Evidence on docosahexaenoic acid and arachidonic acid supplementation for preterm infants

PURPOSE OF REVIEW

For many decades, docosahexaenoic acid (DHA) supplementation was tested in premature infants to achieve an intake equivalent to the average level in breast milk, but this approach has led to conflicting results in terms of development and health outcomes. Higher doses of DHA closer to fetal accumulation may be needed.

RECENT FINDINGS

The efficacy of DHA supplementation for preterm infants at a dose equivalent to the estimated fetal accumulation rate is still under investigation, but this may be a promising approach, especially in conjunction with arachidonic acid supplementation. Current data suggest benefit for some outcomes, such as brain maturation, long-term cognitive function, and the prevention of retinopathy of prematurity. The possibility that supplementation with highly unsaturated oils increases the risk of neonatal morbidities should not be ruled out, but current meta-analyzes do not support a significant risk.

SUMMARY

The published literature supports a DHA intake in preterm infants that is closer to the fetal accumulation rate than the average breast milk content. Supplementation with DHA at this level in combination with arachidonic acid is currently being investigated and appears promising.

Renal function after ductus arteriosus transcatheter closure with or without angiography in very preterm infants

AIM

Transcatheter closure of the patent ductus arteriosus (TCPDA) is increasingly used in preterm infants as an alternative to surgical ligation. However, clinically ill preterm infants are at risk of contrast nephropathy due to the angiography contrast agents used during the procedure.

METHODS

We performed a single-centre before-and-after comparative study in VLBW infants to compare the kinetics of serum creatinine during the first 4 days after TCPDA with or without angiography.

RESULTS

69 patients were included and divided into two groups: TCPDA with (contrast+; n = 37) and without (contrast-, n = 32) use of contrast agent. The median dose [range] of contrast agent was 1.0 mL/kg [0.6-2.4 mL/kg]. The change in serum creatinine level between day 2 to 4 after TCPCA and baseline decreased in the contrast- group (-17% [-46%; 18%]), while it increased in the contrast+ group (7% [-24%; 202%] p = 0.002). Comparison of blood urea levels between groups showed similar significant differences. The change in serum creatinine between day 2 to 4 and baseline was significantly correlated with the dose of contrast agent (r2 = 0.682; p < 0.001).

CONCLUSION

The use of contrast agents during TCPDA can potentially harm the renal function of very preterm infants. Therefore, we advise minimising or avoiding the use of contrast agents.

Hypoxic ischemic brain injury: animal models reveal new mechanisms of melatonin-mediated neuroprotection

Oxidative stress (OS) and inflammation play a key role in the development of hypoxic-ischemic (H-I) induced brain damage. Following H-I, rapid neuronal death occurs during the acute phase of inflammation, and activation of the oxidant-antioxidant system contributes to the brain damage by activated microglia. So far, in an animal model of perinatal H-I, it was showed that neuroprostanes are present in all brain damaged areas, including the cerebral cortex, hippocampus and striatum. Based on the interplay between inflammation and OS, it was demonstrated in the same model that inflammation reduced brain sirtuin-1 expression and affected the expression of specific miRNAs. Moreover, through proteomic approach, an increased expression of genes and proteins in cerebral cortex synaptosomes has been revealed after induction of neonatal H-I. Administration of melatonin in the experimental treatment of brain damage and neurodegenerative diseases has produced promising therapeutic results. Melatonin protects against OS, contributes to reduce the generation of pro-inflammatory factors and promotes tissue regeneration and repair. Starting from the above cited aspects, this educational review aims to discuss the inflammatory and OS main pathways in H-I brain injury, focusing on the role of melatonin as neuroprotectant and providing current and emerging evidence.

