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We followed the clinical course of 21 infants with bronchopulmonary dysplasia enrolled in a prospective home O2 therapy programme during a 4-year-period. Mean gestational age was 28.5 weeks (range, 25–36 weeks) and mean birth weight 1093 g (range 630–2750 g). Infants were regularly monitored to maintain pulse oximeter O2 saturation over 94%–95%. The source of O2 was liquid oxygen and was delivered by nasal cannula. During the follow up oxygenation was assessed by SatO2 measurement, cardiac function by Doppler echocardiography and respiratory function by the occlusion technique. All patients had an ophthalmological follow up. The mean age of the infants at discharge was 3.7 months (range 1.7–8.6) and mean weight 2830 g (range 2150–3780 g). At discharge 8 infants had right ventricular hypertrophy (RVH) and four of them had pulmonary hypertension. Mean duration of home O2 therapy was 97 days (range 15–320 days) and the mean age of discontinuation of O2 was 6.9 months (range 3–14.7 months). The cardiological follow up was benign: the ECG signs of RVH disappeared by 12 months of age in six out of eight infants and the right ventricular pulmonary pressure, as measured by the Doppler method, normalised in the four patients in whom it was detected. No relationship was found between respiratory mechanics and the duration of O2 therapy. Weight gain was poor with mean growth at the 3rd percentile for females and just below the 3rd percentile for males. Twelve of the 21 infants required 25 rehospitalizations. No one presented deterioration of retinopathy of prematurity that was present in 16 infants at discharge; at 12 months retinopathy was resolved in 14 infants. A total of 2025 hospital days were saved, representing a significant financial saving. Conclusion Home O2 therapy permits the safe early discharge of O2-dependent BPD infants and it reduces significantly the length of time spent in hospital which represents a considerable financial saving.

Renal calcification is a known complication of long-term furosemide therapy in infants with bronchopulmonary dysplasia (BPD). In a prospective study the clinical course and long-term renal sequelae of renal calcifications of 19 consecutive premature neonates (birthweight < 1250 g) with bronchopulmonary dysplasia who did not receive furosemide were examined. Infants were divided into two different groups on the basis of ultrasound evidence of renal calcifications (RC group) or absence of renal calcifications (NRC group). Serial examinations, performed at the age of 1, 2, 3, 6, 9 and 12 months, showed that 12 infants at the mean age of 68.5 +/- 12.8 days of life had renal calcifications (63%), and 3 of them had nephrolithiasis; 8 had bilateral renal calcifications. Among the 9 survivors, 2 had chronic renal calcifications at the age of 9 months; however, all normalized at the age of 12 months. Twelve infants received hydrochlorothiazide and spironolactone (63%), 17 had prolonged courses of xanthines and dexamethasone (89.5%), while furosemide was not part of the routine pharmacological administration. Statistical analysis showed that birthweight, gestational age, Apgar score and length of parenteral nutrition were comparable in the RC and NRC group infants. Mean serum creatinine, creatinine clearance, fractional sodium excretion and urinary calcium excretion values during the 12-month study period were comparable in the RC and NRC groups. Mechanical ventilation and hospital stay length were instead associated with renal calcification occurrence. The strongest indicator of renal calcification risk for this high-risk population is the severity of the unresolved acute lung disease, where different facets of respiratory management, other than the addition of furosemide, represent sufficient stimuli and renal injury to potentiate stone formation.

To evaluate the physiologic course of pulmonary function in infants with bronchopulmonary dysplasia (BPD) weighing less than 1,250 g at birth, 24 infants with BPD underwent serial pulmonary function evaluations from birth until 2 yr of age. All infants were intubated at birth and the mean duration of mechanical ventilation was 38 +/- 4 d. Passive respiratory system compliance (Crs) and resistance (Rrs) were measured between 10 and 20 d of life during mechanical ventilation. Thereafter pulmonary mechanics and functional residual capacity (FRC) were evaluated at 3, 6, 9, 12, and 24 mo of postnatal age. Forced expiratory flow (Vmax,FRC) was measured at 2 yr of age. A severe alteration on Crs (50% of predicted) was found during the acute phase of BPD, associated with abnormal values of Rrs. A progressive improvement (ANOVA, p < 0.0001) occurred in the first year of life and, at 24 mo of age, Crs and Rrs reached the range of normalcy. FRC value was 86 +/- 7.5% of predicted at 3 mo and gradually increased to a mean value of 115 +/- 5% of predicted at 2 yr of age. In spite of the good resistance time course over the 2-yr evaluation, less favorable data of Vmax,FRC were found with individual values reduced more than 40% of predicted values in 70% of the children. In conclusion, although pulmonary mechanics of BPD survivors improves during the first years of life, reaching the range of normal values, at 2 yr of age they still present a substantial airway function impairment as revealed by the low forced expiratory flows.

Aim The ‘two-step’ head-to-body delivery method, which involves waiting for the next contraction to deliver the shoulders, causes a decrease in umbilical artery pH. The aim of this study was to assess whether foetal acidemia activates gluconeogenesis. Methods We tested umbilical artery cord blood glucose concentration and pH after 341 spontaneous and 25 vacuum extractor ‘two-step’ vaginal deliveries (VD) and after 85 elective and 49 emergency caesarean sections (CS). Results Cord blood glucose concentration was significantly higher (95.5 ± 21.4 mg/dL vs 75.6 ± 16.4, p

The aim of this study was to determine whether a failure of neonatal hearing screening affected the anxiety level of parents of high-risk infants.Two hundred and eighty-eight parents of infants included in the neonatal hearing screening protocol of our Institution were tested with the Spielberger State-Trait Anxiety Inventory and with an open-question questionnaire investigating parents' attitude to hearing problems in their child, done at the time of audiological follow-up. 105 were parents of high-risk infants who had been discharged from neonatal intensive care unit (NICU) and 183 of low-risk infants discharged from well-baby nursery.No differences in anxiety levels were seen between parents of high-risk infants passing and failing neonatal hearing screening using homogeneous case-control pairs. Additionally, no differences in the level of anxiety were found between parents of high- and low-risk infants failing neonatal auditory screening.Failure of neonatal auditory screening does not affect the anxiety levels of parents of high-risk infants at post discharge from NICU. This finding is a key factor to be considered when evaluating the costs and benefits of tests for universal neonatal hearing screening.

