[show abstract][hide abstract] ABSTRACT: PURPOSE: To evaluate amplitude-integrated EEG (aEEG) in comparison with conventional (cEEG) for the identification of electrographic seizures in neonates with acute neonatal encephalopathies. METHODS: Thirty-one conventional cEEG/aEEG long-term recordings from twenty-eight newborns were reviewed in order to assess the electrographic seizure detection rate and recurrence in newborns. Two paediatric neurologists and one neonatologist, blinded to the raw full array cEEG, were asked to mark any events suspected to be an electrographic seizures on aEEG. They were asked to decide if the displayed aEEG trace showed the pattern of a single seizure (SS), repetitive seizures (RS) or status epilepticus (SE). Their ability to recognize electrographic seizures on aEEG was compared to seizures identified on full array cEEG. RESULTS: 25 of the 31 long-term cEEGs recordings showed electrographic seizures. The two paediatric neurologists and the neonatologist identified SE in 100% of the reviewed traces using aEEG alone while they identified 49.4% and 37.5% of electrographic seizures using aEEG alone. Overall, the correct identification ranged from 23.5% to 30.7% for SS and 66% for RS. The inter-observer agreement (k) for the identification of SE for the two paediatric neurologists and the neonatologist was 1.0. Overall the inter-observer agreement (k) for the detection of SS, RS and SE of the two paediatric neurologists was 0.91. CONCLUSIONS: In our study the observers identified SE in 100% of the reviewed traces using raw aEEG alone, thus aEEG might represent a useful tool to detect SE in the setting of NICU. SS may not be reliably identified using aEEG alone. Simultaneous recording of the raw cEEG/aEEG provides a good level of sensitivity for the detection of neonatal electrographic seizures.
[show abstract][hide abstract] ABSTRACT: There exists a huge gap between protocols issued by scientific bodies and evidence derived by system biology studies on the multifactorial origin of threatened preterm delivery and their different associations with neonatal outcome. The objective of this prospective study was the analysis obstetrical and neonatal outcome in a cohort of pregnant patients treated for the risk of preterm delivery according to maternal and fetal assessment determined by amniotic fluid samples. Methods. Threatened preterm delivery and premature rupture of membranes between 24 + 1 and 32 + 6 weeks of gestation were treated by prolonged tocolytic regimens and if necessary by antibiotics for maternal infections when intra-amniotic inflammation (IAI) was excluded on the basis of negative white blood cell count in the amniotic fluid, or opposite, by delivery after a course of betamethasone and 48 hours maintenance tocolysis. Twenty-three cases were compared with 22 historical controls treated by the same teams according to the 48 hours treat and wait criteria. In addition to this, cases with normal and abnormal amniotic fluid white blood cell were compared. Results. Maternal and fetal conditions at admission were not significantly different between the study and control cohort for all maternal and fetal variables. Clinical indices were significantly improved as regard to latency from admission to delivery, number of newborns admitted to neonatal intensive care unit and length of stay in neonatal intensive care unit. Not any perinatal death or sepsis occurred in the study cohort. Overall, improved neonatal outcomes were observed in the study cohort. Composite major neonatal eventuful outcomes occurred in 26% of cases vs. 50% in controls. The limited number of cases was not powered enough to reach a statistical significance for these variables. Continued tocolysis on demand and full regimen of mono or combined antibiotic regimen for maternal infection acheived significnatly longer delay between admission to delivery with improved in neonatal outcome in cases negative for IAI: only 2 of 14 newborns suffered of major neonatal complications vs. 4 of 9 newborns delivered for IAI. Conclusions. Fetuses without IAI can be treated conservatively and their stay in utero prolonged without harm. However, we confirmed that when IAI is already active in utero a worse neonatal outcome is already partly predetermined. These positive findings must be interpreted with cautions given the limited number of cases considered by this study.
