Comparative effects of epidural analgesia and intramuscular morphine on maternal and neonatal outcomes: a retrospective cohort study.

BACKGROUND: The global practice of pain management during labor involves the use of epidural analgesia or intramuscular morphine. However, the impact of these methods on maternal and neonatal short-term outcomes remains uncertain. OBJECTIVE: This study aimed to evaluate the effect of labor exposure to epidural analgesia and intramuscular morphine on neonatal intensive care unit admission rates and other associated maternal and neonatal outcomes such as sepsis, respiratory distress, instrumental delivery, birth trauma, low Apgar score, and chorioamnionitis. STUDY DESIGN: A study at the Women's Wellness and Research Center in Qatar analyzed 7721 low-risk normal vaginal deliveries from January 2017 to April 2018. Results were analyzed using descriptive and backward stepwise multinomial regression analysis, categorizing outcomes on the basis of pain management during active labor. RESULTS: Of the 7607 participants in the final sample, 2606 received epidural analgesia, 1338 received intramuscular morphine, 286 received both, and 3304 received neither. Multinomial regression analysis revealed no difference in neonatal intensive care unit admission in the epidural analgesia group or in the intramuscular morphine group compared with the group that received neither intervention. However, the analysis showed a significant association between the combined use of epidural analgesia and intramuscular morphine and neonatal intensive care unit admission due to respiratory depression (adjusted odds ratio, 8.63; 95% confidence interval, 1.07-69.46; P=.04). Moreover, there was a significant association between prolonged duration of the second stage of labor and receiving epidural analgesia alone (adjusted odds ratio, 1.02; 95% confidence interval, 1.01-1.02; P<.001) or the combination of epidural analgesia and intramuscular morphine (adjusted odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P<.001). In addition, the combined use of epidural analgesia and intramuscular morphine was associated with gestational age (adjusted odds ratio, 1.86; 95% confidence interval, 1.19-2.90; P=.01) and infant sex (adjusted odds ratio, 3.72; 95% confidence interval, 1.54-9.01; P=.003). Intramuscular morphine alone was only linked to low Apgar score at 1 minute (adjusted odds ratio, 6.29; 95% confidence interval, 1.33-29.83; P=.02). CONCLUSION: In low-risk mothers, combining epidural analgesia and intramuscular morphine during labor increases NICU admission risk due to respiratory depression. However, the individual use of either method shows distinct clinical profile. Further research is warranted to enhance understanding and optimize pain management protocols.

Impact of birth weight to placental weight ratio and other perinatal risk factors on left ventricular dimensions in newborns: a prospective cohort analysis.

OBJECTIVES: To investigate the association between birth weight to placental weight (BW/PW) ratio, and echocardiographic left ventricle (LV) morphology at birth, while accounting for other relevant perinatal factors. METHODS: A prospective cohort study was conducted on neonates at NewYork-Presbyterian Brooklyn Methodist Hospital from 2014 to 2018, categorized by their BW/PW percentile. Missing data were imputed with principal component analysis. Chi-squared and one-way analysis of variance were used to compare BW/PW groups and the best regression model was selected using a genetic and backward stepwise algorithm. RESULTS: We analyzed 827 neonates in three BW/PW groups: small (n=16), normal (n=488), and large (n=323). Placental thickness and smallest diameter were positively correlated with several LV parameters, including inter-ventricular septal thickness during diastole (IVSd) (p=0.002, p<0.001) and systole (IVSs) (p=0.001, p<0.001), LV posterior wall thickness at end of diastole (LVPWd) (p=0.003, p<0.001) and systole (LVPWs) (p<0.001, p<0.001), LV mass (p=0.017, p<0.001), and LV mass/volume (p=0.011, p<0.001). The BW/PW ratio correlated with an increased shortening fraction (estimate=0.29, 95 % CI 0.03-0.55, p=0.027). PW correlated with IVSs (p=0.019), while the longest placental diameter was linked to a decrease in LV internal dimension during diastole (LVIDd) (estimate=-0.07, p=0.039), LV mass (estimate=-0.11, p=0.024), and LV mass/volume (estimate=-0.55, p=0.005). CONCLUSIONS: This study found that several placental factors, including the BW/PW ratio, can independently affect LV dimension and morphology, highlighting the importance of fetal growth and placental health in the physiological adaptation of the fetal heart. More research is needed to establish causation and inform newborn prevention strategies.

