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Kurepa D, Boyar V, Predtechenska O, Gupta V, Weinberger B, Pulju M, Zaytseva A, Galanti SG, Kasniya G, Perveen S. Video laryngoscopy-assisted less-invasive surfactant administration quality improvement initiative. Arch Dis Child Fetal Neonatal Ed 2023; 108:588-593. [PMID: 37028921 DOI: 10.1136/archdischild-2023-325357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/25/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE To describe the use of quality improvement methodology in transitioning from delivery of surfactant by INSURE (INtubation-SURfactant administration-Extubation) to video laryngoscope-assisted LISA (less-invasive surfactant administration) for infants with respiratory distress syndrome (RDS) receiving non-invasive ventilatory support. SETTING Two large neonatal intensive care units (NICUs) at Northwell Health (New Hyde Park, New York, USA). STUDY POPULATION Infants with RDS receiving continuous positive airway pressure in the NICU and eligible for surfactant administration. RESULTS LISA was initiated in our NICUs in January 2021, after extensive guideline development, education programmes, hands-on training and provider credentialing. Our Specific, Measurable, Achievable, Relevant and Timely aim was to deliver surfactant by LISA for 65% of total doses by 31 December 2021. This goal was achieved within 1 month of go-live. In total, 115 infants received at least one dose of surfactant during the year. Of those, 79 (69%) received it via LISA and 36 (31%) via INSURE. Two Plan-Do-Study-Act cycles contributed to improved adherence to guidelines on timely surfactant administration and both written and video documentation. CONCLUSIONS Safe and effective introduction of LISA with the use of video laryngoscopy is achievable with careful planning, clear clinical guidelines, adequate hands-on training and comprehensive safety and quality control.
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Affiliation(s)
- Dalibor Kurepa
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Vitaliya Boyar
- Pediatrics, Cohen Children's Medical Center Division of Neonatology, New Hyde Park, New York, USA
| | - Olena Predtechenska
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Venkata Gupta
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Barry Weinberger
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Margaret Pulju
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Alla Zaytseva
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Stephanie G Galanti
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Gangajal Kasniya
- Division of Neonatology, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Shahana Perveen
- Pediatrics, Cohen Children's Medical Center Division of Neonatology, New Hyde Park, New York, USA
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Muacevic A, Adler JR. Less Invasive Surfactant Administration: A Review of Current Evidence of Clinical Outcomes With Beractant. Cureus 2022; 14:e30223. [PMID: 36381708 PMCID: PMC9651081 DOI: 10.7759/cureus.30223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2022] [Indexed: 01/25/2023] Open
Abstract
Evidence supporting clinical recommendations or approval for less invasive surfactant administration (LISA) has primarily examined heterogeneous or small-volume (e.g., 1.25-2.5 mL/kg) animal-derived surfactant regimens. To address the evidence gap for larger-volume (e.g., 4-5 mL/kg) animal-derived surfactants, the aim of this review was to evaluate and summarize LISA literature for widely used larger-volume beractant. Surfactant treatment and the LISA technique were initially summarized. The available literature on beractant with LISA was thoroughly assessed and reviewed, including a recent systematic analysis, studies from regions where access or preferences may influence reliance on larger-volume surfactants, and investigations of short- and long-term outcomes. The available literature indicated improved short-term outcomes, including less need for mechanical ventilation, death, or bronchopulmonary dysplasia, and no negative long-term developmental outcomes when beractant was administered via LISA compared with older, more invasive techniques. The rates of short-term outcomes were similar to those previously observed in examinations of LISA with small-volume surfactants, including in populations reflecting very preterm infants. As uptake of LISA is expected to increase, future research directions for larger-volume surfactants include cost-effectiveness evaluations and robust examinations of repeat dosing and surfactant reflux to further inform clinical practice. This review provides a detailed assessment of the literature describing surfactant and LISA, with a focus on studies of beractant. Collectively, the available evidence supports the use of beractant with LISA based both on short-term and long-term outcomes relative to more invasive techniques and comparability of outcomes with small-volume surfactants and may be valuable in guiding clinical decision-making.
