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- Changes in Perinatal Care and Outcomes in Newborns at the Limit of Viability in Spain: The EPI-SEN Study. [JOURNAL ARTICLE]
- Neonatology 2014 Dec 10; 107(2):120-129.
Background: Advances in perinatal care can influence morbidity and mortality in newborns at the limit of viability. Knowledge of these changes over time may help improve clinical decision making, optimize resource allocation and increase quality of care. Objectives: To evaluate the influence on morbidity and mortality of changes introduced in the perinatal care of preterm infants (22-26 weeks' gestational age, GA) in Spain between two consecutive periods (2002-2006 and 2007-2011). Methods: An analysis of prospectively collected data in a national database network (SEN1500) was performed. All live newborn infants of 22-26 weeks' GA born in or transferred to referral centers of the SEN1500 network in the first 28 days of life were included. Perinatal interventions, clinical management, neonatal morbidity, and survival until hospital discharge were retrieved. Results: A total of 5,470 newborns were included (2,533 and 2,937 in each period, respectively). The major changes introduced during the second period were as follows: (1) lower proportion of extramural births (11.0 vs. 8.9%, p = 0.01), (2) increase in antenatal steroids (69.5 vs. 80.8%, p < 0.001), (3) delivery by C-section (41.8 vs. 48.3%, p < 0.001) and (4) use of CPAP during resuscitation (7.8 vs. 20.7%, p < 0.001). Death in the delivery room decreased from 5.1 to 3.2% (p < 0.001). Survival increased from 49.9 to 57.9% (p < 0.001), and survival without major morbidity increased from 18.1 to 21.2% (p = 0.006). Conclusions: During the second period, a greater attachment to practices proven to have a beneficial impact on survival and reduction of morbidity in the extremely preterm infant was noted, and survival and survival without major morbidity increased. A more conservative approach was detected for newborns of 22 weeks' GA. © 2014 S. Karger AG, Basel.
- Reliability of Pulse Oximetry during Cardiopulmonary Resuscitation in a Piglet Model of Neonatal Cardiac Arrest. [JOURNAL ARTICLE]
- Neonatology 2014 Dec 3; 107(2):113-119.
Background:Pulse oximetry is widely used in intensive care and emergency conditions to monitor arterial oxygenation and to guide oxygen therapy.
Objective:To study the reliability of pulse oximetry in comparison with CO-oximetry in newborn piglets during cardiopulmonary resuscitation (CPR). Methodology: In a prospective cohort study in 30 healthy newborn piglets, cardiac arrest was induced, and thereafter each piglet received CPR for 20 min. Arterial oxygen saturation was monitored continuously by pulse oximetry (SpO2). Arterial blood was analyzed for functional oxygenation (SaO2) every 2 min. SpO2 was compared with coinciding SaO2 values and bias considered whenever the difference (SpO2 - SaO2) was beyond ±5%.
Results:Bias values were decreased at the baseline measurements (mean: 2.5 ± 4.6%) with higher precision and accuracy compared with values across the experiment. Two minutes after cardiac arrest, there was a marked decrease in precision and accuracy as well as an increase in bias up to 13 ± 34%, reaching a maximum of 45.6 ± 28.3% after 10 min over a mean SaO2 range of 29-58%.
Conclusion:Pulse oximetry showed increased bias and decreased accuracy and precision during CPR in a model of neonatal cardiac arrest. We recommend further studies to clarify the exact mechanisms of these false readings to improve reliability of pulse oximetry during the marked desaturation and hypoperfusion found during CPR. © 2014 S. Karger AG, Basel.
- The Influence of Crying on the Ductus Arteriosus Shunt and Left Ventricular Output at Birth. [JOURNAL ARTICLE]
- Neonatology 2014 Dec 3; 107(2):108-112.
Background:During neonatal transition, ductus arteriosus (DA) flow changes from right-to-left to left-to-right and contributes considerably to the increase in pulmonary blood flow. Large transpulmonary pressures generated by crying at birth can influence the DA shunt.
