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Purpose: Due to early antenatal screening and treatment, HIV mother-to-child transmission (MTCT) rarely occurs in Germany. The study aimed to investigate the impact on prevalence of HIV infection in the antenatal population and the incidence of late-presenting HIV-infected mothers attributable to increased numbers of refugees., Methods: Retrospective analysis and comparison were performed for all deliveries in HIV-infected pregnant women presenting to medical care in Munich (southern Germany) and Hamburg (northern Germany) covering two time periods, A (2010-2012) and B (2013-2015)., Results: In Munich, deliveries in HIV-infected pregnant women increased 1.6-fold from period A (n = 50) to B (n = 79) with late-presenting cases rising significantly from 2% (1/50) in period A to 13% (10/79) in B. In contrast, late-presenting cases in Hamburg decreased from 14% (14/100) in period A to 7% (7/107) in B, while the total number of HIV-infected women giving birth remained stable. From 2010 to 2015, one late-presenting pregnant woman transmitted HIV in Munich by presumed in utero mode of infection (case reviewed here), while no MTCT occurred in Hamburg., Conclusions: HIV infections diagnosed late in pregnancy and leading to delayed ART initiation are rising in Munich compared to Hamburg. Antenatal care of HIV-infected pregnant women in Munich appears to have been more affected by the recent refugee influx than Hamburg. Our study highlights the importance of screening all pregnant women for HIV early in pregnancy and providing timely health care access for pregnant refugees and asylum seekers to effectively prevent MTCT in Germany.

Background: Preterm infants are at increased risk for hypertension in adolescence. Microcirculatory dysfunction has been identified as an underlying cause for cardiovascular disease. Our goal was to document the development of the cutaneous microcirculation in preterm infants during the first weeks of life and to compare it to the situation in term infants at birth. Methods: In 20 preterm infants, microcirculatory parameters were obtained prospectively by Sidestream Dark Field (SDF) Imaging at the upper inner arm once a week until discharge or 37 weeks of gestational age. A single microcirculatory measurement was obtained in 30 term infants during the first 3 days of life. Videos were blinded and analyzed with the AVA software. Results: Microcirculatory parameters in preterm infants differ significantly from term infants with a lower vessel surface (VS), a lower percentage of large and medium but higher percentage of small vessels, a higher Functional Vessel Density (FVD), and a higher Microcirculatory Flow Index (MFI). In multivariable linear regression models we could demonstrate a statistically significant association between the dependent microcirculatory variables (VS, diameter distribution, MFI) and gestational age as independent predictor variable while adjusting for postnatal days of life. Looking at the longitudinal follow-up data of preterm infants by means of a multivariable mixed-effects linear regression model adjusting for clinical variables, there is a significant decrease in FVD with increasing postnatal age, however no other significant changes in microcirculatory parameters over time. Accordingly, comparing the microcirculatory parameters of near term former preterm infants with term born neonates, we could still find significant differences with a higher FVD, lower VS and differences in vessel diameters in the former premature group. Conclusion: Infants born prematurely exhibit distinct microcirculatory alterations compared to term neonates with gestational age at birth being associated with microvascular parameters. Interestingly, this premature vascular phenotype persists even close to corrected term age. In view of the known increased cardiovascular risk of former preterm infants, our observations might have important clinical impact. The factors governing the development of the microvascular network in preterm infants and the contribution of microcirculatory changes observed here to vascular pathology in later life need to be further investigated.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Unlabelled: Red blood cell transfusion can improve but also might temporarily reduce the microcirculation. The buccal microcirculation was visualized and total vessel density (TVD) determined with sidestream dark field imaging in 19 pediatric anemic (Hb 7.2 g/dL, 95 % CI 6.5-7.9) oncology or hematology patients receiving red blood cell transfusions (Tx) and in 18 age-matched healthy non-anemic controls. After transfusion, Hb (8.0 g/dL, 95 % CI 7.3-8.6) and TVD increased (14.7 ± 1.7 versus 16.6 ± 2.0 mm/mm(2)) significantly with a concomitant decrease in RBC velocity in medium-sized vessels (pre-Tx 711 ± 199 versus post-Tx 627 ± 163 μm/s). Compared to the controls, pre-Tx TVD (17.5 ± 1.3 mm/mm(2)) was lower and RBC velocity (476 ± 77 μm/s) was significantly higher. After transfusion, TVD and RBC velocity remained significantly lower and higher, respectively. In a subgroup, analysis of the transfused children with infection of TVD at baseline was lower with a larger increase after transfusion compared to anemic children without infection (ΔTVD 3.4 ± 2.6 versus ΔTVD 1.3 ± 1.5 mm/mm(2))., Conclusion: With the rise of hemoglobin after transfusion, significant improvements of tissue perfusion were demonstrated but differences to non-anemic controls persisted. In particular, the microcirculation of anemic oncology patients with infection improved after transfusion., What Is Known: • Transfusions can improve but also temporarily reduce the microcirculation. • In neonates, transfusion significantly increases total vessel density. What is New: • Pretransfusion, the microcirculation of the anemic children differed significantly from the controls. • After transfusion, the microcirculation improved but still differed from the controls. • These changes were most profound in anemic patients with concurrent infection, therefore transfusion threshholds might need to be higher.