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Devi U, Pandita A. Surfactant delivery via thin catheters: Methods, limitations, and outcomes. Pediatr Pulmonol 2021; 56:3126-3141. [PMID: 34379878 DOI: 10.1002/ppul.25599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/23/2021] [Accepted: 07/23/2021] [Indexed: 01/08/2023]
Abstract
Various less invasive surfactant administration strategies like surfactant replacement therapy via thin catheters, laryngeal mask airway, pharyngeal instillation, and nebulized surfactant are increasingly being practiced to avoid the harmful effects of endotracheal intubation and ventilation. Numerous studies have been done to study surfactant replacement via thin catheters whereas little data is available for other methods. However, there are variations in premedication policies, type of respiratory support used in these studies. Surfactant delivery using thin catheters has been reported to be associated with decrease in the need for mechanical ventilation (MV), duration of MV, bronchopulmonary dysplasia and neonatal mortality. With the current evidence, among all the available surfactant delivery methods, the one using thin catheters appears to be the most feasible and beneficial to improve clinical neonatal outcomes.
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Affiliation(s)
- Usha Devi
- Department of Neonatology, Chettinad Hospital and Research Institute, Kelambakkam, Tamil Nadu, India
| | - Aakash Pandita
- Department of Neonatology, SGPGIMS, Lucknow, Uttar Pradesh, India
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Factors Associated with the Occurrence of Death Outcome in Children with Neonatal Respiratory Distress Syndrome. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2021. [DOI: 10.2478/sjecr-2019-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Neonatal respiratory distress syndrome (NRDS) is a consequence of immaturity at birth and it is still associated with relatively high mortality rate. The aim of this study was to identify the factors associated with the occurrence of fatal outcome in newborns with neonatal respiratory distress syndrome.The research was designed as a case-control study nested in a retrospective cohort, and it enrolled newborns treated during 2015 at Pediatric Clinic of Clinical Center in Kragujevac. Diagnosis of NRDS and decision about the treatment were left at the discretion of attending pediatricians. The cases were patients with fatal outcome, while controls were randomly selected from the pool of survivors and matched with each case by gender in a ratio of 4:1. The study included 371 newborns, of whom 201 (54.2%) were male and 170 (45.8%) female. Lethal outcome occurred in 36 newborns (9,7%). Significant association was found between death and APGAR score (ORadjusted: 0.516, 95% CI: 0.322-0.827), weight on delivery (ORadjusted: 0.996, 95% CI: 0.993-0.999), duration of hospitalization (ORadjusted: 0.901, 95% CI: 0.835-0.972) and mechanical ventilation (ORadjusted: 165.256, 95% CI: 7.616-3585.714). Higher gestational age, higher birth weight, higher APGAR score and longer duration of hospitalization were singled out as protective factors, while use of mechanical ventilation increased the risk of death. Major limitations of the study were retrospective nature and relatively small number of identified cases. Postponing delivery and delivery in institution with neonatal intensive care unit are crucial for survival of newborns with NRDS.
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Wang XA, Chen LJ, Chen SM, Su PH, Chen JY. Minimally invasive surfactant therapy versus intubation for surfactant administration in very low birth weight infants with respiratory distress syndrome. Pediatr Neonatol 2020; 61:210-215. [PMID: 31818537 DOI: 10.1016/j.pedneo.2019.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/22/2019] [Accepted: 11/05/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Minimally invasive surfactant therapy (MIST) is a new mode of surfactant administration without intubation to spontaneously breathing preterm infants with respiratory distress syndrome (RDS). The aims of this study were to assess the feasibility, efficacy and safety of using MIST to give surfactant for very low birth weight (VLBW) infants with RDS. METHODS In total, 53 VLBW infants who were born before 32 gestational weeks with spontaneous breathing, respiratory distress, and requiring surfactant therapy were divided into two groups. The infants in group A (n = 29) were intubated and received surfactant replacement therapy via endotracheal tube, followed by mechanical ventilation (MV). The infants in group B (n = 24) received tracheal instillation of surfactant via a semirigid vascular catheter during spontaneous breathing under nasal continuous positive airway pressure (nCPAP). After surfactant instillation, the infants in group B were still placed on nCPAP. RESULTS Our data showed that infants in group B (MIST group) had significantly lower rate (P < 0.05) of composite outcome of death or bronchopulmonary dysplasia (BPD), duration of intermittent positive airway pressure ventilation (IPPV) or MV, drug treatment of patent ductus arteriosus (PDA), and surgical ligation of PDA than group A. CONCLUSION MIST is feasible, safe and it may reduce the composite outcome of death or BPD for VLBW infants with RDS requiring surfactant replacement therapy.
