Early diagnosis of bacterial infection in the neonate.

The diagnosis of neonatal bacterial infection remains one of the greatest and most tantalizing challenges to neonatologists. At birth it must be based on the history of pregnancy and take into account a number of now well-defined risk factors. In addition, if promptly started, antibiotic therapy can reduce its sequelae and improve the prognosis. However, the number of tests that obstetricians can rely on for the diagnosis of infection is quite limited. Tests of maternal inflammation indicators have a low specificity, culture tests are not immune from the risk of contamination, and the measurement of interleukins in the amniotic fluid and maternal blood serum is not yet routine. Observation of clinical signs therefore remains crucial to neonatologists, at the same time that new and more sophisticated laboratory tests enable them to establish a diagnosis of infection at an increasingly earlier stage. In recent years, several infection markers have been investigated, such as procalcitonin and especially C-reactive protein (CRP). Currently, the measurement of plasma concentrations of interleukins (IL), IL-6 and IL-8 in particular, appears to be one of the most sensitive and specific infection indicators in newborns. Cytokine levels are increased even before infants develop any clinical symptoms and routine laboratory tests turn positive. However, owing to their short half-life, their sensitivity decreases after 12-24 h from the onset of inflammation, increasing the risk of false negatives. Ideally, they should then be used in combination with other inflammation indicators, such as CRP. The measurement of cytokines and other new inflammatory markers might be helpful in the early diagnosis of both early-onset infection (assay in umbilical cord blood) and late-onset infection (serial assays performed during the stay in the neonatal intensive care unit). In spite of their time-consuming techniques, culture tests remain of the utmost importance to plan a targeted treatment; blood culture, in particular, is crucial to the diagnosis of sepsis.

Neonatal seizures in preterm infants: clinical outcome and relationship with subsequent epilepsy.

OBJECTIVE: Neonatal seizures are considered an acute manifestation of disturbance of the neonatal brain. Some of them can be considered as neonatal epilepsy. Our goal was to evaluate perinatal risk factors, electroencephalogram (EEG) findings and ictal semeiological characteristics of our newborns with neonatal seizures in order to identify which clinical variables were the most early predictive factors of poor neurodevelopmental outcome and of epilepsy. METHODS: Among all preterm infants consecutively admitted to the neonatal intensive care unit (NICU) of the University Hospital of Parma in the period between January 1999 and June 2003, 28 preterm infants with gestational age

[Mortality and morbidity in extremely premature newborns]. / Mortalità e morbilità nel pretermine di età gestazionale estrema.

The progress of perinatal medicine greatly reduced neonatal mortality and prognosys of the lowest gestational age (G.A.) newborns is improving continuously. The survival of the newborns with G.A. < 32 weeks doubled from the years 1973-1978 to 1995-99 in the our neonatal intensive therapy (TIN), whereas the incidence of the most serious pathologies of prematurity, which increases with the decreasing of G.A., has not changed in the years. In the surfactant era, Respiratory Distress Syndrome is not the first cause of death and Intra Ventricular Hemorrage and Retinopaty Of Prematurity occur now in the lower stage of severity in comparison with the past. Cortison profilaxys antepartum, delivery with caesarian section and agressive intensive neonatal therapy seem to be the reason of these results.

[Clinical features in subjects with congenital anomalies of the corpus callosum]. / Caratteristiche cliniche in soggetti con anomalie congenite del corpo calloso.

The corpus callosum is a connecting structure between the two cerebral hemispheres. Its development occurs between 8th and 20th week of gestation. Anomalies of the corpus callosum are divided into malformative or acquired anomalies and may be isolated or associated with other cerebral malformations. The diagnosis of an alteration of the corpus callosum is fundamentally based on neuroradiological examinations. In our study we evaluate the major clinical findings, the psychomotor development, the electroencephalographic and neuroradiological features in a group of 14 children with congenital callosal anomalies, trying to single out how the associated cerebral malformations interfered with the clinical manifestations and especially the prognosis. It was not possible to highlight a distinctive symptom indicative of the presence of a corpus callosum anomaly; nevertheless in 11/14 children there was a psychomotor delay of varying degree. 42% of our subjects presented epilepsy, with a typical West syndrome in 5/6. Children affected by isolated callosum anomalies did not present any significant clinical manifestations. Finally, we conclude that the determinating factors in the severity of the clinical-electroencephalographic picture as a whole, and especially in the prognosis of our patients are the cerebral malformations associated to the callosum anomalies.

[Retinopathy of prematurity: incidence and risk factors]. / Retinopatia della prematurità: incidenza e fattori di rischio.

The study analyses the incidence of the retinopathy of prematurity (ROP) and its correlation with the most important risk factors in neonates with gestational age (GE) < or = 32 weeks and/or with birth weight (BW) < or = 1500 g. The cohort of our study is composed by 305 preterms with Mean GE of 29.8 weeks and Mean BW of 1312 g, studied at the Neonatal Intensive Care Unit of the University of Parma during January 1993-December 1999. The incidence of ROP resulted 19.7% in our group and was inversely proportional to the GE and BW. No preterms with GE < or = 32 weeks presented retinopathy, while there has been an incidence of the 65% in the subjects with GE lower than 26 weeks. The most severe grade of ROP was mainly seen in the newborns with the lowest GE (31%), whilst only the 1.5% of the preterms with GE of 30-31 weeks developed ROP of stage 3 or 3+. Similar results were seen when the data were compared with the birth weight. However a direct relation was seen with the duration of the O2 therapy and with the typical pathologies of the prematurity, namely respiratory distress syndrome (RDS) and intraventricular haemorrhages (IVH). Among the other risk factors evaluated, the blood transfusion was the most relevant.