Objective: Perturbation of the endothelial glycocalyx is discussed in the pathogenesis of complications related to cardiopulmonary bypass. We evaluated the effects of cardiopulmonary bypass on the microcirculation and the microvascular endothelial glycocalyx of infants undergoing surgery for congenital cardiac defects., Methods: The microcirculation was visualized at the ear conch using Sidestream dark field imaging before surgery (T0), after admission to the intensive care unit (T1), 24 hours postsurgery (T2), and 7 days postsurgery (T3). Glycocalyx thickness was assessed by measurement of the perfused boundary region. Microcirculatory parameters included total and perfused vessel density, vessel diameters, and microcirculatory flow index., Results: A total of 40 infants undergoing cardiac surgery (36 with cardiopulmonary bypass, 4 without cardiopulmonary bypass) were examined. As controls, measurements before and after cardiac catheterization (n = 6) and before and after surgery for cleft palate (n = 9) were performed. After surgery with cardiopulmonary bypass, the perfused boundary region was significantly increased, indicating reduced glycocalyx thickness at T1 compared with preoperative values with a stepwise return to baseline by T3. In the control groups, no significant perfused boundary region changes were noted. Furthermore, after cardiopulmonary bypass, a transient, significant reduction of the microcirculatory flow index and the perfused vessel density was seen at T1. Similar changes were observed after cardiac surgery without cardiopulmonary bypass, but not in the other controls., Conclusions: Our study reveals for the first time local perturbations of the endothelial glycocalyx and microvascular perfusion in infants after surgery with cardiopulmonary bypass. Microcirculatory monitoring might be a useful tool to evaluate interventions aiming at reduction of bypass-related complications., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Pathology is a discipline that provides the basis of the understanding of disease in medicine. The past decades have seen a decline in the emphasis laid on pathology teaching in medical schools and outdated pathology curricula have worsened the situation. Student opinions and thoughts are central to the questions of whether and how such curricula should be modernized., Methods: A survey was conducted among 1018 German medical students regarding their preferences in pathology teaching modalities and their satisfaction with lecture-based courses. A qualitative analysis was performed comparing a recently modernized pathology curriculum with a traditional lecture-based curriculum. The differences in modalities of teaching used were investigated., Results: Student satisfaction with the lecture-based curriculum positively correlated with student grades (spearman's correlation coefficient 0.24). Additionally, students with lower grades supported changing the curriculum (spearman's correlation coefficient 0.47). The majority supported virtual microscopy, autopsies, seminars and podcasts as preferred didactic methods., Conclusions: The data supports the implementation of a pathology curriculum where tutorials, autopsies and supplementary computer-based learning tools play important roles.

The pros and cons of home monitoring especially for premature infants with continuing apneic episodes and/or chronic lung disease are an ongoing discussion. The controversy spans socio-economic requirements, medical indication as well as patient and family needs. Here, the costs of home monitoring and follow-up care on the one hand and longer hospitalization times on the other need to be considered. This article aims to create a basis for this discussion by summarizing current evidence for the indications and considerations for differential diagnoses while also outlining the established follow-up program for these patients at the Dr. v. Hauner Children's Hospital at the Ludwig-Maximilians-University Munich, Germany., (© Georg Thieme Verlag KG Stuttgart · New York.)

Unlabelled: Neonatal blue light phototherapy (NBLP) is an effective treatment for hyperbilirubinaemia. Concerning the influence on melanocytic nevi, conflicting studies have been published. To assess the role of NBLP according to the incidence of melanocytic nevi in preschool children, a cohort of 104 5- to 6-year-old children were included. The case group consisted of 52 NBLP-exposed children, while the control group (n = 52) never had NBLP and was matched regarding age, gender, gestational age and skin phototype. Six dizygotic twins were included with one twin having received NBLP, respectively. The following parameters were recorded: nevi count, presence of freckles, café-au-lait macules, skin phototype and previous history of sun exposure. There was no significant association between nevi count and exposure to NBLP (median nevi count 17.0 compared to 18.5 in controls). No significant difference was also found in the dizygotic twin pairs with a median nevi count of 10.0 (with NBLP) compared to 14.5 (without NBLP). However, a significantly higher prevalence of café-au-lait macules was found in children with NBLP (mean count 0.5) than in children without NBLP (mean count 0.2; p = 0.001). Significant predictors for the number of melanocytic nevi included skin phototype, sun exposure and vacations in the South., Conclusion: In this study, NBLP had no significant influence on the development of melanocytic nevi, but on café-au-lait macules which was a new finding. Differences with comparable studies regarding age, differentiation between nevi and other pigmented lesions as well as dose and type of NBLP need to be taken into account for further investigations.