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Affiliation(s)
- Xing-An Wang
- Division of Neonatology, Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung, Taiwan
| | - Lih-Ju Chen
- Division of Neonatology, Department of Pediatrics, Changhua Christian Children's Hospital, Changhua City, Taiwan; Institute of Medicine, Chung-Shan Medical University, Taichung, Taiwan
| | - Shan-Ming Chen
- Division of Neonatology, Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung, Taiwan
| | - Pen-Hua Su
- Division of Neonatology, Department of Pediatrics, Chung-Shan Medical University Hospital, Taichung, Taiwan; Institute of Medicine, Chung-Shan Medical University, Taichung, Taiwan
| | - Jia-Yuh Chen
- Division of Neonatology, Department of Pediatrics, Changhua Christian Children's Hospital, Changhua City, Taiwan; Institute of Medicine, Chung-Shan Medical University, Taichung, Taiwan.
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Effect of a new respiratory care bundle on bronchopulmonary dysplasia in preterm neonates. Eur J Pediatr 2020; 179:1833-1842. [PMID: 32488737 PMCID: PMC7266384 DOI: 10.1007/s00431-020-03694-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 02/03/2023]
Abstract
The development of devices that can fix the tidal volume in high-frequency oscillatory ventilation (HFOV) has allowed for a significant improvement in the management of HFOV. At our institution, this had led to the earlier use of HFOV and promoted a change in the treatment strategy involving the use of higher frequencies (above 15 Hz) and lower high-frequency tidal volumes (VThf). The purpose of this observational study was to assess how survival without bronchopulmonary dysplasia grades 2 and 3 (SF-BPD) is influenced by these modifications in the respiratory strategy applied to preterm infants (gestational age < 32 weeks at birth) who required mechanical ventilation (MV) in the first 3 days of life. We compared a baseline period (2012-2013) against a period in which this strategy had been fully implemented (2016-2017). A total of 182 patients were exposed to MV in the first 3 days of life being a higher proportion on HFOV at day 3 in the second period 79.5% (n 35) in 2016-2017 vs 55.4% (n 31) in 2012-2013. After adjusting for perinatal risk factors, the second period is associated with an increased rate of SF-BPD (OR 2.28; CI 95% 1.072-4.878); this effect is more evident in neonates born at a gestational age of less than 29 weeks (OR 4.87; 95% CI 1.9-12.48).Conclusions : The early use of HFOV combined with the use of higher frequencies and very low VT was associated with an increase in the study population's SF-BPD. What is Known: • High-frequency ventilation with volume guarantee improve ventilation stability and has been shown to reduce lung damage in animal models. What is New: • The strategy of an earlier use of high-frequency oscillatory ventilation combined with the use of higher frequencies and lower tidal volume is associated to an increase in survival without bronchopulmonary dysplasia in our population of preterm infants.
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De Bisschop B, Derriks F, Cools F. Early Predictors for INtubation-SURfactant-Extubation Failure in Preterm Infants with Neonatal Respiratory Distress Syndrome: A Systematic Review. Neonatology 2020; 117:33-45. [PMID: 31437836 DOI: 10.1159/000501654] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 06/23/2019] [Indexed: 11/19/2022]
Abstract
The INtubation-SURfactant-Extubation (INSURE) procedure is a widely-used surfactant administration method to treat preterm infants with respiratory distress syndrome (RDS) but is not always successful. We conducted a systematic review to identify early predictive factors for failure of this procedure. A systematic literature search was performed until July 2018 in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Original studies comparing INSURE success with INSURE failure in preterm infants with RDS were included. A predefined data extraction form was used to retrieve data from articles, and methodological quality was assessed using the SIGN checklists. Fifteen studies out of 690 identified records met inclusion criteria. Methodological quality varied, only 8 studies performed multivariate analysis. We identified 20 different risk factors in total. Evidence for birth weight (BW) as a predictor for INSURE failure was inconsistent, but there was a significant association between decreasing gestational age (GA) and failure risk. RDS severity was assessed in multiple ways, using arterial blood gas values, imaging, and scoring systems. In conclusion, extremely low BW, low GA, and severe RDS appear to be risk factors for INSURE failure. However, evidence is inconsistent due to important methodological heterogeneity. Therefore, clinical applicability of these results is limited and implies the need for future large cohort studies on this subject.
