Maheshwari A, Lui K, Motta M. We Need New Thinking to Save Babies. Newborn 2024; 3(2):iv-ix. DOI: 10.5005/newborn-3-2-iv.

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Motta M, Singhal A, Hoyos AB, Lodha A, Michie C, et al. Down Syndrome: Let’s Work Together to End the Stereotypes. Newborn 2024; 3(2):65-69. DOI: 10.5005/jp-journals-11002-0096.

 

Abstract: Each year, we observe the 21st day of March as our World Down Syndrome Day. The goal is to raise public awareness of Down syndrome (DS) and encourage all member states, relevant organizations of the UN system, all member states, other international organizations, non-governmental organizations, and the private sector to join this effort. The epidemiology of DS is complex. The incidence of DS is estimated to be somewhere between 1 in 1,000 and 1 in 1,200 live births worldwide, but there may well be some temporal, racial/ethnic, and geographical variability in the prevalence of DS. Most infants with DS have an extra copy of chromosome 21, which occurs due to the failure of chromosome 21 to separate during gametogenesis. However, a minority with the same phenotype may have a Robertsonian translocation, an isochromosome, or a ring chromosome. Increasing information suggests that many of the most frequently seen phenotypic features may be rooted in sequential variability in only one band, the 21q22. The characteristic facial appearance, cardiac anomalies such as the endocardial cushion defect, neurodevelopmental delay, and many dermatoglyphic changes could result from a small region including the genes for superoxide dismutase in the region 21q22.1, the amyloid precursor protein mapping in 21q11.2-21.05, and six probes for single-copy sequences: D21S46 in 21q11.2-21.05, D21S47 and SF57 in 21q22.1-22.3, and D21S39, D21S42, and D21S43 in 21q22.3. Speaking from this medical perspective, we need to understand the pathophysiology of DS to meet their healthcare needs. If we could do so, we could make a small change in this world..

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Key scientific associations: neonate, newborn, infant, United Nations General Assembly, Down Syndrome International network, age-standardized rate, sociodemographic characteristics, Robertsonian translocation, isochromosome, ring chromosome, 21q22, Cu/Zn-superoxide dismutase, amyloid precursor protein, Cytogenetic analysis, R-banding, G-banding, prometaphase, dermatoglyphic changes, copy number polymorphisms, conserved non-genic regions, microRNA, RNA editing, DNA methylation.

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The LAYA* Group of the Global Newborn Society. A Clinical Care Bundle to Prevent Necrotizing Enterocolitis. Newborn 2024; 3(2):70–82. DOI: 10.5005/jp-journals-11002-0094. *Looking At Your practices in Application

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Abstract: Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality in very-low-birth-weight (VLBW) infants all over the world. Even thought the incidence of NEC has decreased over the past decade, it continues to affect 5–7% of premature infants born ≤ 32–33 weeks. The disconcerting part is that the incidence of NEC has not changed despite continuous efforts to understand its etiopathogenesis. Because of limited information about the cause of this disease, our group has increasingly focused on developing a clinical care bundle to treat these patients. As we know, a bundle is a structured attempt to improve the care of patients with a specific nosological entity, to improve outcomes. The team adopts a small number of, usually 3–5 evidence-based, proven practices which when performed reliably and consistently, have been shown to improve patient outcomes. In this article, we have focused on the use of human milk, including mother’s own, that from donors, and of oral colostrum; standardized feeding practices; prevention of intestinal dysbiosis with antibiotic stewardship and use of probiotics; avoiding certain medications, such as histamine receptor blockers; adequate management of anemia; and antenatal use of corticosteroids. In these efforts, we have combined information from our own peer-reviewed clinical and preclinical studies with an extensive review of the literature from the databases PubMed, EMBASE, and Scopus.

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Key scientific associations: Newborn, neonate. Preterm, intestinal injury, intestinal failure, Institute of Health Care Improvement, NEC Care-bundle, mother’s own milk, human milk oligosaccharides, antimicrobial factors, lactoferrin, secretory IgA antibodies, OptiMoM trial, oral colostrum, Doppler flow abnormalities, brain-sparing vascular redistribution, thickness of the intestinal wall, villous length and weight, crypt depth, superior mesenteric artery, celiac axis, ADERF, Abnormal Doppler Enteral  Prescription Trial, hemodynamically significant PDA, periventricular leukomalacia, post-ligation cardiac syndrome, Transfusion-associated NEC, Withholding Enteral feeds Around packed cell Transfusion, Intestinal dysbiosis, Antibiotic Stewardship, proton pump inhibitors, Probiotics, dysbiosis, multi-strain probiotics, Lactobacilli, Bayesian NMA, Bifidobacterium, splanchnic ischemia, Hemoglobin Thresholds, delayed cord clamping, phlebotomy, iron supplementation, antenatal corticosteroids, delayed cord clamping, implementation science.