The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 10/2012; 25(Suppl 5):54-61. · 1.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Few years ago, elective tracheal intubation in the delivery room was considered as the routine approach in managing respiratory failure in extremely-low-birth-weight infants (ELBW), at least in terms of surfactant administration. Over recent years, the indications and principles of neonatal resuscitation of ELBW infants have been partially reviewed: many randomized clinical trials (RCT) have demonstrated that these infants do not die quickly without intubation in the delivery room, and many infants only need a little help in completing foetal-neonatal transition through the use of lung recruitment manoeuvres in the delivery room (e.g. sustained lung inflation, CPAP) and then only non-invasive ventilation support. Tracheal intubation and mechanical ventilation can be reserved solely for depressed or ELBW, although further RCTs are needed to provide additional information and to provide a conclusive response to the eternal debate as to whether intubation at birth can influence outcome for ELBW infants.
The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 10/2012; 25 Suppl 4:55-7. · 1.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Most preterm babies with a gestational age less than 23-27 weeks need a respiratory support in the delivery room (DR); the aim of ventilation is to create and maintain a functional residual capacity (FRC); to facilitate gas exchange and to minimize acute lung injury. The application of a continuous positive airway pressure (CPAP) from the first breaths helps in obtaining a lung volume stabilization. Efficacy and safety of the application of a sustained lung inflation (SLI) at birth is still under careful evaluation. The prompt increase of the hearth rate and oxygen saturation in the preliminary studies at the moment available in the literature are signs of the good efficacy of the manoeuvre but the effects of the SLI on oxygenation and hemodynamics are undetermined. When preterm infants need respiratory assistance in the DR, respiratory function monitoring is desirable to apply adequate and gentle resuscitation manoeuvres. Clinical large trials taking place in the DR are needed but they are also extremely difficult to be designed and performed.
The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 03/2012; 25 Suppl 1:39-40. · 1.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Hypothermia is used for its neuroprotective effect in perinatal asphyxia. Mechanical ventilation is often used as a supportive therapy for severe asphyxiated infants who can present various degrees of respiratory failure. Animal studies demonstrated a protective effect of cooling on the lungs due to reduced ventilatory requirements. Even if actual knowledge on the effects of hypothermia and rewarming on respiratory parameters during mechanical ventilation is limited, nevertheless human studies seem to demonstrate that hypothermia is safe and does not cause significant changes in the level of respiratory supports.
The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 08/2011; 24 Suppl 1:67-8. · 1.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Preterm infants need the achievement of adequate lung volume. Lung recruitment maneuver (LRM) is applied during high-frequency oscillatory ventilation. We investigated the effect of an LRM with positive end-expiratory pressure (PEEP) on oxygenation and outcomes in infants conventionally ventilated for respiratory distress syndrome (RDS). Preterm infants in assisted controlled ventilation+volume guarantee for RDS after surfactant randomly received an LRM (group A) or did not (group B). LRM entailed increments of 0.2 cm H (2)O PEEP every 5 minutes, until fraction of inspired oxygen (Fi O(2))=0.25. Then PEEP was reduced and the lung volume was set on the deflation limb of the pressure/volume curve. When saturation of peripheral oxygen fell and Fi O(2) rose, we reincremented PEEP until Sp O(2) became stable. Group A ( N=10) and group B ( N=10) infants were similar: gestational age 25 ± 2 versus 25 ± 2 weeks; body weight 747 ± 233 versus 737 ± 219 g; clinical risk index for babies 9.8 versus 8.1; initial Fi O(2) 56 ± 24 versus 52 ± 21, respectively. LRM began at 86 ± 69 minutes of age and lasted for 61 ± 18 minutes. Groups A and B showed different max PEEP during the first 12 hours of life (6.1 ± 0.3 versus 5.3 ± 0.3 cm H (2)O, P=0.00), time to lowest Fi O(2) (94 ± 24 versus 435 ± 221 minutes; P=0.000) and O(2) dependency (29 ± 12 versus 45 ± 17 days; P=0.04). No adverse events and no differences in the outcomes were observed. LRM led to the earlier lowest Fi O(2) of the first 12 hours of life and a shorter O (2) dependency.
