Size at birth by gestational age and hospital mortality in very preterm infants: results of the area-based ACTION project.

BACKGROUND: Size at birth is an important predictor of neonatal outcomes, but there are inconsistencies on the definitions and optimal cut-offs. AIMS: The aim of this study is to compute birth size percentiles for Italian very preterm singleton infants and assess relationship with hospital mortality. STUDY DESIGN: Prospective area-based cohort study. SUBJECTS: All singleton Italian infants with gestational age 22-31 weeks admitted to neonatal care in 6 Italian regions (Friuli Venezia-Giulia, Lombardia, Marche, Tuscany, Lazio and Calabria) (n. 1605). OUTCOME MEASURE: Hospital mortality. METHODS: Anthropometric reference charts were derived, separately for males and females, using the lambda (λ) mu (µ) and sigma (σ) method (LMS). Logistic regression analysis was used to estimate mortality rates by gestational age and birth weight centile class, adjusting for sex, congenital anomalies and region. RESULTS: At any gestational age, mortality decreased as birth weight centile increased, with lowest values observed between the 50th and the 89th centiles interval. Using the 75th-89th centile class as reference, adjusted mortality odds ratios were 7.94 (95% CI 4.18-15.08) below 10th centile; 3.04 (95% CI 1.63-5.65) between the 10th and 24th; 1.96 (95% CI 1.07-3.62) between the 25th and the 49th; 1.25 (95% CI 0.68-2.30) between the 50(h) and the 74th; and 2.07 (95% CI 1.01-4.25) at the 90th and above. CONCLUSIONS: Compared to the reference, we found significantly increasing adjusted risk of death up to the 49th centile, challenging the usual 10th centile criterion as risk indicator. Continuous measures such as the birthweight z-score may be more appropriate to explore the relationship between growth retardation and adverse perinatal outcomes.

Inhaled muscarinic acetylcholine receptor antagonists for treatment of COPD.

Bronchodilators, generally administered via metered dose or dry powder inhalers, are the mainstays of pharmacological treatment of stable COPD. Inhaled long-acting beta-agonists (LABA) and anticholinergics are the bronchodilators primarily used in the chronic treatment of COPD. Anticholinergics act as muscarinic acetylcholine receptor antagonists and are frequently preferred over beta-agonists for their minimal cardiac stimulatory effects and greater efficacy in most studies. Their therapeutic efficacy is based on the fact that vagally mediated bronchoconstriction is the major reversible component of airflow obstruction in patients with COPD. However, bronchodilators are effective only on the reversible component of airflow obstruction, which by definition is limited, as COPD is characterized by a fixed or poorly reversible airflow obstruction. Inhaled anticholinergic antimuscarinic drugs approved for the treatment of COPD include ipratropium bromide, oxitropium bromide and tiotropium bromide. Ipratropium bromide, the prototype of anticholinergic bronchodilators, is a short-acting agent. Oxitropium bromide is administered twice a day. Tiotropium bromide, the only long-acting antimuscarinic agent (LAMA) currently approved, is administered once a day. Newer LAMAs including aclidinium bromide and glycopyrrolate bromide are currently in phase III development for treatment of COPD. Some new LAMAs, including glycocpyrrolate, are suitable for once daily administration and, unlike tiotropium, have a rapid onset of action. New LAMAs and their combination with ultra-LABA and, possibly, inhaled corticosteroids, seem to open new perspectives in the management of COPD. Dual-pharmacology muscarinic antagonist-beta2 agonist (MABA) molecules present a novel approach to the treatment of COPD by combining muscarinic antagonism and beta2 agonism in a single molecule.

Prenatal risk factors for intraventricular hemorrhage, neonatal death and impaired psychomotor development in very low birth weight infants.

AIM: The aim of this study was to determine the relationship between preterm risk factors and neonatal death, cerebral hemorrhage and psychomotor development in very low birth weight infants. METHODS: A retrospective analysis based on a multivariate logistic regression model was conducted on 253 VLBW infants. Cerebral hemorrhage was assessed by cerebral ultrasound screening within 24 hours of life, psychomotor development by Bailey Psychomotor and Development Index test. RESULTS: Pre-eclampsia and elective cesarean section (CS) are statistically protective factors in the prevention of cerebral hemorrhage; gestational age is a protective factor for neonatal death; whereas, multiple pregnancy, symmetrically small for gestational-age infants, asphyxia at birth, altered cardiotocography, and cerebral hemorrhage are risk factors for neonatal death; emergency CS and gestational age are protective factors for problems in psychomotor development. The number of fetuses and cerebral hemorrhage are risk factors for impaired psychomotor development at 2 years of age. CONCLUSION: The great number of obstetrical variables related to neonatal outcome makes it difficult to identify the really important steps, in obstetric management, to prevent long term sequelae. The main risk factors related to psychomotor development still remain gestational age and multiple pregnancy.