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Hoyos AB, Salas A, Osiovich H, Fajardo CA, Baez M, et al. Concerns about Mis-/Overuse of Antibiotics in Neonates Born at ≤32 Weeks Gestational Age in Latin American Neonatal Units: Eight Years of Experience in the EpicLatino Database. Newborn 2024; 3(2):83–89. DOI: 10.5005/jp-journals-11002-0098. 

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Abstract: Introduction: There is considerable variability in the duration of antibiotic in neonatal intensive care units all over the world and is highly dependent on gestational ages. It is difficult to withhold antibiotics in critically ill preterm infants because the possibility of infection is difficult to exclude in these patients and the acuity of illness can progress rapidly with potentially disastrous consequences. Available data encouragingly suggest that the incidence of early onset sepsis (EOS) might be lower in EpicLatino units in Latin America compared to Canadian research network (CNN) in 2022 in infants born at < 30 weeks’ gestation but late onset sepsis (LOS) affects a wider range of gestational ages. However, there is an overall scarcity of detailed information from many countries. There is a high degree of variability reflected in the annual reports from EpicLatino. Hence, we always need to be very cautious in interpretation of these figures. We need to establish clear standards for antibiotic use in premature infants; these drugs are essential for combating infections and saving lives, but mis-/overuse can exacerbate the risk of late-onset infections, necrotizing enterocolitis, bacterial resistance; and increase the cost of care.

Methods: We aimed to find information on the patterns of antibiotic use in patients ≤ 32 weeks gestational age at birth included in the EpicLatino database during the period 2015 to 2022. A specifically designed questionnaire was sent to unit medical directors to determine whether the total antibiotic use per unit per 1000 patient-days correlated with the incidence-rate ratios. This is a data-collecting/descriptive study that was designed to help in planning further efforts and choosing the sites for intervention.

Results: We studied a total of 105 infants with gestational age <30 weeks and weight ≤1500 grams, who were intubated and received assisted ventilation during the study period. 64 neonates were assessed for the probability of successful extubation. Fifty-three neonates were extubated successfully, while 11 required reintubation within 5 days of the first attempt. Forty infants had an ERE score <80% of whom 6 required reintubation. Twenty-four had an ERE score ≥80%, and 5 required reintubation. 

Conclusions: In our study, extubation based on the ERE tool was safe but not predictive of successful extubation.

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Key scientific associations: neonate, newborn, VLBW infant, sepsis, infection, antibiotics utilization, ethical concerns, practical limitations, chorioamnionitis, questionnaire, South America, Caribbean, negative binomial regression, standard errors, confidence intervals, incidence-rate ratios, variables, parameters. 

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Bhatia KS, Tehreem B, Siddiqui F, Taing RH, Travers C, et al. Predictive Validity of a Neonatal Extubation Readiness Estimator in Preterm Neonates: A Retrospective, Pilot Analysis in an Inner-city Level-3 Neonatal Intensive Care Unit. Newborn 2024; 3(2):90-95. DOI: 10.5005/jp-journals-11002-0092. 

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Abstract: Introduction: The children of Iraq have suffered greatly from military conflicts and economic sanctions since 1991. Recent years have shown some improvement in neonatal and infant mortality but more efforts are needed; prematurity and associated respiratory distress syndrome (RDS) remain the two leading causes. In this study, we investigated the efficiency of timely institution of nasal continuous positive airway pressure (nCPAP) in stabilizing these infants. These data are needed for the optimum allocation of financial resources to improve the healthcare outcomes of infants.
Patients and methods: This prospective cross-sectional study was carried out over 6 months from April 1st to September 30th, 2022. Inborn preterm infants born between 26 and 32+0 weeks’ gestation who required respiratory support after delivery or immediately after admission were included. The data for the initial course of respiratory support and outcomes were assessed.
Results: In our cohort of 123 infants, nCPAP significantly increased the likelihood of clinical stabilization in infants with a gestational age (GA) >28 weeks (p = 0.022), birth weight (BW) ≥1500 gm (p = 0.016), use of antenatal steroids (p = 0.002), Apgar score at 5 minutes of life (p = 0.022), mild radiographic findings (p = 0.007), and sepsis without prolonged rupture of membranes (p = 0.027). Nasal continuous positive airway pressure also reduced the need for surfactant (p = 0.001) and mortality (p = 0.0001).
Conclusions: Early institution of nCPAP improved the respiratory status of premature infants who were born at a gestational age from >28 to ≤32 weeks, had birth weight ≥1500 gm, had received antenatal steroids, had a 5-minute Apgar score >7, and had sepsis but no PROM. The success of early nCPAP reduced the need for surfactant and mechanical ventilation, risk of pulmonary hemorrhage, and mortality.