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Affiliation(s)
- Barbara De Bisschop
- Department of Neonatology, Vrije Universiteit Brussel, University Hospital Brussels, Brussels, Belgium,
| | - Frank Derriks
- Department of Neonatology, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Filip Cools
- Department of Neonatology, Vrije Universiteit Brussel, University Hospital Brussels, Brussels, Belgium
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Márquez Isidro E, Sánchez Luna M, Ramos-Navarro C. Long-term outcomes of preterm infants treated with less invasive surfactant technique (LISA). J Matern Fetal Neonatal Med 2019; 34:1919-1924. [PMID: 31405313 DOI: 10.1080/14767058.2019.1651276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of this study is to compare the clinical outcomes at 24 months postmenstrual age of two populations receiving beractant replacement therapy using less invasive surfactant administration (LISA) versus intubation, administration of surfactant, and early extubation (INSURE). Hospital admission requirements, psychomotor development, and respiratory and neurological outcomes were studied. STUDY DESIGN This was a single-center, retrospective, and descriptive study with a sample of 60 patients (30 for each group) on nasal continuous positive airway pressure during the first 3 days of life, requiring surfactant administration. RESULTS We found no significant differences between both groups on psychomotor development and respiratory and neurological outcomes. CONCLUSION Compared to INSURE technique, the administration of surfactant by LISA is feasible and safe and reduces invasive mechanical ventilation exposure with no differences in the follow-up neurodevelopmental and respiratory outcomes at 24 postmenstrual age.
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Kurepa D, Perveen S, Lipener Y, Kakkilaya V. The use of less invasive surfactant administration (LISA) in the United States with review of the literature. J Perinatol 2019; 39:426-432. [PMID: 30635595 DOI: 10.1038/s41372-018-0302-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/17/2018] [Accepted: 12/06/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND The majority of extremely low gestational age neonates undergo intubation for surfactant therapy. Less invasive surfactant administration (LISA) uses a thin catheter inserted into the trachea to deliver the surfactant. During the procedure, the infant is breathing spontaneously while supported with continuous positive airway pressure. Although LISA is widely adapted in Europe and Australia, the rate of LISA use in the United States is unknown. STUDY DESIGN The aim of this study is to evaluate the use of LISA in the US. A web-based survey was distributed via SurveyMonkey to 2550 neonatologists from AAP's SoNPM mailing list. RESULTS Of the 472 neonatologists who answered the survey, 15% used LISA either as a part of routine care (8%) or as part of research (7%). CONCLUSION Unlike several regions of Europe, LISA is not widely used in the US. Future studies should address ambiguities regarding infant selection, procedure training and "roadblocks" to its broader application.
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Affiliation(s)
- Dalibor Kurepa
- Cohen Children's Medical Center, New Hyde Park, NY, USA.
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Ramos-Navarro C, Sánchez-Luna M, Zeballos-Sarrato S, González-Pacheco N. Three-year perinatal outcomes of less invasive beractant administration in preterm infants with respiratory distress syndrome. J Matern Fetal Neonatal Med 2019; 33:2704-2710. [PMID: 30526187 DOI: 10.1080/14767058.2018.1557633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To assess the impact of beractant treatment using the less invasive surfactant administration (LISA) technique on perinatal outcomes in a prospective cohort of preterm infants with respiratory distress syndrome (RDS).Design: Single-center prospective study conducted in a Department of Neonatology of a tertiary care university-affiliated hospital in Madrid, Spain.Methods: Preterm infants born at <31 + 6 weeks' gestation attended in the neonatal intensive care unit (NICU) between 2012 and 2016. The main outcome was the need of invasive mechanical ventilation during the first 3 days of life. Beractant (100 mg; 4 mL/kg) was administered using the intubation-surfactant-extubation (INSURE) method during 2012 and 2013, and using the LISA procedure between 2014 and 2016.Results: The study population included 512 infants, 232 in the first period and 280 in the second period. Mechanical ventilation exposure during hospitalization showed a significant reduction in the second study period, with an adjusted OR of 0.61, 95% CI 0.39-0.96. Also, an increase of free-bronchopulmonary dysplasia (BPD) survival was found (adjusted OR 2.14, 95% CI 1.29-3.55). These significant differences in perinatal outcomes were observed only in the group of infants of 26 + 0 to 28 + 6 gestational weeks. The success rate of the first dose of beractant using LISA regarding no need of intubation during the first 3 days of life was 54% increasing to 69% in the group of 26 + 0-28 + 6 weeks of gestation. The success rate regarding free-BPD survival was 63.5% in the whole series of LISA treated patients and 72.4% in the group of 26 + 0-28 + 6 weeks. Oxygen reduction after surfactant administration (OR 39.6, 95% CI 6.1-255.8, p < .001) was predictor of LISA success, whereas LISA failure was an independent factor for air leak (OR 18.92, 95% CI 1.31-272.32, p = .031) and Death or BPD outcome (OR 19.3, 95% IC 2.5-147.4, p = .004). Gestational age was inversely associated with the need of intubation after LISA (OR 0.53, 95% CI 0.32-0.87, p = .013).Conclusions: Beractant administration by LISA technique effective reduced the need of intubation during the first 3 days of life and was associated with an increase in survival-free BPD in the group of infants born at 26 + 0 and 28 + 6 weeks' gestation.