Preterm infants with positive conjunctival swab culture: risk factors and association with late-onset sepsis-a retrospective cohort study.

Introduction: Purulent conjunctival discharge in hospitalized preterm infants may indicate conjunctivitis and warrant treatment. The purpose of this study was to examine the relationship between positive conjunctival swab (CS) culture and late-onset sepsis (LOS) in preterm infants. Methods: A retrospective cohort study was conducted to determine the relationship between positive CS culture growth results (CSP) obtained in preterm infants ≤34 weeks' gestation and the development of LOS within 120 h of obtaining CS compared with those who had negative CS culture results (CSN). Electronic medical records were reviewed from January 2015 until December 2019 for preterm infants presenting with purulent conjunctival discharge and underwent CS culture testing due to suspected conjunctivitis. Results: Of the 234 CS cultures obtained during the study period, 145 (61.9%) were CSP compared to 89 (38.1%) CSN cultures. Gram-negative organisms accounted for 70% of all CSP cultures, with the remaining 30% being Gram-positive. Patients with CSP were smaller, younger, had lower 1-minute APGAR scores, and required respiratory support more frequently than those with CSN. Infants with CSP received antibiotics for longer periods, both topically and systemically. Infants who developed LOS were more likely to require invasive ventilation (adjusted odds ratio, 33.5; 95% CI, 2.52-446.5, p = 0.008). The incidence of LOS between the two groups was similar, with 6.2% observed in the CSP group compared to 3.4% in the CSN group (p = 0.543). Similarly, the rates of bacteremia were similar in both groups. Of the CSP patients who were presented with bacteremia, four out of seven (57%) exhibited bacteremia caused by the same organism found in their CS cultures. Similarly, within the entire cohort, respiratory cultures were performed on nine intubated patients within two weeks of obtaining CS cultures. Of these, in the CSP group, five out of six (83%) showed an organism identical to that found in the CS cultures. Conclusion: The study found a significant proportion of positive CS cultures in preterm infants, with distinct patient characteristics and treatment compared to negative cultures. While the incidence of LOS was not significantly different between the two groups, some CSP patients demonstrated bacteremia with the same CS organism, suggesting a possible connection between conjunctival or respiratory colonization and bacteremia.

Comparing low-dose (DART) and enhanced low-dose dexamethasone regimens in preterm infants with bronchopulmonary dysplasia.

Introduction: Determining the optimal dexamethasone dosage for facilitating extubation in extremely low birth weight (ELBW) infants with bronchopulmonary dysplasia (BPD) remains uncertain. This study aims to compare the effectiveness of low-dose (DART) and enhanced low-dose dexamethasone regimens in achieving successful extubation in these infants. Methods: We conducted a retrospective cohort study at the Women's Wellness and Research Center (WWRC) involving ELBW infants who received dexamethasone for BPD prevention or treatment, or for extubation between January 1st, 2015, and December 31st, 2019. Our goal was to assess successful extubation within various time points of treatement. Results: A total of 77 patients, matched in gestational age and BW, were enrolled in the study, receiving a total of 121 dexamethasone courses. Low-dose dexamethasone courses were administered 75 times to 49 infants, while 46 courses of enhanced low-dose were given to 28 infants. Treatment commenced at 30.8 ± 3.4 weeks post-menstrual age, compared to 32.1 ± 2.5 weeks in the enhanced low-dose group (p = 0.014). The median (IQR) course duration was seven (3-10) days in the low-dose group, while it was 10 (8-14) days in the enhanced low-dose group (p < 0.001). The median (IQR) course dose was 0.73 (0.53-0.86) mg/kg in the low-dose group and 1.27 (0.97-2.05) mg/kg in the enhanced low-dose group (p < 0.001). There were no differences in extubation success at any time point between the two groups at 72 h and seven days after treatment initiation, by course completion, and within seven days after treatment completion. However, regression analysis identified several predictors of successful extubation; baseline FiO2, course duration, and duration of invasive mechanical ventilation were negatively associated with successful extubation at various time points, while received dose per kg and cumulative dose positively correlated with successful extubation at different time points. No significant differences were observed in secondary outcomes, including death or BPD. Conclusion: The choice between low-dose and enhanced low-dose dexamethasone regimens may not significantly impact extubation success. However, careful consideration of dosing, ventilation status, and treatment duration remains crucial in achieving successful extubation. This study highlights the need for personalized dexamethasone therapy in ELBW infants.