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Key scientific associations: Baby, Infant, extubation, extubation readiness estimator, area under the receiver-operating curve, neonatal extubation, respiratory severity score, mean airway pressure, fraction of inspired oxygen, nasal continuous positive airway pressure, non-invasive mechanical ventilation, non-invasive neurally-adjusted ventilatory assist, meta-analysis, antenatal steroids, INtubation-SURfactant-Extubation, inotropes, power.roc.test.

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Maheshwari A, Huisman TAGM. Artificial Intelligence in Newborn Medicine. Newborn 2024; 3(2):96-110. DOI: 10.5005/jp-journals-11002-0095.

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Abstract: The development of artificial intelligence (AI) algorithms has evoked a mixed-feeling reaction, a combination of excitement but also some trepidation, with reminders of caution coming up each time a novel AI-related academic/medical software program is proposed. There is awareness, with some hesitancy, that these algorithms could turn out to be a continuous, transformational source of clinical and educational information. Several AI algorithms with varying strengths and weaknesses are known, but the deep-learning pathways known as the Generative Pre-trained Transformers (GPT) have evoked most interest as clinical decision-support systems. Again, these tools still need validation and all steps should undergo multiple checks and cross-checks prior to any implementation in human medicine. If, however, testing eventually confirms the utility of these pathways, this is a possibility of a non-incremental advancement of immense value. AI can be helpful by facilitating appropriate analysis of the large bodies of data that are available but are not being uniformly and comprehensively analyzed at all centers. It could promote appropriate, timely diagnoses, testing for efficacy with less bias, fewer diagnostic and medication errors, and good follow-up. Predictive modeling can help in appropriate allocation of resources by identifying at-risk newborns right at the outset. AI can also help develop information packets to engage and educate families. In academics, it can help in an unbiased, all-inclusive analysis of medical literature on a continuous basis for education and research. We know that there will be challenges in protection of privacy in handling data, bias in algorithms, and in regulatory compliance. Continued efforts will be needed to understand and streamline AI. However, if the medical community hesitates today in overseeing this juggernaut, the inclusion (or not) of AI in medicine might not stop – it might just gradually get extrapolated into patient care from other organizations/industry for cost reasons, not justification based on actual clinical data. If we do not get involved in this process to oversee the development/incorporation of AI in newborn medicine, the questions in making decisions will just change from who, to which, when, and how. Maybe this will not be the most appropriate scenario. To conclude, AI has definite benefits; we should embrace AI developments as valuable tools that can assist physicians in analyzing large and complex data sets, which will facilitate the identification of key facts/findings that might be missed if studied by humans. On the other hand, a well-designed and critical expert review board is mandatory to prevent AI-generated systematic errors.

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Key scientific associations: Neonate, premature, critical, timely detection, resource allocation, patient triage, telemedicine consultations, predictive modeling techniques, Generative Pre-trained Transformers, GPT, natural language processing, medicine, healthcare, clinical documentation, medical literature analysis, patient engagement, drug discovery, AI-powered algorithms, resource allocation, patient triage, drug interactions, drug design, chatbots, virtual assistants, data privacy, algorithm bias, regulatory compliance, diagnostic accuracy, personalized treatment strategies, enhanced healthcare delivery, Machine learning, Supervised learning, medical image analysis, disease classification, predictive modeling, Unsupervised learning, clustering, anomaly detection, dimensionality reduction tasks, Semi-supervised learning, Deep learning, Convolutional neural networks, medical imaging, image classification, segmentation, object detection, Recurrent neural networks,  time-series analysis, natural language processing, electronic health record, Transformer models, Generative Pre-trained Transformer, Bidirectional Encoder Representations from Transformers, Expert systems, clinical notes, Computer Vision, medical imaging, Reinforcement learning, Natural language understanding, Large-scale pre-training, linguistic patterns, domain-specific terminology, contextual information, Contextual understanding, Continuous learning, Model architecture, layers, hidden units, attention heads, Pre-training data, Hyperparameters, learning rate, batch size, optimization algorithm, dropout probability, softmax classifier, Evaluation metrics, precision, recall, F1 score, perplexity, BioGPT, GPT-M, MedGPT, Domain specificity, Evaluation metrics, BE language processing model, XLNet language processing model, Transformer-XL language processing model, RoBERTa language processing model, ALBERT language processing model, T5 language processing model, Grammar correction, Language consistency, Summarization, Feedback generation, Plagiarism, Reviewer assistance.

