Introductory Chapter: Neonatology - Combining Intensive Care and Family-Friendly Atmosphere

*Antonina Chubarova*

#### **1. Introduction**

The new millennium is of course the epoch of technologies. New technologies are already everywhere in our life: information technologies, reproductive technologies, new materials, and world globalization. What can this lead to in the inner world of mother and child, in everlasting mystery of childbirth, and in the struggle of physicians for every lifesaving?

This book combines different chapters united by the same idea to improve medical aid to neonate and its parents by the means of modern technologies.

Each of them gives an overview of a very important area of perinatology beginning from technologies applied during the first minutes of life till methods that help family to be socialized.

It is very important to know that perinatal period is a period of adaptation of fetus and child organism to the environment. "Adaptation" means changes in genes working that will allow a child to have the most advantageous metabolism and behavior in future life. The more we know about genotype, the more it is clear that it is not the only one factor that determines phenotype. The environmental factors such as nutrition, microbiota, mother's behavior, and others can be the strong regulators of gene work. Such factors are called epigenetic factors. During some periods of intensive changes of gene activity, the so-called critical window, these factors can lead to permanent changes in gene activity and form a phenotype. In other words epigenetic factors have a programming role in critical periods. The patterns of reaction to infection, stress, food deprivation, and other environmental factors in later periods of life including aging are formed in gestational period and neonatal period. Perinatal period is the most important critical period in mammal's life. It is a period when the health of future generations can be programmed for all the life period [1].

The mechanisms of programming are already discovered. The process of gene methylation is called "the prima donna" of epigenetic. Methylation inactivates gene transcription [2]. In embryo before implantation, the majority of genes are methylated, and all the next development is a series of demethylation and methylation. Other mechanisms are histone modifications, regulatory miRNA, and tiRNA [3, 4].

Nutrition is a strong external factor of programming. It is a signal of availability of nutrient resources, their quantity and quality [5]. Nutrition contains methyl (–CH3) group donors: folates, В12, В6, choline, methionine, and betaine. Also nutrition is a platform for macro- and microorganism interaction. And finally it is a functional molecular donor and direct regulator of gene function.

The mother's under- and overnutrition can lead to placenta regulatory gene changes. The placenta can, for example, increase glucose transport to fetus, but in some critical situations, its functioning may be "selfish" through accumulating nutrients for its own needs [6]. The placenta regulates also the synthesis of neuroactive factors, serving as a major source of serotonin to the fetal forebrain [7].

In the fetus itself, major changes following nutrition impairment are happening in genes and their products regulating reaction to stress, fat, and glucose metabolism [8, 9]. Is now shown in big cohort studies that body composition, rate of metabolic syndrome, obesity, atherosclerosis, type 2 diabetes, and rate of cardiovascular death depend on nutrition in prenatal period and infancy [10]. For example in the population of the survivors of Dutch Hunger Winter at the age of 60–65, birth weight negatively correlated with the rate of glucose intolerance, hyperlipidemia, and arterial hypertension, and there was found less DNA methylation of the maternally imprinted IGF2 gene [11, 12]. Learning ability, behavior, and fertility in adult life are also dependent on nutrition in critical period [13–15]. Psychiatric diseases are also partially programmed by continuous dietary deficiency by inactivation of expression of genes for myelin development and oligodendrocyte-related genes [16].

What can we do to regulate undesirable effects of complicated pregnancy? We should know that the infancy period is also a critical period and neonatologists and other specialists can do a lot to regulate future development, especially in premature neonates.

It is important to minimize stressful factors such as hypo- and hyperoxia, pain, and caloric and protein deficit. The moment of adaptation to extrauterine life is of a great importance. The first hours of life are "golden hours," and they are important not only in the context of lifesaving but in the context of programming.

After birth nutritional programming continues through nutrients, regulatory factors, and microflora of milk, but there are specific ways of continuing direct gene regulation through microvesicles containing mRNA transcripts, which possess reverse transcriptase activity [17].

To provide breast milk feeding [18] with or without combination with artificial parenteral or enteral nutrition, to take care of forming microbiota [19], is a way to prevent a big number of negative metabolic changes.

Finally, the mothers' behavior and her integration in child care also have a programming effect. Animal experiments and big cohort studies [20–22] showed that less anxious and more positive mother more often takes a child and contacts with him or her and this has enormous effect on offspring's reaction to stress in cognitive development in future life.

This book gives an overview of modern strategies in neonatology that can influence health of adult.

**3**

**Author details**

Antonina Chubarova

Pirogov Russian National Research Medical University, Russia

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: ach-12@yandex.ru

provided the original work is properly cited.