Objective: To evaluate the microcirculation of children with type 1 diabetes mellitus who demonstrate no clinical signs of diabetic microangiopathy for the presence of microvascular alterations and glycocalyx perturbation., Study Design: Images of sublingual vessels were obtained in 14 children with diabetes (ages 12.8 ± 2.8 years, diabetes duration 6.7 ± 4.3 years) and 14 control patients (ages 11.8 ± 2.8 years) by the use of sidestream dark field imaging and analyzed for total vessel density, vessel surface coverage, vessel diameter distribution, mean flow index, and glycocalyx thickness. Wilcoxon rank sum test and Pearson correlation were used for statistical analysis., Results: We observed profound microcirculatory changes in children with diabetes compared with control patients, with a significant reduction of glycocalyx thickness (0.38 μm vs 0.60 μm; P = .013), which was inversely correlated with blood glucose levels (r = -0.55; P = .003). Furthermore, the percentage of large vessels (>20 μm diameter) was significantly increased (11% vs 6%; P = .023) at the expense of capillaries (<10 μm diameter) with consequent increase in total vessel surface coverage (30% vs 26.0%; P = .041). No differences were seen in total vessel density and mean flow index., Conclusions: Microvascular alterations, including changes in microvessel distribution and loss of the glycocalyx, can be detected in children with type 1 diabetes mellitus before clinically apparent vascular complications. Our results disclose the glycocalyx as a possible monitoring measurement for earlier detection of diabetic microangiopathy and may provide a basis for new therapeutic strategies aiming at protection or restoration of the glycocalyx., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Background: Hypotension remains a common complication in preterm infants and is associated with high neonatal morbidity and mortality. The underlying mechanisms are still not fully understood. We studied the microcirculation in extremely low birth weight infants to understand the relationship between blood pressure and skin perfusion., Methods: In 21 patients (gestational age <30 wk, birth weight <1,225 g), functional vessel density (FVD) and diameter distribution were obtained prospectively by side stream dark-field imaging at the right arm in the first 48 h after birth. Infants with blood pressure below gestational age and receiving catecholamines were defined as hypotensive as compared with the remaining normotensive control group., Results: In the first 6 h after birth, FVD was significantly higher in the hypotensive group than in the control group. After 12 h, there were no significant differences in either blood pressure or FVD between the two groups. FVD did not change significantly during the observation period in either group., Conclusion: Hypotensive infants have a higher FVD, possibly due to loss of microvascular tone leading to vasodilation and flow redistribution. However, the link between blood pressure and perfusion remains unclear, and no definitive correlation could be found.

Attenuation of the immune response contributes to the high rate of neonatal infections, particularly in premature infants. Whereas our knowledge of innate immune functions in mature neonates is growing, little is known about the ontogeny of neutrophil recruitment. We investigated neutrophils and ECs in the course of gestation with respect to rolling and adhesive functions. With the use of microflow chambers, we demonstrate that the neutrophil's ability to roll and adhere directly correlates with gestational age. These adhesion-related abilities are very rare in extremely premature infants (<30 weeks of gestation), which may correlate with our observation of markedly reduced expression of PSGL-1 and Mac-1 on neutrophils in preterm infants. In parallel, the capacity of HUVECs to mediate neutrophil adhesion under flow increases with gestational age. In addition, HUVECs from extremely premature infants exerting the lowest ability to recruit adult neutrophils show a diminished up-regulation of E-selectin and ICAM-1. Finally, by following neutrophil function postnatally, we show that maturation of PMN recruitment proceeds equivalently during extra- and intrauterine development. Thus, PMN recruitment and EC adhesion-related functions are ontogenetically regulated in the fetus, which might contribute significantly to the high risk of life-threatening infections in premature infants.

