Prenatal prediction of respiratory distress syndrome by multimodality approach using 3D lung ultrasound, lung-to-liver intensity ratio tissue histogram and pulmonary artery Doppler assessment of fetal lung maturity.

OBJECTIVE: Studying the correlation of different lung parameters, using three-dimensional ultrasound (3D US) with fetal lung maturity (FLM) to predict the development of neonatal respiratory distress syndrome (RDS). METHODS: Three-dimensional ultrasound was done to record the fetal lung volume (FLV), fetal lung-to-liver intensity ratio (FLLIR) and the main pulmonary artery (MPA) blood flow parameters; pulsatility index (PI), resistive index (RI) and acceleration time-to-ejection time ratio (At/Et), to 218 women between 32 and 40 weeks gestational age within 24 h from labor. RESULTS: Of 218 fetuses examined, final analysis was done for 143 fetuses. Thirty eight (26.5%) were diagnosed with RDS. The MPA PI and RI were significantly higher in fetuses diagnosed with RDS compared with those without (2.51 ± 0.33 and 0.90 ± 0.03 cm/s versus 1.96 ± 0.20 and 0.84 ± 0.01 cm/s; p value < 0.001 and <0.001 respectively). MPA At/Et was significantly lower (0.24 ± 0.04 vs 0.35 ± 0.04; p value < 0.001). FLLIR was significantly lower (1.04 ± 0.07 vs 1.18 ± 0.11; p value < 0.001), and the mean FLV was significantly smaller (28.23 ± 5.63, vs 38.87 ± 4.68 cm3; p value < 0.001). CONCLUSION: Main pulmonary artery (PI, RI, At/Et ratio), FLIIR, and mean FLV can be used as reliable predictors of neonatal RDS. ADVANCES IN KNOWLEDGE: 3D ultrasound VOCAL technique, ultrasound tissue histogram and pulmonary artery Doppler are reliable tools for prenatal prediction of fetal lung maturity.

Does bloody aspirate reflect the state of upper gastrointestinal mucosa in a critically ill newborn?

BACKGROUND AND STUDY AIMS: Critically ill newborns have many risk factors to develop stress related mucosal lesions (SRML). We used upper endoscopy to evaluate the presence of SRML in these neonates, to know the specificity and sensitivity of the bloody gastric aspirate to detect SRML and to identify the risk factors associated with the presence of SRML and bloody gastric aspirate. PATIENTS AND METHODS: This is a cross-sectional study done on 100 critically ill newborn after becoming clinically stable. SRML were diagnosed if there is hyperaemia, erosions or ulcers in the oesophagus, stomach, and/or the duodenum. RESULTS: SRML were found in 77% of neonates in the NICU though frank bloody aspirate was detected in only 22% of neonates. The presence of bloody aspirate showed low sensitivity (24.68%) and high specificity (86.96%) for the presence of SRML. The presence of bloody gastric aspirate showed a double fold risk for the presence SRML (OR=2.184, CI=0.584-8.171). Factors associated with SRML included respiratory distress (p=0.000, risk=4.006), the use of nasogastric tube (p=0.017, OR=3.281) and the use of triple antibiotics (p=0.001, risk=1.432). Factors associated with the presence of bloody gastric aspirate included the use of nasogastric tube (OR=1.629, p=0.000) and the presence of haemostatic disorders (OR=3.143, p=0.039). It was also associated with lower haemoglobin levels (p=0.000). CONCLUSION: SRML represents an under-diagnosed problem in NICUs. Absence of bloody gastric aspirate does not exclude the presence of SRML.

Echocardiogram done early in neonatal sepsis: what does it add?

BACKGROUND: One of the major organs affected in neonatal sepsis is the heart. Echocardiogram provides real-time information on the cardiovascular performance rather than dependence on the clinical signs alone, which might lead to misjudgment. AIM OF THE WORK: To assess left ventricular (LV) functions in septic neonates early after admission using transthoracic color Doppler Echocardiography. PATIENTS AND METHODS: Echocardiography was done to 30 septic and 30 nonseptic newborns who were divided among 4 groups (septic full-term, 14; septic preterm, 16; nonseptic full-term, 21; and nonseptic preterm, 9). Comparisons were made among the 4 groups using analysis of variance and post hoc test regarding the systolic function (using ejection fraction and fractional shortening), the diastolic function (using the early patrial peak/atrial peak flow velocity ratio), and the global LV function (using myocardial performance index). RESULTS: The E-wave and the early peak flow velocity/atrial peak flow velocity ratio were significantly lower in the septic neonates, whether full-term or premature, compared to their corresponding age groups in the nonseptic newborns, suggesting LV diastolic dysfunction (P < 0.001 and P < 0.014, respectively). No difference was found in the diastolic function between the full-term and the preterm neonates whether lying within the septic group or in the nonseptic group. Myocardial performance index was significantly higher in the septic neonates who died than in the survivors (P < 0.001). CONCLUSION: Neonatal sepsis is associated with LV diastolic dysfunction.

Tracheal colonization in preterm infants supported with nasal continuous positive airway pressure.