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Huseynov O, Huisman TAGM, Hassan AS, Huseynova R. Intracranial Hemorrhage in Neonates: Causes, Diagnosis, and Management. Newborn 2024; 3(2):111–123. DOI: 10.5005/jp-journals-11002-0097.  

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Abstract: The incidence of symptomatic intracranial hemorrhage (ICH) in newborn infants may be up to 1:2000 spontaneous births, 1:850 vacuum extractions, and 1:650 forceps-assisted deliveries. ICH is frequently associated with adverse neurodevelopmental outcomes in neonates as the perinatal period is a crucial window for brain development. In term neonates, ICH usually occurs during labor due to mechanical injury. On the other hand, preterm infants frequently develop ICH due to hemodynamic instability and fragility of the germinal matrix (GM) vasculature. Based on the location of the hemorrhage, ICH is usually described as epidural, subdural, subarachnoid, intraventricular, and parenchymal bleeds. The cause of neonatal ICH is multifactorial and includes hemorrhage related to prematurity, hemorrhagic stroke, infection, vascular malformations, bleeding disorders, and genetic causes. Iatrogenic coagulopathy during cardiopulmonary bypass/extracorporeal membrane oxygenation (ECMO) can also be a cause. Most patients can be managed without surgical intervention. Some symptomatic infants may need neurosurgical procedure(s) such as external ventricular drainage and/or ventriculoperitoneal shunt(s). The neurodevelopmental outcomes vary according to the maturation of the brain, etiology, place, and extent of the hemorrhage. Clinically-concerning complications may include developmental delay, leukomalacia, convulsion, cerebral palsy, and other neurological disorders. In this article, we have reviewed the types, etiology, severity, and clinical outcomes of neonatal ICH.

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Key scientific associations: newborn, infant, germinal matrix vasculature, epidural, subdural, subarachnoid, intraventricular, parenchymal, hemorrhagic stroke, infection, vascular malformations, bleeding disorders, genetic causes, extracorporeal membrane oxygenation, cardiorespiratory failure, cerebral auto-regulation, neurodevelopmental outcomes, pachionic granulations, developmental delay, leukomalacia, convulsion, cerebral palsy, molding, dural sinuses, frontal-occipital elongation, digital subtraction angiography, basal cistern, opisthotonos, nuchal rigidity, duplex sonography, peri-mesencephalic cistern, arteriovenous malformation, transcranial Doppler, continuous intravenous milrinone infusion, dural sinus thrombosis, magnetic resonance venography, cerebellar hemorrhage, stem cell treatment,  endoscopic clot removal, parenchymal venous infarction, impaired cerebral autoregulation, platelet disorders, hypocarbia, hypercarbia, thrombocytopenia, periventricular white matter, caudothalamic groove, caudothalamic notches, post-hemorrhagic ventricular dilatation, Sylvian aqueduct, supratentorial lateral ventricles, periventricular hemorrhagic infarctions, periventricular leukomalacia, post-hemorrhagic ventricular dilatation, Sylvian aqueduct, foramen Monro, ventricular-subgaleal shunt, periventricular hemorrhagic infarction.

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Kumar G, Deshpande S, Sreekantha S, Stevenson A, Sharma A, et al. Utility of Point-of-care Ultrasound in Hypoxic-ischemic Brain Injury in Neonates. Newborn 2024; 3(2):124-138. DOI: 10.5005/jp-journals-11002-0091.

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Abstract:

Background: Perinatal asphyxia and resulting hypoxic-ischemic encephalopathy (HIE) remain a significant cause of neonatal morbidity and mortality. This review focuses on the utilization of bedside cranial ultrasound in HIE to guide appropriate therapy, monitor disease progress, provide prognostic information, and help identify relevant research areas.

Methods: A comprehensive literature search was conducted to review recognized patterns of HIE seen on ultrasound. Further efforts were focused on understanding the clinical relevance of these changes in the management of these infants and prediction of long-term neurodevelopmental outcomes.