Perinatal factors impacting echocardiographic left ventricular measurement in small for gestational age infants: a prospective cohort study.

INTRODUCTION: Infants born small for gestational age (SGA) have an increased risk of developing various cardiovascular complications. While many influencing factors can be adjusted or adapt over time, congenital factors also have a significant role. This study, therefore, seeks to explore the effect of perinatal factors on the left ventricular (LV) parameters in SGA infants, as assessed immediately after birth. METHODS AND MATERIALS: This single-center prospective cohort study, conducted between 2014 and 2018, involved healthy SGA newborns born > 35 weeks' gestation, delivered at New York-Presbyterian Brooklyn Methodist Hospital, and a gestational age (GA)-matched control group of appropriate for gestational age (AGA) infants. Data analysis was performed using multivariate linear regression in STATA. RESULTS: The study enrolled 528 neonates, 114 SGA and 414 AGA. SGA infants exhibited a mean GA of 38.05 weeks (vs. 38.54), higher male representation (69.3% vs. 51.5%), lower birth weight (BW) (2318g vs 3381g), lower Apgar scores at birth, and a higher rate of neonatal intensive care unit admission compared to AGA infants (41.2% vs.18.9%; p<0.001). Furthermore, SGA infants were more likely to be born to nulliparous women (63.16% vs. 38.16%; p<0.001), with lower body mass index (BMI) (29.8 vs. 31.7; p=0.004), a lower prevalence of gestational maternal diabetes (GDM) (14.9 % vs. 35.5%; p<0.001), and a higher prevalence of preeclampsia (18.4 % vs. 6.52%; p<0.001). BW was identified as the most significant predictor affecting most LV parameters in this study (p<0.001), except shortening fraction, asymmetric interventricular septal hypertrophy and Inter-ventricular septal thickness/LV posterior wall ratio (IVS/LVPW). Lower GA (coefficient = -0.09, p=0.002), insulin use in GDM (coefficient = 0.39, p=0.014), and low APGAR scores at 1 minute (coefficient = -0.07, p<0.001) were significant predictors of IVS during diastole (R-squared [R2]=0.24). High maternal BMI is marginally associated with LVPW during systole (R2=0.27, coefficient = 0.01, p=0.050), while male sex was a significant predictor of LV internal dimension during diastole (R2=0.29, p=0.033). CONCLUSION: This study highlights the significant influence of perinatal factors on LV parameters in SGA infants, with BW being the most influential factor. Although LV morphology alone may not predict future cardiovascular risk in the SGA population, further research is needed to develop effective strategies for long-term cardiovascular health management in this population.

Warfarin-Associated Fetal Subdural Hematoma Causing Severe Neurodevelopmental Delay: A Case Report.

Fetal subdural hematoma is an antenatal finding associated with significant morbidity and mortality. It can occur due to maternal or fetal risk factors, and its management varies based on the underlying cause and the anticipated long-term outcomes. We present a case of warfarin-associated fetal subdural hematoma resulting in a live birth and severe neurodevelopmental delay by 10 years of age. In conclusion, counseling regarding the risk of fetal intracranial hemorrhage and the potential neurodevelopmental delay is essential in women who require anticoagulation with warfarin. In addition, close antenatal follow-up with fetal sonography and strict INR monitoring are essential preventative measures.

Case report: Neonatal autoimmune lymphoproliferative syndrome with a novel pathogenic homozygous FAS variant effectively treated with sirolimus.

