó, Anna Tarragó Aregay, Rosario Estudillo Mora, Laura Ripoll Roca

Vall d'Hebron Hospital, Spain

Introduction: Pulmonary air leakage is a severe complication of pulmonary disease in newborn infants,

especially in preterm ones, often associated to resuscitation, mechanical ventilation, administration of

surfactant or during CPAP-treatment. Needle aspiration or thoracostomy solve the condition in most cases,

nevertheless recurrence of air leakage can occur.

Case Report: Female patient born at 25+1 weeks of gestation and birthweight 540 g because of a suspected

chorioamnionitis. She required resuscitation in the delivery room by endotraqueal intubation and surfactant

administration. During the first days of life she suffered from pulmonary collapse which was solved with

high frequency ventilation and presented persistent ductus arteriosus that had to be surgically closured. At

the10th day of life the infant presented sudden deterioration and right tension pneumothorax was diagnosed,

so that, needle aspiration and placement of two drainage tubes were proceeded. She was put again on high

frequency ventilation. Nevertheless, air-leakage persisted, althought mobilizing the drainages and needing

continuous manual aspirations. A bronchopleural fistula was suspected, and a selective left main bronchus

intubation was attempted, unsuccessfully. Rapid deterioration was observed leading to cardiopulmonary

arrest that required advanced cardiopulmonary resuscitation. We decided that a surgical approach by

thoracotomy had to be performed. Macroscopic examination under normal saline revealed an air outflow at

the mediastinal side of the right lower lobe, which was sutured and surface sealed. Afterwards patient

respiratory condition and so her clinical status improved progressively.

Conclusions: Recurrent pneumothorax is an unusual condition, but the patient's survival depends on an

appropriate treatment. When the patient’s intubated and connected to mechanical ventilation, a

bronchopleural fistula has to be suspected. It’s important to assess and perform surgery at the appropriate

time in order to avoid a deterioration which could be fatal. We conclude that surgical approach should be

considered when the conventional treatment has proved insufficient.

102

Hypotonia, Lethargy and Hepatic Failure: Leading Signs of New Case of Galactosemia

Albert Pi Compañó, Anna Tarragó Aregay, Rosario Estudillo Mora, Laura Ripoll Roca

Vall d'Hebron Hospital, Spain

Introduction: Galactosemia is a rare autosomal recessive inherited metabolic disorder. Its defect cause

congenital abnormalities due to galactose accumulation if mother had taken milk during pregnancy, as well

as the intake of milk after delivery will cause a progressive deterioration. An early diagnosis is essential.

Case Report: A 21-day-old Caucasian male newborn was referred to the hospital because of hypotonia,

tendency to lethargy, vomiting, poor feeding and deterioration of his clinical state. The patient was breastfed

since birth. Clinical examination revealed jaundice, hepatomegaly and septic appearance. Lab tests showed

slightly elevated liver enzymes, coagulopathy and metabolic acidosis. Infectious screening, abdominal

ultrasound and metabolic studies were performed. Oral intake was discontinued. Abdominal ultrasound

pointed to hepato-renal syndrome. The patient showed clinical improvement after intravenous rehidratation,

so diet was reinstated. A rapid deterioration was observed, and nil per os was indicated again. Tyrosinemia

was suspected and patient received nitisinone for three days, until laboratory tests rule it out. Other infectious

or deposit causes of hepatic disease were excluded. Galactosemia was also suspected. Funduscopy was

performed, finding bilateral cataracts resembling an oil drop in both eyes, suggesting galactosemia. He was

given a free-galactose diet, improving his clinical state. Laboratory and genetic tests confirmed the

diagnosis, being the patient an homozygous carrier of the most common mutation.

Conclusions: Although is an extremely unusual disorder, galactosemia should be taken into account in the

differential diagnosis of neonatal hepatic disease, as the patient's outcome is largely dependent on early

diagnosis and appropriate treatment, ensuring survival of the affected individual. It’s important to note that

oral intake should not be initiated until metabolic disorders had been discarded, in order to avoid a

deterioration which could be fatal. Nowadays, since few months ago, this disorder is included in all-neonates

metabolic screening tests in our region.

103

Exfoliative-toxin producing Staphylococcus Aureus Neonatal Infection: a Case report

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Rafael Barragán

Milán1

1Centro Médico Teknon, Spain

2Vall d'Hebron Hospital, Spain

Introduction: Neonatal staphylococcal infection is a potentially serious infection in this age group

according to their immunological immaturity, so early identification and establishment of therapeutic

measures are very important. Nowadays is an extremely rare germ causing neonatal sepsis. The severity of

disease in the neonatal period wides from a low grade onfalitis to fulminant septicemia with possible

meningitis and death. We report a case which exemplifies some of the possible complications of the

infection caused by this organism, so rare today as etiologic agent of neonatal sepsis.

Case presentation: Shortly-life male term newborn resulting from normoevolutive gestation which was

ended by emergency cesarean section for suspected clinical corioaminionitis and meconium-stained amniotic

fluid, started difficulty breathing, hypoactivity and rejection of breast milk, being given treatment as early

neonatal sepsis at first hours of life. Maternal cultures for group B streptococcus were negative. Within next

hours, facial, truncal, axillary and inguinal eritrodermia appeared and some bullous elements of few mm of

diameter as well, which rapidly progressed to wide areas of skin exfoliation, suspecting of staphylococcal

scalded skin syndrome. Vancomycin was added to treatment. Rapid and progressive deterioration occurred,

associating respiratory failure that required mechanical ventilation support, hemodynamic collapse and

secondary pulmonary hypertension requiring administration of vasoactive drugs and nitric oxide.

Afterwards, slowly gradual but progressive improvement was followed by satisfactory clinical outcome.

Meticillin-sensitive S.aureus was reported from blood and external cultures.

Conclusion: The purpose of this case report is to highlight the low incidence of exfoliative toxin-producing

S.aureus as microorganism to cause sepsis and/or meningitis in neonatal period, and the presence in our case

of septicemia and no clinical signs of local infection. Is noteworthy in our case the route of vertical

transmission instead of horizontal acquisition as source of infection, being even more exceptional in our

current environment.

104

Neonatal Hyperekplexia Resistant To Clonazepam: A Difficult Challenge for Medical Treatment And

Nurse Caring

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Ainhoa Rivero

Pérez1, Carmen Núñez García

1, Berta Barbosa Nogueira

1

1Centro Médico Teknon, Spain

2Vall d'Hebron Hospital, Spain

Introduction: Neonatal hyperekplexia or startle disease is a congenital disease characterized by an intense

jerk and hypertonia at the lowest stimulus (sounds, tactile stimuli or from internal origin), potentially causing

laryngospasm and apnea, and subsequent neurological sequelae. Its very low prevalence turns the condition a

rare and little-known disease. This case reflects the need of individualized care strategies in these patients,

recommendations which have not been established in prior cases.

Case Report: Proper weight and term neonate, with no family or obstetric history of interest except

meconium stained amniotic fluid, presented generalized muscle hypertonia, cyanosis and hyperexcitability

from first hours of life. Laboratory and metabolic tests of blood and CSF, ultrasound transfontanelar imaging

and cranial MRI were found to be normal, showing the EEG mild paroxysmal activity, which does not

appear in the posterior exam. Hyperekplexia was suspected and clonazepam was initiated, obtaining no

response. Synergistic therapeutic trial with clobazam and clonazepam was begun, decreasing the number and

intensity of crisis. Given this situation a plan of nursing care was outlined: reduction of environmental

stimuli by attention to sound, light and approaching the neonate; careful manipulation and attention in

routine care (grooming, feeding,...); single-room accommodation; Vigevano maneuvring; NGT-feeding

during first months, and enabling parents participating and training them in the cares.

Conclusions: Care-needing of this infant with severe resistant hyperkplexia to the initial medical treatment,

forced to make a very individualized plan based on knowledge of life-threatening events presented in nursing

care. Modification of the environment, careful attention to routine care, continuous monitoring, nurse

training in salvation maneuvers (Vigevano) and active parents inclusion in cares, made possible to overcome

risk situations and aminorate family stress, towards the improvement of the patient when finally partially-

responded to medical treatment, and could be also useful in future cases.

105

Neonatal Continuous Arterio-Venous Exsanguinotransfusion: Description Of The Procedure And

Nursing Care

Albert Pi Compañó2, Anna Tarragó Aregay

1, Rosario Estudillo Mora

1, Laura Ripoll

Roca1

1Vall d'Hebron, Spain

2Centro Médico Teknon, Spain

Introduction: Exsanguinotransfusion is a technique that is used to maintain the serum bilirubin levels below

neurotoxicity. It's indicated in cases of hyperbilirubinemia when phototherapy has failed and there is high

risk of bilirubin encephalopathy , as well as in severe cases of anemia with cardiac dysfunction and death

risk, DIC , etc. ...

Justification: To explain what the exsanguinotransfusion is and what the procedure consists of for the

improvement on nursing handling.

Description: This technique involves the withdrawal of fractional parts of baby's blood and the replacement

with donor's blood. To carry this out, usually umbilical artery is catheterized (newborn blood will go to

wasting bag) and umbilical vein as well (donor blood will be administered). Two infusion pumps are needed,

one for input and the other for output, using a closed circuit. It is a sterile procedure. Preparation of input

circuit: the blood products infusion equipment is connected with donor blood bag and to the hotline system

and once purged is connected to the umbilical venous catheter. Preparation of output circuit : using a two-

lined pump system , the primary line is filled with heparinized serum and connected to bag of rejection and

the secondary line is connected with umbilical artery catheter. The infusion and extraction rythm must

always be the same, and therefore, both pumps started and stoped simultaneously. Nursing care consists of

registering all process, volumes removed, controlling leakage, hemodynamic and gasometric monitoring and

assessing warning signs of complications or disorders.