Vitamin K insufficiency and the prophylaxis strategy in term healthy infants: A multicentre study

BACKGROUND/AIM

Late vitamin K deficiency bleeding (VKDB) during early infancy is a serious problem worldwide. Vitamin K (VK) deficiency commonly occurs in newborns who are exclusively breastfed. Protein Induced by VK Absence (PIVKA-II) has been identified as an early indicator of subclinical VK deficiency in neonates, surpassing prothrombin time. To assess PIVKA-II levels at 48 h, 1 and 3 months of age in full-term newborns who were exclusively breastfed and received varying VKDB prophylaxis regimens.

METHODS

A prospective observational study was conducted in four hospitals, enrolling 105 newborns. PIVKA-II levels were measured using a sandwich-type enzyme-linked immunosorbent assay.

RESULTS

At 48 h of age, there was no significant difference in PIVKA-II concentrations between newborns who received intramuscular administration of 1 mg of phylloquinone (VK1) and those who received oral administration of 2 mg of VK1 at birth. At 1 and 3 months of life, infants who received any supplementation regimen between 2 and 14 weeks exhibited significantly lower PIVKA-II concentrations compared to infants who received only 1 mg of intramuscular VK1 at birth. The prophylaxis involving a dose of 1 mg of intramuscular VK1 at birth followed by oral administration of 150 μg/day of VK1 from the 2nd to the 14th week of life showed the lowest PIVKA-II blood concentrations.

CONCLUSIONS

Oral supplementation of VK1 after discharge significantly reduced PIVKA-II concentrations in exclusively breastfed term infants. These findings suggest the importance of oral VK1 supplementation in exclusively breastfed infants during their first 3 months of life to avoid the risk of VK insufficiency.

Nutrition of the preterm infant with persistent ductus arteriosus: existing evidence and practical implications

The persistence of a patent ductus arteriosus (PDA) is a common condition in preterm infants with a prevalence inversely proportional to gestational age. PDA is associated with mild-to-severe gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which represent a major challenge for the nutritional management in preterm infants. In this context, the Section on Nutrition, Gastroenterology and Metabolism and the Circulation Section of the European Society for Pediatric Research have joined forces to review the current knowledge on nutritional issues related to PDA in preterm infants. The aim of the narrative review is to discuss the clinical implications for nutritional practice. Because there is little literature on postnatal nutrition and PDA in preterm infants, further research with well-designed studies on this topic is urgently needed. Guidelines should also be developed to clearly define the implementation and course of enteral nutrition and the target nutritional intake before, during, and after pharmacologic or surgical treatment of PDA, when indicated. IMPACT: Persistent ductus arteriosus (PDA) is associated with gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which pose a major challenge to the nutritional management of preterm infants. In PDA infants, fluid restriction may lead to inadequate nutrient intake, which may negatively affect postnatal growth and long-term health. The presence of PDA does not appear to significantly affect mesenteric blood flow and splanchnic oxygenation after enteral feedings. Initiation or maintenance of enteral nutrition can be recommended in infants with PDA.

Molecular mechanisms of oxidative stress-related neonatal jaundice

Oxidative stress is a pathological condition characterized by an overload of oxidant products, named free radicals, which are not well counteracted by antioxidant systems. Free radicals induce oxidative damage to many body organs and systems. In neonatal red blood cells, free-radical mediated-oxidative stress leads to eryptosis, a suicidal death process of erythrocytes consequent to alteration of cell integrity. Neonatal red blood cells are targets and at the same time generators of free radicals through the Fenton and Haber-Weiss reactions. Enhanced eryptosis in case of oxidative stress damage may cause anemia if the increased loss of erythrocytes is not enough compensated by enhanced new erythrocytes synthesis. The oxidative disruption of the red cells may cause unconjugated idiopathic hyperbilirubinemia in neonates. High levels of bilirubin are recognized to be dangerous for the central nervous system in newborns, however, many studies have highlighted the antioxidant function of bilirubin. Recently, it has been suggested that physiologic concentration of bilirubin correlates with higher antioxidant status while high pathological bilirubin levels are associated with pro-oxidants effects. The aim of this educational review is to provide an updated understanding of the molecular mechanisms underlying erythrocyte oxidant injury and its reversal in neonatal idiopathic hyperbilirubinemia.