Background: Autoimmune lymphoproliferative syndrome (ALPS) is a rare disease characterized by defective FAS signaling, which results in chronic, nonmalignant lymphoproliferation and autoimmunity accompanied by increased numbers of "double-negative" T-cells (DNTs) (T-cell receptor αß+ CD4-CD8-) and an increased risk of developing malignancies later in life. Case presentation: We herein report a case of a newborn boy with a novel germline homozygous variant identified in the FAS gene, exon 9, c.775del, which was considered pathogenic. The consequence of this sequence change was the creation of a premature translational stop signal p.(lle259*), associated with a severe clinical phenotype of ALPS-FAS. The elder brother of the proband was also affected by ALPS and has been found to have the same FAS homozygous variant associated with a severe clinical phenotype of ALPS-FAS, whereas the unaffected parents are heterozygous carriers of this variant. This new variant has not previously been described in population databases (gnomAD and ExAC) or in patients with FAS-related conditions. Treatment with sirolimus effectively improved the patient clinical manifestations with obvious reduction in the percentage of DNTs. Conclusion: We described a new ALPS-FAS clinical phenotype-associated germline FAS homozygous pathogenic variant, exon 9, c.775del, that produces a premature translational stop signal p.(lle259*). Sirolimus significantly reduced DNTs and substantially relieved the patient's clinical symptoms.

Neonatal Simulation Program: A 5 Years Educational Journey From Qatar.

We describe the process of implementation, adaptation, expansion and some related clinical intuitional impacts of the neonatal simulation program since its launch in 2016 in a non-simulation neonatal unit. The team has developed 6 types of curricula: 1 full-day course and 5 half-day workshops. A total of 35 free of charge simulation courses/workshops were conducted, 32 in Qatar and 3 abroad with a total of 799 diverse participants. There was a steady increase in the overall success rate of PICC insertion from 81.7% (309/378) to 97.6% (439/450) across 3 years (P < 0.0001). The first attempt PICC insertion success rate has been also increased from 57.7% (218/378) to 66.9% (301/450) across 3 years. The mean duration of PICC insertion has been improved from 39.7 ± 25 to 34.9 ± 12.4 min after implementing the program (P = 0.33). The mean duration of the LISA catheter insertion at the beginning of the workshop was 23.5 ± 15.9 compared to 12.1 ± 8.5 s at the end of the workshop (P = 0.001). When it came to clinical practise in real patients by the same participants, the overall LISA catheter insertion success rate was 100% and the first attempt success rate was 80.4%. The mean duration of LISA catheter insertion in real patients was 26.9 ± 13.9 s compared to the end of the workshop (P = 0.001). The mean duration of the endotracheal intubation at the beginning of the workshop was 12.5 ± 9.2 compared to 4.2 ± 3.8 s at the end of the workshop (P = 0.001). In real patients, the first-attempt intubation success rate has been improved from 37/139 (26.6%) in the first year to 141/187 (75.5%) in the second year after the program implementation (P = 0.001). The mean duration of successful endotracheal intubation attempts has been improved from 39.1 ± 52.4 to 20.1 ± 9.9 s (P = 0.78). As per the participants, the skills learned in the program sessions help in protecting neonates from potential harm and improve the overall neonatal outcome. Implementing a neonatal simulation program is a promising and feasible idea. Our experience can be generalised and replicated in other neonatal care institutions.

Peripherally inserted central catheters versus non-tunnelled ultrasound-guided central venous catheters in newborns: a retrospective observational study.