*Introductory Chapter: Neonatology - Combining Intensive Care and Family-Friendly Atmosphere*

*DOI: http://dx.doi.org/10.5772/intechopen.86857*

*Introductory Chapter: Neonatology - Combining Intensive Care and Family-Friendly Atmosphere DOI: http://dx.doi.org/10.5772/intechopen.86857*

#### **Author details**

*Neonatal Medicine*

genes [16].

ture neonates.

reverse transcriptase activity [17].

development in future life.

ence health of adult.

prevent a big number of negative metabolic changes.

The mother's under- and overnutrition can lead to placenta regulatory gene changes. The placenta can, for example, increase glucose transport to fetus, but in some critical situations, its functioning may be "selfish" through accumulating nutrients for its own needs [6]. The placenta regulates also the synthesis of neuroac-

In the fetus itself, major changes following nutrition impairment are happening in genes and their products regulating reaction to stress, fat, and glucose metabolism [8, 9]. Is now shown in big cohort studies that body composition, rate of metabolic syndrome, obesity, atherosclerosis, type 2 diabetes, and rate of cardiovascular death depend on nutrition in prenatal period and infancy [10]. For example in the population of the survivors of Dutch Hunger Winter at the age of 60–65, birth weight negatively correlated with the rate of glucose intolerance, hyperlipidemia, and arterial hypertension, and there was found less DNA methylation of the maternally imprinted IGF2 gene [11, 12]. Learning ability, behavior, and fertility in adult life are also dependent on nutrition in critical period [13–15]. Psychiatric diseases are also partially programmed by continuous dietary deficiency by inactivation of expression of genes for myelin development and oligodendrocyte-related

What can we do to regulate undesirable effects of complicated pregnancy? We should know that the infancy period is also a critical period and neonatologists and other specialists can do a lot to regulate future development, especially in prema-

It is important to minimize stressful factors such as hypo- and hyperoxia, pain, and caloric and protein deficit. The moment of adaptation to extrauterine life is of a great importance. The first hours of life are "golden hours," and they are important

After birth nutritional programming continues through nutrients, regulatory factors, and microflora of milk, but there are specific ways of continuing direct gene regulation through microvesicles containing mRNA transcripts, which possess

To provide breast milk feeding [18] with or without combination with artificial parenteral or enteral nutrition, to take care of forming microbiota [19], is a way to

Finally, the mothers' behavior and her integration in child care also have a programming effect. Animal experiments and big cohort studies [20–22] showed that less anxious and more positive mother more often takes a child and contacts with him or her and this has enormous effect on offspring's reaction to stress in cognitive

This book gives an overview of modern strategies in neonatology that can influ-

not only in the context of lifesaving but in the context of programming.

tive factors, serving as a major source of serotonin to the fetal forebrain [7].

**2**

Antonina Chubarova Pirogov Russian National Research Medical University, Russia

\*Address all correspondence to: ach-12@yandex.ru

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Waterland RA. Epigenetic mechanisms and gastrointestinal development. The Journal of Pediatrics. 2006;**149**(5 Suppl):S137-S142

[2] Santos KF, Mazzola TN, Carvalho HF. The prima donna of epigenetics: The regulation of gene expression by DNA methylation. Brazilian Journal of Medical and Biological Research. 2005;**38**(10):1531-1541

[3] Junien C, Gallou-Kabani C, Vigé A, Gross MS. Nutritional epigenomics: Consequences of unbalanced diets on epigenetics processes of programming during lifespan and between generations. Annales d'endocrinologie. 2005;**66**(2 Pt 3):2S19-2S28

[4] Holliday R. Epigenetics: A historical overview. Epigenetics. 2006;**1**(2):76-80

[5] Mathers JC. Early Nutrition: Impact on Epigenetics. Forum of Nutrition. 2007;**60**:42-48

[6] Hsiao EY, Patterson PH. Placental regulation of maternal-fetal interactions and brain development. Developmental Neurobiology. 2012;**72**(10):1317-1326

[7] Fowden AL. The placenta and intrauterine programming. Journal of Neuroendocrinology. 2008;**20**:439-450

[8] Burdge GC, Hanson MA, Slater-Jefferies JL, Lillycrop KA. Epigenetic regulation of transcription: A mechanism for inducing variations in phenotype (fetal programming) by differences in nutrition during early life? The British Journal of Nutrition. 2007;**97**(6):1036-1046

[9] Myatt L. Placental adaptive responses and fetal programming. The Journal of Physiology. 2006;**572**(Pt 1):25-30

