Pediatrician (St. Petersburg)

Reduction of infant mortality is a priority task for achieving the national development goals of the Russian Federation. The paper analyzes the influence of regional routing of newborns on the infant mortality rate in the subjects of the Russian Federation. The infant mortality rate for the period January–November 2023 in the Russian Federation is below the target value and amounts to 4.1‰, which is lower than the rate for the same period of 2022 (4.3‰). At the same time, subjects implementing insufficiently effective intraregional routing of newborns have a high rate of neonatal deaths in the early and late neonatal period concerning medical organizations of the I and II level of medical care. In order to improve the availability and quality of medical care for newborns, as well as to reduce the number of re-hospitalizations of newborns between medical organizations of the same level, including those requiring emergency surgical correction, it is necessary to update regional and interregional routing schemes in the provision of care to newborns, taking into account the orders of medical care, principles of territorial planning (with a detailed description of the areas of responsibility of each medical organization located on the territory of the subject).

BACKGROUND: Acute kidney injury is one of the most common syndromes in premature neonates requiring treatment in intensive care units. Early diagnosis of acute kidney injury in these patients is extremely difficult due to lack of specific signs, morphofunctional immaturity, low sensitivity and specificity of renal dysfunction markers.

AIM: The aim of the study is to assess the clinical significance of plasma cystatin C concentration in the diagnosis of acute kidney injury in premature newborns in the early neonatal period.

MATERIALS AND METHODS: The design was a primary, prospective, non-randomised study including 100 preterm neonates with gestational age less than 37 weeks and birth weight up to 1500 g. Indicators of renal functional status (creatinine, diuresis rate, cystatin C) were assessed on the first, third and seventh days of life.

RESULTS: Low birth weight (p = 0.001; OR = 0.226), the need for invasive control mechanical ventilation (p = 0.012; OR = 6.32) and inotropic therapy (p = 0.025; OR = 4.99) are associated with a high risk of acute kidney injury development. A direct correlation was found between the presence of acute kidney injury, plasma creatinine (p = 0.001, r = 0.688) and cystatin C (p = 0.001, r = 0.689) levels. The first increase in plasma creatinine levels relative to basal levels in preterm neonates with acute kidney injury was noted from the third day of life, which was statistically significant compared to those of children without acute kidney injury (91.0 vs 57.0 mmol/l; p < 0.001). The concentration of cystatin C in patients with acute kidney injury is increased from the first day of life (1.85 vs 1.57 ng/ml) and continues to steadily increase by the seventh day of life (2.27 vs 1.84 ng/ml; p < 0.001).

CONCLUSIONS: Increased concentration of cystatin C in preterm neonates with acute kidney injury is observed from the first day of life and increases in dynamics, which allows us to consider it a highly sensitive and significant marker of renal dysfunction in the early neonatal period.

BACKGROUND: The most significant pathology in very preterm newborns with very low body weight and extremely low body weight is intraventricular hemorrhage, which can subsequently lead to disability. It is necessary to identify risk factors for the formation of disabling pathology in very premature newborns for a personalized approach to their management.

AIM: The goal is to assess the health status of very premature children who have suffered intraventricular hemorrhage in the early neonatal period by the age of 1 year of life, to identify risk factors for the formation of disabling pathology.

MATERIALS AND METHODS: We examined 580 very premature infants with very low body weight and extremely low body weight who suffered intraventricular hemorrhage of grades I and II in the early neonatal period.

RESULTS: Risk factors for stage II intraventricular hemorrhage in very premature infants with very low body weight and extremely low body weight have been established: fetoplacental insufficiency, threat of miscarriage, pregnancy parity of 3 or more, premature abruption of a normally located placenta, severe asphyxia at birth. By the age of 1 year of life, only 10.2% of the examined children were neurologically healthy. Disability by the age of 1 year of life occurred in 19 children, and in first place among the causes of disability is cerebral palsy — 68.4%, in second place — bronchopulmonary dysplasia (15.8%), in third place — retinopathy of prematurity (10.5%). Risk factors for the formation of cerebral palsy by the year of life in very premature infants with very low body weight and extremely low body weight who have undergone intraventricular hemorrhage in the early neonatal period are: gestation period less than 28 weeks, birth weight less than 500 g, low Apgar score at 5 minutes of life, the need for artificial pulmonary ventilation lasting more than 4 days, the presence of stage 2 intraventricular hemorrhage in the early neonatal period.