OBJECTIVES: We aimed to compare the success rates and other catheter-related parameters between peripherally inserted central catheters (PICCs) and non-tunnelled ultrasound-guided central venous catheters (USG-CVCs) including femoral, jugular, brachiocephalic and subclavian lines. DESIGN: This was a retrospective observational study. SETTING: The study was performed in a level III neonatal intensive care unit (NICU) in Qatar, as a single-site study. PARTICIPANTS: This study included 1333 neonates who required CVC insertion in the NICU from January 2016 to December 2018. Of those, we had 1264 PICCs and 69 non-tunnelled USG-CVCs. OUTCOME MEASURES: The success rate and other catheter-related complications in the two groups. RESULTS: The overall success rate was 88.4% in the USG-CVCs (61/69) compared with 90% in the PICCs (1137/1264) group (p=0.68). However, the first prick success rate was 69.4% in USG-CVCs (43/69) compared with 63.6% in the PICCs (796/1264) group. Leaking and central line-associated blood stream infection (CLABSI) were significantly higher in the USG-CVC group compared with the PICC group (leaking 16.4% vs 2.3%, p=0.0001) (CLABSI 8.2% vs 3.1%, p=0.03). CLABSI rates in the PICC group were 1.75 per 1000 catheter days in 2016 and 3.3 in 2017 compared with 6.91 in 2016 (p=0.0001) and 14.32 in 2017 (p=0.0001) for the USG-CVCs. USG-CVCs had to be removed due to catheter-related complications in 52.5% of the cases compared with 29.9% in PICCs, p=0.001. In 2018, we did not have any non-tunnelled USG-CVCs insertions in our NICU. CONCLUSIONS: The overall complication rate, CLABSI and leaking are significantly higher in non-tunnelled USG-CVCs compared with the PICCs. However, randomised controlled trials with larger sample sizes are desired. Proper central venous device selection and timing, early PICC insertion and early removal approach, dedicated vascular access team development, proper central venous line maintenance, central line simulation workshops and US-guided insertions are crucial elements for patient safety in NICU.

Maternal and neonatal outcomes in mothers with diabetes mellitus in qatari population.

BACKGROUND: Diabetes Mellitus (DM) is a major cause of maternal, fetal, and neonatal morbidities. Our objective was to estimate the effect of both pre-pregnancy and gestational DM on the growth parameters of newborns in the Qatari population. METHODS: In this population-based cohort study, we compared the data of neonates born to Qatari women with both pre-pregnancy and gestational diabetes mellitus in 2017 with neonates of healthy non-diabetic Qatari women. RESULTS: Out of a total of 17020 live births in 2017, 5195 newborns were born to Qatari women. Of these, 1260 were born to women with GDM, 152 were born to women with pre-pregnancy DM and 3783 neonates were born to healthy non-diabetic (control) women. The prevalence of GDM in the Qatari population in 2017 was 24.25%. HbA1C% before delivery was significantly higher in women with pre-pregnancy DM (mean 6.19 ± 1.15) compared to those with GDM (mean 5.28 ± 0.43) (P <0.0001). The mean birth weight in grams was 3066.01 ± 603.42 in the control group compared to 3156.73 ± 577.88 in infants born to women with GDM and 3048.78 ± 677.98 in infants born to women with pre-pregnancy DM (P <0.0001). There was no statistically significant difference regarding the mean length (P= 0.080), head circumference (P= 0.514), and rate of major congenital malformations (P= 0.211). Macrosomia (Birth weight > 4000 gm) was observed in 2.7% of the control group compared to 4.8% in infants born to women with GDM, and 4.6% in infants born to women with pre-pregnancy DM (P= 0.001). Multivariate logistic regression analysis demonstrated that higher maternal age (adjusted OR 2.21, 95% CI 1.93, 2.52, P<0.0001), obesity before pregnancy (adjusted OR 1.71, 95% CI 1.30, 2.23, P<0.0001), type of delivery C-section (adjusted OR 1.25, 95% CI 1.09, 1.44, P=0.002), and body weight to gestational age LGA (adjusted OR 2.30, 95% CI 1.64, 2.34, P<0.0001) were significantly associated with increased risk of GDM. CONCLUSION: Despite the multi-disciplinary antenatal diabetic care management, there is still an increased birth weight and an increased prevalence of macrosomia among the infants of diabetic mothers. More efforts should be addressed to improve the known modifiable factors such as women's adherence to the diabetic control program. Furthermore, pre-pregnancy BMI was found to be significantly associated with gestational DM, and this is a factor that can be addressed during pre-conceptional counseling.

Video didactic at the point of care impacts hand hygiene compliance in the neonatal intensive care unit (NICU).