American Journal of Perinatology 03/2011; 28(7):521-8. · 1.57 Impact Factor
[show abstract][hide abstract] ABSTRACT: In preterm neonates, use of probiotic mixtures is increasingly popular and is effective in preventing NEC, fungal colonization, and improving feeding tolerance. However, concerns exist about safety and tolerability of long-lasting administration of living microrganisms to not-immunocompetent hosts. We report a 6-year, two-NICUs experience of routinary Lactobacillus rhamnosus GG (LGG) use in VLBW infants.
Clinical charts review, retrospective study of VLBW infants admitted to two Italian NICUs in the years 2003-2008. Standard protocol of LGG administration consisted of 3 x 10⁹ CFU/day, in single oral dose, since 4th day-of-life, for 4-to-6-week courses. Nutritional policy relied on administration of fresh, expressed mother's milk, supplementation with preterm formula if needed. Data about LGG safety and tolerability, infections, feeding tolerance, microbiological clinical and surveillance cultures were retrieved and analysed.
Complete data were obtained for 743 of 811 VLBW infants. Mean birth-weight was 1056 g; mean gestational age 29.5 weeks. A total of 17,108 LGG doses were administered (mean 23.1/infant). No adverse effects or intolerances putatively attributable to LGG occurred. Overall, 5350 clinical and surveillance cultures from 13 different sites/devices were performed (mean: 7.2 cultures from 6.5 different sites/infant). None ever grew LGG, or other Lactobacilli. No clinical sepsis episode was attributable to LGG. Full enteral feeding was achieved at 19.2 mean days-of-life; 73% of infants were exclusively/partially breastfed. Fourteen NEC cases occurred (=1.9%), with 5 (=0.7%) being>2b stage.
Routinary supplementation of probiotic LGG in a large, 6-year VLBW infants Italian cohort proved microbiologically safe and clinically well tolerated.
Early human development 02/2011; 87 Suppl 1:S35-8. · 2.12 Impact Factor
[show abstract][hide abstract] ABSTRACT: Sustained lung inflation (SLI) applied at birth has been demonstrated to lead to clearance of lung fluid and achievement of a precocious functional residual capacity in animal studies.
To verify if the application of SLI in preterm infants at birth may reduce the need for mechanical ventilation and improve their respiratory outcome.
We prospectively studied 89 infants with respiratory distress (gestational age (GA) 28.1 ± 2.2 weeks) treated at birth with a SLI (25 cm H(2)O, sustained for 15 s) in addition to AAP recommendations versus a historical control group (n = 119; GA 28.1 ± 2.0 weeks) treated without SLI with the same device (controlled positive end-expiratory pressure of 5 cm H(2)O).
The SLI group had less need for (51 vs. 76%, p < 0.0001) and shorter duration of mechanical ventilation (5 ± 11 vs. 11 ± 19 days, p = 0.008), a more frequent occurrence of exclusive nasal continuous airway pressure support (49 vs. 24%, p < 0.0001) and INtubation-SURfactant-Extubation (INSURE) treatment (16 vs. 3%, p = 0.01), less need for surfactant (45 vs. 61%, p = 0.027) and postnatal steroids (10 vs. 25%, p = 0.01), a shorter duration of oxygen therapy (21 ± 27 vs. 31 ± 31 days, p = 0.016), and, finally, a lower occurrence of bronchopulmonary dysplasia in survivors (7 vs. 25%, p = 0.004). Multiple regression analysis showed that 23-27 weeks of GA and birth weight <750 g increased the risk of mechanical ventilation, while a clinical risk index for babies (CRIB) score <3 as well as INSURE strategy and SLI treatment in the delivery room decreased it.
The application of a SLI at birth in preterm infants with respiratory distress may decrease the need for mechanical ventilation without inducing evident adverse effects.
[show abstract][hide abstract] ABSTRACT: To evaluate the clinical course, respiratory outcomes and markers of inflammation in preterm infants with moderate respiratory distress syndrome (RDS) assigned from birth to nasal continuous positive airway pressure (NCPAP) or bi-level NCPAP.