To determine whether there is an association between histological chorioamnionitis (HCA) and postnatal growth of preterm infants in the neonatal period.This case-control study is part of a larger prospective histological study on placentas performed in all deliveries prior to 32 weeks of gestation. Eligible cases involved all placentas with a diagnosis of HCA. Control subjects were those without HCA, matched 1:1 with case subjects according to gestational age (±1 week). Placental inflammatory status and serial weight gain were analyzed for all infants during the first four postnatal weeks. Based on placental inflammation extension, HCA was defined as maternal HCA (MHCA) or fetal HCA (FHCA).Of the 320 mother-infant pairs, 71 (22.1%) presented with HCA (27 MHCA and 44 FHCA). Decreases in weight gain at 21 and 28 days were associated with the presence of FHCA (β coefficient ± SE = -4.40 ± 2.21, p = 0.05 and -6.92 ± 2.96, p = 0.02, respectively), whereas no significant differences were found between MHCA and no-HCA groups. FHCA and MHCA were not identified as risk factors of weekly weight gain, after adjusting for possible confounders (maternal ethnicity, parity, smoking during pregnancy, infant gender, IUGR status, SGA status, antenatal steroids, total fluid intake, late-onset sepsis, BPD).We found an association between fetal placental inflammation and poor neonatal growth but we were not able to identify a specific week wherein weight gain could be mostly affected. Placental findings may be used to identify preterm infants at risk of postnatal growth failure.

OBJECTIVES We aimed to test the hypothesis that aortic intima thickness is greater in intrauterine growth-restricted (IUGR) twin fetuses compared to normally developing twins, thus defining an increased cardiovascular risk that reflects genetic factors in fetuses sharing the same womb. METHODS We conducted a prospective study performed on twins from January 2009 to July 2011. Twins were classified into 3 groups: IUGR fetuses with an estimated fetal weight below the 10th percentile and an umbilical artery pulsatility index of greater than 2 SDs (group A), fetuses with an estimated fetal weight below the 10th percentile and normal Doppler findings (group B), and fetuses with an estimated fetal weight appropriate for gestational age (group C). Aortic intima thickness was measured at a median gestational age of 32 weeks. Values were compared among groups and between each twin and cotwin, also considering sex and chorionicity. RESULTS Twenty-five fetuses were classified as group A, 36 as group B, and 95 as group C. The median aortic intima thickness values were 0.9 mm in group A, 0.7 mm in group B, and 0.6 mm in group C (P < .0001). There was a statistically significant difference between the aortic intima thickness of the twins and cotwins in groups A and B (P < .0001). Sex and chorionicity did not correlate with aortic intima thickness. CONCLUSIONS In this study, IUGR fetuses with Doppler abnormalities had greater aortic intima thickness, and IUGR twins with normal Doppler findings had intermediate thickness, supporting a genetic predisposition to cardiovascular risk independent of sex and chorionicity.

There is no study to support a relationship between placental transfusion and active management techniques of the second stage of labor.To examine the association between head-to-body delivery by a "two-step" approach (which includes waiting for the next contraction to deliver the shoulders) and its effect on the amount of blood that remains in the infant's circulation at birth.Observational study on 500 consecutive, singleton, and at term deliveries from January to June 2012 in Policlinico Abano Terme, Abano Terme, Italy. Umbilical artery hematocrit (Htc) was evaluated in reference to contemporary tested pH values, involving neonates vaginally delivered by the "two-step" approach and by cesarean section, respectively.Head-to-body delivery by the "two-step" approach significantly increased Htc values with respect to cesarean delivery (50.16% versus 47.24%, p0.001) and at the same time reduced pH (7.31 ± 0.09 versus 7.33 ± 0.06, p = 0.007) in umbilical artery. In addition, Htc levels for this group were significantly negatively correlated with umbilical artery pH (r = -0.137, p0.018).Head-to-body delivery by the "two-step" approach increases the red cell mass in term infants without any clinical risk of neonatal acidemia.

Fetuses with intrauterine growth restriction (IUGR) have significant aortic intima-media thickening (aIMT), which suggests that preclinical atherosclerosis might predispose the infants to hypertension. However, the natural course of aIMT in babies with IUGR remains an open question.The study enrolled 77 pregnant women between January 2007 and August 2009. The fetuses were classified as AGA (appropriate for gestational age) or IUGR, if the estimated fetal weight was between the 10th and 90th percentile or below the 10th percentile (with umbilical artery pulsatility index (PI) >2s.d.), respectively. Anthropometric parameters and aIMT were detected in each IUGR and AGA fetus at a mean gestational age of 32 weeks. The follow-up was performed in 25 IUGR and 25 AGA infants at a mean postnatal age of 18 months; the previous measurements were repeated, and blood pressure measurements were taken. The maximum aIMT was significantly higher in the IUGR fetuses and infants compared with the AGA infants, both in utero (2.05±0.43 vs. 1.05±0.19 mm, P

Background and objective: Intrauterine growth restriction (IUGR) may be associated with significantly higher aortic intima–media thickening (aIMT) values. It is unknown if fetal aIMT is associated with glomerulosclerosis and amniotic albuminuria in utero. Design, setting, participants, and measurements: Fetal abdominal aIMT and amniotic albumin/creatinine ratio (ACR) were measured in 126 individual twin fetuses, recruited by the Obstetrics and Gynaecology Clinics of the University of Padua (Italy) Medical Center. The IUGR twin fetuses were classified into two groups: Group A were those fetuses whose estimated fetal weight (EFW) was 2 SD and Group B were those fetuses whose EFW was Results: The median fetal aIMT was significantly different in the three groups (Group A = 0.9 mm; Group B = 0.7 mm; and appropriate for gestational age (AGA) = 0.5 mm; p < .0001). It was significantly higher in Group A than in the AGA group (p < .0001) and than in the Group B fetuses (p = .003), respectively. In addition, ACR was different in the three groups (Group A = 183,500 mg/g; Group B = 6,4720 mg/g; and AGA = 8,2750 mg/g; p = .0002). It was significantly higher in Group A than in the AGA group (p = .03) and than in Group B (p = .02), respectively. Conclusions: Growth-restricted twin fetuses with velocimetry abnormalities present are associated with aIMT and higher ACR levels in amniotic fluid, which could be possible markers in utero of preclinical atherosclerosis, and early glomerulosclerosis.

