Short antibiotic prophylaxis for bacterial infections in a neonatal intensive care unit: a randomized controlled trial.

We compared the effectiveness of a single dose and a three-day course of antibiotic prophylaxis in preventing bacterial infections in high-risk neonates. The study was a prospective, randomized controlled trial conducted in a 20-bed tertiary referral neonatal intensive care unit (NICU). A series of 130 neonates admitted consecutively to the NICU, fulfilling risk factors for infection, were assigned at random to receive intravenous antibiotic prophylaxis with ampicillin and netilmicin either in two daily doses for 72 h (three-day-administration group, 67 infants) or in a single bolus injection on admission (bolus group, 63 infants). Hospital-acquired infection, the main outcome measure, was defined as infection that developed at least 48 h after admission, and vertical infection (maternally transmitted) was considered to be present when clinical symptoms and abnormal laboratory findings became evident within 48 h of birth. Infections were considered as suspected when clinical and laboratory findings of infection were present, without positive cultures, and as confirmed when positive cultures were also present. No significant differences were found between the two groups of neonates studied in mean birth weight, gestational age or postnatal age on admission. The incidence of vertical infection was similar in the two groups (16/67, 23.9% vs. 14/63, 22.2%). Of the 130 newborns studied, 29 (22.3%) acquired at least one nosocomial infection during their NICU stay; total hospital-acquired infections, calculated as the incidence density of infection (the number of infective episodes divided by the number of days in the NICU), were less frequent among newborns who received the three-day course than the bolus (relative risk 0.69). This difference, although not statistically significant, depended on the different incidence density of confirmed nosocomial infections rather than on suspected infections (relative risk 0.59; 95% confidence interval 0.32-1.09; P=0.1). There were no significant differences between the two groups in overall mortality. A single bolus administration on admission is therefore likely to be as effective as a three-day course of antibiotic prophylaxis in preventing bacterial infection in high-risk infants admitted to an NICU.

Prophylactic nasal continuous positive airways pressure in newborns of 28-31 weeks gestation: multicentre randomised controlled clinical trial.

BACKGROUND: The role of nasal continuous positive airways pressure (nCPAP) in the management of respiratory distress syndrome in preterm infants is not completely defined. OBJECTIVE: To evaluate the benefits and risks of prophylactic nCPAP in infants of 28-31 weeks gestation. DESIGN: Multicentre randomised controlled clinical trial. SETTING: Seventeen Italian neonatal intensive care units. PATIENTS: A total of 230 newborns of 28-31 weeks gestation, not intubated in the delivery room and without major malformations, were randomly assigned to prophylactic or rescue nCPAP. INTERVENTIONS: Prophylactic nCPAP was started within 30 minutes of birth, irrespective of oxygen requirement and clinical status. Rescue nCPAP was started when Fio2 requirement was > 0.4, for more than 30 minutes, to maintain transcutaneous oxygen saturation between 93% and 96%. Exogenous surfactant was given when Fio2 requirement was > 0.4 in nCPAP in the presence of radiological signs of respiratory distress syndrome. MAIN OUTCOME MEASURES: Primary end point: need for exogenous surfactant. Secondary end points: need for mechanical ventilation and incidence of air leaks. RESULTS: Surfactant was needed by 22.6% in the prophylaxis group and 21.7% in the rescue group. Mechanical ventilation was required by 12.2% in both the prophylaxis and rescue group. The incidence of air leaks was 2.6% in both groups. More than 80% of both groups had received prenatal steroids. CONCLUSIONS: In newborns of 28-31 weeks gestation, there is no greater benefit in giving prophylactic nCPAP than in starting nCPAP when the oxygen requirement increases to a Fio2 > 0.4.

Long gap esophageal atresia and esophageal replacement: moving toward a separation?