Background. In adults severely disturbed microcirculatory flow can be observed by Orthogonal Polarized Spectral (OPS) imaging techniques during sepsis. Therefore we set out to assess for microcirculatory changes in term newborns with suspected early onset infection using OPS. Methods. OPS images were obtained prospectively from the vascular bed of the ear conch and upper arm of 47 newborns on their 1st, 2nd, and 3rd day of life. OPS sequences were analyzed semiquantitatively offline and blinded to clinical status of the infant. Flow in vessels was classified as continuous or noncontinuous flow and given as proportion of total vessels per image as in the studies in adults. Results. The proportion of vessels with continuous flow was significantly lower in the infants with infection (69% [56-81] versus 90% [87-94] (P = 0.0003)). None of the infants with infection was in shock or severely septic. Conclusion. In term neonates the microcirculatory flow is impaired in a large proportion of vessels even in mild to moderate infection. These changes can be observed at the onset of disease at the external ear, an optimal site for microcirculatory measurements in term infants.

Perfluorinated compounds (PFCs) are a group of chemicals widely used for many applications. In this study PFCs were investigated in maternal blood during pregnancy (at two time points) (n = 40 and 38) and 6 months after delivery (n = 47), in cord blood (n = 33) and in blood of infants six (n = 40) and nineteen months (n = 24) after birth, and monthly in breast milk samples in Germany. Concentrations in maternal serum ranged from 0.5 to 9.4 μg/L for perfluorooctane sulfonate (PFOS) and 0.7 to 8.7 μg/L for perfluorooctanoic acid (PFOA). In cord serum, the values ranged from 0.3 to 2.8 μg/L and from 0.5 to 4.2 μg/L for PFOS and PFOA, respectively. The median results from serum at six and nineteen months of age were 3.0 and 1.9 μg/L for PFOS and 6.9 and 4.6 μg/L for PFOA, respectively. In breast milk samples, PFOS ranged from <0.03 to 0.11 μg/L (median: 0.04 μg/L), while PFOA was detected only in some samples as were all other PFCs. Overall, we found low levels of PFCs in cord sera and an increase in concentrations through the first months of infant life. Although the concentrations in breast milk were low, this intake led to a body burden at the age of six months similar to (PFOS) or higher than (PFOA) that found in adults.

The ductus arteriosus (DA) is a fetal shunt vessel between the pulmonary artery and the aorta that closes promptly after birth. Failure of postnatal DA closure is a major cause of morbidity and mortality particularly in preterm neonates. The events leading to DA closure are incompletely understood. Here we show that platelets have an essential role in DA closure. Using intravital microscopy of neonatal mice, we observed that platelets are recruited to the luminal aspect of the DA during closure. DA closure is impaired in neonates with malfunctioning platelet adhesion or aggregation or with defective platelet biogenesis. Defective DA closure resulted in a left-to-right shunt with increased pulmonary perfusion, pulmonary vascular remodeling and right ventricular hypertrophy. Our findings indicate that platelets are crucial for DA closure by promoting thrombotic sealing of the constricted DA and by supporting luminal remodeling. A retrospective clinical study revealed that thrombocytopenia is an independent predictor for failure of DA closure in preterm human newborns, indicating that platelets are likely to contribute to DA closure in humans.

Changes in microcirculation have been recognized as central to many disease processes. The aim of this study was to evaluate factors, which influence the microcirculation of the skin during the first month of life in premature infants. Red blood cell (RBC) velocity, vessel diameter, and functional small vessel density (FSVD) were measured daily for the first 30 d on the upper arm in preterm infants with gestational age <30 wk. Orthogonal polarization spectral (OPS) images were analyzed off-line with the Capi- Scope-Image program. In 25 infants, FSVD decreased significantly from week 1 (mean +/- SD 236 +/- 33 cm/cm2) to week 4 (207 +/- 30 cm/cm2) and correlated directly with Hb levels and incubator temperature. Vessel diameters and RBC velocity did not change significantly, nor did clinical parameters such as blood pressure, heart rate or body temperature. Microvascular parameters were not dependent on gestational or postnatal age. The microcirculation of the skin might be an easily accessible window to obtain better understanding of circulatory changes in the postnatal period. Our data are essential as basis for further studies in this field. Hb levels and possible incubator temperatures have a substantial influence on functional small vessel density and therefore need to be taken in account.

The optimal thermal environment for sick preterm infants is unknown. Incubator temperature can be regulated to an abdominal wall temperature of 36.5 degrees C [neutral temperature (NT)] or to a minimal temperature difference (<2 degrees C) between abdominal wall and extremities [comfort temperature (CT)]. This could affect the microcirculation, particularly in infants with impaired perfusion. We assessed the microvascular perfusion with near-infrared photoplethysmography (NIRP) at these two target temperatures between d 1 and 4 of life in preterm infants with normal (NL group) or impaired (RED group) microcirculation as determined by a clinical score. Signal strength variables such as area under the curve (AUC) and the first derivate of the amplitude (FLUX) were calculated. Starting temperature was randomized to NT or to CT and then followed by the other temperature. A significant increase of FLUX and AUC in the RED group was found with NT as starting temperature (FLUX: 282 +/- 76 at NT versus 627 +/- 211 at CT; p = 0.025; AUC: 73 +/- 47 at NT versus 234 +/- 112 at CT; p = 0.009), but not with CT. In NL infants, both parameters did not change significantly. Increasing the incubator temperature to CT changes thermoregulatory flow to the extremities in preterm infants with impaired microvascular perfusion and might improve tissue flow.