sentant un syndrome de detresse respiratoire L'aginine-vasopressine (AVP), le peptide natriuretique auriculaire humain (hANP) et le bilan electrolytique du liquide corporeal ont ete etudies durant les cinq premiers jours de vie de onze enfants prematures (poids a la naissance) sous ventilation mecanique pour RDS. Les concentrations plasmatiques du hANP et urinaire de l'AVP ont ete determinees par radio-immunologie le premier, le troisieme et le cinquieme jour. Les taux d'arginine-vasopressine dans les urines sont restes constamment eleves pendant toute la periode d'etude (moyenne ± SD 13,5 ± 7,8 1 er jour, 12,0 ± 9,9 3 e jour, 13,2 ±.5,1 ng/l 5 e jour, p = ns), par contre le hANP plasmatique s'etait accru de facon significative au troisieme jour (626 ± 495 vs. 298 ± 240 pg/ml 1 er jour, p

Infection with herpes simplex is one of the most common sexually transmitted infections. Because the infection is common in women of reproductive age it can be contracted and transmitted to the fetus during pregnancy and the newborn. Herpes simplex virus is an important cause of neonatal infection, which can lead to death or long-term disabilities. Rarely in the uterus, it occurs frequently during the transmission delivery. The greatest risk of transmission to the fetus and the newborn occurs in case of an initial maternal infection contracted in the second half of pregnancy. The risk of transmission of maternal-fetal-neonatal herpes simplex can be decreased by performing a treatment with antiviral drugs or resorting to a caesarean section in some specific cases. The purpose of this paper is to provide recommendations on management of herpes simplex infections in pregnancy and strategies to prevent transmission from mother to fetus.

Over the centuries, great interest has been devoted to the placenta and to its highly symbolic significance. The Renaissance represented the age of historical and cultural transition between classical and modern scientific paradigms. In the medical setting, Realdo Colombo represents one of the protagonists of this revolution. In his masterpiece, De Re Anatomica , he revolutionized the former medical perspective. We present a passage from this book, which carries invaluable information on the Renaissance viewpoint on pregnancy and placental biology. The connections between Colombo's theories and the previous medical tradition are also analysed.

Intrauterine growth restriction (IUGR) and/or neonatal low birth weight are often associated with increased intima/media thickness of the abdominal aortic wall (aIMT). Several studies in children suggested that aIMT might be related to inflammation, probably indicating an early stage of adulthood diseases, such as atherosclerosis. Our previous study performed on the abdominal aortic wall of a stillbirth presenting with IUGR and aIMT suggested an association among IUGR, aIMT, and inflammation, also highlighting the presence of fibroblastoid cells, which are thought to represent peculiar elements of the pre-atherosclerotic lesions. These observations led us to analyze two cytokines involved in the inflammation cascade, IL-1β and IL-23, in amniotic fluid samples of IUGR fetuses and small-for-gestational-age newborns presenting with aIMT and in normal controls. Our results indicate that IL-23, but not IL-1β, concentrations differed in the groups analyzed. Therefore, IL-23, a regulatory element that bridges the innate and adaptive arms of the immune system, might be involved in the inflammatory process observed in fetal aIMT.

We aimed to determine the correlation and the agreement between end-tidal carbon dioxide (ETCO(2)) and partial pressure of arterial carbon dioxide (PaCO(2) ) in very low birth weight infants (VLBWI); furthermore, we assessed factors that could affect the ETCO(2)-PaCO(2) relationship.Simultaneous end-tidal and arterial CO(2) pairs were obtained from ventilated VLBWI who were monitored by mainstream capnography and had umbilical arterial catheter. Correlation and agreement between ETCO(2) and PaCO(2) were evaluated by using Spearman test and Bland-Altman method, respectively.A total of 143 simultaneous ETCO(2)-PaCO(2) pairs were analyzed from 45 ventilated VLBWI. There was a significant correlation (r = 0.69; P0.0001) between ETCO(2) and PaCO(2) values. The ETCO(2) value was lower than the corresponding PaCO(2) value in 94% pairs, with a mean bias of 13.5 ± 8.4 mmHg (95% agreement levels, -3.0 to 29.9 mmHg). Mean PaCO(2)-ETCO(2) bias was similar between ELBWI (13.1 ± 7.7 mmHg; 95% agreement levels, -1.9 and 28.2 mmHg) and infants with birth weight 1,001-1,500 g (14.8 ± 9.7 mmHg; 95% agreement levels -4.3 and 33.8 mmHg). The bias between ETCO(2) and PaCO(2) was significantly increased with increasing FiO(2), mean airway pressure and oxygenation index. Within each patient, there was a positive correlation (r = 0.78, P0.0001) between the changes in PaCO(2) and the simultaneous changes in ETCO(2).In ventilated VLBWI, the correlation between mainstream ETCO(2) and PaCO(2) is good, but the agreement is poor and negatively influenced by the severity of pulmonary disease. Capnography is feasible in ELBWI. ETCO(2) should not replace PaCO(2) measurements in ventilated VLBWI, but may have a role to detect trends of PaCO(2).