Conclusions: The technique of automatic exsanguinotransfusion brings more precision, comfort, safety and

sterility being more physiological than the manual method, thus avoiding possible infections or

complications. It requires well-knowledge of nursing care in this technique because it is fundamental for

assembling the procedure and controlling potential clinical disorders during process.

106

Benefits of Breastfeeding and Exclusive Breastfeeding in the Newborn Focusing on Preterms

Albert Pi i Compañó1, Anna Aregay Tarragó

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d’Hebron Hospital, Spain

Introduction: Breastfeeding contains not only appropriate nutrients but also provides digestive enzymes,

vitamins and minerals for optimal baby's needs and development in their first months of life. In addition it

also contains antibodies that come from the mother and help the newborn fighting infections. It must be

started, if not contraindicated, in the first hour of life, as it is considered that colostrums is the most complete

food at that time, and should be extended to 6 months exclusively or more. Thus, it is especially beneficial in

preterm babies because of its digestive properties which make breast milk the most well-tolerated for the

preterm and also immature gut.

Justification: The support given to mothers must be very important for the implementation of breastfeeding

be complete and could be extended for more, and our aim is specially focused in preterm infants.

Description: This can be seen from 31 weeks onwards, but even 28 weeks can breastfeed with help. It results

in an increase of survival of babies born below 1500g. Mother’s chest will warm automatically if her baby is

cold, and even cool baby if too hot. For premature they need mother even more to stabilize.

Conclusion: It’s very important that nurses and health professionals we provide adequate information on the

benefits of breastfeeding and support mothers solving their concerns and supporting in the technique, as it

could suppose leaving or, on the contrary, succession breastfeeding. Breastfed infants are less prone to

gastrointestinal and respiratory infections, allergies, constipation, and prevent long-term childhood obesity,

diabetes, sudden death syndrome and caries. And more over in case of preterm delivery: the smaller the

premature, the more they need their mother’s chest to stabilize even if they need medical technology as well.

107

Importance of Breastmilk Banks when Mother’s Breastfeeding is not Possible: Best Alternative to

Artificial Milk Formula

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d'Hebron Hospital, Spain

Introduction: Breastmilk banks are specialized services aimed at promoting and supporting breastfeeding

and responsible for providing donated human milk to patients who need it, ensuring its safety and quality.

There is strong evidence on the benefits feeding infants with breast milk in short and long term.

Milk banks: They collect, process, store and disperse breastmilk. They produce a safe product concerning

the risk of infections transmission: strict control in the selection of the donor, pasteurization process of milk

before dispensing it, strict microbiological tests before and after processing.

Breastmilk from bank: Offers: - better digestive tolerance, - immunological protection against infectious

diseases, -protection against necrotizing enterocolitis. Contains growth factors which: -protect the immature

tissue, -promote gut maturation, - promote the recovering of tissues damaged by infections. Long-term

effects: -best psychomotor development, - decreased cardiovascular risk factors.

Indications: • Nutritional : - prematurity, - malabsorption syndrome, - some metabolic congenital errors, -

postoperative nutrition. • Therapeutical: - infectious diseases, - immunodeficiencies, - organ transplantation,

- chronical diseases. • Preventive: -necrotizing enterocolitis, - cow's milk protein allergy, -

immunosuppressive therapy.

Conclusions: Breastmilk processed in milk bank retains largely the nutritional and immunological properties

of human milk which make it an irreplaceable product concerning feeding of the newborn. Milkbanks will

raise awareness in society about the value of breastfeeding and enable research and development of

techniques that collaborate in its maintenance worldwide.

108

Nursing Care in Preterm Infants Posture

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d’Hebron Hospital, Spain

Introduction: Caring postural changes in preterm newborns is known as the set of activities serving to

promote some concrete positions that will be beneficial for the neurodevelopment of the child.

Justification: This poster aims to spread the effectiveness of nursing intervention in the process of early

child evelopment through positional care. Focusing mainly on the maintenance of physiological flexion,

midline orientation and containment in the nest, the physiological position the fetus still in the maternal

uterus would enjoy.

Description: Our proposal is focused on making both health careers and parents and relatives of infants

admitted to the neonatal unit conscious on the subject, providing the basics of positional care, as well as the

benefits and disadvantages of each type of decubitus. Similarly, to provide all them several items (such as

yawning, facial expressions, concrete behaviors,..) so they know how to understand the signs and symptoms

of comfort or discomfort that newborns have.

Conclusion: Awareness of nurses about the behavior and physical signs of newborns show us is needed to

be able to modify infant postures since there is evidence that postural patterns that remain for weeks and

months influence the formation of neural connections and cerebral pathways of the infant.

109

Nutrition in Infants with Congenital Heart Disease

Albert Pi Compañó, Anna Tarragó Aregay, Rosario Estudillo Mora, Laura Ripoll Roca

Centro Médico Teknon, Spain

Introduction: Children born with congenital heart disease often have alterations in nutrition, an important

problem that must be treated with a multidisciplinary assessment, which will ensure optimal growth

and development allowing entering surgery on best conditions and decreasing risk of complications on

surgery room and also during postoperative period avoiding for example risk of edema and capillary leak if

plasma proteins are on good levels.

Nutritional Management: Proper assessment of nutritional status: Detailed clinical findings and laboratory

data. - Ensure an adequate calorie-protein intake, fluid and sodium restriction, and supplementation of

vitamins and minerals, especially iron and calcium. Type of food depends on the age, functional status of

gastrointestinal tract and heart disease. Promote breastfeeding whenever possible. - Gradually increase the

caloric density, but without altering metabolic balance and avoiding increasing volume. Oral feeding is the

route of choice, provided that hemodynamically be possible, although enteral nutrition almost always be

necessary. - Parenteral nutrition is only indicated when inability to use gastrointestinal tract.

Conclusion: With successful nutritional assessment and an adequate nutritional support, morbidity and

mortality associated to malnutrition are avoided and it allows entering surgery in optimal condition and

decreases postoperative complications.

110

Importance of Breast Milk Banks when Mother’s Breastfeeding is not Possible: Best Alternative to

Artificial Milk Formula

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d’Hebron Hospital, Spain

Introduction: Breast milk banks are specialized services aimed at promoting and supporting

breastfeeding and responsible for providing donated human milk to patients who

need it, ensuring its safety and quality. There is strong evidence on the

benefits feeding infants with breast milk in short and long term.

Milk banks: They collect, process, store and disperse breast milk. They produce a safe productconcerning

the risk of infections transmission: strict control in the selectionof the donor, pasteurization process of milk

before dispensing it, strictmicrobiological tests before and after processing.

Breast milk from bank: Offers: - better digestive tolerance, - immunological protection againstinfectious

diseases, -protection against necrotizing enterocolitis. Containsgrowth factors which: -protect the immature

tissue, -promote gut maturation, -promote the recovering of tissues damaged by infections. Long-term

effects:-best psychomotor development, - decreased cardiovascular risk factors.Indications: Nutritional: -

prematurity, - malabsorption syndrome, - some metabolic congenital errors,- postoperative nutrition.

Therapeutical: - infectious diseases, -immunodeficiencies, - organ transplantation, - chronical

diseases.Preventive: -necrotizing enterocolitis,- cow's milk protein allergy, -immunosuppressive therapy.

Conclusions: Breast milk processed in milk bank retains largely the nutritional and immunologicalproperties

of human milk which make it an irreplaceable product concerningfeeding of the newborn. Milk banks will

raise awareness in society about thevalue of breastfeeding and enable research and development of

techniques thatcollaborate in its maintenance worldwide.

111

Improved Handling of Withdrawal Syndrome of the Newborn

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d’Hebron Hospital, Spain

Introduction: The withdrawal syndrome is one of the most prevalent NICU disorders because of use of

sedation and analgesic drugs. An early diagnosis will affect prognosis, morbidity and staying in the unit.

Justification: We believe that the introduction of supplementary tables a part from Finnegan score during

the stay will contribute to improving the assessment of the syndrome, customizing cares for each infant.

Description: In our NICUs, Finnegan score is tested every 6-12 hours to adjust the phenobarbital or

morphine (Brompton solution) dose in each infant needing those drugs. Sometimes is found that children do

not be well-adapted to the treatment dosage, causing a delay in weaning and thus, more stress, problems with

feeding and disposal, and finally in their neurodevelopment. The Finnegan test was initially created for

children whose mothers had a drug -an opioid- addiction, but was former generalized toall cases of

withdrawal syndrome. The application of Wat-1 tables and the Cunliffe Score will help complementing

the above, thus providing a proper handling of the newborn suffering withdrawal syndrome arising from use

of sedation and analgesic drugs.

Conclusions: Using of complementary scores to Finnegan test will help providing better individual attention

to newborns needed and avoid potential complications arising from the treatment.

112

Nutritional Needs during Pregnancy

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d’Hebron Hospital, Spain

Introduction: Pregnancy period requires a diet providing necessary energy and nutritional resources to

maintain mother health, allow body metabolic changes experienced by the pregnant mother, and achieve

optimal development and fetal growth. Nursing should have clear nutritional guidelines during pregnancy

and must be well known, for transmission to pregnant patients whenever needed, raising their awareness of

their relevance.

Description: It has been estimated that in energy terms must be necessary during the second and third

trimester up to 300 Kcal per day over the requirements before pregnancy. It is considered sufficient an intake

of 2200 Kcal per day (with a standard deviation of 390Kcal), reaching to 2500 kcal – 2750 kcal per day

during the fifth month of pregnancy. A good diet would be 5-6 meals / day, avoiding coffee, alcohol and

carbonated drinks and resting semi sitting with feet up.