A total of 40 infants with a gestational age (GA) of 28-34 weeks (<35 weeks' GA), affected by moderate RDS, were considered eligible and were randomised to NCPAP (group A; n=20, CPAP level=6 cm H(2)O) or to bi-level NCPAP (group B; n=20, lower CPAP level=4.5 cm H(2)O, higher CPAP level=8 cm H(2)O), provided with variable flow devices. Inflammatory response was the primary outcome; serum cytokines were measured on days 1 and 7 of life. Length of ventilation, oxygen dependency, need for intubation and occurrence of air leaks were considered as secondary outcomes.
Infants showed similar characteristics at birth (group A vs group B: GA 30.3+/-2 vs 30.2+/-2 weeks, birth weight 1429+/-545 vs 1411+/-560 g) and showed similar serum cytokine levels at all times. Group A underwent longer respiratory support (6.2+/-2 days vs 3.8+/-1 days, p=0.025), longer O(2) dependency (13.8+/-8 days vs 6.5+/-4 days, p=0.027) and was discharged later (GA at discharge 36.7+/-2.5 weeks vs 35.6+/-1.2 weeks, p=0.02). All infants survived. No bronchopulmonary dysplasia (BPD) or neurological disorders occurred.
Bi-level NCPAP was associated with better respiratory outcomes versus NCPAP, and allowed earlier discharge, inducing the same changes in the cytokine levels. It was found to be well tolerated and safe in the study population.
Archives of Disease in Childhood - Fetal and Neonatal Edition 11/2009; 95(2):F85-9. · 3.45 Impact Factor
[show abstract][hide abstract] ABSTRACT: Background:
Probiotics are important in restoring gut normal microbiota, and/or in preventing its disturbances. Several data from neonatal studies disclose efficacy of certain mixtures of probiotics in preventing NEC, ameliorating feeding tolerance, and preventing gut fungal colonization. Nevertheless, concerns still exist about safety and tolerability of routinary, long-lasting administration of living microorganisms in immature patients. We report a 6-year clinical experience from two large tertiary NICUs in Italy.
Retrospective study by review of patient charts on infants with birth weight < 1500 g admitted to two large tertiary NICUs in Northern Italy (Sant'Anna Hospital NICU in Torino, and V. Buzzi Children's Hospital Neonatology in Milano) in the years 2003 to 2008.
Standard protocol of administration of Lactobacillus GG in the two NICUs consisted of 3 × 109 CFU/day, in a single oral dose, since the 4th day of life, for 3 to 4 week courses. Nutritional policy in the two NICUs relied on administration of fresh, expressed maternal milk, whenever possible, and supplementation of premature formaulae when needed.
Data about safety and tolerance to probiotic administration, concomitant sepsis, feeding tolerance, and microbiological clinical and surveillance cultures, were retrieved and analysed.
During the study period, 811 VLBW infants (mean birth weight 1056 g [± 88]; mean gestational age 29.5 weeks [± 1.1]) were born at the two facilities and survived till discharge. Complete data were obtained for 743 of them.
A total number of 17,108 doses of the probiotic LGG were administered (mean 23.1 per infant). No adverse effects or intolerances putatively attributable to LGG occurred. Over the study period, 5350 clinical and surveillance cultures from 13 different sites or devices were performed (7.2 mean cultures from 6.5 mean different sites per infant). None of these cultures ever grew Lactobacillus GG, or other Lactobacilli; no episode of sepsis was attributable to LGG. Full enteral feeding was achieved at 19.2 mean days-of-life [± 8]; 73% of the infants were fed exclusive or partial maternal milk. 14 cases of NEC occurred (1.9%), among them 5 (0.7%) were > stage 2b.
Routinary use of probiotic Lactobacillus GG in two large Italian NICUs over a 6-year period was safe and well tolerated. No isolation of Lactobacillus GG from clinical and surveillance cultures occurred. No clinical episode of sepsis attributable to Lactobacillus GG was recorded.
Early Human Development - EARLY HUM DEV. 01/2009; 85(10).