The experience in performing intubation procedures gained by a single operator has been previously reported for adult, but not for neonatal patients.In order to evaluate the process of skill acquisition, we reviewed the first 150 neonatal tracheal intubations performed by a pediatric trainee.For logbook purposes, a pediatric trainee prospectively recorded all neonatal tracheal intubation procedures that she performed during a 5-year training period.During the study period, Nicoletta Doglioni performed for 152 intubation procedures. Of the 152 procedures, the author was successful on 120 (79%) occasions. Of these, 77 (64%) were performed on the first attempt, and 43 (36%) on the second attempt. Author successful intubation improved by the training year 1 (67%) to training year 2 (79%), 3 (77%), 4 (80%) and 5 (91%), respectively.Intubation success rate progressively improved with training year experience. A recommended level of proficiency, defined as 90% of procedure success, was obtained after 100 attempts suggesting that a significant amount of experience is needed for obtaining proficiency in neonatal intubation.

The study aims to compare the performances (ease of insertion, time to establish effective ventilation and maximal inflation pressure) of classic™ (cLMA), ProSeal™ (PLMA) and Supreme™ (SLMA) Laryngeal Mask Airway when used in a neonatal airway management manikin by inexperienced delivery room trainees. The quality of the three devices, as perceived by participants, was also evaluated.Health-care professional trainees were given a brief supervised training with the three devices. Every trainee was then observed positioning each of the three different LMAs in a single occasion. Success rate, time (IT) and maximal inflation pressure (PI(max)) were recorded by a single unblinded observer. A 4-point scale was used to rate participants' perceived quality.A total of 40 health-care professional trainees participated in the study. There were five, three and one failed insertions at the first attempt with the cLMA, PLMA and SLMA, respectively. No failures to establish an effective airway within three attempts were recorded. The success rate at first attempt was comparable among the three devices. The mean IT was significantly lower with the SLMA as compared with PLMA (p0.01), but not to cLMA. The mean PI(max) was higher with SLMA than with cLMA and PLMA (p0.01). The ease of insertion as well as the effectiveness of ventilation were perceived by the participants as superior with SLMA as compared with cLMA and PLMA (p0.01).Neonatal SLMA is superior to PLMA in terms of time to establish effective ventilation; furthermore, maximal inflation pressure and quality perceived by the operator are higher with neonatal SLMA than with cLMA and PLMA. These manikin data could provide a useful guide for planning potential future clinical research involving the newly developed supraglottic device in neonates.

Paes et al 1 showed that the tympanic and infrared skin (Beurer and Thermofocus) thermometers cannot reliably predict rectal temperature in general paediatric population. Only a few studies examined the accuracy of infrared skin thermometers in children and the results are conflicting.2,–,4 In a prospective study, we evaluated the correlation and the agreement between two types of infrared skin thermometers (Thermofocus and Exergen) and axillary measurements (Terumo digital clinical thermometer) in patients admitted to the …

Background and aims: Histological chorioamnionitis (HCAM) has been associated with inflammatory diseases of preterm infants. Recently, we have observed that VLBW infants with HCAM present an increased risk of speech delay and hearing loss. So the aim of this study was to evaluate the relationship between sensorineural hearing loss (SNHL) in VLBWI and HCAM.

Intrauterine growth restriction is a condition fetus does not reach its growth potential and associated with perinatal mobility and mortality. Intrauterine growth restriction is caused by placental insufficiency, which determines cardiovascular abnormalities in the fetus. This condition, moreover, should prompt intensive antenatal surveillance of the fetus as well as follow-up of infants that had intrauterine growth restriction as short and long-term sequele should be considered.

Aim of the study Newborn infants, in particular those needing resuscitation maneuvers at birth, must be readily positioned under a radiant infant warmer (RIW). However, temperature of exposure and/or level of RIW power to set up are not specified. We aimed to evaluate the temperature of exposure generated by three different RIWs at pre-selected power outputs and to assess whether the delivery room temperature may affect this condition. Methods Irradiation temperature was measured under 3 RIWs at environmental temperatures of 22, 24 and 26 °C, chosen in a random order. Each device was set in manual control and turned on three randomly chosen power levels (0–33%, 0–100%, 33–100%) lasting 20 min. We considered 3 measurements, calculated every 1 min, at the following times: before (time 0), 10, and 20 min after the RIW was turned on at the preselected power output. Results Temperatures under RIWs ranged from 21.5 to 44.7 °C; under one RIW, it never reached 37 °C. Thermal exposure was significantly different among the three devices based on the time of measurement and preselected power output. Room temperature did not significantly influenced temperature under RIWs. Conclusions Exposure temperature under RIW (turned on pre-selected power outputs) significantly varies among commercially available devices suggesting that neonates can be easily put at risk of hypo- or hyperthermia. Specific dependent-machine algorithms or servo-control modes are indicated to guide neonatal temperature control at birth.

Several studies have reported that fetuses with intrauterine growth restriction (IUGR) and infants with low birth weight present increased intima/media thickness (aIMT) of the abdominal aorta wall compared with fetuses and infants appropriate for gestational age (AGA). Evidence suggested that aIMT might be related to inflammation, probably indicating a very early stage of future adulthood disease, such as atherosclerosis. We aimed to investigate histological findings in the abdominal aorta wall of one IUGR stillbirth in which ultrasound had detected aIMT. Microscopy observations of the abdominal aorta wall confirmed the intima thickening and detected condensation of the elastic fibers forming an evident internal elastic membrane and presence of inflammatory elements, such as macrophages, activated endothelial cells, and fibroblastoid cells. The present study highlights that IUGR associated with aIMT is related to inflammation, which might represent a very early sign of future adult lesions.

Objectives To evaluate the extent of oxidative stress in neonates born from multiple gestation pregnancies who are at high risk of prematurity and growth abnormalities. Design and methods Blood samples were collected from umbilical cord of 72 twins, born at gestational age of 28–38 weeks, and 20 consecutive control singletons. Oxidative stress parameters (15-F2t-isoprostane, a marker of lipid peroxidation, and total antioxidant capacity, tAOC), were measured in cord plasma. Results Levels of 15-F2t-isoprostane showed a moderate negative correlation with birth weight and were higher in small co-twins of discordant pairs; tAOC was positively correlated with birth weight but no significant difference was found between co-twins. Conclusions Oxidative stress levels in twins are mainly influenced by birth weight and weight discordance. We suggest that evaluation of cord blood 15-F2t-isoprostane might be of clinical value as maker of pre- and perinatal distress in twinning.