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Affiliation(s)
- Cristina Ramos-Navarro
- Neonatology Department, Gregorio Marañon University Hospital, Biomedical Research Institute Gregorio Marañón, Complutense University of Madrid, Madrid, Spain
| | - Manuel Sánchez-Luna
- Neonatology Department, Gregorio Marañon University Hospital, Biomedical Research Institute Gregorio Marañón, Complutense University of Madrid, Madrid, Spain
| | - Susana Zeballos-Sarrato
- Neonatology Department, Gregorio Marañon University Hospital, Biomedical Research Institute Gregorio Marañón, Complutense University of Madrid, Madrid, Spain
| | - Noelia González-Pacheco
- Neonatology Department, Gregorio Marañon University Hospital, Biomedical Research Institute Gregorio Marañón, Complutense University of Madrid, Madrid, Spain
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Ramos-Navarro C, Sanchez-Luna M, Sanz-López E, Maderuelo-Rodriguez E, Zamora-Flores E. Effectiveness of Synchronized Noninvasive Ventilation to Prevent Intubation in Preterm Infants. AJP Rep 2016; 6:e264-71. [PMID: 27500013 PMCID: PMC4974112 DOI: 10.1055/s-0036-1586205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Noninvasive ventilation is being increasingly used on preterm infants to reduce ventilator lung injury and bronchopulmonary dysplasia. The aim of this study was to evaluate the effectiveness of synchronized nasal intermittent positive pressure ventilation (SNIPPV) to prevent intubation in premature infants. METHODS Prospective observational study of SNIPPV use on preterm infants of less than 32 weeks' gestation. All patients were managed using a prospective protocol intended to reduce invasive mechanical ventilation (iMV) use. Previous respiratory status, as well as respiratory outcomes and possible secondary side effects were analyzed. RESULTS SNIPPV was used on 78 patients: electively to support extubation on 25 ventilator-dependent patients and as a rescue therapy after nasal continuous positive airway pressure failure on 53 patients. For 92% of patients in the elective group and 66% in the rescue group, iMV was avoided over the following 72 hours. No adverse effects were detected, and all patients were in a stable condition even if intubation was eventually needed. CONCLUSIONS The application of SNIPPV in place of or to remove mechanical ventilation avoids intubation in 74.4% of preterm infants with respiratory failure. No adverse effects were detected.
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Affiliation(s)
- Cristina Ramos-Navarro
- Neonatology Division, Department of Pediatrics, Gregorio Marañon Biomedical Research Institute, Gregorio Marañon University Hospital, Complutense University, Madrid, Spain
| | - Manuel Sanchez-Luna
- Neonatology Division, Department of Pediatrics, Gregorio Marañon Biomedical Research Institute, Gregorio Marañon University Hospital, Complutense University, Madrid, Spain
| | - Ester Sanz-López
- Neonatology Division, Department of Pediatrics, Gregorio Marañon Biomedical Research Institute, Gregorio Marañon University Hospital, Complutense University, Madrid, Spain
| | - Elena Maderuelo-Rodriguez
- Neonatology Division, Department of Pediatrics, Gregorio Marañon Biomedical Research Institute, Gregorio Marañon University Hospital, Complutense University, Madrid, Spain
| | - Elena Zamora-Flores
- Neonatology Division, Department of Pediatrics, Gregorio Marañon Biomedical Research Institute, Gregorio Marañon University Hospital, Complutense University, Madrid, Spain
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