[show abstract][hide abstract] ABSTRACT: Ventilation with an inappropriate tidal volume (Vt) triggers lung inflammation, an important predisposing factor of bronchopulmonary dysplasia. It still remains uncertain what the appropriate starting target Vt should be during the acute phase of respiratory distress syndrome (RDS). Our aim was to evaluate lung inflammation in preterm infants undergoing synchronized intermittent positive-pressure ventilation (SIPPV) with two different tidal volumes Vt during the acute phase of RDS. Thirty preterm infants (gestational age, 25-32 weeks) with acute RDS were randomly assigned to be ventilated with Vt = 5 ml/kg (n = 15) or Vt = 3 ml/kg (n = 15). Proinflammatory cytokines (interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor (TNF)-alpha) were determined in the tracheal aspirate on days 1, 3, and 7 of life. IL-8 and TNF-alpha levels collected on day 7 were significantly higher (P < 0.05), and mechanical ventilation lasted longer in the group with Vt = 3 ml/kg (16.8 +/- 4 vs. 9.2 +/- 4 days; P = 0.05). In conclusion, our data show significantly higher lung inflammation in preterm infants ventilated with Vt = 3 ml/kg, suggesting a role for Vt = 5 ml/kg in reducing both inflammatory response during the acute phase of RDS and the length of ventilation. Whether the use of this starting Vt prevents bronchopulmonary dysplasia requires further study.
[show abstract][hide abstract] ABSTRACT: To evaluate the efficacy and safety of bronchoalveolar lavage (BAL) with diluted porcine surfactant in mechanically ventilated term infants with severe acute respiratory distress syndrome (ARDS) due to meconium aspiration syndrome (MAS).
Eight consecutive mechanically ventilated term infants with severe ARDS due to MAS underwent BAL with 15 mL/kg of diluted (5.3mg phospholipid/mL) surfactant saline suspension (porcine surfactant [Curosurf]). Treatment was administered slowly in aliquots of 2.5 mL. The mean age of neonates at treatment was 3.5 (range 1-8) hours. Heart rate, systemic blood pressure and oxygen saturation were monitored continuously. Arterial blood gases were measured immediately before treatment, and again at 3 and 6 hours post-treatment. Chest x-rays were taken 6 and 24 hours after treatment.
Radiological improvement was evident in all eight patients 6 hours post-treatment. Compared with pre-BAL values, significant improvements (p < 0.05) in mean values for partial pressure of oxygen in arterial blood, partial pressure of carbon dioxide in arterial blood, pH, arterial/alveolar O2 ratio and oxygenation index were documented at 3 and 6 hours after BAL. In all patients, tracheal fluids that had been meconium-stained prior to BAL were clear of meconium after BAL. Only one patient required nitric oxide therapy for transient pulmonary hypertension. No adverse sequelae of treatment occurred during the study.
BAL with dilute porcine surfactant administered slowly in 2.5 mL aliquots improved oxygenation and chest x-ray findings, without causing major adverse effects, in mechanically ventilated term infants with ARDS due to MAS.
Clinical Drug Investigation 02/2006; 26(1):13-9. · 1.92 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: SGA (birth weight-BW- <10 p for gestational age-GA) is frequently associated with an increased risk of preterm delivery and adverse outcome. Data regarding the association of SGA with different outcome variables are not always univocal and sometimes contrasting.
Pediatric Research 01/2005; 58(2). · 2.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: To evaluate cardiorespiratory changes in hypothermic asphyxiated ventilated infants compared with controls.
Retrospective chart analysis with historical controls. Cardiorespiratory status of 10 asphyxiated newborns in hypothermia (H) (32 degrees-34 degrees C) (H group) was compared with that one of 11 asphyxiated newborns [control group, (C group)].
3/10 patients in H group needed an increased mean tidal volume (from 5.8 to 8 ml/Kg) during hypothermia when temperature reached a value of 32 degrees C, to maintain adequate gas exchange. Length of mechanical ventilation was similar in the two groups (H=5.4+/-4.4 vs C=2.8+/-2.7 days, p=ns). Heart rate, similar at the baseline (H group: 129+/-11 beats/min; C group: 129+/-12 beats/min), dropped to an average of 102+/-10 beats/min (p<0.05) during cooling in H group, while it remained stable in C group. Mean arterial blood pressure, comparable at birth, increased by a median of 8 mmHg during hypothermia (p=ns).