To assess whether investments for medical equipments assigned by a team of experts to a mother and child health hospital located in Mongolia were correlated with structural, organizational, and educational level of its services/departments.A score was used for evaluating the level of each service/department. It was based on a 'structural area' and an 'organizational and educational area'. Destination of funds was determined by a team of experts in collaboration with the head of the service/department.Thirty-three of 36 services/departments (91.6%) were evaluated. A total sum of 4,432,140 Euros to invest in medical equipment was estimated. Assigned investments were inversely correlated with the total (structural plus organizational and educational area) score (n = 33; r = -0.59; p = 0.0002), and the specific scores for structural area (n = 33; r = -0.46; p = 0.005) and organizational and educational area (n = 33; r = -0.56; p = 0.0006).A large part of the funds for medical equipment was destined to services/departments with low organizational and educational conditions, limiting the potential effect of the aid meanwhile supporting the most in need departments. Educational efforts and monitoring of specific long-term indicators are mandatory.

To measure aortic intima media thickness and diameter by ultrasonography in fetuses with intrauterine growth restriction (IUGR) and in appropriate for gestational age (AGA) fetuses and in the same children after a mean follow-up of 18 months.This was a prospective study performed between January 2006 and August 2008. Fetuses were classified as having IUGR if the estimated fetal weight was below the 10th percentile and umbilical artery pulsatility index was greater than 2 standard deviations; they were classified as AGA if the estimated fetal weight was between the 10th and 90th percentiles. Abdominal aortic intima media thickness and diameter were measured in each fetus with IUGR and in each AGA fetus at a mean gestational age of 32 weeks. The same measurements were taken in the children after a mean follow-up of 18 months.Thirty-eight fetuses with IUGR and 32 AGA fetuses were enrolled in the study. Aortic intima media thickness median values were significantly higher in IUGR than in AGA both in utero (1.9 mm compared with 1.15 mm; P.001) and after birth (2.4 mm compared with 1.03 mm; P.001) and were significantly correlated (P=.018, r=0.48). At 32 weeks of gestation, aortic intima media thickness in fetuses with IUGR was inversely correlated with estimated fetal weight (P.003; r=-0.58). Median diameter of the abdominal aorta and blood-flow velocity at 32 weeks of gestation were significantly higher in fetuses with IUGR compared with AGA fetuses (median diameter 4.5 mm compared with 3.6 mm, P.001, blood-flow velocity 42.5 cm/s compared with 23.3 cm/s, P.001). At follow-up, in 25 children who had had IUGR and 25 children who had been AGA, there was no significant difference in median diameter of the abdominal aorta (6.8 mm compared with 7.5 mm, P=.21).Aortic wall thickening in fetuses and children with IUGR shows differences with respect to those who were AGA. This may reflect a correlation between impaired growth in utero, Doppler abnormalities, low birth weight, and early signs of vascular dysfunction.II.

Auditory processing during sleep was investigated in premature infants by auditory event related potentials (AERPs). Twenty-six premature infants (mean GA 30 week– range 25–35) admitted to a neonatal intensive care unit were studied, prior to discharge, in active and quiet sleep at a mean post-conceptional age of 35 weeks. Infant state was determined by behavioral observation according to standard criteria. An auditory odd-ball paradigm was used with frequently occurring ‘standard’ tones at 1000 Hz and infrequent ‘deviant’ tones at 2000 Hz. Waveforms were recorded at Fz, Cz, Pz, T3 and T4 scalp locations. Measurements were performed in 18 patients because 8 preterm infants were excluded since they had less than the required artifact-free deviant trials in each sleep state. The responses to standard tones were equally recorded in both active and quiet sleep, but auditory responses to deviant tones consisting of an increased frontal negativity in the time period from 200 to 300 ms after the stimulus were recorded only in active sleep. A significant effect of electrode placement, for frontal location by sleep condition and sleep condition by 50 ms time windows was shown by repeated measures analyses of variance. The significance of these findings on evoked potential methodology in preterm infants admitted to neonatal intensive care unit is discussed.

Background: Small for gestational age (SGA) infants have an increased risk of later cardiovascular disease. At birth, high sensitivity-C reactive protein (hs-CRP), a prognostic marker of cardiovascular disease, is significantly higher in SGA than in appropriate for gestational age (AGA) infants. Aim: To measure aortic and carotid intima media thickness (aIMT - cIMT) and blood pressure (BP) in children (aged 3-5 years) who were born SGA and AGA, and to assess the correlation between hs-CRP concentrations obtained at birth and these hemodynamic variables. Methods: Umbilical cord hs-CRP concentrations were obtained in 38 neonates. In the same subjects aged 3-5 years, aIMT and cIMT were measured by high-resolution ultrasound scan, in the dorsal arterial wall. Anthropometical variables and BPs were obtained for each child. Results: Maximum (median 0.700 mm, range 0.500-1.080 vs 0.650 mm, 0.400-0.860; p = 0.32) aIMTs were similar between children who were born SGA (n 17) and AGA (n 21), respectively. Concentrations of hs-CRP were not correlated with IMTs. In children who were born SGA, systolic BP was significantly correlated with umbilical cord hs-CRP concentrations (r = 0.60; p = 0.009). Conclusions: Children who were born SGA have a higher, although not significant, aortic thickening than those who were born AGA. Umbilical cord hs-CRP concentrations don’t seem to be involved in this process. Instead, hs-CRP concentrations were significantly related to systolic BP values in children who were born SGA suggesting that hs-CRP at birth could be associated to the sympathetic system hyperactivity and to the stress-response during childhood.

