The Bronchopulmonary Dysplasia score: A predictive model for bronchopulmonary dysplasia or death in high-risk preterm infants.

AIM: Progressive respiratory deterioration in infants at high risk of bronchopulmonary dysplasia (BPD) is associated with patent ductus arteriosus (PDA) exposure. This study aimed to design an early predictive model for BPD or death in preterm infants using early echocardiographic markers and clinical data. METHODS: Infants born with gestational age (GA) ≤ 29 weeks and/or birth weight (BW) < 1500 g at Cork University Maternity Hospital, Ireland were retrospectively evaluated. Those with echocardiography performed between 36 h and 7 days of life were eligible for inclusion. Exclusion criteria were pulmonary hypertension and major congenital anomalies. The primary outcome was a composite of BPD and death before discharge. RESULTS: The study included 99 infants. A predictive model for the primary outcome was developed, which included three variables (BW, Respiratory Severity Score and flow pattern across the PDA), and yielding an area under the curve of 0.98 (95% CI 0.96-1.00, p < 0.001). Higher scores were predictive of the primary outcome. A cut-off of -1.0 had positive and negative predictive values of 89% and 98%, and sensitivity and specificity of 98% and 88%, respectively. CONCLUSION: Our prediction model is an accessible bedside tool that predicts BPD or death in premature infants.

Impact of cord clamping on haemodynamic transition in term newborn infants.

OBJECTIVE: To assess the haemodynamic consequences of cord clamping (CC) in healthy term infants. DESIGN: Cohort study. SETTING: Tertiary maternity hospital. PATIENTS: 46 full-term vigorous infants born by caesarean section. INTERVENTIONS: Echocardiography was performed before CC, immediately after CC and at 5 min after birth. MAIN OUTCOME MEASURES: Pulsed wave Doppler-derived cardiac output and the pulmonary artery acceleration time indexed to the right ventricle ejection time were obtained. As markers of loading fluctuations, the myocardial performance indexes and the velocities of the tricuspid and mitral valve annuli were determined with tissue Doppler imaging. Heart rate was derived from Doppler imaging throughout the assessments. RESULTS: Left ventricular output increased throughout the first minutes after birth (mean (SD) 222.4 (32.5) mL/kg/min before CC vs 239.7 (33.6) mL/kg/min at 5 min, p=0.01), while right ventricular output decreased (306.5 (48.2) mL/kg/min before vs 272.8 (55.5) mL/kg/min immediately after CC, p=0.001). The loading conditions of both ventricles were transiently impaired by CC, recovering at 5 min. Heart rate progressively decreased after birth, following a linear trend temporarily increased by CC. The variation in left ventricular output across the CC was directly correlated to the fluctuation of left ventricular preload over the same period (p=0.03). CONCLUSIONS: This study illustrates the cardiovascular consequences of CC in term vigorous infants and offers insight into the haemodynamic transition from fetal to neonatal circulation in spontaneously breathing newborns. Strategies that aim to enhance left ventricular preload before CC may prevent complications of perinatal cardiovascular imbalance.

Association between the development of bronchopulmonary dysplasia and platelet transfusion: a protocol for a systematic review and meta-analysis.

Background: There is a lack of consensus on the management of thrombocytopenia in preterm infants, and the threshold for prophylactic platelet transfusion varies widely among clinicians and institutions. Reports in animal models suggested that platelets may play a relevant role in lung alveolarization and regeneration. Bronchopulmonary dysplasia (BPD) is a severe respiratory condition with a multifactorial origin that affects infants born at the early stages of lung development. Recent randomized controlled trials on the platelets count threshold for prophylactic transfusions in preterm infants with thrombocytopenia suggest that a higher exposition to platelet transfusion may increase the risk of BPD. Here, we report a protocol for a systematic review, which aims to assist evidence-based clinical practice and clarify if the administration of platelet products may be associated with the incidence of BPD and/or death in preterm infants. Methods: MEDLINE, Embase, Cochrane databases, and sources of gray literature for conference abstracts and trial registrations will be searched with no time or language restrictions. Case-control studies, cohort studies, and nonrandomized or randomized trials that evaluated the risk for BPD and/or death in preterm infants exposed to platelet transfusion will be included. Data from studies that are sufficiently similar will be pooled as appropriate. Data extraction forms will be developed a priori. Observational studies and nonrandomized and randomized clinical trials will be analyzed separately. Odds ratio with 95% confidence interval (CI) for dichotomous outcomes and the mean difference (95% CI) for continuous outcomes will be combined. The expected heterogeneity will be accounted for using a random-effects model. Subgroup analysis will be performed based on a priori-determined covariate of interest. In case of sufficient homogeneity of interventions and outcomes evaluated, results from subgroups of studies will be pooled together in a meta-analysis. Discussion: This systematic review will investigate the association of BPD/death with platelet components administration in preterm infants, and, consequently, it will provide reliable indications for the evidence-based management of premature patients with thrombocytopenia.