Hypothermia induces mild changes in cardiovascular status and in lung mechanics.
[show abstract][hide abstract] ABSTRACT: Premature lungs are highly susceptible to lung injury induced by chorioamionitis, mechanical ventilation or persistent exposure to high O2 concentrations. The Authors linger on the central role of atelectrauma and volutrauma (by inadequate tidal volume-Vt) in course of mechanical ventilation of preterm infants with RDS. In particular, they evaluate the efficacy and safety of the targeted volume ventilation with the option of the Volume Guarantee (VG). For this reason they present the results of randomized clinical trials in preterm infants (25-32 wks of gestational age) with severe RDS, in mechanical ventilation, without VG or with two different VG (Vt = 3 or 5 ml/Kg). Data collected demonstrate a significative difference (p < 0.05) in terms od reduction of mean airway pressure (PAW), peak inspiratory pressure (PIP) and cytokines production (IL6-IL8 and TNF alfa) in tracheal aspirate fluid in preterm infants in synchronized ventilation with VG set at 5 ml/Kg. These preliminary results seem to demonstrate the protective role of targeted volume ventilation with Vt = 5 ml/Kg (minimal volutrauma with less lung inflammatory response), but without significative reduction of chronic lung disease (CLD) in this group (probably due to multifactorial pathogenesis of CLD).
La Pediatria medica e chirurgica: Medical and surgical pediatrics 01/2003; 25(1):35-41.
[show abstract][hide abstract] ABSTRACT: Perinatal asphyxia remains one of the most devastating neurologic processes. There is experimental and clinical evidence that cerebral cooling may suppress the biochemical cascades leading to delayed cerebral damage.
To determine if hypothermia started soon after delivery reduces cerebral damage in term infants.
Retrospective chart analysis with historical controls. Ten asphyxiated newborns treated with hypothermia between October 1998 and October 1999 were compared to 11 asphyxiated newborns admitted from September 1997 to September 1998. Characteristics at birth of infants of the two groups (control and hypothermia) were comparable. After obtaining parental consent, whole-body hypothermia was induced before the 6th hour of life by placing a cold blanket (Polar Air, Augustine Medical Inc., model 600) around the body of the patients. Rectal temperature was maintained between 32 and 34 degrees C for 72 h. Outcome was assessed by neurological evaluation at birth and every 3 months up to the 12th month. Brain MRI was performed in the 2nd month. We had no evidence of severe adverse events related to hypothermia. In the hypothermic group there was a significant (p < 0.05) reduction of major neurologic abnormalities at follow-up and abnormal MRI findings.
Hypothermia appears to be safe. Our results on morphological damage evaluated by brain MRI and neurological outcome are encouraging: randomized controlled trials are needed to confirm this experience.
Biology of the Neonate 01/2002; 82(4):222-7. · 1.90 Impact Factor
[show abstract][hide abstract] ABSTRACT: The treatment of severe respiratory distress in infants (e.g. respiratory distress syndrome--RDS, meconium aspiration syndrome--MAS and pulmonary haemorrage) with HFOV can cause sometimes a volume delivery (VTHF) exceeding the anatomical dead space, with the possibility of an increased risk of volutrauma, implicated in the pathogenesis of chronic lung disease (CLD). The authors examined the possible correlations between VTHF and the severity of respiratory distress in order to limit the risk of ventilator-induced lung injury (VILI). Thirty-five infants in HFOV because of respiratory distress were studied. The median VTHF registered was 2.25 ml/Kg (range: 1.3-3.4) with a significant correlation to some parameters espression of severity of the respiratory distress: arterial/Alveolar ratio (a/AO2) (r = 0.519), oxygen index (OI) (r = 0.512) and mean airway pressure (MAP) (r = 0.543).
La Pediatria medica e chirurgica: Medical and surgical pediatrics 26(2):124-5.