Aim This observational study aims to describe: (1) the use of positive pressure ventilation (PPV) for resuscitation in the delivery room among newly born near-term infants; (2) the methods used for PPV resuscitation [e.g., bag–facial mask (BFM), laryngeal mask airway (LMA), endotracheal tube (ETT)]; and (3) the association of each device with short-term neonatal outcomes. Methods We identified near-term (34 0/7–36 6/7 weeks) infants delivered at the Padua University Hospital (Padua, Italy) during the years 2002–2006. The mode of delivery, gestational age, birth weight, Apgar scores, methods of resuscitation and respiratory outcome after NICU admission were analysed. Results During the 5-year study period, 921 (4.9%) near-term infants were identified from a total of 18,641 live births. PPV was provided in the delivery room to 86 (9.3%) of these infants. Among them, 36 (41.8%) were managed by LMA, 34 (39.5%) by BFM and 16 (18.6%) by ETT. Thirty-four (39.5%) resuscitated near-term infants were admitted to the Neonatal Intensive Care Unit (NICU): 15 (44.1%) after BFM, 12 (75%) after ETT and seven (19.4%) after LMA. Resuscitation with an ETT was associated with an increased rate of respiratory distress syndrome when compared with either BFM or LMA. Resuscitation with an LMA was associated with a lower rate of NICU admission and shorter length of stay when compared with either BFM or ETT. Conclusion The LMA is an effective device for primary airway management of near-term infants and for secondary airway management among near-term infants failing BFM or ETT resuscitation.

Positive pressure resuscitation by laryngeal mask airway (LMA) may expose the neonate to gas leak and gastric air insufflation, influencing postnatal gastrointestinal adaptation and breastfeeding success.Term neonates admitted to regular nursery of the Department of Pediatrics of Padua University (Italy), from January 2005 to December 2005, after positive pressure resuscitation by LMA (Group A, 50) were compared with neonates who required positive pressure resuscitation by endotracheal tube (ETT) (Group B, 13) and to non resuscitated control neonates, matched for gestational age, (Group C, 100).Gestational age and birth weight were comparable among Group A, B, and C neonates. In addition, their ages at the first feeding and those of the first meconium emission were comparable. Diversely, LMA-, and ETT-resuscitated neonates presented a reduced exclusive breastfeeding rate at discharge and an increased hypoglycemia occurrence during postnatal adaptation. Moreover, ETT-resuscitated neonates presented a lower Apgar's score at 1 min, a significant increased regurgitation rate, and a delayed urine emission in comparison to LMA-resuscitated neonates.LMA- and ETT-positive pressure resuscitation impair postnatal gastrointestinal adaptation and breastfeeding success at discharge with equal frequency and to similar degree in term neonates. Regurgitation reflex is instead, enhanced after ETT-resuscitation.

When compared with the Classic laryngeal mask airway (cLMA), the recently introduced ProSeal laryngeal mask airway (PLMA) has modified features to produce higher airway seal pressures and enable ventilation in circumstances where the cLMA might fail. The first neonatal size 1 PLMA recently became available. This study was designed to compare the effectiveness of the size 1 cLMA and PLMA during positive pressure ventilation in anesthetized neonates and infants.Forty-six consecutive patients undergoing elective cardiac surgical procedures were randomized for initial airway management with the cLMA or PLMA. Insertion time (IT), number of placement attempts, ease of placement, quality of the initial airway, maximum tidal volume (TVmax), and airway pressure at which an audible leak in the mouth (P(leak)) occurred were collected. All data were recorded before performing tracheal intubations.IT and success rate were similar for both LMAs. The initial quality of the airway was significantly better for the PLMA (P0.05). TVmax and P(leak) were significantly higher for PLMA (77 vs 58 ml, P0.02 and 29.8 vs 24.4 cm H2O, P0.02). No adverse events were recorded during the study.The size 1 PLMA forms a more effective seal than size 1 cLMA in neonates. This might allow the PLMA to be used in those newborn infants requiring high airway pressures for ventilation.

Objective: Neonates produce predominantly skeletal muscle troponin I (TnI) in the myocardium; however, in asphyxiated neonates, high levels of cardiac troponin I (cTnI) have been found. We hypothesised that in these circumstances cTnI could be from the mother or the result of a change in fetal/neonatal production in response to an insult. In this study, we aimed to compare cTnI concentrations in asphyxiated neonates with those of their respective mothers. Methods: In this prospective observational study, we enrolled all asphyxiated neonates transferred by the Veneto Region Neonatal Transport Service in the period 1 January 2006 to 31 March 2007. Asphyxia was defined as a pH⩽7.00 and/or a base deficit of ⩾16 mmol per litre. Neonatal and maternal blood samples were obtained for cTnI determination. Results: We enrolled 19 asphyxiated neonates (median gestational age: 39 weeks, interquartile range 34–40; birth weight 3100 g, 1950–3340). Their cTnI concentrations were significantly higher in comparison with their mothers: 0.24 μg/l (0.13–0.50) vs 0.04 μg/l (0.04–0.04); p Conclusions: Increased cTnI concentrations detected in asphyxiated neonates are of neonatal origin and are not derived from the mother. In asphyxiated neonates, there may be predisposing factors that could cause earlier switching from skeletal TnI to cTnI in the myocardium.

OBJECTIVE : Studies in animals indicate that stress and anxiety can depress lactation, but there is much less information available concerning humans. We aimed to determine whether maternal anxiety in puerperium, potentially exacerbated by the primiparity inexperience, has a negative impact on breast-feeding outcomes. SUBJECTS AND METHODS : The state-trait anxiety inventory Y form (Spielberger, 1983) was administered to a total of 204 mothers, 101 primiparae, and 103 pluriparae on the third to fourth day postpartum. RESULTS : We found that primiparae had state anxiety (T) scores significantly higher than pluriparae (44.57 +/- 5.85 vs 43.28 +/- 7.10, P = 0.03). Increased state anxiety levels impaired breast-feeding success. In addition, in the logistic regression analysis model used to assess factors predictive of breast-feeding longer than 3 months, maternal state anxiety was the most significant risk factor (odds ratio 0.99; 0.88-0.98, P < 0.01). CONCLUSIONS : In the puerperium, anxiety, potentially exacerbated by primiparae inexperience, is associated with impaired lactation. Alleviating maternal anxiety could be beneficial for stimulating breast-feeding in more vulnerable women.