Cord blood presepsin as a predictor of early-onset neonatal sepsis in term and preterm newborns.

BACKGROUND: To date, no studies on presepsin values in cord blood of term infants with risk factors for early-onset sepsis (EOS) are available, whereas only one study reported presepsin values in cord blood of preterm infants at risk. In this study, we investigated the presepsin values in cord blood of term and preterm infants with documented risk factors for EOS. METHODS: In this single-center prospective pilot study, we enrolled neonates presenting with documented risk factors for EOS. P-SEP levels were assessed in a blood sample collected from the clamped umbilical cord after the delivery in 93 neonates, using a point-of-care device. The primary outcome of our study was to evaluate the role of cord blood P-SEP in predicting clinical EOS in term and preterm infants. RESULTS: During the study period, we enrolled 93 neonates with risk factors for EOS with a gestational age ranging between 24.6 and 41.6 weeks (median 38.0). The median P-SEP value in all infants was 491 pg/ml (IQR 377 - 729). Median cord P-SEP values were significantly higher in infants with clinical sepsis (909 pg/ml, IQR 586 - 1307) rather than in infants without (467 pg/ml, IQR 369 - 635) (p = 0.010). We found a statistically significant correlation between cord P-SEP value at birth and the later diagnosis of clinical sepsis (Kendall's τ coefficient 0.222, p = 0.002). We identified the maximum Youden's Index (best cut-off point) at 579 pg/ml, corresponding to a sensitivity of 87.5% and a specificity of 71.8% in predicting clinical sepsis. CONCLUSIONS: Maximum Youden's index was 579 pg/ml for clinical EOS using cord P-SEP values. This could be the starting point to realize multicenter studies, confirming the feasibility of dosing P-SEP in cord blood of infants with risk factors of EOS to discriminate those who could develop clinical sepsis and spare the inappropriate use of antibiotics.

Evaluation of the Hypotensive Preterm Infant: Evidence-Based Practice at the Bedside?

Choosing the appropriate management approach for the preterm infant with low blood pressure during the transition period generally involved intervening when the blood pressure drifted below a certain threshold. It is now clear that this approach is too simplistic and does not address the underlying physiology. In this chapter, we explore the many monitoring tools available for evaluation of the hypotensive preterm and assess the evidence base supporting or refuting their use. The key challenge relates to incorporating these outputs with the clinical status of the patient and choosing the appropriate management strategy.

Cardiopulmonary Ultrasound Patterns of Transient Acute Respiratory Distress of the Newborn: A Retrospective Pilot Study.

Acute transient respiratory distress in the first hours of life is usually defined as transient tachypnea of the newborn (TTN). TTN is a respiratory self-limiting disorder consequent to delayed lung fluid clearance at birth. While TTN is the most common etiology of respiratory distress near term, its pathogenesis and diagnostic criteria are not well-defined. Lung ultrasound and targeted neonatal echocardiography are increasingly being used to assess critically ill infants, although their combined use to improve diagnostic precision in neonatal intensive care units has not yet been described. This retrospective pilot analysis aimed to identify possible cardiopulmonary ultrasound (CPUS) patterns in term and late preterm infants suffering from transient respiratory distress and requiring non-invasive respiratory support. After retrospectively revising CPUS images, we found seven potential sonographic phenotypes of acute neonatal respiratory distress. Up to 50% of the patients presented with signs of increased pulmonary vascular resistance, suggesting that those patients may be diagnosed with mild forms of persistent pulmonary hypertension of the newborn. Approximately 80% of the infants with a history of meconium-stained amniotic fluid displayed irregular atelectasis, indicating that they may have suffered from mild meconium aspiration syndrome. CPUS evaluation may improve accuracy in the approach to the infants presenting with transient acute respiratory distress, supporting communication with the parents and carrying important epidemiological consequences.