Conclusions: In pregnancy and also during breastfeeding higher amounts of some nutrients are required, so

nurses should propose and include in the pregnant diet all the basics, ensuring they are sufficient, and

adapting it to her various tastes and habits: over 10 – 20 g of protein a day (total 100g/day), 20-30g/day of fat

(better vegetable oil), sufficient carbohydrate diet, high starched and avoiding rapidly absorbed sugars, folate

400mcg/day, iron 25-30mg/day, calcium 1.200mg/day, magnesium 450mg/day, iodine 175mcg/day, and

10g/day of yeast specially in second trimester

113

Nutritional Plan in Gestational Diabetes Mellitus

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d’Hebron Hospital, Spain

Introduction: Gestational diabetes is a risk factor for pregnant women and behaves health problems for the

fetus. Diet is the mainstayof treatment, and is used to achieve therapeutic blood sugar levels and thus optimal

metabolic control.

Description: Gestational diabetes refers to intolerance to carbohydrates first recognized during pregnancy.

The self-care plan includes first a nutrition plan. If this results not being enough, the addition of

other therapeutic measures, such as mild exercise or insulin treatment would be considered. Nutrition plan

design: 1) Assessment based on clinical history, physical findings, laboratory tests, nutritional habits and

preferences and resources destined for food.2) Strategies for controlling carbohydrate intake, to romote

nutritional habits that achieve glycemic goals, gaining weight reasonably and avoiding appearing of

ketonuria. 3) Program subsequent follow-upvisits to avoid weight gain, control blood glucose levels and the

ability ofthe pregnant patient to fulfill the meal plan.

Conclusions: Once detected gestational diabetes is essential to implement the evidence of the benefits

achieved with current dietary recommendations for their management and assessment, because with

good metabolic control adapted to the physiological stage of pregnancy may reduce fetal morbidity and

mortality.

114

Giving Support to Neonatal Losses

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d’Hebron Hospital, Spain

Introduction: Neonatal losses are situations in which the arrival of a new family member is lived with hope

and enthusiasm towards this new future loved one and the fact that there occurs an unexpected death makes

parents and relatives not easily accept them. Moreover, death is something that exists as a clinical failure

and health staff tends to focus on other patients forgetting sometimes those parents, and coming up death in a

surrounded environment by strange people performing procedures that they do not understand, isolated from

their loved ones, becomes a fact without emotional support.

Justification: Highlight the important role of nurses and nursing activities that will facilitate the duel of

prenatal death, giving emotional support and caring, a part from the newborn, both the parents and the

relatives to help assimilate the loss and prevent the emergence of future psychiatric disorders, giving some

guidance on possible interventions and activities to do.

Methodology: Description nursing activities aimed at facilitating bereavement of perinatal death following

the lived experience of cases in our unit.

Results: Analyzing our experience we have seen the importance of measures such as: - Encourage

participation in decision making about the interruption of life support once the parents have realized and

understood the situation and the future implications - Encourage parents to catch the baby during or after his

death , - Prepare the baby to be seen, - Have time for the family to remain alone with the baby - Encourage

parents to verbally express the memories of loss - Encourage the identification of the deepest fears about the

loss.

Conclusions: The grieving process may continue towards assimilation loss and reorganization of life

or towards creating a more lasting mental impairment, which will set up a pathological dimension, being

important the nursing role.

115

Improving Handling of Withdrawal Syndrome in Newborns

Anna Tarragó Aregay1, Rosario Estudillo Mora

1, Laura Ripoll Roca

1, Albert Pi

Compañó2

1Vall d'Hebron Hospital, Spain

2Centro Médico Teknon, Spain

Introduction: The withdrawal syndrome is one of the most prevalent NICU disorders because of use of

sedation and analgesic drugs. An early diagnosis will affect prognosis, morbidity and staying in the unit.

Justification: We believe that the introduction of supplementary tables appart from Finnegan score during

the stay will contribute to improving the assessment of the syndrome, customizing cares for each infant.

Description: In our NICUs, Finnegan score is tested every 6-12 hours to adjust the phenobarbital or

morphine (Brompton solution) dose in each infant needing those drugs. Sometimes is found that children do

not be well-adapted to the treatment dosage, causing a delay in weaning and thus, more stress, problems with

feeding and disposal, and finally in their neurodevelopment. The Finnegan test was initially created for

children whose mothers had a drug -an opioid- addiction, but was former generalized to all cases of

withdrawal syndrome. The application of Wat-1 tables and the Cunliffe Score will help complementing the

above, thus providing a proper handling of the newborn suffering withdrawal syndrome arising from use of

sedation and analgesic drugs.

Conclusions: Using of complementary scores to Finnegan test will help providing better individual attention

to newborns needed and avoid potential complications arising from the treatment.

116

Nutritional Needs during Pregnancy

Anna Tarragó Aregay1, Rosario Estudillo Mora

1, Laura Ripoll Roca

1, Albert Pi

Compañó2

1Vall d'Hebron Hospital, Spain

2Centro Médico Teknon, Spain

Introduction: Pregnancy period requires a diet providing necessary energy and nutritional resources to

maintain mother health, allow body metabolic changes experienced by the pregnant mother, and achieve

optimal development and fetal growth. Nursing should have clear nutritional guidelines during pregnancy

and must be well known, for transmission to pregnant patients whenever needed, raising their awareness of

their relevance.

Description: It has been estimated that in energy terms must be necessary during the second and third

trimester up to 300 Kcal per day over the requirements before pregnancy. It is considered sufficient an intake

of 2200 Kcal per day (with a standard deviation of 390Kcal), reaching to 2500 kcal – 2750 kcal per day

during the fifth month of pregnancy. A good diet would be 5-6 meals / day, avoiding coffee, alcohol and

carbonated drinks and resting in a semisitting position with legs up.

Conclusions: In pregnancy and also during breastfeeding higher amounts of some nutrients are required, so

nurses should propose and include in the pregnant diet all the basics, ensuring they are sufficient, and

adapting it to her various tastes and habits: over 10 – 20 g of protein a day (total 100g/day), 20-30g/day of fat

(better vegetable oil), sufficient carbohydrate diet, high starched and avoiding rapidly absorbed sugars, folate

400mcg/day, iron 25-30mg/day, calcium 1.200mg/day, magnesium 450mg/day, iodine 175mcg/day, and

10g/day of yeast specially in second trimester.

117

After a Newborn Death is not the end: Giving Support to Neonatal Losses to avoid Pathological

Parents Mental Dimension

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d'Hebron Hospital, Spain

Introduction: Neonatal losses are situations in which the arrival of a new family member is lived with hope

and enthusiasm towards this new future loved one and the fact that there occurs an unexpected death makes

parents and relatives not easily accept them. Moreover, death is something that exists as a clinical failure and

health staff tends to focus on other patients forgetting sometimes those parents, and coming up death in a

surrounded environment by strange people performing procedures that they don't understand, isolated from

their loved ones, becomes a fact without emotional support .

Justification: Highlight physicians and nursing activities that will facilitate the duel of perinatal death,

giving emotional support and caring, appart from the newborn, both the parents and the relatives to help

assimilate the loss and prevent the emergence of future psychiatric disorders, giving some guidance on

possible interventions and activities to do.

Methodology: Description nursing activities aimed at facilitating bereavement of perinatal death following

the lived experience of cases in our unit.

Results: Analyzing our experience we have seen the importance of measures such as: - Encourage

participation in decision making about the interruption of life support once the parents have realized and

understood the situation and the future implications - Encourage parents to catch the baby during or after his

death , - Prepare the baby to be seen, - Have time for the family to remain alone with the baby - Encourage

parents to verbally express the memories of loss - Encourage the identification of the deepest fears about the

loss.

Conclusions: The grieving process may continue towards assimilation loss and reorganization of life, or

instead, towards creating a more lasting mental impairment, which will set up a pathological dimension. To

avoid the last, is important both nursing and physicians role after newborn death has occurred.

118

Timing of Both Elective Inductions or Cesarean Deliveries and neonatal late Preterms and early

Terms Outcomes: Two Populations at Risk

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d'Hebron Hospital, Spain

Late preterm births (34 to 36 weeks) and earlyterm ones (37 to 38) have increased over the last decades in

developed countries. Although with less risk than smaller preterm gestational age, recent publications show

higher rates of mortality and morbidity for these groups, if compared with full term infants, both in the short

and long term. The risk of mortality and morbidity increases with decreasing gestational age, with the lowest

risk being at 39 weeks of gestation. So that, elective delivery before 39 completed weeks' gestation is

inappropiate. Complications of late preterm or early term birth are related to immaturity of the different

organs and systems.

During the neonatal period, the most frequent complications are hyaline membrane disease, feeding

problems and hypoglycemia in late preterms; and transient tachipnea and hyperbilirubinemia in both. In the

long term, outcomes show that late preterms have an increased risk for developmental delay, academic and

behavioral difficulties. While most complications are less frequent and less severe than extremely preterm

infants, the large number of children that are born as late preterms or induced early terms represent a large

population at risk. The purpose of this poster is to highlight the increase on mortality, morbidity and

increased risk for short and long term development in this population, especially in late preterms. As

newborn health professionals, we should make our obstetricians colleagues to be aware of the true risks of

births in the near-term gestational ages: women assessing elective births before 39 completed weeks’ should

be counseled regarding these outcomes and also those who contemplating elective induction before 39

weeks' gestation with an unfavorable cervix, regarding an increased rate of cesarean delivery. Hopefully,

it may help obstetricians, neonatologists, pediatricians and midwives to pay attention to this young

population at risk, trying to reduce their incidence.

119

Whooping Cough (pertussis) Vaccination in Pregnancy: A New Indication

Albert Pi Compañó1, Anna Tarragó Aregay

2, Rosario Estudillo Mora

2, Laura Ripoll

Roca2

1Centro Médico Teknon, Spain

2Vall d'Hebron Hospital, Spain

Introduction: Pertussis (whooping cough) is an important cause of infant death worldwide and continues to

be a public health concern even in countries with high vaccination coverage. Despite the last, the incidence

of pertussis is increasing since 2010, including developed countries. Particularly alarming is the increase of

pertussis in infants too young to be (fully) vaccinated because the highest morbidity and mortality is

observed in this first months, when the risk of apparition of life-threatening complications as maligne

pulmonary hypertension is higher. Furthermore, about 30 to 40% of babies who get pertussis catch it from

their mother (when source was identified).