OBJECTIVE: To increase the hand-washing (HW) duration of staff and visitors in the NICU to a minimum of 20 seconds as recommended by the CDC. METHODS: Intervention included video didactic triggered by motion sensor to play above wash basin. Video enacted Centers for Disease Control and Prevention (CDC) HW technique in real time and displayed timer of 20 seconds. HW was reviewed from surveillance video. Swabs of hands plated and observed for qualitative growth (QG) of bacterial colonies. RESULTS: In visitors, the mean HW duration at baseline was 16.3 seconds and increased to 23.4 seconds at the 2-week interval (p = .003) and 22.9 seconds at the 9-month interval (p < .0005). In staff, the mean HW duration at baseline was 18.4 seconds and increased to 29.0 seconds at 2-week interval (p = .001) and 25.7 seconds at the 9-month interval (p < .0005). In visitors, HW compliance at baseline was 33% and increased to 52% at the 2-week interval (p = .076) and 69% at the 9-month interval (p = .001). In staff, HW compliance at baseline was 42% and increased to 64% at the 2-week interval (p = .025) and 72% at the 9-month interval (p = .001). Increasing HW was significantly associated with linear decrease in bacterial QG. CONCLUSIONS: The intervention significantly increased mean HW time, compliance with a 20-econd wash time and decreased bacterial QG of hands and these results were sustained over a 9-month period.

Prominent Eustachian Valve in Newborns: A Report of Four Cases.

The Eustachian valve (EV) is an embryological remnant of the inferior vena cava that during fetal life helps divert oxygenated blood from the IVC toward the foramen ovale to escape the pulmonary circulation. This remnant usually regresses after birth and is considered a benign finding in the majority of cases. However, EV can lead to complications in the neonatal period or later in life. In this short case series, we present four newborn infants with prominent EV who were symptomatic after birth and required admission to the neonatal intensive care unit.

Histologic chorioamnionitis as a consideration in the management of newborns of febrile mothers.

INTRODUCTION: Chorioamnionitis (CA) presents a risk for neonatal sepsis, but its diagnosis remains a challenge. Maternal fever is often used as a clinical predictor of infection, but may be affected by other factors. There is no consensus among neonatologists regarding the length of treatment of babies born to febrile mothers with negative blood culture, but whose placentas are positive for the presence of histologic CA (HCA). OBJECTIVES: A prospective observational cohort study was conducted on term infants to determine the association of HCA with C-reactive protein (CRP) and elevated immature/total neutrophil (I/T) ratio and other perinatal factors. METHODS: I/T ratio, CRP, blood culture and placental pathology were performed on 100 infants born to mothers with temperature ≥ 100.4 °F. Placental pathology performed on 100 control infants born to afebrile mothers. RESULTS: There was a significant association between HCA and maternal fever (MF). The presence of elevated CRP was associated with HCA. There was no significant association between HCA and anesthesia, mode of delivery, nor elevated I/T ratio. CONCLUSIONS: Maternal fever is associated with HCA. The HCA in conjunction with an elevated CRP can guide the duration of antimicrobial therapy in infants born to febrile mothers.

Simulated transport alters surfactant homeostasis and causes dose-dependent changes in respiratory function in neonatal Sprague-Dawley rats.