Aim: neonatal resuscitation program (NRP) course is effective in improving knowledge in participants coming from developed as well as developing countries; however, its impact on practical performances has not been yet formally evaluated in participants coming from developing countries. We evaluate the knowledge and the performance on clinical simulations gained by Iraqi residents following participation in the NRP course. Methods: A 71-item questionnaire derived from the standard test contained in the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Manual was administered to participants before and after the course. All participants were tested with a final Mega code (Mega code A scenario–NRP textbook) to evaluate their performance on clinical simulations. Results: Twenty-six obstetrical and 2 pediatric residents participated in the NRP course, respectively. The percentages of correct answers significantly improved from before (52 ± 14%) to immediately after the course (85 ± 7%); p < 0.001. Mean score obtained at the final Mega code was 68 ± 8%. Four out of 28 (14%) participants reached the minimum score required for passing the exam (80%). Conclusion: Residents coming from a developing country (Iraq) significantly improved their knowledge attainment following participation in the NRP course; however, their performance on clinical simulations was unsatisfactory, suggesting that this aspect needs to be improved.

Widened pulse pressure is a classic sign of significant left-to-right shunting patent ductus arteriosus (PDA), but little evidence supports this statement in the early life of premature infants with respiratory distress syndrome (RDS) needing nonsteroidal anti-inflammatory drugs (NSAIDs), the pharmacological treatment for PDA. Pulse pressure and urinary endothelin-1 (ET-1) and arginine vasopressin (AVP) vasoactive factors involved in the transitional circulation were measured before and after the NSAIDs treatment of 46 RDS premature infants receiving either ibuprofen (n = 22) or indomethacin (n = 24), with 28 responders and 18 nonresponders to the first NSAIDs course. We found that following pharmacological PDA closure, systolic and diastolic blood pressure significantly increased, maintaining a stable pulse pressure. However, when pharmacological closure failed, the trend (nonsignificant) was for a more consistent increase in systolic than in diastolic blood pressure, which determined a statistically significant widening pulse pressure. In addition, urinary ET-1 excretion rates decreased significantly after PDA closure, whereas persistent more aggressive pharmacological therapy failed. Urinary AVP excretion rates decreased insignificantly after therapy, uninfluenced by the efficacy of the drugs. We concluded that widened pulse pressure is a clinical sign of failed PDA pharmacological closure in RDS premature infants. ET-1 levels remain elevated when NSAIDs fail to interrupt left-to-right PDA shunting that complicates recovery from RDS.

Neonatal mortality has remained steady or increased in many developing countries. A pragmatic approach to the organization of the delivery room setting where a large part of neonatal deaths occurs could detect the priorities for potential ameliorative interventions. We evaluated the local health caregivers opinions regarding the priority areas for improving the hospital delivery room setting in developing countries. Twenty-eight participants to a World Health Organization (WHO) workshop were asked to fill out an anonymous written questionnaire regarding the priorities that could significantly improve their hospital delivery room setting. The three most important interventions for improving the delivery room setting were classified as following: education of all staff in newborn care (28%) optimize doctor-nurse/patient ratio (15%) equipment (14%) maternal-antenatal care (13%) role and responsibilities (8%) salary (8%) neonatal intensive care unit facilities (6%) availability of a specialized team for neonatal resuscitation (5%) and improve the building (3%). Education of health staff in newborn care personnel organization and equipment availability are valued as high priorities by local health caregivers for improving the delivery room setting in developing countries. The opinion of operators involved in maternal and neonatal health may contribute to better design interventions in setting with limited resources. (authors)

changes in myocardial function and hemodynamics after ligation of the ductus arteriosus in preterm infants. Noori et al found that during the first 24 hours after ligation, 35% of the patients required at least a 25% increase in the dosage of dopamine to maintain blood pressure (BP) in the normal range. However, among the various indices of cardiac function evaluated in these patients, none were found to predict an increase in the need for vasopressor support. This is relevant, considering the paucity of information in the literature on the effect of PDA medical or surgical closure on systemic hemodynamics. We studied the changes in BP and in urinary excretion rates of endothelin-1 (ET-1) and vasopressin (AVP) after treatment of PDA with nonsteroidal anti-inflammatory drugs (NSAIDs) in a cohort of 56 preterm infants (32 weeks gestation) diagnosed with respiratory distress syndrome. We found that after medical PDA closure (60.8%), both systolic and diastolic BP increased significantly, maintaining a stable pulse pressure. When pharmacologic closure failed, the trend (nonsignificant) was for a more consistent increase in systolic BP than in diastolic BP, along with a statistically significant widening pulse pressure. In addition, urinary ET-1 excretion rates decreased significantly after PDA closure (UET-1/Ucr, 0.15 0.07 vs. 0.10 0.05 fenton/mmol; P .005), whereas they remained elevated if pharmacologic therapy failed. Urinary AVP excretion rates decreased (albeit not significantly) after therapy and was uninfluenced by the efficacy of treatment. ET-1 and AVP are potent vasoconstrictors that play a fundamental physiological role in circulatory adaptation to extrauterine life and in the maintenance of BP. 2,3 Elevated ET-1 excretion rates in preterm infants who are unresponsive to NSAIDs indicate the need to extend the investigation after surgical PDA ligation into an area in which changes in myocardial function and hemodynamics have shown to have

Chronic cough can be a complicated and frustrating diagnostic dilemma. The aim of this study was to identify the possible causes of chronic nonspecific cough in seemingly healthy children using fiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL). Eighteen children responded to criteria of selection for chronic cough. The average age was 5.8 years (range, 1.7-10.7 years) and BAL findings were compared with those of 16 nonatopic controls. Children with chronic cough had an increased percentage of BAL neutrophils in comparison with the control group (p = 0.098). Using a BAL neutrophil percent cutoff of 17%, 6 children had high BAL neutrophils (HBNs; median, 77%; range, 27-96%) and 12 children had normal BAL neutrophils (NBNs; median, 3%; range, 0-13%). In the HBN group, FOB showed endoscopic abnormalities in four patients, BAL culture was positive in three patients, and chest x-ray (CXRs) showed minimal densities in four. The IL-8 levels showed a significant increase with respect to the NBN group (p = 0.005). The combination of endoscopic anomalies, BAL culture, BAL IL-8 levels, and minor CXR changes can support the diagnosis of subclincal infection in seemingly healthy children with chronic nonspecific cough and HBN.