Discussion: Recent publications show maternal vaccination offers the possibility to protect infants by

getting vaccinated against pertussis when they are pregnant and creating protective antibodies passing some

of them to the baby before birth via trasplacentaria. These antibodies provide short-term protection against

pertussis in early life, from birth till immunity is induced by active vaccination at two months of life. The

best time to get pregnant women vaccinated is between 27 and 36 weeks of pregnancy, with between 28 and

32 weeks the ideal time. Maternal vaccination studies with both whole-cell and a cellular pertussis vaccines

have not shown serious adverse effects neither in mother nor child. Additional support for the efficacy of

maternal vaccination comes from studies showing that transfer of antibodies confers protection against

pertussis. Since October 2012 is recommended that pregnant women receive the Tdap vaccine during each

pregnancy irrespective of prior history of receiving pertussis vaccine, replacing the original recommendation

that pregnant women get the vaccine only if they had not previously received it.

Conclusion: Maternal vaccination might be an effective way to decrease morbidity and mortality caused by

pertussis in newborn babies.

120

Nail Changes Among Very Low Birth Weight Babies – a Hospital Based Study

Swealina Pradhan, Tanmay Padhi

Veer surendra sai medical college burla, India

Introduction: The diagnosis of neonatal nail disorders can be a sign of systemic disorders. It can reflect

developmental defects as well as metabolic alterations. Although there have been studies on nail disorders

among children, no data exists about their prevalence among very low birth weight babies.

Aims and objective: To study nail changes among very low birth weight babies. So that we can rule out any

systemic disorders and can find any developmental defect at earliest.

Materials and methods: 100 consecutive patients admitted to a neonatal unit for very lowbirth weight were

included in the study. A detailed history was recorded about demographic details of mother and child,

obstetric course and presence of cutaneous and systemic disorders. Nails were examined clinically and

digital photographs were taken. Dermatoscopy was done in selected cases.

Results: Out of100, 36 patients had some abnormalities in their nail. Ingrowing toe nail with hypertrophy of

lateral nail fold of big toes was the most common abnormality seen in 18 patients followed by

hyperpigmentation of proximal nail folds which was found in 8 patients. Beau’s line, onychogryphosis and

longitudinal pigmented bands were seen in 3 patients each. One patient had anonychia.

Conclusion: Nail abnormalities are seen commonly among neonates who belong to the very low birthweight

category. A routine examination of the nail apparatus in all such cases should be done so that an early

diagnosis can be made about the presence of developmental and systemic abnormalities.

121

Early-Onset Neonatal Sepsis: Group B Streptococcal Compared to E. Coli Disease

Bettina Renoldner, Bettina Renoldner, Nora Hofer, Nora Hofer, Bernhard Resch,

Bernhard Resch

Medical University of Graz, Austria

Objective: To compare perinatal, laboratory, and short-term follow-up data of neonates with early-

onset sepsis (EOS) either due to group B streptococci (GBS) or E. coli infection. Retrospective cohort

analysis of all neonates with culture proven GBS and E. coli EOS born between 1993 and 2011 and

hospitalized at the NICU of the Medical University of Graz, Austria. Data were analyzed regarding perinatal,

laboratory and short-term outcome data.

Results: During the study period 100 neonates with EOS due to GBS and 11 neonates with E.coliinfection

were hospitalized at our NICU. Perinatal and short-term outcome data differed between GBS and E. coli

infection regarding gestational age (median 38 vs. 32 weeks, p=.005), birth weight (median 3095 vs. 1836

grams, p=.031), presence of hypothermia (0 vs. 18%, p=.009), duration of mechanical ventilation (4 vs. 8

days, p=.019), length of hospitalization (15 vs. 22 days, p=.039), presence of chorioamnionitis (18 vs. 46%,

p=.041) and maternal fever (2 vs. 18%, p=.049). Mortality rates did not differ (6 vs. 18%, p=.180).

Laboratory data regarding white blood cell count, IT-ratio, and CRP values were not different between

groups within the first 72 hours of life.

Conclusion: Main differences were due to higher rates of preterm birth in the E. coli group, clinical and

laboratory characteristics differed marginally.

122

Follow-up of Preterm and Term Infants up to Two Years in Kharkiv Regional Perinatal Center

Olena Riga1, Tetyana Znamenska

2, Tetyana Kurilina

2, Ganna Senatorova

1, Iryna

Kondratova1, Iryna Gordienko

1, Iryna Gordienko

3, Andrey Penkov

3, Ganna Kukuruza,

Ganna Kukuruza4

1Kharkiv National Medical University, Ukraine

2SI Institute of Paediatrics, Obstetrics & Gynaecology, Ukraine

3Kharkiv Spesialized regional orphanage, Ukraine

4SI "IOZDP NAMS of Ukraine", Ukraine

Background: The neurological complication and delay of development occur in 15-52% of preterm infants,

and term infants with severe hypoxic ischemic injury. The follow-up system helps to determinate of early

child delay development. Objective of study was a monitoring of development from birth to 24 month of

high risk group.

Methods: During 2012-2013 yrs the developmental assessment was performed in 112 infants (78 preterm

and 34 term). There were used Albert scale AIIMS (gross motor) in infants to 12 mo old and and KID -

RSDI scale (cognitive, fine motor, speech and language, social and adaptive development) in older. The

medical problems have been estimated also.

Results: The comorbidity of premature were following: retinopathy of newborn (6,4%); neurosensory

deafness (3.8%), bronchopulmonary dysplasia with medical treatment requirement (5.1%). To 12 mo

physical delay and motor delay of development had 29.4% of preterm and only 5.8% of term infants (p0,05).

There was significant delay of motor development (-3-6 mo) in third preterm infants compare in term (-3 mo,

11.7%, p=0.0442). To 24 mo 23% preterm infants had delay of development and 17.6% of term infants at

that in cognitive, social-emotional development. Mean cognitive delay in preterm was 3,1 mo; in term – 3,9

mo one (p0,05) by KID-RSDI. To 12 mo 5,1% of preterm infant had hemiplegic and tetraplegic cerebral

palsy. The follow-up was perform only in 37.3% preterm and term needs infants

from high risk group. The redirection to early interventional program was only in 19.6% high risk group

infants.

Conclusions: About third preterm infants, that had follow-up monitoring demonstrated delay of motor

development at first year. The follow-up program involved only third needs infants and helps to make an

early cerebral palsy diagnosis and cognitive delay in order to redirect to

early interventional service.

123

The Association of GSTT2B Gene Deletion Polymorphism with Prematurity and Low Weight in

Ukrainian Neonates

Zoia Rossokha1, Svetlana Kyriachenko

1, Olena Kovalova

2, Valeriy Pochylko

2, Tetiana

Znamenskaya3, Natalia Gorovenko

4

1State institution “Reference centre for molecular diagnostic of Public Health Ministry of

Ukraine”, Ukraine 2Ukrainian Medical Dental Academy, Ukraine

3State University «Institute of pediatrics, obstetrics and gynecology NAMS in Ukraine»,

Ukraine 4National Medical Academy for post-graduate education named after P.L. Shupyk, Ukraine

Introduction: Genetic testing may be useful for the risk evaluation of pathological conditions in neonates.

Prediction of pathology will contribute to the development of new preventive measures. The existing data of

the impact of important GSTT2B gene regulatory to reduced activity of the enzyme-isomer in the brain tissue

in the presence of deletion polymorphism of this gene led to the aim of our work.

Material and Methods: Molecular genetic testing was performed in 262 neonates, 191 neonates with

critical condition (71 – full-term, 120 – preterm, gestational age 22-37 weeks, including those with extremely

low birth weight) and 71 healthy full-term neonates (control group). Statistical analysis was performed using

the program «SPSS17.0».

Results: Preterm neonates had significantly increased frequency of the del/del genotype–

45,83%(χ2=4,09, OR=1,88 (95%CI:1,02-3,50), p0,05) and significantly decreased frequency of the

del/N genotype–38,33% (χ2 = 4,18, OR=0,54 (95%CI:0,30-0,98), p0,05) compared to del/del - 30,98%,

del/N - 53,52% in control group, respectively.The investigated genotypes had no impact on the severity and

course of perinatal asphyxia, respiratory failures and organ disfunction. We found a significant correlation

between GSTT2B gene polymorphism and low birth weight. The birth weight average was significantly

lower in neonates with genotype del/del - 2868,80+42,30 compared to in neonates with genotype N/N-

3189,20+75,70 (p0,05).

Conclusion: Further research is needed to identify other profile genes in prematurity and low birth weight.

Genetic testing of fetal cells in the mother's whole blood can be provided, thus preventive measures for

pregnant women may be created.

124

The Protective Effect of Maternal Breast Milk in the Development of Necrotising Enterocolitis in

Newborn Infants

Mussa Sabiha

University of Liverpool, UK

Background: Necrotising Enterocolitis (NEC) is a highly lethal disease of the gastrointestinal tract

in newborn infants, in particular those who are premature. Statistics from the National Institute of Child

Health and Developmental Neonatal Multicenter ResearchNetwork established that 10% of infants born with

low birthweights (1500g) are affected by the condition. Although a range of factors are thought to contribute

to the pathophysiology of the disease, formula feeding, prematurity and ischaemia of the intestine are

significant. However, an association has been found between breast milk and NEC, demonstrating a decrease

in the incidence

of the disease in newborn infants fed exclusively this. This is thought to be due to the protective factors,

especially the immunological factors such as IgA, lysosymes and certain macrophages and lymphocytes.