Objective: Population- but also center-based mortality and major morbidity rates of premature infants are essential for prenatal counseling and quality control., Methods: Records of all infants <30 + 6 weeks (n=674) admitted (1991-2000) to a single neonatal intensive care unit were reviewed and compared to the state-wide mortality., Results: Six hundred and ninety-one infants were born in or transferred to the hospital and 600 infants (89%) survived. The mean (SD) birth weight was 1018 g (+/-314) and the mean gestational age 27+5 weeks (+/-2.0). Mortalityand morbidity did not change significantly over the 10-year period but correlated inversely with gestational age from 45% at 23(0/7) weeks to 5% at 30(6/7) weeks. Study center mortality rate for extremely low birth weight infants with birth weight <750 g was significantly lower than reported for the entire state (local 25%; Bavaria 36% p = 0.0003). Thirty-four per cent (251/600) of the survivors had one or more major complications: intracranial hemorrhage III-IV 8% (88/600), periventricular leucomalacia 6% (41/600), bronchopulmonary dysplasia with oxygen requirement at 36 weeks 20% (128/600), necrotizing enterocolitis 6% (43/600), and retinopathy of prematurity grade III-IV 9% (55/600). Survival without major morbidity increased from 32% at 23 weeks to 92% at 30 weeks., Conclusions: Despite changes in obstetric and neonatal care during the 1990s, mortality and major morbidity rates did not change significantly after the introduction of surfactant in 1991. Comparison of local, regional, national, and international mortality and morbidity rates are becoming more important in allocating resources and in decision-making at the limits of viability.

Unlabelled: Early enteral nutrition improves growth of extremely low birth weight infants, but growth curves beyond 30 days of life are lacking for such infants receiving early enteral nutrition. Based on the data of all infants born in a 4-year interval with a birth weight <1000 g and surviving for >56 days, we calculated growth rates and weight gain over 120 postnatal days. Infants with major congenital anomalies or necrotising enterocolitis were excluded. Daily weight, weekly length, head circumference and nutritional data were collected until discharge or for maximal 120 days. Curves were calculated in 100 g birth weight intervals, and separately for appropriate for gestational age (AGA) and small for gestational age (SGA) infants. Data were available from 163 infants (birth weight 768 g +/- 153 g; gestational age 26.8+/-1.8 weeks; mean +/- SD) including 55 SGA infants (33.7%). Full enteral feeding was achieved at day 21.7 (+/-10.4). After 12.8% (+/-6.6%) maximal postnatal weight loss at day 7.5 (+/-3.0), birth weight was regained at 14.6 (+/-6.0) days. Mean overall weight gain was 15 g/kg per day with a significantly higher weight gain for SGA than for AGA infants (P <0.05)., Conclusion: Our early fed infants achieved better weight gain than those recently published receiving late enteral nutrition, but nevertheless fell below the 10th percentile of intrauterine curves. Which postnatal growth is ideal for extremely low birth weight infants infants is unclear. Our growth curves should not be taken as reference curves of a "normal population" but may help to identify infants with growth failure.

Aim: To determine whether infants with compromised fetomaternal circulation, but not yet critically threatened by absent end-diastolic flow velocities in the umbilical arteries, are at a risk for feeding problems., Methods: In a retrospective case-control study, enteral feeding and clinical data were compared between infants with decreased prenatal end-diastolic umbilical flow velocity (DEDFV) or brain-sparing pathology and controls matched for gestational age (GA). In all infants, enteral feedings were advanced according to a standardized enteral feeding protocol., Results: 11 (GA>34 wk) of the 87 infants with DEDFV were fully enterally fed by day 5 and excluded, leaving 76 infants (and matched controls) for final analysis. DEDFV infants were significantly smaller (1,230+/-550 g vs 1,600+/-682 g). Advancement of enteral feedings varied widely, with a significant difference between DEDFV infants and controls. There was no difference in the incidence of NEC (five in both groups). In the most severely affected subgroup of 25 infants with GA<30 wk and prenatal brain sparing, enteral feedings were significantly delayed in comparison to the controls (parenteral amino acid administration for 22 vs 15 d; significantly fewer enteral calories through day 15)., Conclusion: Enteral feeds were introduced more slowly to infants who had shown signs of prenatal distress with brain sparing. However, a predisposition to NEC could not be proven. Our results thus do not support the delay of enteral feedings based on prenatal Doppler pathology.

