Lactobacillus paracasei subsp. paracasei F19 in Bell's stage 2 of necrotizing enterocolitis.

AIM: The aim of this trial is to evaluate the role Lactobacillus paracasei in Bell's stage 2 in order to prevent the clinical progression to stage 3. METHODS: A prospective study was approved and started in December 2008. Patients were infants with birth weight 600 to 1500 g. One group received probiotic supplementation (L. paracasei susp.paracasei F-19) and the control group received only standard medical treatment. The primary outcome was the progression to stage 3 as defined by Bell's modified criteria. Inclusion and exclusion criteria were created and discussed with parents before treatment. RESULTS: Thirty-two patients (stage 2 NEC) were considered eligible for the study. Group A: 18 patients and Group B: 14 patients. Three patients in group A and six patients in group B had a clinical history of Bell's stage 3 NEC (P<0.05); oral supplementation of L. paracasei reduced the clinical progression of NEC. It was considered that an improvement in intestinal motility might have contributed to this result. CONCLUSION: The use of Lactobacillus paracasei subsp. paracasei F-19 is safe; the low progression rate to stage 3 NEC suggests that the use of this probiotic in stage 2 NEC could be a valuable therapeutic option.

Invasive and non-invasive long-term mechanical ventilation in Italian children.

BACKGROUND: To date, few studies have been published regarding the number of children in Italy who require long-term mechanical ventilation (LTV) and their underlying diagnoses, ventilatory needs and hospital discharge rate. METHODS: A preliminary national postal survey was conducted and identified 535 children from 57 centers. Detailed data were then obtained for 378 children from 30 centers. RESULTS: The estimated prevalence in Italy of this population was 4.3/100000. The majority of children (72.2%) were followed in pediatric units. The primary physicians who cared for these patients were either pediatric intensivists or pediatric pulmonologists. Neurological patients (78.2% of cases) represented the principal disorder category. 57.2% of the patients were non-invasively ventilated, with a nasal mask being the most common interface (85% of cases). The presence of clinical symptoms that were associated with abnormal findings on diagnostic testing was the primary indication for ventilatory support, whereas weaning failure was the primary indication for tracheotomy. Invasive ventilation was significantly related to younger age, longer daily hours on ventilation and cerebral palsy. Ventilatory modes with guaranteed minimal tidal volume were more often used in patients with tracheotomy. Despite their age, illness severity and need for technological care, 98% of the study population were successfully home discharged. CONCLUSION: Managing pediatric home LTV requires tremendous effort on the part of the patient's family and places a significant strain on community financial resources. In particular, neurological patients require more health care than patients in other categories. To further improve the quality of care for these patients, it is essential to establish a dedicated national database.

From neonatal to paediatric intensive care: an educational pathway.

Neonatal and paediatric intensive care units (NICUs and PICUs) are growing in number, size and complexity, and each unit is staffed by a highly specialized group of doctors and nurses. Indeed, practitioners within these subspecialties acquire specific cognitive and procedural skills garnered from focused multidisciplinary training, as well as from experience with critically ill newborns and children. Although the NICUs and PICUs share many commonalities, the relationship between caregivers in the neonatal and paediatric critical care units often is characterized by rivalry and antagonism rather than by cooperation. In addition, as in the Italian scenario, the scientific and professional background in most cases differ between neonatologists, predominantly coming from a paediatric-oriented curriculum, and paediatric intensivists, mainly affiliated to adult anaesthesia and intensive care residency programs. However, in some circumstances, particularly when dealing with smaller patients, the limits between these two distinct disciplines appear quite vague, and undoubtedly many clinicians have the perception that the two branches, namely neonatology and paediatric anaesthesia and intensive care, would get a mutual benefit by a stronger collaboration and cross-contamination. Indeed, in some situations, such as shortage of PICU beds or patients not easily transferable to a PICU, neonatologists are occasionally called to take care of critically ill infants and young children. However, these "paediatric" patients may often present with complex pathologies which the neonatologist may not be familiar with. This condition raises important issues about the advisability to provide specific education and training in paediatric intensive care also to neonatologists, according to local needs and caregivers' expectations.

[Management of pleural drainage]. / La gestione del drenaggio pleurico.

In the neonatal population, pleural effusion and particularly tension pneumothorax can be a deadly situation. Pneumothorax occurs more often in the neonatal period that any other time of life. Tension pneumothorax can result in very high pressures within the pleural space, collapsing the lung on the involved side and resulting in immediate hypoxia, hypercapnia and subsequent circulatory collapse. For these reasons, the ability to recognize, understand and treat these pathologies is essential for neonatal health and a good outcome. Neonates have many factors that can contribute to. these problems. These include respiratory distress syndrome, mechanical ventilation, sepsis, pneumonia, aspiration of meconium, congentital malformation, hydrothorax, congenital or acquired chylothorax. The diagnosis can be made by clinical examination, transillumination (pneumothorax) and chest x-ray. Besides, lung ultrasound constitutes a visual medicine and provides a transparent approach to the acutely ill patient, newborn included, guiding diagnosis, management and care. Newborns with moderate to severe symptoms and those receiving positive pressure ventilation require tube thoracostomy. If a tension pneumothorax is suspected, emergency needle decompression in the second intercostal space in the midclavicular line is required. In this article, we describe the management of tube thoracostomy using trocar tubes or pigtail catheters. Besides, we pay attention to the use of pain control for neonates undergoing painful procedures such as chest tube insertion.