Aims: This literature review aims to determine whether breast milk plays a protective role in

the development of NEC in newborn infants.To investigate whether the benefits of maternal breast milk

outweigh formula or preterm milk.

Methods: A range of procedures were implemented to search online databases and journals. Relevant

articles on breast milk and its effect on NEC in neonates were sought, with inclusion and exclusion criteria

applied. Four articles were chosen to critically appraise.

Results: All four studies found that when breast milk was fed to neonates in comparison to those fed formula

or preterm milk, the infants were less likely to acquire NEC.

Conclusions: Maternal breast milk was found to be more effective than formula or preterm milk, as it

offered the most resistance against NEC from developing, even when it was used as a supplement. There is

enough evidence to conclude that maternal breast milk can be effectively used as a protector against NEC in

neonates, reducing the incidence of this highly fatal disease.

125

Lansoprazole in Preterm Infants with Gastroesophageal Reflux ; a Pilot Study

Seung Han Shin, Hye Jeong Jin, Han-Suk Kim, Ee-Kyung Kim, Jung-Hwan Choi

Seoul National University College of Medicine, South Korea

Objectives: Recently, proton pump inhibitors have been increasingly used to treat preterm infants with

gastroesophageal reflux. The primary objective of this pilot study was to evaluate efficacy of lansoprazole in

preterm infants with gastroesophageal reflux.

Methods: Five preterm infants with gastroesophageal reflux documented by 24 hour impedance-pH

monitoring were enrolled. They were given lansoprazole 1mg/kg once daily for 14 days. During study

period, additional 24 hour impedance-pH monitoring was conducted on baseline, day 5, day 10, and day 14.

Results: Median (min, max) gestational age was 27+6

(25+0

, 31+3

) weeks, and median birth weight was 1,390

(590, 1,740) grams. Postmenstrual age at study enroll was 35+6

(32+6

, 36+2

) weeks, and weight at study enroll

was 1,800 (1,710, 1,980) grams. Percent time esophageal pH 4 (mean ± SD) was 14.28 ± 18.67 at baseline,

5.28 ± 7.73 at day 5, 4.5 ± 6.39 at day 10 and 3.18 ± 2.38 at day 14. Composite score (Boix-Ochoa) was

42.46 ± 51.09 at baseline, 15.66 ± 22.43 at day 5, 5.36 ± 20.57 at day 10, and 10.18 ± 5.89 at day 14.

Conclusions: For preterm infant with gastroesophageal reflux, lansoprazole could be an option for

treatment. Further large-scale studies should be conducted to address the safety issue and symptom

correlation as treatment outcome.

126

Breastfeeding Difficulties in a Woman Affected by Mammary Neurofibromatosis Type-1

Vasiliki Sideri1, Thomas Papalexandris

1, Panagioula Mexi-Bourna

1, Anna Daskalaki

1,

Emmanouela Sdona, Eleni Kontaki1, Sofia Spanou

1, Giannis Agouridakis

1, Kleopatra

Chrelia1, Eleni Alexiou

2, Vasiliki Papaevangelou

1

1Attikon Hosptial, Greece

2Attikon Hospital, Greece

Introduction: Neurofibromatosis (NF) type-1, also known as von Recklinghausen disease, is the most

frequent form of NF, presenting a variety of skin lesions, such as café au lait spots and neurofibromas.

Multiple neurofibromas affecting the mammary gland often disturb normal breastfeeding, through irritation

of the lesions or nipple confusion.

Methods: A 36 years old puerpera presented at the Attikon Hospital Breastfeeding Referring Center after

having delivered a healthy term offspring, complaining difficulties in lactating, due to multiple

neurofibromas around her nipple and areola bilaterally. At home feeding of the newborn with milk formula

has already started, while lactation was suppressed. Neither efforts with breast pump, nor by digital

squeezing evocated spontaneous milk dropping. Furthermore, during breastfeeding the newborn tended to

confuse nipples with the surrounding neurofibromas. Mother was encouraged to restart breastfeeding, to use

breast pump and silicon nursing pads, otherwise continue entirely bottle feeding. She was directed to a

breast-surgeon specialist for further examination and she was addressed to her local breastfeeding-support

team.

Conclusion: Mammary neurofibromatosis is a rare condition, which is located mainly around the areola.

Interferes with normal breastfeeding when these lesions get lacerated or confused with nipples. Lactation is

supported by encouraging affected mothers to continue breastfeeding.

127

Challenges in Coordination of Ventilator Treatment in Premature and Sick Newborns in a Norwegian

Neonatal Intensive Care Unit (NICU)

Marianne Trygg Solberg1,2

, Thor Willy Ruud Hansen3, Ida Torun Bjørk

1

1Faculty of Medicine,University of Oslo, Norway

2University College, Norway

3Faculty of Medicine, University of Oslo, Norway

Background and aims: Interprofessional collaboration in mechanically ventilated premature and sick

newborn infants is essential to the quality of care, by reducing errors and length of stay. The quality of care

could be improved by more effective interprofessional communication and coordination of

ventilator treatment. In order to develop best practice in oxygenation and ventilation the aim of this study

was to explore how physicians and nurses experienced their collaboration when working with oxygen and

ventilator therapy.

Method: This was a qualitative study using four focus groups during September - October 2012 at the

NICU, Oslo University Hospital, RH, in Norway. The study included 20 participants, with varied

background and experience. Three focus groups consisted of nurses, and one group of physicians. The focus

group sessions lasted 60 minutes and were audiotaped and transcribed verbatim.

Results: We found that physicians and nurses perceived collaboration regarding newborns on mechanical

ventilation to be unsystematic and lacking in coordination. Both professions considered communication to be

the most important element when collaborating, but nurses felt that they had few opportunities to discuss and

formulate plans with physicians. This led to inadequate utilization of the medical and clinical expertise in the

nursing staff. In the physicians’ opinions, the nurses had more education regarding ventilator treatment and

lung function in premature and newborn infants than the house officers, who often made changes in the

ventilator settings based on suggestions from the nurses. Nurses and physicians approached decision-making

differently and there was limited flexibility and dynamics in allocation of responsibility between them.

Conclusions: Findings from this study indicate that nurses and physicians may improve the quality of care

by advancing their communication strategies, which includes the formulation of strategies and goals

together, the development of skills that facilitate two-way communication, and the use of guidelines to

coordinate ventilator treatment.

128

Reducing Nuisance Alarms with Nellcor OxiMax N-600x SatSecondsTM alarm Settings during

Oxygen Saturation Monitoring: Influence on Performance

Beatrice Stefanescu1, T Michael O'Shea

2, Fran Haury

3, Jeffrey Sigl

4, Minyi Lu

4,

Waldemar Carlo5

1Vanderbilt University School of Medicine, USA

2Wake Forest University School of Medicine, USA

3Covidien, USA

4Covidien, USA

5University of Alabama at Birmingham, USA

Objective: The Nellcor OxiMax N-600x containing SatSecondsTM alarm management software was

designed to assist clinicians in discriminating nuisance alarms from those that are clinically relevant. Instead

of sounding an alarm the moment the oxygen saturation reading violates the upper or lower limit settings, a

magnitude and duration of tolerance can be set.

Our primary objective was to study the proportion of nuisance alarms relative to the proportion of clinically

relevant alarms being filtered under four different SatSecondsTM alarm settings (i.e. 10, 25, 50, and 100) in

the NICU environment.

Methods: This is an observational prospective study of 50 infants cared for in three large NICUs. Infants

were monitored for 4 continuous hours each by a study observer with the study monitor (a blinded and

muted MAX-N sensor of a Nellcor OxiMax N-600x with a MAX-N sensor), in addition to standard multi-

parameter monitors. Results: There were 6496 incidences of standard threshold-based SpO2 alarms during

195 hours of monitoring, with a mean duration of 12.7 sec. Half of all desaturations had a duration of 5

seconds or less and 75% had a duration of 10 seconds or less. SatSecondsTM reduced the total alarm number

by 23, 31, 36, and 40% at SatSecondsTM settings of 10, 25, 50, and 100,

respectively. The area under the curve (AUC) and 95% Confidence intervals (CI) for SatSecondsTM alarm

settings when

compared to nursing intervention were as follows: 0.61 (0.57-0.66) when the SatSecondsTM alarm setting

was off, 0.63 (0.59-0.68) for 10 SatSecondsTM alarm setting, 0.64 (0.59-0.69) for 25 SatSecondsTM alarm

129

setting, 0.64 (0.59-0.69) for 50 SatSecondsTM alarm setting, and 0.63 (0.58-0.68) for 100 SatSecondsTM

alarm setting, respectively.

Conclusion: The SatSecondsTM feature of the Nellcor OxiMax pulse oximeter reduced clinically

insignificant interventions, however its specificity to nurse-identified desaturations events does not

significantly improve with lengthening SatSecondsTM alarm settings.

130

Role of Bedside Targeted Neonatal Echocardiography (fECHO) in the Neonatal Intensive Care Unit

Zhen Han Tan, Woei Bing Poon

Singapore General Hospital, Singapore

Objective: To review the utility of bedside functional echocardiography (fECHO) in the clinical

management in the neonatal intensive care unit (NICU) in terms of common indications, and its impact

on clinical management and/or outcome.

Methods: Retrospective cohort study of all patients admitted in the NICU between 1 January 2012 till 31

December 2012 who had a fECHO performed by a neonatologist.

Results: A total of 40 neonates underwent 94 fECHO with a median of 2 scans per neonate. 87.5% were

preterm neonates, with a median gestational age of 27 weeks. The indications included assessment of patent

ductus arteriosus (PDA, n=69, 73%), pulmonary haemodynamics (n=18, 19%),central venous catheter tip

position (n=4, 4%), volume status (n=2, 2%), and cardiac contraction (n=1, 1%). Following the fECHOs

done for PDA assessment, non-steroidal anti-inflammatory drug treatment was initiated in 39%,

fluid restriction in 6%, conservative management in 16%, and PDA was documented closed in 17%

requiring no further treatment. The assessment of pulmonary haemodynamics allowed weaning of

vasodilator therapy (inhaled nitric oxide/magnesium sulphate) in 44%, and respiratory support in 17%.