Direct visualization of the microcirculation at the level of the skin capillaries may provide information on the quality of tissue perfusion. Orthogonal polarization spectral imaging (OPS) enables noninvasively direct observation of those blood vessels. OPS was applied to the upper arm of 13 preterm anemic infants [median (95% confidence interval) gestational age: 26 wk (25-26 wk); birth weight: 730 g (652-789 g)] before and 2 and 24 h after transfusion (Tx). OPS images of skin perfusion were continuously recorded on video. Off-line quantitative data of microvascular perfusion were obtained by measuring functional capillary density, vessel diameter, red blood cell velocity, and flow. We found a significant increase in functional capillary density 2 h after transfusion with an additional significant rise after 24 h [before: 142 (134-155); 2 h after Tx: 185 (166-196); 24 h after Tx: 206 (185-219) cm/cm2; p < 0.001), thus indicating improved microvascular perfusion. Vessel diameter, red blood cell velocity, and flow did not change significantly. There were no significant changes in clinical variables, such as blood pressure, heart rate, or body temperature. Whereas conventional monitoring methods did not show any changes after transfusion, quantitative analyses of OPS images indicated improved perfusion; hence, it seems a useful monitor for assessing the response to therapies aimed to improve tissue perfusion.

Objective: Transfusion practices for neonates are controversial and based on limited scientific information. We examined the use of the plethysmographic volume pulse to assess anemia., Design: We used near-infrared photoplethysmography (NIRP) to investigate signal strength parameters as area under the curve (AUC) and the first derivate of the amplitude (flux) in anemic infants before and after elective transfusion., Setting: Tertiary intensive care unit., Patients: Thirty-four neonates on day 25+/-15 of life with a pretransfusion hemoglobin level of 8+/-0.9 g/dl. Four infants were excluded for incomplete data., Interventions: Transfusion of 10 ml packed red cells per kilogram body weight, Measurements and Results: The volume pulse signal was obtained with a sensor attached to the sole of the foot. After transfusion we found a significant decrease in number of bradycardia episodes per hour (0.35 vs. 0.16) and episodes of pulse oximeter desaturation less than 85% per hour (1.8 vs. 1.3) and a significant increase in daily weight gain (12+/-7 vs. 20+/-18 g), but neither of the microcirculatory parameters changed significantly (AUC 102+/-38 vs. 101+/-44; flux 435+/-160 vs. 405+/-120)., Conclusions: Even though infants were transfused at very low levels of hemoglobin with significant clinical effects, microcirculation assessed by NIRP seemed not be affected. Infrared photoplethysmographs present flow not only in the nutritive capillaries but mainly in the subpapillary plexus at a greater depth. This thermoregulatory flow seems not be affected by blood transfusions of anemic infants.

Purpose: Multifetal pregnancy reduction is a widespread "therapy" to diminish the risk of prematurity and adverse outcome for the survivors in higher order multiple gestation. The aim of our study was to determine the maternal and neonatal outcome of multifetal pregnancies under a conservative pregnancy management., Study Design: A retrospective review of 112 multifetal pregnancies is presented. All higher order multiple pregnancies delivered after 25 weeks of gestation and managed at a single institution between 1982 and 1999 are included., Results: Triplets, quadruplets and quintuplets were delivered at a mean gestational age of 31 + 5, 29 + 5 and 28 + 4 weeks, respectively. The perinatal mortality was 14 for triplets and 36 for quadruplets. No quintuplet died in the perinatal period. Respiratory distress syndrome occurred in 23% of triplets, 65% of quadruplets and 75% of quintuplets, intracranial hemorrhage was diagnosed in 14% of triplets, 15% of quadruplets and 10% of quintuplets and retinopathy of prematurity was found in 10% of triplets, 9% of quadruplets and 25% of quintuplets., Discussion: Despite a low neonatal mortality, morbidity of higher order multiple gestations remains significant. Mortality and morbidity are related to preterm delivery but do not exceed the rates of singletons or twins of an identical gestational age. Favorable prognostic landmarks are a gestational age >30 weeks and a number of fetuses per pregnancy < or =4., Conclusion: The risks of multifetal pregnancies are significant. Therefore, evidence-based counseling of couples seeking treatment for infertility and prevention of higher order multiple pregnancies through the prudent use of reproductive techniques attains paramount importance., (Copyright 2002 S. Karger AG, Basel)

