Iranian Journal of Neonatology
Volume:15 Issue: 1, Winter 2024

Decisions about neonatal end-of-life care have been done in several countries and Neonatal ethics must answer several basic questions:Is withholding potentially life-saving treatment from infants morally justified?What are the necessary criteria for stopping treatment in cases of futile and ineffective treatment?Who has the authority to make decisions for a critically ill baby? Abandoning life-saving treatment is definitely not morally justified, but if the treatment is useless and we are faced with an incurable disease, is it necessary to continue the treatment? And is stopping treatment morally wrong?We definitely need scientific and evidence-based protocols for any decision to stop the treatment of an incurable patient.The first 28 days of life – the neonatal period – is the most vulnerable time for a child’s survival. According to UNICEF January 2023 statistics: Globally, 2.3 million children died in the first month of life in 2021 – approximately 6,400 neonatal deaths every day. One of the successful interventions in reducing infant mortality is overcoming ethical challenges in infant care and treatment. Failure to comply with the laws and code of ethics in some special care departments for newborns can cause challenges. Codes of ethics are general principles, rules and standards, including ethical standards and guidelines for the performance of employees in their roles. When ethical codes are followed in the provision of health care services, the quality of care is improved.The Groningen Protocol created in 2004 by Eduard Verhagen, at the University Medical Center Groningen (UMCG) in Groningen, the Netherlands. It contains directives with criteria under which physicians can perform "active ending of life on infants" (child euthanasia) without fear of legal prosecution.[1][2][3]  and has been ratified by the Dutch National Association of Pediatricians.[4]The protocol, drawn up after extensive consultation between physicians, lawyers, parents and the Prosecution Office, offers procedures and guidelines to achieve the correct decision and performance. The final decision about "active ending of life on infants" is not in the hands of the physicians but with the parents, with physicians and social workers agreeing to it. Criteria are, amongst others, "unbearable suffering" and "expected quality of life". Only the parents may initiate the procedure. The procedure is reported to be working well.[5]For the Dutch public prosecutor, the termination of a child's life (under age 1) is acceptable if four requirements were properly fulfilled:The presence of hopeless and unbearable suffering.The consent of the parents to termination of life.Medical consultation having taken place.Careful execution of the termination.[5]Doctors who end the life of a baby must report the death to the local medical examiner, who in turn reports it to both the district attorney and to a review committee.

Infantile hemangioma is a common benign vascular tumor that affects up to 10% of infants. Propranolol, a beta-blocker, has been used as a promising treatment for infantile hemangioma, but its effectiveness remains controversial. Therefore, the aim of the current study was to investigate the effect of propranolol in the treatment of infantile hemangioma in Erbil, Iraq. This prospective interventional study was conducted between May 2021 and December 2022 at Rapareen Teaching Hospital in Erbil, Iraq. A total of 42 children entered the study, considering the inclusion criteria. Propranolol was given at a dose of 1 mg/kg/day and increased to 2-3 mg/kg/day within a few days if tolerated. Infants were treated and followed up for 3 to 6 months. During this follow-up, the infants were checked for cardiac, respiratory, and hypoglycemic symptoms. The obtained data were analyzed using paired, independent, and chi-square tests. The mean age of the infants was 11.48 ± 5.251 months. Regarding the gender distribution of the participants, 14 (33.3%) of the infants were males and 28 (66.7%) were females. Hemangiomas were observed in different body regions, including 6(14.3%) cases in the limbs, 28 (66.7%) in the head and neck, and 8 (19%) in the trunk. Regarding the response to treatment, the results revealed that 27 (64.3%) infants responded well to the treatment. There was a moderate response in 9 (21.4%) infants and a mild response in 6 (14.3%) infants. Based on the findings of this study, propranolol can be used as an effective and safe drug for hemangioma treatment.