OBJECTIVE: Forces transmitted to the neonate as a consequence of accelerations during transport have been associated with adverse neonatal outcomes including broncho-pulmonary dysplasia. In this study, we sought to determine the relationship between the duration of transport and respiratory performance in the rat model. METHODS: Four groups of Sprague-Dawley rat pups (10-12 pups/groups) were exposed to simulated medical transport on postnatal day of life 11 or 12. Each group was exposed to an average impulse of 27.4 m/s(2)/min for 0, 30, 60 or 90 min. During the exposure periods, impulse was monitored by computerized sampling using a digital accelerometer. Post-exposure, animals were immediately prepared, placed on mechanical ventilation and analyzed for elastance, tissue damping, airway resistance, ratio of damping to elastance (eta), hysteresivity, and inertance at positive end expiratory pressures (PEEPs) of 0, 3 and 6 cm(3) of H(2)O. Total phospholipid content and surfactant proteins A, B, and C mRNA levels in broncho-alveolar lavage fluid and lung tissue were obtained. RESULTS: Increased transport time resulted in a significant step-wise increase in airway resistance at all levels of PEEP (P<0.01). Static compliance decreased significantly after 60 min at PEEPs of 3 and 6 cm H(2)O (P<0.01). Eta significantly decreased with greater transport time at a PEEP of 6 cm H(2)O (P<0.05). Tissue damping increased with duration of transport time across all PEEP levels, but only exhibited statistical significance at a PEEP of 0 cm H(2)O (P<0.05). No differences were seen in hysteresivity or inertance. Compared with controls, transport was associated with significant reductions in total phospholipid content and mRNA levels of surfactant proteins B and C. CONCLUSION: Rat pups experienced significant deterioration of respiratory function with increasing duration of simulated transport.

Perinatal isolated atrial flutter associated with maternal cocaine and opiate use in a late preterm infant.

Atrial flutter is a serious form of neonatal tachyarrhythmia. Maternal drug use of cocaine and/or opiate is associated with central and autonomic nervous signs in fetuses and newborn infants. The fetal cardiovascular effects of cocaine and opiate exposure are not well characterized. We present the case of isolated atrial flutter in a late preterm infant who has been perinatally exposed to cocaine and opiate.

Transient in utero disruption of cystic fibrosis transmembrane conductance regulator causes phenotypic changes in alveolar type II cells in adult rats.

BACKGROUND: Mechanicosensory mechanisms regulate cell differentiation during lung organogenesis. We have previously demonstrated that cystic fibrosis transmembrane conductance regulator (CFTR) was integral to stretch-induced growth and development and that transient expression of antisense-CFTR (ASCFTR) had negative effects on lung structure and function. In this study, we examined adult alveolar type II (ATII) cell phenotype after transient knock down of CFTR by adenovirus-directed in utero expression of ASCFTR in the fetal lung. RESULTS: In comparison to (reporter gene-treated) Controls, ASCFTR-treated adult rat lungs showed elevated phosphatidylcholine (PC) levels in the large but not in the small aggregates of alveolar surfactant. The lung mRNA levels for SP-A and SP-B were lower in the ASCFTR rats. The basal PC secretion in ATII cells was similar in the two groups. However, compared to Control ATII cells, the cells in ASCFTR group showed higher PC secretion with ATP or phorbol myristate acetate. The cell PC pool was also larger in the ASCFTR group. Thus, the increased surfactant secretion in ATII cells could cause higher PC levels in large aggregates of surfactant. In freshly isolated ATII cells, the expression of surfactant proteins was unchanged, suggesting that the lungs of ASCFTR rats contained fewer ATII cells. Gene array analysis of RNA of freshly isolated ATII cells from these lungs showed altered expression of several genes including elevated expression of two calcium-related genes, Ca2+-ATPase and calcium-calmodulin kinase kinase1 (CaMkk1), which was confirmed by real-time PCR. Western blot analysis showed increased expression of calmodulin kinase I, which is activated following phosphorylation by CaMkk1. Although increased expression of calcium regulating genes would argue in favor of Ca2+-dependent mechanisms increasing surfactant secretion, we cannot exclude contribution of alternate mechanisms because of other phenotypic changes in ATII cells of the ASCFTR group. CONCLUSION: Developmental changes due to transient disruption of CFTR in fetal lung reflect in altered ATII cell phenotype in the adult life.

Special immunization considerations of the preterm infant.

More changes to the American Academy of Pediatrics Recommended Immunization Schedule have occurred in the past 3 years than in the previous decade. Selection of the optimal immunization regimen is essential to forestall immunization delay. New complications to the schedule pose challenges for the care of preterm infants who are at increased risk of mortality and morbidity from vaccine-preventable diseases. This article reviews the relevant data regarding immunization of preterm infants and suggests strategies for prevention of immunization delay. Protection of preterm infants, especially for pertussis and influenza, involves not just assessing a child's vaccination status but those of other close contacts and household members.