Urgent cardiology review was required in 3 neonates – 1 had an incidental large pericardial effusion, 1 was a

case of pulmonary atresia with intact ventricular septum in which the PDA was noted to be smaller, and the

last case was that of a large ventricular septal defect with fluid overload.

Conclusions: fECHO appears to be a useful tool in enhancing clinical care and decision making for critically

ill neonates in the NICU.

131

Kangaroo Mother Care Method While Performing Neonatal Invasive Procedures In NICU: Should

We Separate Neonates From Their Mothers?

Anna Tarragó Aregay1, Albert Pi Compañó

2, Rosario Estudillo Mora

1, Laura Ripoll

Roca1

1Vall d'Hebron Hospital, Spain

2Centro Médico Teknon, Spain

Introduction: Kangaroo mother care (KMC) is the procedure whereby newborn babies skin makes contact

with parents' skin promoting health and newborn neurodevelopment by achieving homeostasis regulation,

favouring bonding with parents, and facilitating feeding. All this together will fire and wire circuits to brain

making possible a healthy development.

Justification: We believe that KMC shouldn't be not only for little periods, it should be as continuous as

possible, and much broader, we don't believe that baby must be "stable" before KMC can start, so we think

neither conventional mecanical ventilation nor carrying catheters or drainages have to by themselves be a

contraindication, and going beyond, that some procedures could be done during KMC, such as weaning and

extubation, taking a blood sample for an analysis, or getting peripheric venous accesses. We think preterm

babies could stay unstable partly because they are denied the skin-to-skin contact that would make them

stable. Heart rate, breathing and oxygen saturation, blood pressure and temperature all stabilize far faster on

mum than when they are separated, as well baby crying decreases using less calories getting less

hypoglycaemic. So that, we measured heart rate variability in full-term and preterm neonates holding in skin-

to-skin contact with their mothers and staying alone during the interventions above, and also infants'

behavior was observed and manually recorded according to a validated scale. We found a decrease in

autonomic activity by registering low beating heart rates, and an early onset of quiet sleep when comparing

both.

Conclusion: From our experience we have seen wide acceptance of this method by parents when asked for

during interventions. We propose KMC while performing some interventions in NICU whereby KMC

decreases the load of stress, being able to influence their earliest development and May having a good effect

on their development.

132

Solar Powered Baby/radiant warmer Installed at Neonatal Intensive Care Unit at Lok Nayak

Hospital, New Delhi

Vasantha Thavaraj1, Sankara Sastry

2, Nav Nidhi Sharma

3, Siddharth Ramji

4

1Indian council of Medical Research, India

2Solar Energy Centre, 9th Milestone, Institutional Area, Gurgaon- Faridabad Road,

Gwalpahari,, India 3Indian council of Medical research, India

4Maulan Azad Medical College, India

Background: The important health challenges before India is that India has a high Neonatal mortality (death

within 28 days after birth), Infant mortality (death within one year).

The Open care system of baby radiant warmer is presently being used in our health system in Level I

(tertiary care hospitals) and Level II in Special care newborn unit (SCNU) , Neonatal stabilization Unit, New

born care corner.

Methods: A single open care system of infant radiant warmer with 400 watts of infra red heating element

and an energy meter , with baby bassinet was installed in the NICU,in Lok Nayak Hospital The radiant

warmer was kept near the window so that the connection can be made easily with the panel in the roof. The

Thermostatic skin servo control device regulates radiant heat. Details of the power plant used: 400W is the

peak power during its full load operation. Accordingly the present PV system is designed for about 10 hours

of working, the system consumes about 4kWh (or 4units) in a day. Therefore, the designed PV system is for

approximate generation of 4 kWh of energy per day.

Findings: The Solar powered Radiant warmer has been successfully installed Neonatal nursery, Lok Nayak

Hospital and fully functional since 10-12-2012. The preliminary energy consumption study shows that PV

panels of 1.2kWp can be connected to 2-3 radiant warmers.

Interpretation: The Solar powered baby warmer is environment friendly. It can be used in Tertiary care

hospitals and also in rural areas where power supply is erratic and where there is plenty of sunshine this

product will help in the care of high risk infants in Level II .

133

Intestinal Atresia and Prenatal findings. Our Experience of the Last Ten Years

Cinzia Tripodi, Carmen Marrero, Roman Papoyán, Pedro Arango, Tania De Ganzo,

Lorenzo Martin

University Hospital Nuestra Señora de Candelaria, Spain

Introduction: An atresia is a complete congenital obstruction of the lumen of a hollow viscus. Intestinal

atresia is one of the most frequent causes of bowel obstruction in the newborn and can occur at any point in

the gastrointestinal tract. The most common site is the small intestine (jejunum and ileum) with an incidence

rate from one in 1500 to 12,000 births. The colon is the least affected site with an incidence of one in 40,000

live births. A typical clinical feature is abdominal distension while vomiting usually begins in the first 24 to

48 hours after birth. Intestinal atresia can be detected by prenatal ultrasounds examination with the presence

of polyhydramnios or a dilated loop of bowel. Radiographic studies should be performed after birth to

confirm the diagnosis. The treatment

of intestinal atresia is surgical correction with a long-term survival that varies from 84 to 100%. Most of the

mortality occurs in infants with associated medical conditions.

Method: A retrospective, descriptive study of case series of the patients with intestinal atresia attended in

University Hospital “Nuestra Señora de Candelaria” since 2002, January to 2013, December.

Results: 8 patients included. 4 of them were premature infants. In 5 of them there was a prenatal suspicion.

The most frequent clinical features were vomiting and abdominal distension. Theradiographic studies were

helpful in the 100% of patients. 1 case of colonic atresia. All the children were operated, and 3 of them more

than once. We experienced 3 deaths.

Conclusions: Intestinal atresia should be suspected in a newborn with abdominal distension, bilious

vomiting and failure to pass meconium. We think we experienced a mayor rate of mortality than other series

due to associated medical conditions and the complexity of the lesions.

134

Overview of Two Cases of Epidermolysis Bullosa in our Hospital

Cinzia Tripodi, Dinesh Lalchandani, Pedro Arango, Garazi Castelar, Carmen Marrero,

Lorenzo Martin

University Hospital Nuestra Señora de Candelaria, USA

Introduction: Epidermolysis bullosa comprises a clinically and genetically heterogeneous group of rare

inherited disorders characterized by marked mechanical fragility of epithelial tissues

with blistering and erosions following minor trauma. This illness is caused by mutations involving at least 18

genes encoding structural proteins within keratin intermediate filaments, focal adhesions, desmosome cell

junctions and hemidesmosome attachment complexes, which form the intraepidermal adhesion and

dermoepidermal anchoring complex within the basement membrane zone of the skin and mucosae. The

prevalence of epidermolysis bullosa

was estimated to be approximately 8 per million and the incidence 19 per million live births.

Clinical cases: Case 1. A term newborn appropriate for gestational age, a physiological pregnancy and a

vaginal delivery. During the physical examination, intraoral blisters with superficial erosions and more

lesions in shoulders and thorax come out .New vesicles starts to spread all over his body in response to

minimal frictional trauma. His father has been studied by Dermatology for blisters in pretibial region in his

left leg.

Case 2. A term newborn appropriate for gestational age, a physiological pregnancy and a vaginal delivery.

He shows respiratory distress that disappears in a few hours, while

blisters and erosions stat to be patent all over his body including oral mucosae. In both cases we consult

with a dermatologist and a nutritionist as their mayor problems were pain control and appropriate nutritional

support due to oral lesions. When solving that, we decide the

discharge from the hospital and going on with a multidisciplinary study of the

case.

Conclusions: The management of these patients is largely supportive and involves a multidisciplinary team.

Pain control is an important aspect together with the nutritional compromise. Disabling and severe

complications would need specialty teams when they appear.

135

Kasabach-Merritt Phenomenon And Kaposiform Hemangioendothelioma in A Neonate

Sevim Unal, Hatice Tatar Aksoy, Deniz Gonulal, Derya Ozyoruk, H Ahmet Demir

Ankara Research and Educational Hospital, Turkey

Introduction: Kasabach-Merritt phenomenon (KMP) is a rare consumptive coagulopathy characterized by

profound thrombocytopenia and hypofibrinogenemia occurring in association with vascular tumors,

kaposiform hemangioendothelioma (KHE) and tufted angioma. Treatment remains challenging without

consensus on the optimal medical management. We reported a neonate with KMP and KHE, also debated

regarding the management.

Case report: He was born by vaginal delivery at term with birth weight of 3600 g. There were extensive

petechiae all over the body and a small lumbal mass supposed to be hematom at birth.

The fresh-frozen plasma and thrombocyte suspension were transfused because of thrombocytopenia. He was

transported to our hospital on 3rd day. Magnetic resonans imaging (MRI) revealed a giant lobulated

heterogeneous 76x54x86 cm mass invading right vertebral muscles, subcutaneous adipose tissue, and

extending into the inguinal region, forcing right kidney, bladder and abdominal aorta anteriorly, spreading

into the spinal canal at this level. The boundaries of mass and both renal vascular structures were

indistinguishable. The vena cava inferior and vertebral posterior elements were pressured by mass (Figure 1).

We diagnosed disseminated intravascular coagulation (DIC) due to low fibrinogen and thrombocytes,

increased PT, aPTT, and INR. He was supported by cryoprecipitate and fibrinogen concentrate. The mass

proggressively enlarged due to hemorrhage into mass and transfused erithrocyte suspension betweenwhiles

(Figure 2). Since malign clinical course and possible KHE, he was given pulse sterod, vincristine,

actinomycin-D. We managed to control DIC and hypofibrinogenemia, but biopsy was not possible because

of DIC.