Objective:This study aimed to assess differences in DA shunt during quiet breathing and crying directly after birth.
Methods:In healthy term infants born by caesarean section, echocardiography was performed at 2, 5 and 10 min after birth. The velocity time integral of DA flow, DA flow ratio (right-to-left/left-to-right flow) and left ventricular output were assessed using echocardiography. Shunting was compared within each patient during crying and quiet breathing, and between time points.
Results:A total of 23 infants were studied. The velocity time integral of left-to-right shunting was significantly larger during the inspiratory phase of crying than during quiet breathing [12.8 (9.2-17.4) vs. 5.9 (3.9-7.7) cm at 2 min, p < 0.0001; 14.3 (11.5-22.3) vs. 6.7 (4.1-11.1) cm at 5 min, p < 0.0001, and 18.6 (14.8-22.5) vs. 6.7 (4.4-10.7) cm at 10 min, p < 0.0001, after birth]. The increase in left-to-right shunting during crying was independent from the cardiac cycle as the QRS start of shunt interval time was 138 (82) ms during crying and 156 (35) ms during quiet breathing (n.s.). The DA flow ratio was lower in infants who cried at 0-1 time points versus those who cried at 2-3 time points (n.s.) out of the 3 time points measured. Left ventricular output was higher in infants who cried at 2-3 time points versus 0-1 time points (n.s.).
Conclusion:Crying at birth significantly influences the DA shunt during transition. © 2014 S. Karger AG, Basel.
- Cardiocirculatory Monitoring during Immediate Fetal-to-Neonatal Transition: A Systematic Qualitative Review of the Literature. [JOURNAL ARTICLE]
- Neonatology 2014 Nov 18; 107(2):100-107.
Background:The fetal-to-neonatal transition is a complex process that includes changes in cardiac and respiratory systems.
Objective:The aim of this study is to review the different methods of cardiocirculatory monitoring during the immediate neonatal transition period.
Methods:A systematic search of PubMed and Ovid Embase was performed using the following terms: infant, newborn, newborn infant, neonate, neonates, heart, cardiac, blood pressure, haemodynamic, hemodynamics, blood circulation, circulation, echocardiography, ultrasonography, sonography, electrocardiography, ECG, oximetry, pulse, pulse oximetry, monitoring, measurement, acclimatization, adaptation, transition, after birth and delivery room. Additional articles were identified by manual search of cited references. Only human studies describing cardiocirculatory monitoring during the first 15 min after birth were included.
Results:Thirteen studies were identified that described heart rate (HR). Additional five studies were identified that measured blood pressure. Four studies performed functional echocardiography during neonatal transition; two in addition to blood pressure monitoring and three in addition to HR monitoring.
Conclusion:Routine HR monitoring using electrocardiography or pulse oximetry is used to evaluate adequate hemodynamic transition, and reference ranges have been established. Measuring blood pressure noninvasively though noncontinuously might be of some value in future, considering that the normative data have been established recently. Echocardiographic monitoring during the immediate transition period will improve the knowledge about cardiac function changes, but introduction in clinical routine remains questionable. © 2014 S. Karger AG, Basel.
- Effect of Postnatal Nutrition Restriction on the Oxidative Status of Neonates with Intrauterine Growth Restriction in a Pig Model. [JOURNAL ARTICLE]
- Neonatology 2014 Nov 18; 107(2):93-99.
Objective:In offspring with intrauterine growth restriction (IUGR), where oxidative stress may play an important role in inducing metabolic syndrome, nutrition restriction has been shown to improve oxidative status. In this study, we aimed to investigate the effect of postnatal nutrition restriction on the oxidative status of IUGR neonates.