Little is known about the microvascular perfusion of the skin postnatally. Skin microvascular parameters can be assessed noninvasively with orthogonal polarization spectral imaging (OPS), a technique where, through the use of special optics, a virtual light source is created at a depth of 1 mm within the tissue. The light is absorbed by the Hb, yielding an image of the illuminated Hb-carrying structures in negative contrast. In nine term (weight 2100-4470 g) and 28 preterm infants (weight 550-2070 g; gestational age 24-33 wk) red blood cell velocity and vessel diameter and density were determined off-line with the Cap-Image program in vessels video-recorded by OPS near the axilla on d 1 and 5 of life. Blood pressure, heart rate, hematocrit, and body and incubator temperature were noted. Vessel diameter ranged from 6 to 24 microm, vessel density from 219 to 340 cm/cm(2) with no change between d 1 or 5 and no difference between term and preterm infants. Red blood cell velocity increased in preterm infants from d 1 [median 528 microm/s, 95% confidence interval (CI) 486-564 microm/s] to d 5 (median 570 microm/s; 95% CI 548-662 microm/s; p = 0.001) and correlated with the decrease in median hematocrit from 44% (CI 40%-60%) to 39% (CI 37%-43%) with r(2) = -0.37 with a 95% CI -0.59 to -0.11, p = 0.006. Hematocrit correlates with red blood cell velocity in the microvessels of the skin. The new technology can be used to assess quantitative changes in the microvessels and thus allows noninvasive assessment of tissue perfusion in term and preterm infants.

Background/aim: We have previously shown that infants receiving total parenteral nutrition have low apolipoprotein AI levels which are associated with high-density lipoprotein (HDL) class distributions as in lecithin:cholesterol acyltransferase deficiency. This study investigates the influence of early enteral feedings on apolipoprotein AI and HDL subclasses., Methods: Apolipoprotein AI and HDL distributions were determined in 15 total parenterally fed preterm infants (TPN group) receiving early feedings, in 28 enterally fed preterm infants (ENT group), and in 26 term infants at birth and on day 5. The HDL subclasses were determined by gradient gel electrophoresis., Results: In the TPN group, the apolipoprotein AI levels increased significantly postnatally (from 73 +/- 16 to 104 +/- 23 mg/dl) to levels found in the term and ENT groups on day 5 (88 +/- 16 and 96 +/- 19 mg/dl). The HDL subclass distributions at birth and on day 5 were similar in both TPN and ENT groups with more large HDL(2b) and less small HDL(3c )than in term infants. Whereas the HDL subclass distribution of term infants remained unchanged, in TPN and ENT infants, a shift from HDL(2b) to HDL(3c) was observed, with no difference between term and preterm infants on day 5., Conclusion: In contrast to exclusively parenterally fed infants, infants receiving early enteral feedings exhibited a significant rise of apolipoprotein AI and HDL subclass distributions as fully enterally fed preterm infants., (Copyright 2002 S. Karger AG, Basel)

A 40-week gestational age infant was delivered by cesarean section because of intense contractions and pathological fetal heart rate pattern. The umbilical artery pH was 7.03, Apgar scores were 1/4/7 at 1, 5 and 10 min of age. The 3,250-gram infant had a skull depression of 5 x 7 cm in the left temporal-parietal region with a depth of 1.5 cm. There were no edemas or hematomas in this area; neurological examination was normal. A CT scan did not show a fracture, but the cortex below the depression appeared slightly compressed. At the age of 11 days, the depressed part of the parietal squama was surgically elevated. The child was discharged in good condition 8 days later and remained well at a 6-month follow-up examination.

The influence of very early enteral feedings on plasma fatty acid levels in 29 sick, very premature infants with gestational age < 30 weeks was assessed at age 1, 3 and 7 weeks. Eighteen infants (birthweight 963 +/- 245 g, gestational age 27 +/- 1.3 weeks) received breast milk and 11 infants (829 +/- 159 g and 26 +/- 1.3 weeks) received formula, starting with small amounts on the first day after birth. Plasma phospholipid arachidonic acid (AA) levels decreased in both groups, but only the decline at 3 weeks in the formula-fed group was statistically significant (10.6 +/- 0.5 versus 8.0 +/- 0.4% weight, P < or = 0.05). The plasma phospholipid docosahexaenoic acid (DHA) levels of the formula-fed infants also declined from Week 1 to Week 7 (2.1 +/- 0.1 to 1.7 +/- 0.2 weight %; p < or = 0.05). In contrast, human milk-fed infants maintained their plasma phospholipid DHA levels, which were significantly higher at 7 weeks than those of the formula-fed infants (1.7 +/- 0.2 vs 2.3 +/- 0.2; p < or = 0.05). The decline in plasma DHA levels of our formula-fed very premature infants was of similar magnitude to that previously reported for larger premature infants. On the other hand, it is reassuring that very premature infants are able to maintain plasma DHA levels during the first weeks of life, if they receive even small amounts of breast milk.