BACKGROUND/PURPOSE: Treatment of long gap esophageal atresia (EA) is still a major challenge. Gastric transposition and colon interposition are the 2 most popular choices for esophageal replacement, but there is general agreement that the child's own esophagus is the best. The aim of the study was to critically evaluate the feasibility and outcome of primary repair of long gap EA with or without tracheoesophageal fistula (TEF) by direct esophago-esophageal anastomosis as the only technique. METHODS: Seventy-one neonates with EA+/-TEF were considered. Nineteen cases were classified as long gap (> or =3 cm). All infants underwent either primary or shortly delayed repair. In the latter group, a gastrostomy was performed along with an x-ray evaluation of the gap a few days before surgery (mean age, 46.4 days). To avoid disruptive anastomotic force, all infants were kept paralyzed and mechanically ventilated for an additional 6 days after esophageal anastomosis. Before starting feeding, postoperative esophagogram was done on day 7. Endoscopy was done routinely, starting 1 month after surgery; pH monitoring was conventionally performed at 1 year of age or even earlier, should gastroesophageal reflux disease (GERD) be suspected. Follow-up ranged from 11 months to 7 years. RESULTS: In all 19 long gap EA infants an esophago-esophageal anastomosis was performed. Six of them (31%) required an anterior esophageal flap to bridge residual gap. Complications included minor anastomotic leak in 2 cases and anastomotic stricture (<5mm) in 12 (80%) cases, which were treated with an average of 5 dilatations (1 of which with resection of the stricture). GERD occurred in 8 cases (53.3%), of which, 3 required fundoplication. None of the patients had esophageal swallowing difficulties or persistent dysphagia. Two children experienced food aversion. Mean hospital stay was 66.2 (22 to 230) days. There were 4 deaths (very low birth weight, 1; associated anomalies, 1; and late sepsis, 2). CONCLUSIONS: Considering heat gap determination remains imprecise, it seems possible to conclude that in a well-established tertiary care level referral center: (1) long gap EA could be treated successfully with primary repair and anastomosis; (2) strictures and GER represent the most frequent postoperative problem, but additional procedures required seem "acceptable" to maintain the patient's own esophagus and avoid replacement; (3) esophageal substitution in long gap EA should be reserved for cases in which a previous attempt of esophageal reconstruction failed.

Should euthanasia be legal? An international survey of neonatal intensive care units staff.

OBJECTIVE: To present the views of a representative sample of neonatal doctors and nurses in 10 European countries on the moral acceptability of active euthanasia and its legal regulation. DESIGN: A total of 142 neonatal intensive care units were recruited by census (in the Netherlands, Sweden, Hungary, and the Baltic countries) or random sampling (in France, Germany, Italy, Spain, and the United Kingdom); 1391 doctors and 3410 nurses completed an anonymous questionnaire (response rates 89% and 86% respectively). MAIN OUTCOME MEASURE: The staff opinion that the law in their country should be changed to allow active euthanasia "more than now". RESULTS: Active euthanasia appeared to be both acceptable and practiced in the Netherlands, France, and to a lesser extent Lithuania, and less acceptable in Sweden, Hungary, Italy, and Spain. More then half (53%) of the doctors in the Netherlands, but only a quarter (24%) in France felt that the law should be changed to allow active euthanasia "more than now". For 40% of French doctors, end of life issues should not be regulated by law. Being male, regular involvement in research, less than six years professional experience, and having ever participated in a decision of active euthanasia were positively associated with an opinion favouring relaxation of legal constraints. Having had children, religiousness, and believing in the absolute value of human life showed a negative association. Nurses were slightly more likely to consider active euthanasia acceptable in selected circumstances, and to feel that the law should be changed to allow it more than now. CONCLUSIONS: Opinions of health professionals vary widely between countries, and, even where neonatal euthanasia is already practiced, do not uniformly support its legalisation.

Risk factors for nosocomial infections in a neonatal intensive-care unit.

The clinical records a years cohort of 280 newborn infants consecutively hospitalized for 48 h or more in our neonatal intensive-care unit (NICU) were reviewed. Information on the infants' conditions during the first 12h of life, and on the procedures used in the NICU, were collected. Statistical significance was tested by univariate analysis with the chi(2) test and by multivariate logistic regression analysis with the software program SPSS (Version 10). Over the one-year period reviewed, 90 hospital-acquired infections (HAIs) were contracted; 55 (19.6%) of infants had at least one infection during their stay. The overall in-hospital mortality was 7.1%, and mortality was higher in infants in whom at least one infection developed than in non-infected infants (12.7 vs. 5.8% P=0.13). Very low birthweight infants (VLBW<1,501 g) who had more severe clinical conditions on admission [clinical risk index for babies (CRIB) score >/=5] had an almost two-fold higher risk of contracting a HAI. In the multivariate regression analysis, the onset of a HAI was strongly associated with a low gestational age and the presence of an intravascular catheter. HAIs frequently complicate hospitalization in NICUs and are associated with increased mortality. Our findings also suggest that CRIB could be predictive for the risk of infection in VLBW infants.

Severe congenital diaphragmatic hernia (CDH): a critical analysis of eight years' experience.