Methods:A total of twelve pairs of piglets, of normal birth-weight (NBW) and with IUGR (7 days old), respectively, were randomly allocated to have adequate nutritional intake (ANI) and restricted nutritional intake (RNI) for a period of 21 days, respectively. This design produced 4 experimental groups: NBW-ANI, IUGR-ANI, NBW-RNI and IUGR-RNI (n = 6 per group). Serum, ileum and liver samples were analyzed for antioxidant parameters and the mRNA expression of genes with regard to oxidative status. The data were subjected to general linear model analysis and Duncan's test with a 5% significance level.
Results:Irrespective of nutritional intake, the IUGR pigs had markedly lower activity of glutathione peroxidase (GPX), gene expressions of liver mitochondrial manganese superoxide dismutase (Mn-SOD) and ileum cytoplasmic copper/zinc (CuZn)-SOD and, accordingly, there was a markedly higher malondialdehyde concentration in the liver of these pigs compared to in the NBW pigs. Irrespective of body weight, pigs receiving ANI treatment had significantly lower activities of antioxidant enzymes in the serum (total antioxidative capability, CuZn-SOD and GPX) and liver (total SOD and glutathione reductase) and decreased gene expression of liver CuZn-SOD and Mn-SOD compared to the pigs receiving RNI. In addition, the IUGR pigs had a markedly lower concentration of liver reduced glutathione (GSH), ratio of GSH to oxidized glutathione, gene expression of ileum CuZn-SOD and extracellular SOD than the NBW pigs when receiving ANI, but not all of these differences were observed in those receiving RNI.
Conclusion:IUGR neonates may have poor antioxidant defense systems, and postnatal nutrition restriction has the potential to prevent oxidative stress. © 2014 S. Karger AG, Basel.
- Timing of Pharmacological Treatment for Patent Ductus Arteriosus and Risk of Secondary Surgery, Death or Bronchopulmonary Dysplasia: A Population-Based Cohort Study of Extremely Preterm Infants. [JOURNAL ARTICLE]
- Neonatology 2014 Nov 18; 107(2):87-92.
Background:The optimal timing of pharmacological treatment for patent ductus arteriosus (PDA) in extremely preterm infants is unknown.
Objective:To investigate whether timing of pharmacological PDA treatment is associated with a risk of secondary PDA surgery or death before 3 months of age, or bronchopulmonary dysplasia (BPD) in extremely preterm infants.
Methods:In this population-based cohort of infants born before 27 gestational weeks in Sweden in 2004-2007, 290/585 infants (50%) received pharmacological PDA treatment. Cox proportional hazards regression estimated the hazard ratio (HR, with 95% confidence interval, CI) of secondary PDA surgery or death as a composite outcome in relation to postnatal age at the start of pharmacological treatment: early (0-2 days); intermediate (3-6 days); late (≥7 days). Furthermore, the odds ratio (OR, with 95% CI) of BPD was estimated in relation to postnatal age at PDA treatment by conditional logistic regression.
Results:The median postnatal age at the start of pharmacological PDA treatment was 4 days. 102 infants had secondary PDA surgery. Timing of PDA treatment was not associated with risk of PDA surgery or death; adjusted HRs were 0.89 (95% CI 0.57-1.39) after an intermediate start and 1.10 (95% CI 0.53-2.28) after a late start, compared to an early start of treatment. Compared to the early start of PDA treatment, the intermediate start was not associated with any risk of BPD, while late PDA treatment was associated with a lower BPD risk; adjusted ORs were 0.83 (95% CI 0.42-1.64) and 0.28 (95% CI 0.13-0.61), respectively.
Conclusion:Timing of pharmacological PDA treatment after extremely preterm birth is not associated with the risk of secondary PDA surgery or death. Moreover, expectant PDA management is not associated with an increased risk of BPD. © 2014 S. Karger AG, Basel.
- Case Series of Bifidobacterium longum Bacteremia in Three Preterm Infants on Probiotic Therapy. [Journal Article]
- Neonatology 2015; 107(1):56-9.