Effects of cyclo-oxygenase inhibition on exhaled eicosanoids in patients with COPD.

BACKGROUND: Leukotriene (LT) B4 concentrations are increased and prostaglandin (PG) E2 concentrations are decreased in exhaled breath condensate (EBC) in patients with chronic obstructive pulmonary disease (COPD). A study was undertaken to investigate the short term effects of cyclo-oxygenase (COX) inhibition on exhaled LTB4 and PGE2 concentrations in patients with COPD and to identify the COX isoform responsible for exhaled PGE2 production. METHODS: Two studies were performed. A double blind, crossover, randomised, placebo controlled study with ibuprofen (400 mg qid for 2 days), a non-selective COX inhibitor, was undertaken in 14 patients with stable COPD, and an open label study with oral rofecoxib (25 mg once a day for 5 days), a selective COX-2 inhibitor, was undertaken in a different group of 16 COPD patients. EBC was collected before and after drug treatment. Exhaled LTB4 and PGE2 concentrations were measured with specific immunoassays. RESULTS: All patients complied with treatment as indicated by a reduction in ex vivo serum thromboxane B2 concentrations (ibuprofen) and a reduction in lipopolysaccharide induced increase in ex vivo plasma PGE2 values (rofecoxib) of more than 80%. Exhaled LTB4 was increased after ibuprofen (median 175.5 (interquartile range 128.8-231.5) pg/ml v 84.0 (70.0-98.5) pg/ml, p < 0.001) and exhaled PGE2 was reduced (93.5 (84.0-105-5) pg/ml v 22.0 (15.0-25.5) pg/ml, p < 0.0001). Rofecoxib had no effect on exhaled LTB4 (p = 0.53) or PGE2 (p = 0.23). CONCLUSIONS: Non-selective COX inhibition decreases PGE2 and increases LTB4 in EBC, whereas selective COX-2 inhibition has no effect on these eicosanoids. PGE2 in EBC is primarily derived from COX-1 activity, and COX inhibition may redirect arachidonic acid metabolism towards the 5-lipoxygenase pathway.

[Induction of fetal lung maturation in the prevention of hyaline membrane disease: the connection with neonatal sepsis]. / Induzione della maturazione polmonare fetale nella profilassi della malattia da membrane ialine e sepsi neonatale.

BACKGROUND: The aim of this study was to evaluate the effect of antenatal maternal corticosteroid treatment on the frequency of neonatal outcomes and perinatal infectious morbidity among singleton pregnancies complicated by preterm delivery. METHODS: A nonrandomized analysis was performed on 189 neonates of 24-34 weeks' gestation who were born at the Department of Obstetrics and Gynecology, University of Udine, between January 2000 to December 2001. The neonates were subdivided into 3 groups: 1) 143 neonates received 2 doses of corticosteroids in a 24-hour interval and repeated after 10 days; 2) 26 neonates received 2 doses; 3) 20 neonates did not receive any treatment. Data were analysed with the Fisher exact test. p<0.05 was considered significant. RESULTS: The incidence of respiratory distress syndrome (RDS), neonatal mortality and intraventricular hemorrhage was respectively 43.4%, 3.2 % and 6.3 %. The rate of early-onset neonatal sepsis was 4.9% in the 1st group, 3.9% in the 2nd group and 5% in the 3rd group. There were no significant differences in the early-onset neonatal sepsis and the antenatal corticosteroids treatment. CONCLUSIONS: The single or the multiple courses of antenatal steroids did not apparently increase neonatal sepsis in patients with preterm delivery.

Techniques of enteral feeding in the newborn.

Among techniques of enteral feeding, gastric bolus feeding still appears to be the method of choice for most newborn babies because it is both practical and inexpensive. Unstable preterm infants and those with severe respiratory diseases or with delayed gastric emptying time may not tolerate intermittent gastric feedings and may benefit from continuous gastric feedings. Transpyloric feedings do not seem to offer any advantage over continuous gastric feedings and should be reserved for infants at risk of aspiration, such as those with gastroesophageal reflux or delayed gastric emptying. Early low-volume feedings appear beneficial and are not associated with increased morbidity. Once enteral feedings are established, daily increments of 10-20 ml/kg appear to be safe and not associated with an increased risk of necrotizing enterocolitis.

Aminophylline and increased activity of peripheral chemoreceptors in newborn infants.