UNLABELLED: OBJECTIVES. 1) To define the best outcome of severe Congenital Diaphragmatic Hernia (CDH); 2) to critically evaluate deaths in order to identify possible criteria of exclusion from ECMO; and 3) to identify CDHs which could benefit from ECMO. MATERIALS AND METHODS: 63 severe CDHs, 35 (55.6 %) survivors and 28 (44.4 %) nonsurvivors, subdivided into 2 groups according to age at death: Group I dying at 12 < or = 24 hours, and Group II dying at > 24 hours after birth. The three groups were compared on the basis of prenatal diagnosis, polyhydramnios, gestational age, birth weight, pneumothorax, best values of postductal PaCO 2 and PaO 2, clinical and echocardiographic signs of persistent pulmonary hypertension, and severity of pulmonary hypoplasia (i.e., body weight to bilateral lung weight ratio at autopsy). RESULTS: PaCO 2, PaO 2 and degree of pulmonary hypoplasia were significantly worse in Group I compared to Group II and to survivors. PaCO 2 and PaO 2 in Group II did not differ significantly from those of survivors. CONCLUSIONS: In severe CDH it is possible: 1) to achieve a survival rate of 56 % without ECMO; 2) to identify a group of patients (Group I = 27 %) with severe pulmonary hypoplasia who would probably die even with ECMO; and 3) to identify a group of patients (Group II = 17 %) who might benefit from ECMO treatment.

Extracorporeal dialysis in neonatal hyperammonemia: modalities and prognostic indicators.

We investigated the prognostic indicators in ten hyperammonemic neonates: four treated by continuous arteriovenous hemodialysis (CAVHD), four with continuous venovenous hemodialysis (CVVHD), and two with hemodialysis (HD). Plasma ammonium levels decreased significantly within the first 24 h irrespective of dialysis modality (from 1419 to 114 micromol/l, median values; P<0.0001). CVVHD achieved the highest ammonium clearance. HD provided highest ammonium extraction but clearance was hampered by severe hemodynamic instability. Five patients had a good outcome (normal at follow-up of 9-59 months), five had poor outcome (four died and one has severe neurological damage). Total coma duration was shorter in patients who had a good outcome (47+/-11 vs 78+/-13 h; P=0.02). Remarkably, only coma duration before dialysis determined this difference (22.2+/-10.1 vs 48.8+/-11.2 h; P=0.02). In cases with good outcome, coma duration was <33 h, whereas the others exceeded this limit. The prognosis was not related to dialysis modality, rapidity in reducing ammonium levels or to the underlying metabolic defect. In conclusion, results showed CVVHD to be the optimal modality for extracorporeal ammonium detoxification. However, the most relevant indicator for prognosis was coma duration before the start of dialysis. Therefore, major efforts should be made to refer patients quickly to highly specialized centers.

[Hypoxic-ischemic encephalopathy in newborns]. / Encefalopatia ipossico-ischemica nel neonato.

Cerebral hypoxia-ischaemia occurring in the fetus and newborn is a major cause of acute mortality and chronic neurologic disability in survivors. Statistics suggest an incidence of systemic asphyxia in 1-2/1000 full-term infants and an incidence that approaches 60% in very low birth-weight newborns. Although the neuropathological features are not exclusively characteristic of full-term or preterm babies, it is well known that the gray matter is predominantly involved in the term baby while the white matter is damaged in the preterm newborn. In the premature infant encephalopathy is often accompanied by peri-intraventricular haemorrhage. The different distribution of neuropathologic lesions arising from perinatal hypoxia-ischaemia depend on several factors such as intrinsic cellular and regional vulnerability, vascular factors, nature and duration of the insult, age and maturity of the infant.

End-of-life decisions in neonatal intensive care: physicians' self-reported practices in seven European countries. EURONIC Study Group.