The use of probiotics as prophylaxis for necrotizing enterocolitis (NEC) in preterm infants is being increasingly practised.We report, for the first time, a case series of 3 preterm, very-low-birth-weight (VLBW) infants who developed bacteremia with Bifidobacterium longum on probiotic therapy with Infloran® containing viable B. longum.We retrospectively reviewed data of 3 infants (of gestational age <30 weeks and birth weight <1,230 g). They were admitted to the neonatal intensive care unit. Clinical data were retrieved from their medical records.In infants 1 and 2, B. longum was isolated from the blood cultures when they were on probiotic therapy with Infloran or shortly after, respectively, and was interpreted as transient bacteremia. The clinical presentation of these infants did not require antibiotic treatment after the isolation of B. longum. Infant 3 developed an NEC despite probiotic therapy with Infloran and the blood cultures showed B. longum growth. This infant required explorative laparotomy and antibiotic treatment. The clinical isolates of B. longum and the strain of the Infloran capsule showed an identical profile on biochemical, mass-spectrometric and molecular analyses, suggesting a direct correlation between the administration of probiotics and bacteremia with B. longum in all 3 infants.The occurrence of bacteremia with bifidobacteria after its prophylactic administration in VLBW infants and its possible clinical consequences are a matter of concern. In the interests of safety, the use of probiotics in such a population should be indicated with caution and requires further investigation. © 2014 S. Karger AG, Basel.
- Allogeneic Umbilical Cord Blood Red Cell Concentrates: An Innovative Blood Product for Transfusion Therapy of Preterm Infants. [JOURNAL ARTICLE]
- Neonatology 2014 Nov 15; 107(2):81-86.
Background:Preterm infants often receive blood transfusions early in life. In this setting, umbilical cord blood (UCB) might be safer than adult blood (A) with respect to infectious and immunologic threats.
Objectives:To evaluate, as a first objective, the feasibility of fulfilling transfusion needs of preterm infants with allogeneic UCB red blood cell (RBC) concentrates and, as a secondary objective, to assess the safety of allogeneic cord blood transfusions.
Methods:At the Neonatal Intensive Care Unit and the UNICATT Cord Blood Bank of 'A. Gemelli' Hospital in Rome, a prospective study was carried out over a 1-year period, enrolling newborns with gestational age ≤30 weeks and/or birth weight ≤1,500 g requiring RBC transfusions within the first 28 days of life. At first transfusion, patients were assigned to receive UCB-RBCs or A-RBCs depending on the availability of ABO-Rh(D)-matched UCB-RBC units. The same regimen (UCB-RBC or A-RBC units) was thereafter maintained, unless ABO-Rh(D)-matched UCB-RBC units were not available.
Results:Overall, 23 UCB-RBC units were transfused to 9 patients; the requests for UCB-RBC units were met in 45% of patients at the first transfusion and in 78% at the subsequent transfusions. At a median follow-up of 57 days (range 6-219), no acute or delayed transfusion-related adverse events occurred. Hematocrit gain after transfusion and time intervals between transfusions were similar in the UCB-RBC and A-RBC group, as well.
Conclusions:Transfusing allogeneic UCB-RBC units in preterm infants appears a feasible and safe approach, although the transfusion needs of our study population were not completely covered. More data are necessary to validate this novel transfusion practice. © 2014 S. Karger AG, Basel.
- Need to optimize nutritional support in very-low-birth-weight infants. [Journal Article]
- Neonatology 2015; 107(1):79-80.
- Defining Adequate Nutritional Targets in Very-Low-Birth-Weight Infants to Reduce Postnatal Growth Restriction. Concerning the Article by M. Sáenz de Pipaón et al.: Growth in Preterm Infants until 36 Weeks' Postmenstrual Age Is Close to Target Recommendations [Neonatology 2014;106:30-36]. [Letter]
- Neonatology 2015; 107(1):76-8.