[10] Langley-Evans SC. Developmental programming of health and disease. The Proceedings of the Nutrition Society. 2006;**65**(1):97-105

[11] Stanner SA, Yudkin JS. Fetal programming and the Leningrad Siege study. Twin Research. 2001;**4**:287-292

[12] Roseboom TJ, van der Meulen JH, Ravelli AC, Osmond C, Barker DJ, Bleker OP. Effects of prenatal exposure to the Dutch famine on adult disease in later life: An overview. Twin Research. 2001;**4**:293-298

[13] Walker CD. Nutritional aspects modulating brain development and the responses to stress in early neonatal life. Progress in Neuro-Psychopharmacology & Biological Psychiatry. 2005;**29**(8):1249-1263

[14] Saugstad LF. From superior adaptation and function to brain dysfunction—The neglect of epigenetic factors. Nutrition and Health. 2004;**18**(1):3-27

[15] Ramakrishnan U, Grant F, Goldenberg T, Zongrone A, Martorell R. Effect of women's nutrition before and during early pregnancy on maternal and infant outcomes: A systematic review. Paediatric and Perinatal Epidemiology. 2012;**26**(s1):285-301

[16] Casper RC. Nutrients, neurodevelopment, and mood. Current Psychiatry Reports. 2004;**6**(6):425-429

[17] Irmak MK. Integration of maternal genome into the neonate genome through breast milk mRNA transcripts and reverse transcriptase. Theoretical Biology & Medical Modelling. 2012;**9**:20

[18] Fernandez-Twinn DS, Ozanne SE. Early life nutrition and metabolic programming. Annals of the New York Academy of Sciences. 2010;**1212**:78-96

[19] Grenham S, Clarke G, Cryan JF, Dinan TG. Brain–gut–microbe

**5**

*Introductory Chapter: Neonatology - Combining Intensive Care and Family-Friendly Atmosphere*

*DOI: http://dx.doi.org/10.5772/intechopen.86857*

[20] Mulder C, Kain J, Uauy R, Seidell JC. Maternal attitudes and child-feeding practices: Relationship with the BMI of Chilean children. Nutrition Journal.

[21] Viltart O, Vanbesien-Mailliot CC.

Impact of prenatal stress on neuroendocrine programming. ScientificWorldJournal. 2007;**7**:1493-1537

[22] Quah PL, Fries LR, Chan MJ. Validation of the children's eating behavior questionnaire in 5 and 6 yearold children: The GUSTO Cohort Study. Frontiers in Psychology. 2019;**10**:824

2009;**8**:37

communication in health and disease. Frontiers in Physiology. 2011;**2**:94

*Introductory Chapter: Neonatology - Combining Intensive Care and Family-Friendly Atmosphere DOI: http://dx.doi.org/10.5772/intechopen.86857*

communication in health and disease. Frontiers in Physiology. 2011;**2**:94

[20] Mulder C, Kain J, Uauy R, Seidell JC. Maternal attitudes and child-feeding practices: Relationship with the BMI of Chilean children. Nutrition Journal. 2009;**8**:37

[21] Viltart O, Vanbesien-Mailliot CC. Impact of prenatal stress on neuroendocrine programming. ScientificWorldJournal. 2007;**7**:1493-1537

[22] Quah PL, Fries LR, Chan MJ. Validation of the children's eating behavior questionnaire in 5 and 6 yearold children: The GUSTO Cohort Study. Frontiers in Psychology. 2019;**10**:824

**4**

*Neonatal Medicine*

**References**

[1] Waterland RA. Epigenetic mechanisms and gastrointestinal development. The Journal of Pediatrics.

2006;**149**(5 Suppl):S137-S142

2005;**38**(10):1531-1541

during lifespan and between

2005;**66**(2 Pt 3):2S19-2S28

2007;**60**:42-48

[2] Santos KF, Mazzola TN, Carvalho HF. The prima donna of epigenetics: The regulation of gene expression by DNA methylation. Brazilian Journal of Medical and Biological Research.

Proceedings of the Nutrition Society.

[12] Roseboom TJ, van der Meulen JH, Ravelli AC, Osmond C, Barker DJ, Bleker OP. Effects of prenatal exposure to the Dutch famine on adult disease in later life: An overview. Twin Research.