BACKGROUND: The ethical issue of foregoing life-sustaining treatment for newborn infants at high risk of death or severe disability is extensively debated, but there is little information on how physicians in different countries actually confront this issue to reach end-of-life decisions. The EURONIC project aimed to investigate practices as reported by physicians themselves. METHODS: The study recruited a large, representative sample of 122 neonatal intensive-care units (NICUs) by census (in Luxembourg, the Netherlands, and Sweden) or stratified random sampling (in France, Germany, the UK, Italy, and Spain) with an overall response rate of 86%. Physicians' practices of end-of-life decision-making were investigated through an anonymous, self-administered questionnaire. 1235 completed questionnaires were returned (response rate 89%). FINDINGS: In all countries, most physicians reported having been involved at least once in setting limits to intensive care because of incurable conditions (61-96%); smaller proportions reported such involvement because of a baby's poor neurological prognosis (46-90%). Practices such as continuation of current treatment without intensification and withholding of emergency manoeuvres were widespread, but withdrawal of mechanical ventilation was reported by variable proportions (28-90%). Only in France (73%) and the Netherlands (47%) was the administration of drugs with the aim of ending life reported with substantial frequency. Age, length of professional experience, and the importance of religion in the physician's life affected the likelihood of reporting of non-treatment decisions. INTERPRETATION: A vast majority of neonatologists in European NICUs have been involved in end-of-life limitation of treatments, but type of decision-making varies among countries. Culture-related and other country-specific factors are more relevant than characteristics of individual physicians or units in explaining such variability.

Parental visiting, communication, and participation in ethical decisions: a comparison of neonatal unit policies in Europe.

AIM: To compare neonatal intensive care unit policies towards parents' visiting, information, and participation in ethical decisions across eight European countries. METHODS: One hundred and twenty three units, selected by random or exhaustive sampling, were recruited, with an overall response rate of 87%. RESULTS: Proportions of units allowing unrestricted parental visiting ranged from 11% in Spain to 100% in Great Britain, Luxembourg and Sweden, and those explicitly involving parents in decisions from 19% in Italy to 89% in Great Britain. Policies concerning information also varied. CONCLUSIONS: These variations cannot be explained by differences in unit characteristics, such as level, size, and availability of resources. As the importance of parental participation in the care of their babies is increasingly being recognised, these findings have implications for neonatal intensive care organisation and policy.

Mechanical work of breathing during maximal voluntary ventilation.

With the use of the esophageal balloon technique, the working capacity of the respiratory muscles was assessed in four normal subjects by measuring the work per breath (W) and respiratory power (W) during maximal voluntary ventilation with imposed respiratory frequencies (f) ranging from 20 to 273 cycles/min. Measurements were made in a body plethysmograph to assess the work wasted as a result of alveolar gas compressibility (Wg'). In line with other types of human voluntary muscle activity, W decreased with increasing f, whereas W exhibited a maximum at f of approximately 100 cycles/min. Up to this f value, Wg' was small relative to W. With further increase in f, the Wg'/W ratio increased progressively, amounting to 8-22% of W at f of 200 cycles/min.

Intravenous correction of neonatal hypomagnesemia: effect on ionized magnesium.

OBJECTIVES: Neonatal hypomagnesemia is defined as total magnesium (TMg) < or = 0.65 mmol/L (1.6 mg/dl). However, magnesium (Mg) deficiency and sufficiency overlap at serum values of 0.57 to 0.74 mmol/L (1.4 to 1.8 mg/dl). We hypothesized that (1) some infants with TMg < or = 0.65 mmol/L (1.6 mg/dl) have normal ionized Mg values (normal neonatal range 0.40 to 0.56 mmol/L (0.97 to 1.36 mg/dl)); (2) the dose (6.0 mg of elemental Mg/kg) used to correct hypomagnesemia does not lead to elevation of ionized Mg; (3) after intravenous magnesium sulfate infusion, ionized calcium increases in patients with low baseline ionized Mg and decreases in patients with normal baseline ionized Mg. STUDY DESIGN: We recruited 22 neonates with TMg < or = 1.6 mg/dl. They received intravenous sulfate (6 mg elemental Mg/kg) over a 1-hour period. Serum TMg, ionized Mg, and ionized Ca were measured before and after magnesium sulfate infusion. An ion-selective electrode was used to allow direct measurement of ionized Mg and ionized Ca. RESULTS: Thirteen (59%) of 22 neonates with TMg < or = 0.65 mmol/L (1.6 mg/dl) had normal IMg. In 7 (31%) of 22 cases ionized Mg increased slightly above 0.56 mmol/L (1.36 mg/dl); the maximum value was 0.61 mmol/L (1.48 mg/dl). The change in ionized Ca concentrations and the baseline ionized Mg value were inversely correlated (r = -0.79; p < 0.0001). CONCLUSIONS: (1) Measurement of ionized Mg should prevent overdiagnosis and treatment of hypomagnesemia. (2) The dose used in this study is safe. (3) Ionized Mg concentrations are inversely correlated to the response of ionized Ca concentrations to an Mg load.

Radial aplasia and chromosome 22q11 deletion.