[Early discharge project appropriate for the healthy newborn]. / Progetto di dimissione precoce appropriata del neonato sano.

Recently the stay in the hospital of the pueperae and of their newborns has progressively been shortened in several Countries. A lot of reports evaluating the risks of early discharges have not shown any significant differences in the hospital readmission rates between newborn early discharged and case-controls. This phenomenon is occurring also in Italy and the early discharge after the delivery is one of the aims of the "Percorso-Nascita" in the National Health Program of 1998-2000. Since three years ago, in the Nursery of the Department of Neonatal Medicine of University of Parma we have been discharging the newborns at term in the second day of life, choosing the healthy newborns in agreement with the obstetricians. The increment of the early discharges has happened in our Department after realizing that those did not create an increment of the hospital admissions in the neonatal period. Since January 2000 in Parma the project of appropriate discharge named "around the cradle" derived from the cooperation between hospitals and territory is working. This project consists of a continuous essistential support for mothers and children throughout an organic integration between hospital and territory. The women that take part to this project have the opportunity to be discharged from the hospital between the 44 and the 56 hours after the physiological delivery, being followed at home by the local obstetrician and paediatrician. The project is divided into three parts. The first part, pre-partum, is based on the information that is delivered to all the pregnant women that are eligible; the second part, the hospital phase, implies the usual and routinary care to the pueperae and their newborns as well as the clinical neonatal and obstetrical evaluation that allows to select our cohort. In the latter phase, extra-hospital, the local paediatrician take care of the newborn and start examining him/her within 72 hours after the discharge, while the home assistance of the local obstetrician will be within 48 hours. After initial difficulties, the organization of this project is quite efficient with a constant increment of attending requests to our project by the patients. Of course this is an organizative model quite complex that needs to verify process, efficiency and results, but anyway it sees the cooperation among many professionists of different specialities: neonatologists, paediatricians, obstetricians, practitioners, all working together for a common programme.

Use of surfactant for prophylaxis versus rescue treatment of respiratory distress syndrome: experience from an Italian-Bulgarian trial.

OBJECTIVE: To show if surfactant applied in different social-sanitary realities as prophylaxis of respiratory distress syndrome (RDS) is equally useful and able to reduce mortality and incidence of 3-4 radiological grade RDS. METHODS AND PATIENTS: Two neonatal intensive care units (NICU) in Italy, one NICU in Bulgaria and one NICU in Romania were involved in a randomized controlled clinical trial of prophylaxis vs rescue treatment of RDS. Babies with gestational age 26-30 wks were randomized before birth to prophylaxis in the delivery-room with 200 mg/kg of porcine surfactant (prophylaxis) or to routine assistance (control). Subsequently the babies developing RDS requiring mechanical ventilation and fraction of inspired oxygen (FiO2) > or = 0.4 to maintain PaO2 about 50 mmHg were allowed to be treated rescue with 200 mg/kg of the same surfactant. To reach end-points of reducing mortality by 40% and incidence of radiological grade 3-4 RDS a total number of 174 patients were required. RESULTS: Due to logistic, practical and social-political problems the study was interrupted after enrollment of 93 babies (61 in Italy and 32 in Bulgaria). The Romanian centre did not start the study because it was impossible in the scheduled times to equip it for mechanical ventilation of the newborn infants. Analysis done on an intention to treat basis did not show significant reductions of mortality and 3-4 radiological grade RDS, even if there was a trend towards a reduction in the babies given prophylaxis. A significantly lower number of babies given prophylaxis required a subsequent rescue treatment compared to controls (p < 0.001). There was no difference in other complications such as intraventricular haemorrhage, air-leak syndromes and infections between prophylaxis and control infants. As regards pulmonary gas exchange, the PaO2/FiO2 ratio was significantly improved in the babies given prophylaxis for the first 12 hours of life vs the controls. CONCLUSION: Even if the study was terminated before term, the analysis of the data shows that prophylaxis with surfactant is equally effective in different social-clinical conditions to improve pulmonary gas-exchange, especially in the first critical hours of life of premature babies.

Antenatal prevention of respiratory distress syndrome; a multicentre survey.

Obstetric and neonatal data were collected on 934 preterm deliveries in 11 Italian centres in 1980, 1985 and 1986. Therapeutic regimens for prevention of respiratory distress syndrome (RDS) were applied in 42% of the cases in 1980, 32% in 1985 and 42% in 1986. Prevention was made in most cases with corticosteroids, although their use fell progressively from 94% in 1980 to 74% in 1986. A combination of two substances was used in a percentage of cases varying from 5 to 10% in all three years. In 903 non-malformed infants, the overall incidence of RDS was not significantly different in cases in which pharmacological prevention was attempted compared with cases without prevention. The only factors significantly affecting the incidence of RDS were gestational age, birth weight and Apgar score.

[Nosological limits of wet lung syndrome. Clinical and radiological investigations (author's transl)]. / Limiti nosololgici della sindrome del polmone bagnato. Indagine clinicoradiologica.

41 hyaline membrane diseases (H.M.D.), 39 fetal aspiration syndromes (F.A.S.) and 81 wet lung syndromes (W.L.S.) observed during the last four years have been critically examined by the Authors. Anamnestic, clinic and radiological findings have revealed how it is difficult to make a differential diagnosis between W.L.S. and the two other neonatal respiratory disorders and therefore how it is difficult to classify the W.L.S. as an autonomous nosological entity. Therefore the AA. think that the neonatal respiratory disorders can be divided in only two groups: H.M.D. and F.A.S., and suggest the hypothesis that W.L.S. is not an autonomous nosological entity but may be only a milder clinic and radiological aspect of the two other syndromes.