Peripheral chemoreceptor activity was studied in nine healthy, unsedated neonates (with a mean (SD) postconceptional age of 39 (2) weeks and birth weight of 3000 (400) g) by measuring the inhibition of ventilation elicited by five breaths of 100% oxygen (Dejours technique). Changes in tidal volume, frequency, and minute ventilation were measured before and after administration of aminophylline (10 mg/kg by mouth). Before aminophylline hyperoxia induced a decrease in minute ventilation (from a mean (SE) of 825 (55) to 520 (30) ml/kg/min) as result of reduction of tidal volume (from 12 (0.3) to 8 (0.3) ml/kg). After aminophylline administration the hyperoxia induced decrease in tidal volume (from 14 (0.7) to 6 (0.3) ml/kg) and minute ventilation (from 847 (57) to 386 (21) ml/kg/min) was significantly greater than before. It is concluded that in neonates peripheral chemoreceptors are more active in the presence of aminophylline. It is speculated that aminophylline increases the activity of peripheral chemoreceptors, reducing the breakdown of cAMP, which is a crucial mediator for peripheral chemoreceptor discharge.

[IgG subclasses against bovine alpha-lactalbumin and beta-lactoglobulin in infants fed with a seroprotein hydrolysate]. / Sottoclassi IgG anti-alfa-lattoalbumina e anti-beta-lattoglobulina bovina in lattanti alimentati con un idrolisato di sieroproteine.

Prevention of food allergy in infancy has been the aim of important researches in the last years but many studies have produced conflicting conclusions. The use of hydrolysate formulas seems to be an helpful tool in prevention of cow milk protein allergy but confusion often remains about capability of small hydrolysate molecules to be "allergens" or "antigens". In order to clarify this point IgE, IgG and IgM as well as IgG subclasses against alfa-lactoalbumin (ALA) and beta-lactoglobulin (BLG) have been evaluated in 41 infants at risk for allergy and in 30 controls at the fourth month. The same evaluation has been done on their mothers. The 41 "at risk" children were fed with breast milk or with an hypoallergenic formula (Nidina HA, Nestlè) or both. The control children received an adapted formula. No difference between the two groups of children was found regarding IgM or IgG against ALA while antibodies against BLG were more frequently found in controls than in "at risk" children. Only one child in the group fed with Nidina HA developed specific IgE against whole milk. Therefore hydrolysate formula seems to be as antigenic (not allergenic) as adapted formula in respect of ALA while BLG contained in adapted formula seems to be a stronger immunogen. The pattern of specific IgG subclasses against ALA and BLG is different between the two groups of children because of the absence in "at risk" group of specific IgG2 and IgG3. As for the mothers, the presence in their sera of IgG against ALA or BLG seems to induce in infants a reduced response to the same antigen.

Oral versus intramuscular loading of caffeine in idiopathic apnoea of prematurity.

The loading dose of caffeine (15 mg/kg) was administered orally to nine newborn babies and intramuscularly to nine others. The oral maintenance dose (2 mg/kg per day) was administered 24 h after the loading dose and then once a day for as long as necessary. The two groups were statistically similar with regard to gestational age, birth weight and Apgar score at 1 and 5 min. There was no statistical difference between the two groups in serum levels of caffeine at 1, 12 or 24 h and 7, 14 or 21 days. Therefore, oral administration appears to be the better route for loading, as it is effective and non-traumatic. Moreover, low maintenance doses allow therapeutic serum levels to be kept to a minimum reducing the likelihood of side-effects.

[Evaluation problems and indications for handling premature infants (VLBW)]. / Problemi di valutazione e indicazioni per l'handling del neonato pretermine (VLBW).

The authors present their approach to the care of the preterm very-low-birth-weight infant. They consider the importance of the handling of the preterm infant in the Neonatal Intensive Care Unit (NICU) and the co-operation among the neonatologist, the physiotherapist and the parents in the individualized care, both in the NICU and in the follow-up.

[Hematoma of the sternocleidomastoid. Results of a non-invasive treatment in newborn infants]. / L'ematoma dello sternocleidomastoideo. Risultati di un trattamento non invasivo in età neonatale.

Nine infants with haematoma of the SCM muscle were evaluated. A review of previous reports and a comparison of the clinical features of this group of patients to ones considered in other reports is reported and a simple therapeutic program is outlined: during the first year of life, postures and simple exercises performed by the mother under the pediatrician's supervision are suggested. In the eight cases in which the therapeutic program was followed, the long-term outcome was satisfactory from both cosmetic and functional point of view. Therefore this method should be preferred during the first year of life, also taking into account the lack of negative influence on the mother-infant relationship and on the infant's neurological development.