We report on a neonate with deletion 22q11 (del22q11) presenting with facial dysmorphism, ocular coloboma, congenital heart defect, urogenital malformations, and unilateral radial aplasia. This malformation complex includes features frequently occurring in velocardiofacial syndrome as well as findings described in the CHARGE and VACTERL associations. To our knowledge, the present case is the first report of radial aplasia in del22q11. This observation further supports and extends the clinical variability of del22q11.

Care procedures in the healthy full-term newborn infant: a territorial survey.

The Italian Academy of Pediatrics and the Italian Academy of Neonatology have carried out an investigation regarding assistance routines for the healthy full-term newborn. The results confirm a need for modifications in the majority of the centers, especially with regard to Vitamin K prophylaxis which is implemented with extremely variable dosages and not repeated, and to breast-feeding and rooming-in, both of which should be more encouraged. The length of stay in hospital for both vaginal and cesarean deliveries, especially in Lazio, is excessive. Regarding ocular prophylaxis and allergic disease prophylaxis, the attitude is uniform and in agreement with recent literature.

'Idiopathic' jaundice in Sardinian full-term newborn infants: a multivariate study.

'Idiopathic' hyperbilirubinaemia in the first 4 days of life was studied in 431 unselected healthy full-term (gestational age > or = 37 weeks) singleton Sardinian infants with birthweight > or = 2500 g. All infants were free from malformations or any disease requiring treatment other than jaundice, they were ABO and Rh compatible with their mothers and were not G6PD deficient. The serum bilirubin level was > 11.9 mg/dl (204 mumol/l) and > 14.9 mg/dl (256 mumol/l) in 37.1% and 15.3% of the study subjects. The vast majority of the infants (94%) were breast fed; no difference in the incidence of jaundice was found between breast-fed and bottle-fed infants. A logistic regression analysis indicated that high alpha-fetoprotein concentrations in cord blood, history of neonatal jaundice in previous full-term siblings, delayed first meconium passage and weight loss were associated with jaundice, defined as a serum bilirubin level > 11.9 mg/dl. These results suggest that the high rate of neonatal hyperbilirubinaemia in Sardinia is mostly related to constitutional and possibly hereditary factors.

[Controversial aspects and rational bases of the treatment in neonatal jaundice]. / Aspetti controversi e basi razionali del trattamento dell'ittero neonatale.

High serum bilirubin levels (SBL), over 20-25 mg/dl are toxic for the Central Nervous System (CNS) of newborn infants. However, the possible toxicity on the CNS of "intermediate" SBL both in term and preterm neonates are still a matter of debate. An extensive review of the literature in this respect did not provide conclusive evidence for a dose-response pattern of toxicity for SBL 18-20 mg/dl in infants without hemolysis and/or other risk factors (such as extreme prematurity, hypoxia, hypercapnia, acidosis, sepsis, hyperosmolarity, etc.). Therefore, an aggressive approach to the treatment and/or prophylaxis of neonatal jaundice when SBL are below 20 or even 25 mg/dl is not justified on the basis of the present knowledge. This is particularly true when treatment includes phototherapy and/or exchange-transfusion which are associated with clinically significant complications and side effects. Guidelines for treatment of neonatal hyperbilirubinemia in full-term and preterm infants, with and without added complications and/or risk factors, are provided in the attempt of encouraging a more critical approach to neonatal jaundice, which is coherent with the data available in the literature and which should optimize the risk/benefit ratio.

[Incidence and duration of breast feeding in the city of Sassari from 1976 to 1987]. / Incidenza e modalità dell'allattamento al seno nella città di Sassari dal 1976 al 1987.

The authors have studied the incidence and duration of breast feeding (BF) among children from Sassari born in the period 1976 to 1987 (3608 full-term, normal infants). The data have shown a progressive decrease in the incidence and duration of B.F. from 1976 to 1983 followed by a progressive increase in the last 4 years of the study. The authors point out the need for structured incentive program aimed at a better education of the mothers concerning the advantages of breast feeding.

[Anthropometric study of the Sassari population 6 to 11 years of age]. / Studio antropometrico della popolazione sassarese da 6 a 11 anni.

The average values [+/- SD) for height and weight of 1518 males and 1333 females between 6 and 11 years of age from the city of Sassari (Sardinia) have been determined. Numerical values and smooth curves from the 3rd to the 97th percentile for height and weight have also been calculated. The results were compared with those of the literature and particularly with those published by De Toni et Al. 20 years ago. The data show a significant increase in height and weight among Sardinian children during the past 20 years. The availability of these new curves will permit a more correct evaluation of growth in Sardinian children.