CONCLUSIONS: Taking into account risk factors for the development of disabling pathology in very preterm newborns with very low body weight and extremely low body weight is necessary for a personalized approach to the management of such children to improve outcomes.

Bronchial asthma in children is a heterogeneous disease; therefore, determination of the disease endotype is important for personalized therapy, overcoming refractoriness to bronchial asthma treatment, and selecting a targeted biologic drug. The endotype of the disease, which is not associated with eosinophilia and, therefore, characterized by an insufficient response to inhaled corticosteroids, may begin at school age. The prevalence of low T2-inflammatory bronchial asthma in school-aged children is poorly understood, but the evidence presented in this article supports the presence of this endotype. This endotype of bronchial asthma in children is characterized by clinical and pathogenetic features, including low degree of allergic sensitization, reduced level of total IgE, limited number of positive allergy tests, decreased concentration of nitric oxide in exhaled air and eosinophil content in blood. The role of neutrophils in the development and prognosis of bronchial asthma in children is currently insufficiently studied and defined, nevertheless, it is known that the neutrophilic type of inflammation is associated with a more severe course of the disease and inadequate control. It is important to emphasize the need for further research into the endotypes of bronchial asthma in children with the identification of novel biomarkers and molecular mechanisms underlying asthma with low T2-inflammation. This may further enable the achievement of control of bronchial asthma with different inflammatory endotypes.

Corticosteroids are widely used in clinical practice in the care of children in critical condition, but data on their efficacy in neonatal practice are very limited. This publication attempts to summarize and systematize the literature data on the use of exogenous corticosteroids in various diseases of the neonatal period. Special attention is paid to the pathophysiology of acute adrenal dysfunction in the structure of critical conditions, its diagnosis and treatment. The results of a number of studies confirming the effectiveness of various corticosteroids in neonatal cardiac surgery, arterial hypotension, neonatal sepsis, refractory septic shock, meconium aspiration syndrome and bronchopulmonary dysplasia are presented. It has been demonstrated that hydrocortisone is the drug of choice in critical situations due to its minimal half-life and low probability of side effects. It has been established that current data on the feasibility, efficacy and safety of corticosteroid use in critical conditions of the neonatal period are very controversial and require further experimental and clinical studies. The question of the necessity of corticosteroids use in neonatal cardiac surgery and in various lung diseases (meconium aspiration syndrome, bronchopulmonary dysplasia) remains open, although there is enough evidence of their positive therapeutic effect, but there are no randomized multicenter studies, which limits the use of corticosteroids in clinical practice. An absolute indication for the administration of corticosteroids in neonates is the presence of acute adrenal insufficiency, congenital adrenal cortical hyperplasia and catecholamine-resistant septic shock.

Iron overload syndrome is a pathological condition that occurs as a result of congenital disorders of its regulation, as well as due to repeated hemotransfusions, hemolytic anemia or excessive intake of iron preparations. Accurate data on the prevalence of secondary liver iron overload are not available in the literature. Liver biopsy remains the gold standard for assessing iron overload, however, non-invasive methods, in particular magnetic resonance relaxometry, also allow for an accurate quantitative assessment of the body’s iron overload. In secondary iron overload, chelation therapy is the only therapeutic option to prevent excessive accumulation of iron in tissues, which reduces complications and improves patient survival. The presented clinical case in a 5-year-old child is interesting for a combination of factors contributing to the formation of liver iron overload, as well as the rapid development of hyperferritinemia. The boy has a history of prolonged neonatal jaundice. At 6 months old, the child was first diagnosed with grade 2 iron deficiency anemia, splenomegaly and liver cavernoma were detected during abdominal ultrasound, and therefore the child was referred for consultation to a surgeon. At the age of 1.5 years old, the boy underwent surgical treatment — the formation of splenic-renal anastomosis due to the danger of bleeding from dilated veins of the esophagus. However, in the postoperative period, the failure of the anastomosis was noted, and therefore an H-shaped mesenteric-caval anastomosis was performed. At 2 years old of age, a planned examination revealed an increase in ferritin to 1149.2 ng/ml. During the molecular genetic study, hereditary hemochromatosis was excluded. After the start of chelation therapy, there was a decrease in ferritin levels in dynamics and with its normalization in October 2023, therapy was canceled. The boy is currently under the supervision of a hematologist, a pediatric surgeon and a pediatrician. The clinical case demonstrates the peculiarities of the course of liver iron overload in a child with liver cavernoma and extrahepatic portal hypertension, which required a personalized approach to diagnosis and treatment.