Discussion: KMP does not occur with common hemangioma. Rather it is associated with more aggressive

KHE and rarely with other vascular neoplasms. We suspected KHE in our patient, due to malign clinical

course and MRI findings. Variable response to current pharmacologic therapy underscores inadequate

knowledge of the pathogenesis of thrombocytopenia in KHE. We presented our case as rarely diagnosed in

neonates and acchievement in controlling both KMP and possible KHE with multidisciplinary approach.

136

Perception and Practice of Kangaroo Mother Care after Discharge from Hospital in Kumasi, Ghana:

A longitudinal Study

Priscilla Wobil1, Priscilla Wobil

1, Samuel Blay Nguah

1, Gyikua Plange-Rhule

1,2, Joy

Lawn3, Kate Kerber

3, Regina Obeng

1

1Komfo Anokye Teaching Hospital, Ghana

2Kwame Nkrumah University of Science and Technology, Ghana

3Save the Children, South Africa

Kangaroo Mother Care (KMC) is life saving among low birth weight (LBW) babies. Little is known about

mothers’ continued unsupervised practice after discharge from hospital. This study aimed to evaluate KMC

practice in the community among mothers of LBW infants after discharge from hospital.

A longitudinal study of 202 mothers and LBW neonates was conducted from November 2009 to May 2010.

Mothers were interviewed about their knowledge, practice and community perceptions of KMC after

discharge from hospital. A repeated measure logistic regression analysis was done to assess variability in the

binary responses at the various follow up visits.

At recruitment 23 (11.4%, 95%CI: 7.4 to 16.6%) mothers knew about KMC. At discharge over 95% thought

KMC was beneficial to them and were willing to continue KMC at home, and recommend KMC to other

mothers. At first follow up visit 99.5% were still practicing KMC. This proportion did not change

significantly over the four weeks (OR: 1.4, 95%CI: 0.6 to 3.3, p-value: 0.333). Household chores and

potentially negative community perceptions of KMC did not affect its practice with odds of 0.8 (95%CI: 0.5

to 1.2, p=0.282) and 1.0 (95%CI: 0.6 to 1.7, p=0.934) respectively. During the follow-up period the neonates

gained 23.7 sg (95%CI: 22.6 g to 24.7 g) per day.

Maternal knowledge of KMC was low at the outset. Once initiated mothers continued practicing KMC in

hospital and at home with their infants gaining optimal weight. Continued KMC practice was not affected by

perceived community attitudes.

137

The Predictive Power of Serial Neonatal Therapeutic Intervention Scoring System Scores for

Mortality in Very Low Birth Weight Infants

Pei-Ling Wu1, Pei-Lun Lee

2, Wei-Te Lee

2, Hsiu-Lin Chen

2,3

1Kaohsiung Medical University, Taiwan

2Kaohsiung Medical University Chung-Ho Memorial Hospital, Taiwan

3Kaohsiung Medical University, Taiwan

Background: The Neonatal Therapeutic Intervention Scoring System (NTISS) is used to indicate disease

severity for neonates who need intensive care. We examined the ability of serial NTISS scores to

predict mortality in very low birth weight (VLBW) preterm infants.

Methods: We reviewed the medical records of all preterm infants who had a birth weight less than 1500 g

and were admitted to a neonatal intensive care unit from 2007 to 2011. We calculated the NTISS scores at

24, 48 and 72 hours after admission and assessed the predictive power for mortality using receiver- operating

characteristic curve and area under the curve (AUC) analysis. We also constructed a predictive model with

gestational age, birth weight and NTISS scores to predict the possibility of mortality in these VLBW infants.

Results: In total, 172 infants were enrolled into this study. Eighteen (10.5%) infants died in the seven days

after birth. The AUC of the NTISS score was 0.913 at 24 hours, 0.955 at 48 hours, and 0.958 at

72 hours. However, there was no significant difference in overall average NTISS scores between 48 and 72

hours. The NTISS score at 48 hours was a better predictor of mortality than that at 24 hours after admission.

Combined with gestational age, birth weight, and NTISS score at 48 hours, the birth weight had

little contribution to the predictive power of mortality. The model with gestational age and NTISS score at

48 hours had better predictive power than NTISS score alone (AUC = 0.99).

Conclusion: NTISS scores at 48 hours seemed to be an effective method to predict mortality in preterm

infants whose birth weight was less than 1500 g. In addition, gestational age played a more important role in

predicting mortality than birth weight.

138

The Crisis of PAN Resistant Bacteria: How to Know What to Prescribe

Mary Wyckoff, Sandra Ellingson

UC Davis, USA

According to the WHO, high percentage of hospital-acquired infections is caused by highly resistant bacteria

such as methicillin-resistantStaphylococcus aureus (MRSA). Inappropriate and irrational use of

antimicrobial medicines provides favorable conditions for resistant microorganisms to emerge, spread and

persist.

This presentation will provide an overview of the epidemiology of antimicrobial resistance on a global

scale. Multi-drug resistant organisms are prevalent worldwide and theseinfections cause severe illness,

especially in acute and chronically ill neonatal intensive care patient populations. Choosing appropriate

antimicrobial therapy has become increasingly complex as more choices become available and resistant

bacteria continue to evolve. Multiple factors affect the choice of agent, and resistance forces vary widely

between clinical settings, patient populations, and geographic areas. This bacterial culture specific data will

be used to demonstrate how to implement antibiograms into everyday prescriptive practice. Facilitating the

understanding of the cellular mechanisms through which bacteria become resistant is vital for healthcare

providers. Individual patient care practices affect resistance within patients and clinical environments. This

research-based information and recommendations on how to manage the use of antimicrobial agents,

minimize iatrogenic infections in the acutely-ill neonatal population, and responsibly care for patients, in an

age of widespread bacterial resistance will enhance the individual’s knowledge base. Recommendations will

include description of evidence-based guidelines from professional societies, as well as provision of multiple

resources through which participants may further gain knowledge of the state of the science of this important

topic.

139

How Cool is Cool! Evidence Based Practice for Whole Body Hypothermia in Neonates

Mary Wyckoff, Jennifer Solano, Sandra Ellingson

UC Davis, USA

Term infants who suffer hypoxic ischemic events due to acute perinatal asphyxia may suffer acute morbidity

sequelae if immediate intervention does not occur, specifically within the first 6 hours of life. This is a tight

timeline with respect to outreach and transport case scenarios.

As a tertiary center for outreach facilities we have developed protocols and practice timelines to facilitate

and initiate whole body hypothermia to decrease mortality and morbidity in this population. This

presentation will encompass our treatment regimen inclusive of birth to intervention, from initiation of

outreach transport call to initiation of treatment protocols. This presentation will encompass how to cool,

sedation and analgesia for shivering, treatment for seizures, video recording of seizure activity and

understanding the aEEG. The bedside aEEG has placed another evaluation tool for healthcare providers and

facilitates further diagnostics, understanding this tool facilitates nurses at the bedside and their ability to

intervene and prevent ongoing further devastation. Brain cooling has been shown to have a favorable effect

on multiple pathways contributing to brain injury, including excitatory amino acids the cerebral energy state,

cerebral blood flow and metabolism, nitric oxide production,and apoptosis. Brain cooling is effective in

reducing the extent of brain injury when it is initiated in less than 6 hours of life. Whole-body cooling

provides homogeneous cooling to all brain structures, including peripheral and central brain regions. The

protocols developed will be presented including our experiences and outcomes. This presentation will

provide the audience with detailed information on how to cool, anticipated outcomes, scoring evaluations

and how to interpret the aEEG. Outcome data will also be presented. Further information on how to explain

cooling to the families and facilitate understanding will be presented.

140

Author Index

A

Abbasoglu, Aslıhan · 67 Abdel Latif, Mohammed · 87 Abdul-mumin, Alhassan · 65 AbouBakr Hashem, Alaa · 98 Agouridakis, Giannis · 126 Alburke, Salima · 69 Alemany, E · 27 Alexiou, Eleni · 126 Alhamdani, Abdurahman · 98 Alhoulan, Asma · 98 Ali, Haytham · 66 Alia, Rana · 66 Alina, Botiz · 85 Almakadma, Yosra · 98 Almatari, Abdulrahman · 56 Alsaad, Sulaiman · 64 Amantayeva, Maral · 57 Amsa, Mairami · 70 Anthuvan, Rajesh · 18 Anuk Ince, Deniz · 67, 68 Arango, Pedro · 133, 134 Aregay Tarragó, Anna · 106 Arıkan, İnci · 16, 49 Ashur, Bashir · 69 Audu, Lamidi · 70 Aydın, Banu · 21 Aziz, Khalid · 17

B

Badeva Gajdova, Emilija · 86 Baigazieva, Guljan · 28, 57 Bar Meir, Maskit · 19 Barbaric, Irena · 71 Barbosa Nogueira, Berta · 104 Barragán Milán, Rafael · 103 Barreto-Arroyo, Itzel · 36 Bassiouny, Mohamed Reda · 11 Bäuerl, Christine · 42, 59 Beken, Serdar · 21, 80 Bener, Abdulbari · 91 Bhat, Vishnu · 6, 29 Bilic Cace, Iva · 71 Binder, Corinna · 17 Bjørk, Ida Torun · 127 Blagojevic, Ana · 99 Blay Nguah, Samuel · 136 Bordoy, A · 27 Bournas, Nikos · 40 Boychenko, Alena · 51 Bozdağ, Şenol · 12 Bozhbanbayeva, Nyshangul · 28, 57 Bromiker, Ruben · 19

C

Cardiello, Valentina · 37 Carlo, Waldemar · 128 Castelar, Garazi · 134 Cernada, Maria · 42, 59 Chalia, Maria · 43, 72, 74 Chandran, Suresh · 38