Renal function and volume of infants born with a very low birth-weight: a preliminary cross-sectional study.

AIM: The aim of our study was to compare the function and volumes of kidneys of very low birth-weight (VLBW) and of extremely low birth-weight (ELBW) infants at pre-school ages. PATIENTS AND METHODS: We did a revision of the neonatal records of infants born in our hospital that weighed < or =1500 g at birth. The children were divided into two groups according to their weight at birth: ELBW (<1000 g) and VLBW (1000-1500 g). At the age of 5.7 +/- 1.4 years, the children underwent clinical, laboratory and ultrasound renal assessments. RESULTS: Sixty-nine children fulfilled the requirements for the study. The rate of neonatal treatment with aminoglycosides was higher in ELBW preterms. Renal function parameters, i.e. estimated glomerular filtration rate and albuminuria, did not differ between the two groups of children. Urinary alpha1-microglobulin excretion was significantly higher and kidneys were significantly smaller in the ELBW group than in the VLBW group. CONCLUSION: No impairment or differences in renal parameters were found in pre-school children born ELBW compared with those born with VLBW, except for differences in kidney volume, renal cortical thickness and urinary alpha1-microglobulin excretion. Thus, patients born with ELBW would require a longer follow-up period.

How much and for how long does the neonatal myocardium suffer from mild perinatal asphyxia?

Cardiac troponins can be useful in monitoring cardiac injury following perinatal distress. We report here an increase of cardiac troponin I (cTnI) to 2.84 microg/l at 3 weeks (age-related median: 0.07 microg/l) followed by normalization in a newborn with an uneventful clinical course after resuscitation at birth. Serial echocardiographs showed normal cardiac function. Such a time course of cTnI, not previously reported, could be due to either a greater sensitivity of biochemical markers than of instrumental tools or birth asphyxia. Larger studies are needed

[Administration of inhaled nitric oxide in newborns]. / Somministrazione di ossido nitrico per via inalatoria nei neonati.

The use of inhaled nitric oxide (iNO) in newborn hypoxemic respiratory failure is based on the evidence of selective pulmonary vasodilation, without systemic side effects. It is use in more than 34 weeks old newborns, with severe acute pulmonary hypertension and right-left extrapulmonary shunt. In the other cases (i.e. pneumonia, sepsis, ARDS), the therapeutic effect is less evident; no final data are available on the use of iNO in pre-term babies. The recommended dosage is 20 ppm, scaling down until 5 ppm and the 40 ppm should never be reached. The length of treatment is variable, usually no more than 7 days and the weaning should be progressive. In conclusion,the use of iNO in newborns with persistent pulmonary hypertension reduces the need of ECMO, but does not substantially modify the outcome.

[Head trauma: clinical and diagnostic factors in pediatric emergency]. / Il trauma cranico: aspetti diagnostico-terapeutici nell'emergenza-urgenza pediatrica.

The Authors describe the clinical spectrum of head trauma. The importance of history (the way the trauma occurred) and of the intrinsic dynamics of the lesions are emphasized, as is their role for the outcome. They delineate the major intervention the pediatrician should perform in emergency, and the diagnostic and therapeutical approach. In particular, recommendations are made about the best neuroradiological test which should be done.

Mixed exhaled nitric oxide and plasma nitrites and nitrates in newborn infants.

Plasma nitrite (NO2-) and nitrate (NO3-) are the stable end-products of endogenous nitric oxide (NO) metabolism. NO is present in the exhaled air of humans, but it is not clear if exhaled NO may be an indicator of the systemic endogenous NO production. The aims of the study were to determine the levels of exhaled NO and plasma NO2-/NO3- in healthy term and preterm newborns, and to assess if exhaled NO correlates with plasma NO2-/NO3- at birth. After the stabilization of the newborn, we measured by chemiluminescence the concentration of NO in the mixed expired breath of 133 healthy newborns. Measurement of exhaled NO was repeated after 24 and 48 hours. Plasma NO2-/NO3- levels at birth were measured by the Griess reaction. NO concentrations were 8.9 (CI 8.1-9.8) parts per billion (ppb), 7.7 (CI 7.2-8.3) ppb and 9.0 (CI 8.4-9.6) ppb at birth, 24 and 48 hours, respectively. At birth, exhaled NO was inversely correlated with gestational age (p=0.008) and birth weight (p<0.001). Plasma NO2-/NO3- level was 27.30 (CI 24.26-30.34) micromol/L. There was no correlation between exhaled NO and plasma NO2-/NO3- levels at birth (p=0.88). We speculate that the inverse correlation between exhaled NO and gestational age and birth weight may reflect a role of NO in the postnatal adaptation of pulmonary circulation. At birth, exhaled NO does not correlate with plasma NO2-/NO3- and does not seem to be an index of the systemic endogenous NO production.