Lung UltraSound Targeted Recruitment (LUSTR): A Novel Protocol to Optimize Open Lung Ventilation in Critically Ill Neonates.

This study investigated the effectiveness of an original Lung UltraSound Targeted Recruitment (LUSTR) protocol to improve the success of lung recruitment maneuvers (LRMs), which are performed as a rescue approach in critically ill neonates. All the LUSTR maneuvers, performed on infants with an oxygen saturation/fraction of inspired oxygen (S/F) ratio below 200, were included in this case-control study (LUSTR-group). The LUSTR-group was matched by the initial S/F ratio and underlying respiratory disease with a control group of lung recruitments performed following the standard oxygenation-guided procedure (Ox-group). The primary outcome was the improvement of the S/F ratio (Delta S/F) throughout the LRM. Secondary outcomes included the rate of air leaks. Each group was comprised of fourteen LRMs. As compared to the standard approach, the LUSTR protocol was associated with a higher success of the procedure in terms of Delta S/F (110 ± 47.3 vs. 64.1 ± 54.6, p = 0.02). This result remained significant after adjusting for confounding variables through multiple linear regressions. The incidence of pneumothorax was lower, although not reaching statistical significance, in the LUSTR-group (0 vs. 14.3%, p = 0.15). The LUSTR protocol may be a more effective and safer option than the oxygenation-based procedure to guide open lung ventilation in neonates, potentially improving ventilation and reducing the impact of ventilator-induced lung injury.

Presepsin levels in neonatal cord blood are not influenced by maternal SARS-CoV-2 infection.

OBJECTIVES: Coronavirus disease (COVID-19) can present with various symptoms and can involve multiple organs. Women infected during pregnancy have a higher incidence of obstetrical complications and infants born to "positive" mothers may get the infection with different manifestations. Presepsin seems to be a promising sepsis biomarker in adults and neonates. The aim of this study was to assess if presepsin levels in neonatal cord blood could be influenced by maternal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS: A total of 119 neonates born from women with a confirmed diagnosis of SARS-CoV-2 infection were enrolled and presepsin levels of cord blood samples were collected. All neonates were tested for SARS-CoV-2 infection at birth and after 48-72 h. RESULTS: The median presepsin value in umbilical cord blood samples collected after birth was 455 pg/mL. Presepsin levels were not influenced by maternal symptoms of COVID-19, weight for gestational age, or delivery mode, and did not significantly differ between infants with and without adverse neonatal outcomes. Infants hospitalized for more than 5 days had a significantly higher presepsin level at birth rather than those discharged up to 4 days of life. Three infants with positive nasopharyngeal swab at birth had higher Presepsin levels than two infants tested positive at 48 h. CONCLUSIONS: This is the first study reporting cord presepsin levels in term and preterm infants born to mothers with COVID-19, that appeared to be not influenced by maternal clinical presentation. However, further studies are needed to explain the mechanisms of P-SEP increase in neonates exposed to perinatal maternal SARS-CoV-2 infection or with an indeterminate/possible SARS-CoV-2 infection in the same neonates.

Steroid use for established bronchopulmonary dysplasia: study protocol for a systematic review and meta-analysis.

INTRODUCTION: Postnatal steroids during the first few weeks of life have been demonstrated to be effective in decreasing the incidence of bronchopulmonary dysplasia (BPD), a serious chronic respiratory condition affecting preterm infants. However, this preventive option is limited by the concern of neurological side effects. Steroids are used to treat established BPD in an attempt to reduce mortality, and length of stay and home oxygen therapy, both of which associated with high levels of parental stress and healthcare costs. Moreover, a late timing for steroid treatment may show a more favourable safety profile in terms of neurodevelopment outcomes, considering the added postnatal brain maturation of these infants. Here, we report a protocol for a systematic review, which aims to determine the efficacy and long-term safety of postnatal steroids for the treatment of established BPD in preterm infants. METHODS AND ANALYSIS: MEDLINE, Embase, Cochrane databases and sources of grey literature for conference abstracts and trial registrations will be searched with no time or language restriction. We will include case-control studies, cohort studies and non-randomised or randomised trials that evaluate postnatal steroids for infants diagnosed with moderate or severe established BPD at 36 weeks' postmenstrual age. We will pool data from studies that are sufficiently similar to make this appropriate. Data extraction forms will be developed a priori. Observational studies and non-randomised and randomised clinical trials will be analysed separately. We will combine OR with 95% CI for dichotomous outcomes and the mean difference (95% CI) for continuous outcomes. We will account for the expected heterogeneity by using a random-effects model. We will perform subgroup analysis based on the a priori determined covariate of interest. ETHICS AND DISSEMINATION: Systematic reviews are exempted from approval by an ethics committee. Attempts will be sought to publish all results. PROSPERO REGISTRATION NUMBER: CRD42021218881.