[13] Walker CD. Nutritional aspects modulating brain development and the responses to stress in early neonatal life. Progress in Neuro-Psychopharmacology & Biological Psychiatry. 2005;**29**(8):1249-1263

[14] Saugstad LF. From superior adaptation and function to brain dysfunction—The neglect of epigenetic factors. Nutrition

Goldenberg T, Zongrone A, Martorell R. Effect of women's nutrition before and during early pregnancy on maternal and infant outcomes: A systematic review. Paediatric and Perinatal Epidemiology.

neurodevelopment, and mood. Current Psychiatry Reports. 2004;**6**(6):425-429

[17] Irmak MK. Integration of maternal genome into the neonate genome through breast milk mRNA transcripts and reverse transcriptase. Theoretical Biology & Medical Modelling. 2012;**9**:20

[18] Fernandez-Twinn DS, Ozanne SE. Early life nutrition and metabolic programming. Annals of the New York Academy of Sciences. 2010;**1212**:78-96

[19] Grenham S, Clarke G, Cryan JF, Dinan TG. Brain–gut–microbe

and Health. 2004;**18**(1):3-27

2012;**26**(s1):285-301

[16] Casper RC. Nutrients,

[15] Ramakrishnan U, Grant F,

[11] Stanner SA, Yudkin JS. Fetal programming and the Leningrad Siege study. Twin Research. 2001;**4**:287-292

2006;**65**(1):97-105

2001;**4**:293-298

[3] Junien C, Gallou-Kabani C, Vigé A, Gross MS. Nutritional epigenomics: Consequences of unbalanced diets on epigenetics processes of programming

generations. Annales d'endocrinologie.

[4] Holliday R. Epigenetics: A historical overview. Epigenetics. 2006;**1**(2):76-80

[5] Mathers JC. Early Nutrition: Impact on Epigenetics. Forum of Nutrition.

[6] Hsiao EY, Patterson PH. Placental regulation of maternal-fetal interactions and brain development. Developmental Neurobiology. 2012;**72**(10):1317-1326

[7] Fowden AL. The placenta and intrauterine programming. Journal of Neuroendocrinology. 2008;**20**:439-450

[8] Burdge GC, Hanson MA, Slater-Jefferies JL, Lillycrop KA. Epigenetic regulation of transcription: A

mechanism for inducing variations in phenotype (fetal programming) by differences in nutrition during early life? The British Journal of Nutrition.

[9] Myatt L. Placental adaptive responses and fetal programming. The Journal of Physiology. 2006;**572**(Pt 1):25-30

[10] Langley-Evans SC. Developmental programming of health and disease. The

2007;**97**(6):1036-1046

**7**

**Chapter 2**

**Abstract**

Golden Hours: An Approach

to Postnatal Stabilization and

*Omid Fathi, Roopali Bapat, Edward G. Shepherd* 

improvement are critical to the care of these vulnerable patients.

infant, resuscitation, quality improvement

**1. History and introduction**

The "Golden Hour" model of care originated in adult trauma medicine. Recently,

**Keywords:** Golden Hour, prematurity, preterm, neonate, extremely low birth weight

The "Golden Hour" concept derives from the adult trauma literature, and generally describes the period after a traumatic injury during which prompt medical attention is needed to prevent death. The term was first introduced by a military surgeon, R. Adams Cowley. Cowley's research was directed primarily at the management of post-traumatic shock. According to Cowley, shock is a "momentary pause" in the pathway leading to death, and the "golden hour" is that period in which life-saving interventions can be initiated to prevent death or extreme morbidity. Cowley's research was instrumental in the study of shock and trauma in the United States, and his contribution has influenced the care of high-risk newborns as well. For over a decade, neonatologists have been applying this concept to the care of high-risk newborns in the neonatal intensive care unit (NICU) [1]. However, the Golden Hour conveys a slightly different meaning in the NICU. In the NICU, the term generally refers to the first few hours immediately after birth. High-quality, timely, and efficient care, initiated within the Golden Hour window, can mitigate at least some of the risks associated with high-risk newborn care. Golden Hour protocols generally include standards and guidelines based on available evidence that can decrease morbidity and mortality. Here we discuss the Golden Hour concept for care of preterm infants, especially those born less than 28 weeks post-menstrual age

this concept has been applied to premature neonates and the care they receive immediately after birth. This is not limited to the first hour of life, however, as this approach encompasses the first hours and days after birth. While no universal description defines the Golden Hour model, critical domains include initial delivery room management, thermoregulation, ventilation and oxygenation, glycemic control and prevention of infection. Strong evidence favors standardization of care to improve short- and long-term outcomes. This approach to care for the most at-risk premature infant is typically institution-specific; thus, team-building and quality

Improving Outcomes

*and John Wells Logan*

#### **Chapter 2**