[Neurologic outcome in infants surgically treated for congenital cardiopathy: preliminary data]. / Outcome neurologico di lattanti operati per cardiopatia congenita: dati preliminari.

INTRODUCTION: Both surgical techniques for correction of congenital heart diseases (CHD) and intraoperatory neurologic protection improved during the last 20 years. Nevertheless cardiac surgery is still a risk for neurologic morbidity. METHODS AND PATIENTS: Analysis of the postoperative neurologic status of infants younger than 6 months who underwent cardiac surgery from January 1998 to December 1999. We reviewed the EEG tracings, cranial ultrasound reports (CUS) and CT scans of 48 patients. Diagnoses were: ventricular septal defect = 15, Fallot (TOF) = 9, patent ductus arteriosus (PDA) = 5, coarctation of aorta = 4, atrio-ventricular septal defect = 4, transposition of great arteries (TGA) = 3, hypoplastic left heart syndrome = 2, pulmonary atresia = 2, total anomalous pulmonary veins drainage = 2, double outlet right ventricle = 1, cor triatriatum = 1. Mean age (range) at intervention was 54 days (2-150), 44 infants (91.7%) survived at follow-up: 23 EEG, 22 CUS and 2 CT were performed in the recent postoperative. Among survivors 5/44 had neurologic complications. EEG was altered in 4: two of them (1 TOF, 1 TGA) had pathologic CUS and CT as well (ischemic pattern in the former, atrophy in the latter). Finally a preterm newborn with PDA had mild abnormalities at CUS. After a mean follow-up of 16 +/- 6 months 3/5 patients had mild-to-moderate psychomotor delay and 2 recovered. CONCLUSIONS: According to our preliminary data the prevalence of neurologic complications in infants who undergo cardiac surgery seems to be low. The pathological findings of the recent postoperative seem to recover up to normalization in some cases at mid-term follow-up. As expected, permanent complications effect more often complex CHD. Further follow-up studies to school age will be mandatory to check the very final results of cardiac surgery performed during early infancy.

[Positioning of umbilical vein catheter with ECG-guided technique: randomized study]. / Posizionamento del catetere ombelicale venoso con tecnica ECG-guidata: studio randomizzato.

GOAL: To evaluate the effectiveness of electrocardiography-guided technique to aid in the correct positioning of umbilical vein catheters. DESIGN: A prospective, randomized controlled study. METHODS: Term and preterm newborns who required an umbilical venous catheter were managed by an ECG-guided technique (group A) or by a conventional method (group B). Correct positioning was defined by a chest-X-ray when the catheter tip was located above the diaphragm and outside the right atrium. For the ECG-guided technique we utilized a conductive device Vygocard (Medival, Padova) inserted in a 3-way stopcock connected with the catheter. The catheter was inserted under ECG observation until the appearance of a tall P-wave in lead III, which indicated the tip was within the right atrium. The catheter was then withdrawn until the P wave size returned to normal. RESULTS: We enrolled 44 patients (16 F, 28 M). Median gestational age (GA) and birth weight (BW) were 34 weeks (range 26-41) and 2130 g. (590-3870), respectively. Sex distribution, GA, BW and Apgar scores were not different between patients in group A (n = 22) and group B (n = 22). Catheters could not be advanced till the estimated insertion depth in 11 patients (A = 5, B = 6). In the remaining 33 patients, correct tip placement was more frequent in group A (88%) compared with group B (50%) (p = 0.021 by Fisher's exact test). No side effects specific to the ECG-guided method were noted. CONCLUSIONS: The ECG-guided technique seems to be a safe and effective method for the proper placement of umbilical vein catheters in newborns.

[A neonatal case of congenital myotonic dystrophy]. / Su un caso neonatale di distrofia miotonica congenita.

Congenital myotonic dystrophy is a rare autosomal disease, caused by an increased number of cytosine-thymine-guanine (CTG) trinucleotide on chromosome 19q. In the neonatal period the most peculiar clinical features are arthrogryposis, hypotonia, facial diplegia, respiratory and feeding difficulties. Clinical and electrical myotonic discharges are difficult to elicit in the newborn. We report a case of congenital myotonic dystrophy in a female newly born presenting with hypotonia, diaphragmatic paralysis, facial diplegia, and contractures of hips, knees and ankles. The diagnosis was confirmed by genetical study on lymphocyte DNA.