Chen, Hsiu-Lin · 137 Cheung, Po-Yin · 17 Choi, Jung-Hwan · 125 Chrelia, Kleopatra · 126 Collado, Maria Carmen · 42, 59 Corsello, Mirta · 25, 37 Costa, Simonetta · 37 Cota, Francesco · 25, 37

D

Daga, Subhashchandra · 33, 35 Dago -Oc, Frances Jane · 79 Dallar Bilge, Yıldız · 16, 49 Daskalaki, Anna · 40, 126 De Ganzo, Tania · 133 de la O-Cavazos, Manuel · 36 de Waal, Koert · 22 Demir, H Ahmet · 135 de-Wahl Granelli, Anne · 3, 5 Dikanbayeva, Saule · 28 Dilli, Dilek · 12, 21, 80 Dilmen, Uğur · 12 Dollberg, Shaul · 81 Doyle, Lex · 62, 63

E

Eaton, Farah · 18 Ecevit, Ayse · 67, 68 Ellingson, Sandra · 23, 82, 138, 139 Elshahed, Amr · 11 Estudillo Mora, Rosario · 101, 102, 103, 104, 105, 106, 107, 108,

109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 131 Evsyukova, Inna · 83

F

Fettah, Nurdan Dinlen · 80 Foo, Robyn · 52 Fourie, Andrea · 53 Frewan, Naima · 13

G

Gabriela, Olariu · 84, 85 Gane, Bahubali · 6, 29 Garcia, M · 27 Garu, Mercy · 70 Gaylord Ashmead, Graham · 48 Gianna, Kyrkou · 40 Gökmen, Tülin · 12 Gonchar, Margaret · 51 Gong, Linmin · 10 Gonulal, Deniz · 135 Gopagondanahalli Revanna, Krishna · 38 Gordienko, Iryna · 122 Gorovenko, Natalia · 94, 123

H

Haghani, Hamid · 55

141

Hamadah, Reem · 98 Hannah, Andrews · 31 Hansen, Thor Willy Ruud · 127 Hassan, Ahmed · 72 Haury, Fran · 128 Hernández-Garduño, Adolfo · 36 Hochwald, Ori · 8 Hofer, Nora · 121 Holjar Erlic, Izidora · 71

I

Ionescu, Lavinia · 18 Iwakawa, Mayumi · 30

J

Jabr, Mohammed · 8 Janchevska, Snezhana · 86 Jiang, Mei · 10 Jin, Hye Jeong · 125 Josephine, Kamagaju · 96

K

K T, Harichandrakumar · 6 Kabataş, Emrah Utku · 80 Kapil, Arti · 32 Kapur, Neeraj · 32 Karsdon, Jeffrey · 48 Keenan, William · 11 Kerber, Kate · 136 Khan, Junaid · 60 Khan, Tehreem · 98 Khassawneh, Mohammad · 56 Kim, Ee-Kyung · 125 Kim, Han-Suk · 125 Kleanthous, Kleanthis · 40 Kondratova, Iryna · 122 Konjevic, Stojislav · 99 Kontaki, Eleni · 126 Koval'chuk-Kovalevskaya, Ol'ga · 83 Kovalova, Olena · 123 Kripail, Mathew · 87 Krstevska Blazevska, Svetlana · 88 Kukuruza, Ganna · 122 Kumar, Uday · 89 Kurdi, Bader · 90, 91 Kurilina, Tetiana · 92 Kurilina, Tetyana · 122 Kurt, Abdullah · 67, 68 Kwarteng, Peter · 65 Kyriachenko, Svetlana · 94, 123 Kyriachenko, Svitlana · 93

L

Lahav, Amir · 24, 50 Lakkundi, Anil · 22 Lalchandani, Dinesh · 134 Laura, Olariu · 84 Lavoie, Pascal · 8 Lawn, Joy · 136 Lee, Pei-Lun · 137 Lee, Wei-Te · 137 Lu, Minyi · 128

M

M Huang, William · 48 M. Perez, Lucila · 54 Magaspi, Rumar · 54 Magera, Ingabire · 95, 96 Maggio, Luca · 37 Mangel, Laurence · 81 Maria, Soulioti · 40 Marrero, Carmen · 133, 134 Martin, Lorenzo · 133, 134 Maslyanyuk, Natalia · 83 Mbwele, Bernard · 34 McNamara, Patrick · 8 Mexi-Bourna, Panagioula · 40, 126 Miah, Jennifer · 97 Mian, Qaasim · 17 Mihaela, Tunescu · 84, 85 Miller, Steven · 8 Milosevic, Veroslava · 99 Moebius, Marius · 18 Montes, Fernando · 36 Mosher, Cynthia · 98 Mshelia, Lauretta · 70 Mukhtar-Yola, Mariya · 70 Muratovska, Radica · 88 Mustaphasade, Tykaz · 28, 57

N

Natalia, Gorovenko · 93, 94 novakovic, vesna · 99 Núñez García, Carmen · 104

O

Obeng, Regina · 136 Okumuş, Nurullah · 21, 80 O'Reilly, Megan · 17, 18 O'Shea, Michael · 13 O'Shea, T Michael · 128 Osiovich, Horacio · 8 Oskay Acar, Banu · 68 Otabek, Fayziev · 100 Othman, Farrah · 22 Otuneye, Adekunle · 70 Özyazıcı, Elif · 21 Ozyoruk, Derya · 135

P

Padhi, Tanmay · 120 Papaevangelou, Vasiliki · 40, 126 Papalexandris, Thomas · 126 Papoyán, Roman · 133 Parasuraman, Jaya · 7 Penkov, Andrey · 92, 122 Perez-Martinez, Gaspar · 42, 59 Perri, Alessandro · 25 Peter, Branimir · 71 Pi Compañó, Albert · 101, 102, 103, 104, 105, 107, 108, 109, 110,

111, 112, 113, 114 115, 116, 117, 118, 119, 131 Pianini, Teresa · 37 Pichler, Gerhard · 17 Plange-Rhule, Gyikua · 136 Pochylko, Valeriy · 123

142

Ponpuo, Gladys · 65 Pons, Montse · 27 Poon, Woei Bing · 52, 130 Pradhan, Swealina · 120

Q

Quero, José · 36

R

Rajab, Ali · 69 Rajabali, Saima · 18 Ramji, Siddharth · 41, 132 Rand, Katherine · 50 Rao, Ramachandra · 6 Renoldner, Bettina · 121 Resch, Bernhard · 121 Riga, Olena · 51, 92, 122 Ripoll Roca, Laura · 101, 102, 105, 106, 107, 108, 109, 110, 111,

112, 113, 114, 115, 116, 117, 118, 119, 131 Rivero Pérez, Ainhoa · 104 Rodríguez-Balderrama, Isaías · 36 Rodríguez-Taméz, Antonio · 36 Romagnoli, Costantino · 25, 37 Rossokha, Zoia · 94, 123

S

S, Nandakumar · 6 Sabiha, Mussa · 124 Sadi, Muktar · 69 Samanta, Lee · 39 Samuel Rajadurai, Victor · 39 Saracoglu, Ahmet · 68 Sarkar, Abdullah · 98 Sastry, Sankara · 41, 132 Schadrack, Nambayisa · 95 Schmolzer, Georg · 17 Sdona, Emmanouela · 126 Sebastian, Olariu · 85 Senatorova, Anastasia · 51 Senatorova, Ganna · 122 Senok, Abiola · 98 Serna, Eva · 42, 59 Shahali, Shadab · 55 Sharma, Nav Nidhi · 41, 132 Shin, Seung Han · 125 Shlifer, Margarita · 81 Sideri, Vasiliki · 40, 126 Sigl, Jeffrey · 128 Simonova, Anna · 26 Slaughter, Chris · 13 Sola, Augusto · 2, 4 Solano, Jennifer · 139 Solberg, Marianne Trygg · 127 Soni, Roopali · 58 Spanou, Sofia · 126 Sriram, Bhavani · 39 Stefanescu, Beatrice · 13, 128 Suleimenova, Indira · 28, 57 Suresh, Chandran · 39

T

Taavoni, Simin · 55

Taksande, Amar · 20 Tan, Zhen Han · 130 Tarcan, Aylin · 67, 68 Tarragó Aregay, Anna · 101, 102, 103, 104, 105, 107, 108, 109,

110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 131 Taşar, Serçin · 16, 49 Tatar Aksoy, Hatice · 16, 49, 135 Tekindal, Mustafa Agah · 67, 68 Thavaraj, Vasantha · 32, 41, 132 Thebaud, Bernard · 18 Tiberi, Eloisa · 25 Tripodi, Cinzia · 133, 134 Tugcu, Ulas · 67

U

Umran, Raid · 30 Unal, Sevim · 135 Upton, Michele · 43, 74 Ur Rahman, Asad · 87 Urlesberger, Berndt · 17

V

Vadivel, Arul · 18 Vashishth, Brijesh · 32 Vasilyeva, Iryna · 51 Velaphi, Sithembiso · 9 Vento, Maximo · 42, 59 Vladimir, Estrin · 26 Vliora, Christiana · 40 Vohr, Betty · 61

W

Wang, Danhua · 10 Wang, Huishan · 10 Wang, Lixin · 10 Wobil, Priscilla · 136 Wu, Pei-Ling · 137 Wyckoff, Mary · 23, 82, 138, 139

X

Xia, Shiwen · 10 Xu, Tao · 10

Y

Yakobi, Nurit · 19 Yarkoni, Inbal · 81 Yue, Qing · 10 Yusupov, Anvar · 100

Z

Zecca, Enrico · 25, 37 Zenciroğlu, Aysegül · 21, 80 Zhang, Tong · 10 Znamenska, Tetiana · 92 Znamenska, Tetyana · 122 Znamenskaya, Tetiana · 123 Zoia, Rossokha · 93

143