Rooming-In Practice During the Pandemic: Results From a Retrospective Cohort Study.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic emerged in December 2019 and spread rapidly worldwide. So far, evidence regarding the breastfeeding and rooming-in management of mothers with COVID-19 and their newborn infants is scarce. RESEARCH AIMS: 1) To assess the rate of exclusive breastfeeding at discharge among mothers with COVID-19 and their newborn infants managed either using a rooming-in or a separation regimen; and 2) to evaluate different neonatal outcomes, including the need for re-hospitalization related to COVID-19 among newborn infants in the two groups. METHOD: We conducted a retrospective two-group comparative observational study. The sample was participants with COVID-19 and their newborn infants (N = 155 dyads) between March 1, 2020, and April 30, 2021. Two time periods were outlined resulting from the two different clinical practices of mother-infant separation and rooming-in. RESULTS: Within the sample, 145 (93.5%) were asymptomatic. All neonates had documented Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) test results, and six tested positive by reverse transcriptase polymerase chain reaction within 48 hr of life. The rate of exclusive breastfeeding was significantly higher (p < .0001) within the rooming-in group. Length of hospital stay was significantly lower (p = .001) within the rooming-in group. CONCLUSIONS: Protected rooming-in practice has proven to be safe and effective in supporting breastfeeding: None of the infants enrolled were hospitalized due to COVID-19 infection and the rate of exclusive breastfeeding at discharge was increased compared to those infants separated from their mothers.

Targeted management of evolving and established chronic lung disease of prematurity assisted by cardiopulmonary ultrasound: A case report of four patients.

Bronchopulmonary dysplasia (BPD) is one of the most common complications of premature birth. The current definition of BPD is based on the duration of oxygen therapy and/or respiratory support. Among the pitfalls of all the diagnostic definitions, the lack of a proper pathophysiologic classification makes it difficult to choose an appropriate drug strategy for BPD. In this case report, we describe the clinical course of four premature infants, admitted to the neonatal intensive care unit, for whom the use of lung and cardiac ultrasound was an integral part of the diagnostic and therapeutic process. We describe, for the first time to our knowledge, four different cardiopulmonary ultrasound patterns of evolving and established chronic lung disease of prematurity and the consequent therapeutic choices. This approach, if confirmed in prospective studies, may guide the personalized management of infants suffering from evolving and established BPD, optimizing the chances of success of the therapies and at the same time reducing the risk of exposure to inadequate and potentially harmful drugs.

Lung ultrasound guided pulmonary recruitment during mechanical ventilation in neonates: A case series.

BACKGROUND: Recently, the first report of lung ultrasound (LUS) guided recruitment during open lung ventilation in neonates has been published. LUS guided recruitment can change the approach to open lung ventilation, which is currently performed without any measure of lung function/lung expansion in the neonatal population. METHODS: We included all the newborn infants that underwent a LUS-guided recruitment maneuver during mechanical ventilation as a rescue attempt for an extremely severe respiratory condition with oxygen saturation/fraction of inspired oxygen (SpO2/FIO2) ratio below 130 or the inability to wean off mechanical ventilation. RESULTS: We report a case series describing 4 LUS guided recruitment maneuvers, underlying crucial aspects of this technique that can improve the effectiveness of the procedure. In particular, we describe a novel pattern (the S-pattern) that allows us to distinguish the recruitable from the unrecruitable lung and guide the pressure titration phase. Additionally, we describe the optimal LUS-guided patient positioning. CONCLUSIONS: We believe that the inclusion of specifications regarding patient positioning and the S-pattern in the LUS-guided protocol may be beneficial for the success of the procedure.