Although neonatal resuscitation has the potential to prevent neonatal mortality rates, several factors hinder it is effectiveness. This study aimed to assess the neonatal resuscitation practice and associated factors among health workers in public health facilities in West Guji zone, Oromia, Ethiopia 2021. A facility-based cross-sectional study design was conducted from February 01 to March 30/2021. Data were collected with a structured self-administered questionnaire and observational checklist. Finally, a convenience sampling technique was employed to select 407 study participants. Binary and Multivariable logistic regression analyses were conducted with 95% confidence intervals and statistical significance is declared at P<0.05. Out of the 407 sampled study population, 402 healthcare workers were involved in the study with a 98.7% response rate and 270 (67.2%) of healthcare workers had good practice in neonatal resuscitation with a 95% confidence interval of 62.6% to 71.8%.  Factors associated with neonatal resuscitation practice were the age of health care workers who are 30 to 34 (AOR= 3.52, 95%CI; 1.27 - 9.74) and 35 to 39 years AOR= 4.00, 95%CI; 1.24 -12.97), work experience (AOR= 5.72, 95%CI; 2.72 - 12.03, training on neonatal resuscitation (AOR=3.6,95%CI;2.16-6.00), availability of neonatal resuscitation guidelines (AOR= 2.29, 95%CI; 1.13 - 4.69), knowledge status (AOR=1.82, 95%CI; 1.0 -3.10), and attitude of healthcare workers towards neonatal resuscitation(AOR=2.18, 95%CI; 1.37 -3.48).  The finding shows the neonatal resuscitation practice was low compared with others. Factors associated with neonatal resuscitation practice were identified.  Health institutions should organize healthcare providers on neonatal resuscitation by giving on-the-job training, providing guidelines, and supervising all health facilities to produce competent healthcare workers and reduce neonatal mortality and morbidity.

Neonate screening is a preventative measure that can contribute to early diagnosis of treatable diseases. Hypothyroidism in neonates is among the common preventable factors leading to intellectual disability. This study aims to describe the prevalence and experience with four-step screening to diagnose congenital hypothyroidism. The statistical population of this cross-sectional study included 392 preterm neonates (gestational ages less than 36 weeks and 6 days) in 2018-2019 from the health centers covered by Shahid Beheshti University of Medical Sciences (Tehran, Iran) who had been referred for screening. Neonates were screened in the first 3-6 days after birth and then on days 14, 42, and 72. In neonates with TSH serum levels of 10 mU/L, TSH-T4 was measured. Next, the physician decided on the medication based on the results. At the primary screening of the neonates average TSH level was 2.08 ± 2.4 mU/L. Thirty-three neonates (8.4%) indicated disrupted screening results. The secondary screening of 388 neonates (98.97%) revealed an average TSH serum level of 1.9 ± 1.96 mU/L, and 19 (5.9%) indicated TSH serum levels higher than 5 (mU/L). The third screening test was performed on 382 (97.44%) of the neonates. The average TSH level was 1.3 ± 2.4 mU/L, 340 (85.96%) indicated normal levels, and 42 (11.47%) had unfavorable results. Finally, the fourth screening test was performed on 373 (95.15%) neonates. The mean TSH level was 2.21 ± 1.9 mU/L, which revealed 24 (6.12%) unfavorable test results. The percentage of hypothyroidism in neonates was 5.6% (23 cases).  In this study, the prevalence of hypothyroidism was 4.33% (17 cases) in girls and 1.53% (6 cases) in boys.    The results of this study revealed the high incidence rate of congenital hypothyroidism among preterm neonates. Therefore, preventing congenital hypothyroidism misdiagnosis requires a series of screening tests. Also, findings indicated that the results of screening tests for preterm neonates with prolonged GAs and higher birth weights are more accurate and reliable.

The World Health Organization has introduced two sets of child growth standards for growth assessment. These reference values may not be suitable for use in other populations. Therefore, this study aimed to determine specific Z scores in the population covered by Mashhad University of Medical Sciences in Iran.

This cross-sectional study was conducted on data obtained from the evaluation of height, weight, and head circumference of children aged from 0 to 18 months visiting the healthcare centers of Mashhad University of Medical Sciences from March 2018 to March 2021. A total data of 128,472 children were extracted from the Electronic Health Records (SinaEHR®) and included in the study. Finally, the collected data were analyzed using Minitab and SPSS software (version 16).  

The L, M, and S parameters were used to calculate Z scores for weight, height, and head circumference. These Z scores were then compared to standard deviation values ​for each age from our study and international standards to determine any differences. Our study found that mean weight scores were 0.16 kg higher than the CDC standard and 0.34 kg higher than the WHO growth standard.  

The provision of this exclusive reference to children's growth indicators not only allows for a more accurate evaluation but also provides the possibility of comparison with other populations using their specific growth charts. It seems that one of the best plans is to compare growth charts with international populations and national growth charts, which due to the electronization of the entire processes of the health system, is more possible than ever.