In a retrospective study we investigated the mortality and the most important complications of all very low birth-weight infants (VLBW; < or = 1500 g and/or < or = 32 weeks) born with vital signs between 1984 and 1992 at the Klinikum Grosshadern, Munich University Hospital. During this period 859 premature infants fulfilled the entrance criteria. The perinatal mortality rate was 174/859 infants (20%). During the study period the mortality rate dropped significantly from 25% (1984-1986) to 15% (1990-1992). Premature infants born after 26 gestational weeks showed the most significant decrease in mortality. Excluding non viable infants with extreme immaturity ( < 24 weeks of gestation) or lethal malformations; the mean corrected mortality rate was 11%, decreasing over the years from 16% (1984-1986) to 5% (1990-1992). Caesarean section was performed in 70% of all children (602/859), vaginal delivery in 28% (239/859), delivery by forceps in 1% (7/859), and the mode of delivery was not clearly registrated in 1% (11/859). The incidence of Caesarean section increased significantly from 55% (1984-86) to 79% (1990-92). Evaluating the mode of delivery in relation to mortality, a significant difference was found between the infants delivered vaginally (40%, 95/239) and those delivered by Caesarean section (11%, 67/602). This improved survival after Caesarean section was statistically significant for the group with a birth weight of less than 1500 g. The rate of pneumothorax also declined significantly from 19% to 9%. The rate of intracranial haemorrhage (ICH) remained almost constant during these years, but the incidence of ICH grade 3 and 4 decreased from 15% (1984-1986) to 6% (1990-1992). Probably because of improved antenatal care and the progress in neonatal intensive care, the chance of survival for VLBW infants has substantially improved over the last decade. Estimations of the prognosis of VLBW infants based on data from the 1980s are out of date.

Background: The properties of iv-fat emulsions are similar to those of triglyceride-rich plasma lipoproteins and rapidly hydrolyzed by lipoprotein lipase. Neonates frequently do not tolerate iv-fat because of low levels of the key enzymes for fat metabolism., Purpose of the Study: We examined the effect of iv-fat therapy on LDL subclass distribution of 20 neonates unable to tolerate enteral feeding., Methods: Particle size was determined by non-denaturing gradient gel electrophoresis., Results: The LDL size distribution profiles at baseline showed unexpected diversity in the position of the major lipoprotein peak with three different profiles identified by peak position; profile I with a major peak of large-sized LDL (26.3-28.2 nm), profile II with a major peak at 25.2-26.7 nm and profile III with a major peak of small-sized particles (24.9-25.6 nm). None of the profiles fit the classical LDL pattern A or B found in adult plasma since the skewness associated with the adult pattern was not present. With iv fat feeding and enteral nutrition, no major shift in peak position was observed, even though plasma triglyceride and apo B concentrations increased suggesting that there was an increased number of LDL particles rather than an increase in the size of particles., Conclusion: The constancy of the LDL peak position in the face of increases in plasma triglyceride and apo B concentrations during iv fat and the onset of enteral nutrition in neonates suggests that other metabolic events, such as hormone status and lipid and transfer protein activities need to be considered.

Changes in high-density lipoprotein (HDL) subclass distribution were evaluated in a group of premature infants during the early postnatal period to ascertain whether enteral feeding brought about a rapid shift from neonatal to adult-like distributions. All infants were fed a combination of breast milk and formula. Cord blood of premature infants had a predominance of large, less dense (HDL2b)gge and a paucity of intermediate-sized (HDL3a)gge particles. Lack of a peak in the (HDL3a)gge is a characteristic feature for cord blood, whereas a prominent (HDL3a)gge peak is characteristic of adult plasma. After the start of enteral feeding, blood was obtained at two time-points: 6-14 days (sample A) and 17-32 days (sample B) postdelivery. With the onset of feeding, triglyceride increased significantly from an average of 34 mg/dl in cord blood to 120 mg/dl in sample B, and cholesterol increased from 86 to 112 mg/dl in the same period. Increases in plasma lipid concentrations were paralleled by a redistribution of subclasses such that three components of almost equal intensity were evident in sample B; these consisted of (HDL2b)gge, (HDL2a2)gge, and (HDL3b)gge. A paucity of (HDL3a)gge particles persisted even after onset of enteral feeding; thus, increases in plasma triglyceride and cholesterol per se are not sufficient to induce the adult-like distribution. It is suggested that development of the normal adult HDL subclass pattern is complex and is probably related to the development and interaction of several factors, including plasma enzymes involved in lipid hydrolysis and esterification, lipid exchange proteins, and hormonal status.