Results: We reviewed cranial sonographic changes in asphyxiated neonates. Dynamic changes are observed across various time-frames; hyperechogenicity of the thalamus, basal ganglia, and the altered appearance of posterior limb of the internal capsule (PLIC) are frequently seen in acute and subacute insults. Also, a resistive index of 0.55 or less in cerebral Doppler studies within the first 72 hours of life is associated with adverse short- and long-term outcomes and increased mortality.

Conclusion: Bedside cranial ultrasound is a useful screening tool for the diagnosis and monitoring of neonates with HIE. However, further studies are needed to improve our understanding of sonographic findings as predictors of adverse neurodevelopmental outcomes and mortality in affected neonates.

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Key scientific associations: neonates, birth asphyxia, hypoxic-ischemic encephalopathy, acoustic window, anterior fontanelle, basal ganglia, cerebral doppler, cranial ultrasound, convex transducer, echogenicity, ex-vacuo, four-column sign, grey-white matter differentiation, internal capsule, linear transducer, magnetic resonance imaging, near-total asphyxia, partial prolonged asphyxia, perinatal Asphyxia, parenchymal edema, periventricular leukomalacia, PLIC sign, resistive Index, thalamus, therapeutic hypothermia.

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Maheshwari A, Huisman TAGM. Abnormalities of Corpus Callosum and Other Interhemispheric Commissures. Newborn 2024; 3(2):139-156. DOI: 10.5005/jp-journals-11002-0093.

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Abstract:The two neocortical cerebral hemispheres are connected by white matter tracts such as the corpus callosum (CC), and the anterior and the hippocampal commissures. Complete agenesis of the CC is seen in about 7 persons per 1000; the incidence in patients with developmental delay can be as high as 3%. In addition, many patients show a paucity, not complete absence, of commissural axons due to altered development. Others may develop secondary destruction of the CC following infarction, hemorrhage, trauma, and in some metabolic diseases. One notable structural feature in these patients with agenesis or hypogenesis of the CC are the Probst Bundles, which are longitudinal, rostrocaudally-oriented coiled white matter fascicles running alongside the lateral ventricles into the tapetum. The presence or absence of these PBs can affect the clinical presentation and outcome of these patients. Many patients with agenesis of the CC manifest with seizures within the first weeks of life. Others present with developmental delay and a multitude of neurological manifestations. The etiopathogenesis of agenesis of the CC is unknown and is still being investigated. These commissural defects can also be seen as a part of several genetic associations such as Aicardi syndrome, Andermann syndrome, Mowat-Wilson syndrome, and XLAG (X-linked lissencephaly with ambiguous genitalia). As of now, no specific treatment is known for any of these conditions. Careful clinical and genetic evaluation of these patients is necessary for symptomatic management and for counseling the families. In this article, we present our clinical/imaging experience and have combined it with an extensive search of the databases PubMed, EMBASE, and Scopus. To avoid bias, keywords were identified from discussions in our group and from PubMed’s Medical Subject Heading (MeSH) thesaurus.

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Key scientific associations: commissural, white matter tracts, eutherian mammals, chorioallantoic placenta, axonal projections, cortical layers, pyramidal neurons, rostrum, genu, body, isthmus, splenium, anterior commissure, hippocampal commissure, amygdaloid nuclei, subcallosal sling, midline glial populations, pioneering axons, guidance molecules, chemorepellent molecules, ACC  Network, interhemispheric cyst, myelination, Probst Bundles, olfactory apparatus, heterotopia,  abnormal sulcation, telencephalic, diencephalic, rhombencephalic, pachygyria, polymicrogyria, oversulcation, cerebellar size, cerebellar folia, callosal agenesis, callosal hypogenesis, Classic lissencephaly, cobblestone lissencephalies, polymicrogyria, schizencephaly, cingulum, paramedian gyri, hemispheric dysplasia, Sperry paradox, fasciculated axon tracts, callosal axon guidance, fornix, altered topographic organization, tapetum, PB-like fibers, cingulate bundle, glutamatergic neurons, Sema3C cells, probostomy, callosal remnant, indusium griseum, prelimbic, anterior cingulate, retrosplenial, Cingulum bundles, fronto-occipital fasciculus projection, Database for Annotation, Visualization and Integrated Discovery, DCC, TUBB3, TUBA1A, L1CAM, EPG5, CHD7, HGNC, Human Genome Organization, Fgf8, Nfia, Nfib, Draxin, midline zipper glia, Zika, SATB2+ neurons, Chiari II malformations, Slit2, Robo1, Satb2, autism spectrum.