Breast-fed infants have higher bilirubin levels than formula-fed infants, possibly because of variations in the composition of the breast milk. The aim of this study was to investigate whether there is a relationship between cytokine levels in the colostrum of nursing mothers and neonatal jaundice (NJ). Breast milk samples were collected from breast-feeding mothers of healthy full-term neonates, 32 with NJ and 29 without jaundice. The concentrations of IL-1beta, IL-6, IL-8, IL-10, and tumor necrosis factor (TNF)-alpha were measured by chemiluminescence enzyme immunometric assays. Mothers of infants with NJ had a higher concentration of IL-1beta in colostrum, compared with those feeding neonates without NJ, and similar trends were seen for IL-6, IL-8, IL-10, and for TNF-alpha. The concentrations of IL-1beta significantly correlated with IL-6, IL-8, IL-10, and TNF-alpha concentrations, but not with serum bilirubin levels of infants with NJ. In conclusion, the concentrations of IL-1beta were increased in colostrum from breast-feeding mothers whose infants had NJ. The correlation between the concentrations of cytokines involved in the function of hepatic uptake and excretory systems and in the enterohepatic circulation of bilirubin provides additional data to the delineation of the cascade of pathophysiological events that can lead to NJ.

Numerous functional features that promote the natural progression of the birth to breastfeeding continuum are concentrated in the human female's areolar region. The aim of this study was to look more closely into the thermal characteristics of areola, which are said to regulate the local evaporation rate of odors and chemical signals that are uniquely important for the neonate's 'breast crawl'. A dermatological study of the areolae and corresponding intern breast quadrants was undertaken on the mothers of 70 consecutive, healthy, full-term breastfed infants. The study took place just after the births at the Policlinico Abano Terme, in Italy from January to February 2014. Temperature, pH and elasticity were assessed one day postpartum using the Soft Plus 5.5 (Callegari S.P.A., Parma, Italy). The mean areolar temperature was found to be significantly higher than the corresponding breast quadrant (34.60 ±1.40°C vs. 34.04 ±2.00°C, p

Summary Background: The efficacy of a Neonatal Resuscitation Program (NRP) has been previously evaluated in developed countries, but there is a lack of information regarding the impact of this teaching program in developing countries. Our aim was to compare the knowledge gained by University of Khartoum (Sudan) and University of Padova (Italy) pediatric residents following participation in the NRP course. Methods: An 80-item questionnaire derived from the standard test contained in the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Manual was given to participants before and after the course. Results: Twenty-five Sudanese and 26 Italian pediatric residents answered the pre- and postcourse questionnaire. The percentages of correct answers significantly improved from before to immediately after the course for both Sudanese (51.9 ± 10.5% vs 84.9 ± 5.8%; P

1 m 4 2 i female infant was born at 35 weeks of gestation by cesarean ection, performed because of intrauterine growth restriction nd absent or reversed end-diastolic (ARED) flow in the mbilical artery. Birth weight was 1690 g (3rd percentile), ength was 41 cm ( 3rd percentile), and head circumference as 33.3 cm (75-90th percentile). Apgar scores were 8 and 9 t 1 and 5 minutes, respectively. The umbilical cord had 38 ounterclockwise complete coils (Figure), and the length was 1 cm. The umbilical cord is usually spiraled. A counterclockise spiral is more frequent than a clockwise spiral with a ratio f 7:1. The origin of umbilical cord coiling is unknown. ypotheses include fetal movements, active or passive torsion f the embryo, differential umbilical vascular growth rates, etal hemodynamic forces, and the arrangements of muscular bers in the umbilical arterial wall. The coiling of the umbilcal vessels develops as early as 28 days after conception and is resent in about 95% of fetuses by 7 weeks of conception. The elices may be seen by ultrasonographic examination as early igure. Umbilical cord with counterclockwise complete coils. (Available n color at www.jpeds.com.)

Some earlier reports identified neonatal pneumothorax in as many as a third of infants with iatrogenic respiratory distress syndrome. More recently, pneumothorax and/or severe, persistent pulmonary hypertension have been observed in infants delivered by elective cesarean section. These studies, however, were limited to infants admitted to intensive care. The lethality of iatrogenic pneumothorax necessitates prompt diagnosis and specialized care. This study enrolled 66,961 term infants born during a 2-year study period in an attempt to learn whether the timing of elective cesarean delivery influences the risk of neonatal pneumothorax. Just over one-fourth of infants were delivered by cesarean section: electively in 56% of instances and by emergency section in 44%. In 5408 instances, elective cesarean section was carried out before 39 completed weeks of gestation. Pneumothorax was diagnosed in 59 newborn infants, representing 0.8 per 1000 births. All of them were managed by thoracostomy. The incidence of pneumothorax was increased at 2.9 per 1000 births in those infants who were delivered by elective cesarean section, compared with both infants delivered by emergency section and those delivered vaginally. The odds ratio (OR) for pneumothorax following elective cesarean delivery, compared to emergency cesarean delivery, was 4.21 (95% confidence interval [CI], 2.04-8.74), and compared to vaginal delivery, 7.95 (95% CI, 4.41-14.32). In elective cesarean deliveries, the incidence of pneumothorax declined progressively and significantly from the 37th gestational week onward. There was a similar but less significant trend for vaginal delivery but not for emergency cesarean delivery. None of the infants with pneumothorax died, but 14% of those born by elective cesarean section developed pulmonary hypertension, necessitating high-frequency oscillatory ventilation and nitric oxide inhalation. Elective cesarean delivery at term carries an increased risk of neonatal pneumothorax compared to either emergency section or vaginal delivery. Performing elective cesarean deliveries after 39 completed weeks of gestation would be expected to lower the risk of iatrogenic neonatal pneumothorax.