Fetal and neonatal health is of particular importance in pregnant women. Secondhand smoke (SHS) can jeopardize the health of the mother, fetus, and neonate. The present study was conducted to determine the relationship between exposure to secondhand smoke during pregnancy and neonatal-related outcomes. This retrospective cohort study was conducted in 2022 on 270 mother-newborn pairs through convenience sampling in two equal groups (n=135), including exposure and non-exposure to SHS at  Rohani Hospital, Babol, Children's Hospital, Amirkola, and Imam Ali Hospital, Amol. In order to collect the data, a checklist including the demographic characteristics, medical variables, questions related to the exposure of mothers to cigarette smoke, the neonatal outcomes questionnaire, and the SNAPPE-II scale were used. Data analysis was performed using STATA statistical software (version 17), and the significance level of all tests was considered less than 0.05. The mean age of mothers was 28.30±5.83 years, and 61% of births were by cesarean section. The SNAPPE-II score was 8.23​±5.29 in the non-exposure group and 20.68±13.53 in the exposure group (P=0.005). The prevalence of neonates with a birth weight of less than 2500gr was higher in mothers exposed to SHS (P=0.033).  Considering confounding variables, the neonates in the non-exposure group were, on average, 1.46 cm taller than those in the exposure group (P=0.005). Exposure to smoking increases the risk of premature birth by 1.65 times (P=0.032).   Exposure of pregnant mothers to SHS is associated with adverse neonatal outcomes. Therefore, it is recommended to train families to avoid exposure to cigarette smoke, especially during pregnancy, and also for health centers to pay special attention to this matter in the care of pregnant mothers.

Neonatal sepsis is a systemic infection that affects newborns within the first 28 days of life. It has a significant effect on newborn mortality Worldwide. It could be responsible for as much as one-third of all neonatal deaths globally each year. The associated factors as well as clinical outcomes of neonatal sepsis are not well quantified. The aim of this study was to assess the treatment outcome and associated factors of Neonatal Sepsis in Hawassa University Comprehensive Specialized Hospital. A retrospective Cohort study was conducted. All neonates admitted to neonatal intensive care unit from July 28, 2014 to July 28, 2019 were included. The source of data was registration book and patients’ card. After being double checked for accuracy, data was entered into EpiData 3.1 and analyzed using SPSS version 22.  Testing for statistical association between the variables was done using bivariate and multivariate logistic regressions Poor treatment outcome includes refuse to take the treatment, development of complications, being referred to other health facilities and neonatal death. All charts met enrollment criteria. More than three forth of the infants who treated were improved or recovered. Among the study participants, More than half were male and about half of them were younger than 3 days on admission. Majority of the mothers were found in the age group of 18 to 25 years. The poor treatment outcome for neonatal sepsis was high (16%). The predictors for poor treatment outcome of neonatal sepsis were being referred from other health facility (AOR=0.29, 95% CI: 0.24-0.89) and longer duration of treatment (AOR=0.36, 95% CI: 0.14-0.90). The poor outcome of neonatal sepsis was a significant health problem in the study area. Strengthening referral system and focusing on quality of care will improve poor outcome of neonatal sepsis.

The fetus receives various vestibular stimuli as a result of its mother’s walking and other activities, while premature infants are deprived of these typical stimuli due to hospitalization in a neonatal intensive care unit (NICU).

A single blinded randomized controlled clinical trial was designed to evaluate the effect of rhythmic maternal movements (RMM) on motor performance of infants born preterm with gestational age under 34 weeks. The aim of this plan is to stimulate the vestibular system in infants after preterm birth in hopes of improving motor performance. Seventy preterm infants will be randomized to experimental and control groups. The infants in the experimental group will be given RMM to improve motor development, heart rate and sao2. A neonatal occupational therapist trains mothers to do the RMM with a doll and explains the protocol. RMM is performed twice a day for a week. The Test of Infant Motor Performance (TIMP) is carried out at baseline and after a week of intervention by a blinded assessor.

This paper designed to study the effects of rhythmic maternal movements on motor performance, heart rate and sao2 of preterm infants hospitalized in a Neonatal Intensive Care Unit.

Congenital Chylothorax (CC) is a rare condition, which is defined as an accumulation of the chyle in the pleural cavity;moreover, it is associated with significant morbidities, including respiratory distress, malnutrition, immunodeficiency, and infections.

 Case Report:

 The diagnosis of chylothorax was made upon count cell analysis of the pleural fluid with ≥80% lymphocytesdetected before birth or within 28 days after birth. In this study, we presented five cases of CC infants. They were dischargedfrom our tertiary center at Hedi Chaker Hospital, Sfax, Tunisia, from January 2010 to December 2018. There were three malesand two females. Prenatal diagnosis was made in four cases. There were four full-term newborns and one near-term of 36weeks. Pleural effusion was on the right side in three cases, on the left side in one case, and bilateral in one case. Four casesrequired mechanical ventilation. Somatostatin was indicated in one case. The treatment was successful in four cases. One casepresented a dysmorphic syndrome and died of pneumothorax.

The treatment of CC is based on conservative management. Somatostatin or its analog octreotide is considered anadjunctive treatment of CC. However, the refractory cases are treated with chemical pleurodesis or surgical treatment. Wepropose an algorithm for the treatment of CC.