BACKGROUND: The aim of this study was to examine endotracheal bacteriological status in premature infants who are supported by nasal continuous positive airway pressure (CPAP) without any history of tracheal intubation. METHODS: In this prospective study, we enrolled 60 premature infants with respiratory distress; of these, 30 were supported by CPAP without tracheal intubation, and 30 were intubated and mechanically ventilated. Infants were enrolled at a postnatal age of < 24 h. Endotracheal (ET) cultures were taken at 24 h and at the 5th day of life. In the CPAP group, a suction catheter was sterilely inserted into the trachea while directly visualizing the vocal cords using a laryngoscope. RESULTS: ET cultures taken on the 1st day of life showed colonization in 7/30 (23%) in the CPAP group versus 19/30 (63%) in the mechanically ventilated group (P= 0.002). Tracheal cultures on day 5 were positive in 5/30 (17%) and 11/30 (37%), respectively (P= 0.093). Klebsiella ssp. represented the most frequently isolated organism in both groups. A positive tracheal culture at 5 days was associated with a longer duration of respiratory support in the CPAP group (P= 0.05) but not in the ventilation group. Endotracheal culture at 5 days was associated with mortality in the ventilation group (8/11 vs 5/19, P= 0.02), but not in the CPAP group (1/5 vs 2/25, P= 0.45). Early endotracheal cultures did not relate with mortality in either of the groups. CONCLUSION: The trachea of premature infants supported with CPAP is at risk for bacterial colonization. Predisposing factors, mechanisms and clinical implications of these novel findings need to be studied.

Assessment of exposure of Egyptian infants to aflatoxin M1 through breast milk.

BACKGROUND: Mothers are exposed to many toxins that can reach their infants through breast milk. One of these toxins is aflatoxins, produced by Aspergillus fungus. Aspergillus colonizes grains, especially in tropical regions where there is high temperature and humidity. Aflatoxins are highly toxic, mutagenic, teratogenic, and carcinogenic. One of these is aflatoxin B1 that is excreted in breast milk as aflatoxin M1 (AFM1). MATERIALS AND METHODS: This is a cross-sectional study in which 150 mother-infant dyads were included. All the infants were exclusively breastfed. Infant weights' standard deviation scores were documented at birth and at 6 months. At 6 months, before starting weaning, AFM1 was measured in breast milk by enzyme-linked immunosorbent assay and by liver enzymes; alanine aminotransferase (ALT) and aspartate aminotransferase (AST) for all mothers and infants. RESULTS: Ninety-eight mothers (65.3%) had AFM1-positive breast milk samples (AFM1>0.05 µg/l according to the European Community and Codex Alimentarius). AFM1 levels ranged between 0.2 and 19.0 µg/l (mean: 7.1±5.0 µg/l). In cases considered negative, AFM1 levels ranged between 0.01and 0.05 µg/l (mean: 0.04±0.01 µg/l). Infants of AFM1-positive mothers had lower weight standard deviation scores at birth and at 6 months (P=0.04 and 0.0001). ALT and aspartate aminotransferase of mothers and ALT of infants were significantly higher in dyads having AFM1-positive breast milk (P=0.0001, 0.0001, and 0.03, respectively). CONCLUSION: Aflatoxins represent a real threat in Egypt. The higher liver enzymes in AFM1-positive cases might represent an alarm toward future development of hepatocellular carcinoma. RECOMMENDATIONS: Cooperation of ministries is recommended to combat this problem. The public should be educated about proper food storage and about the hazards of aflatoxin ingestion.

Infants' fussiness on the breast; a window to salvage breastfeeding before breast rejection.

BACKGROUND: Infants' fussiness on the breast is a common lactation problem that can proceed to complete breastfeeding refusal if not professionally handled. AIM OF WORK: To study the factors associated with infants' fussiness while breastfeeding and the effect of proper lactation counselling on the breastfeeding outcome. SUBJECTS AND METHODS: This is an interventional study conducted in the breastfeeding clinic of the Cairo university children's hospital. Forty-six fussy infants were recruited. Personal interview together with assessment of the act of breastfeeding were done for each mother-infant dyad. The mothers' milk letdown was assessed by manual expression. Intervention was done by proper lactation counselling, guided by the WHO/UNICEF breastfeeding counselling training course. RESULTS: 28 (61%) of the mothers had forceful milk letdown versus 9 (19.5%) having average letdown and 9 (19.5%) having inhibited letdown (p<0.01). 13 infants were using pacifiers, which was stopped in 10 of them (p=0.01), 8 infants received formula and 5 mothers were smokers and all couldn't stop smoking. Upon counselling, 37 infants continued breastfeeding without fussiness and 9 stopped it (p<0.01). The greatest success was accomplished in mothers having forceful letdown (p=0.0001) and average letdown (p=0.01), rather than those having inhibited letdown (p=0.57). 19 of the 37 mothers having acceptable let down were presenting with perceived low milk supply and only 3 remained unconvinced (p<0.01). 46.2% of pacifier users, 100% of formula users and 80% of infants of smoker mothers quitted breastfeeding. Conclusion & Recommendations: Forceful milk letdown is commonly associated with fussiness on the breast with good outcome if properly managed. Inhibited letdown, smoking, bottle-feeding and pacifier use are associated with breastfeeding rejection. Low milk supply is a commonly "perceived" problem that should be properly assessed and handled by lactation consultants. Medical professionals should be oriented about the common breastfeeding problems, their prophylaxis and management and their role should go beyond just "motivating" mothers to breastfeed without practical guidance.