Erythropoietin as a Neuroprotective Drug for Newborn Infants: Ten Years after the First Use

Protective strategies against perinatal brain injury represent a major challenge for modern neonatology. Erythropoietin (Epo) enhances endogenous mechanisms of repair and angiogenesis. In order to analyse the newest evidence on the role of Epo in prematurity, hypoxic ischemic encephalopathy (HIE) and perinatal stroke, a critical review using 2020 PRISMA statement guidelines was conducted. This review uncovered 26 clinical trials examining the use of Epo for prematurity and brain injury-related outcomes. The effects of Epo on prematurity were analysed in 16 clinical trials. Erythropoietin was provided until 32–35 weeks of corrected postnatal age with a dosage between 500–3000 UI/kg/dose. Eight trials reported the Epo effects on HIE term newborn infants: Erythropoietin was administered in the first weeks of life, at different multiple doses between 250–2500 UI/kg/dose, as either an adjuvant therapy with hypothermia or a substitute for hypothermia. Two trials investigated Epo effects in perinatal stroke. Erythropoietin was administered at a dose of 1000 IU/kg for three days. No beneficial effect in improving morbidity was observed after Epo administration in perinatal stroke. A positive effect on neurodevelopmental outcome seems to occur when Epo is used as an adjuvant therapy with hypothermia in the HIE newborns. Administration of Epo in preterm infants still presents inconsistencies with regard to neurodevelopmental outcome. Clinical trials show significant differences mainly in target population and intervention scheme. The identification of specific markers and their temporal expression at different time of recovery after hypoxia-ischemia in neonates might be implemented to optimize the therapeutic scheme after hypoxic-ischemic injury in the developing brain. Additional studies on tailored regimes, accounting for the risk stratification of brain damage in newborns, are required.

Oxidative Stress in Preterm Newborns

Preterm babies are highly susceptible to oxidative stress (OS) due to an imbalance between the oxidant and antioxidant systems. The generation of free radicals (FR) induces oxidative damage to multiple body organs and systems. OS is the main factor responsible for the development of typical premature infant diseases, such as bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage, periventricular leukomalacia, kidney damage, eryptosis, and also respiratory distress syndrome and patent ductus arteriosus. Many biomarkers have been detected to early identify newborns at risk of developing a free radical-mediated disease and to investigate new antioxidant strategies. This review reports the current knowledge on OS in the preterm newborns and the newest findings concerning the use of OS biomarkers as diagnostic tools, as well as in implementing antioxidant therapeutic strategies for the prevention and treatment of these diseases and their sequelae.

The challenge to define the optimal prophylactic regimen for vitamin K deficiency bleeding in infants

Infants are at risk of vitamin K deficiency that may lead to vitamin K deficiency bleeding (VKDB). Although many vitamin K prophylactic regimens have been developed throughout the years, still cases of late form VKBD may occur. The introduction of combined prophylactic strategy with prolonged oral prophylaxes after the intramuscular dose at birth has showed a decrease of the late severe VKDB incidence. Nevertheless, there is still lack of consensus about the administration scheme after the first dose at birth. CONCLUSION: Late form VKBD is not eradicated, and the best prophylactic regimen in term and preterm infants is still an open debate.

Case Report: A Case of Glioblastoma in a Patient With Haberland Syndrome

Haberland syndrome or encephalocraniocutaneous lipomatosis is a rare ectomesodermal dysgenesis defined by the triad including ocular, skin, and central nervous system involvement, which is commonly unilateral. This disorder is attributed to a post-zygotic mutation responsible for a neural tube and neural crest dysgenesis. We report the case of a 15-year-old female with Haberland syndrome with pharmacoresistant epilepsy who developed a World Health Organization-grade IV glioblastoma. This is the first case of pediatric glioblastoma associated with Haberland syndrome. The previously reported pediatric cases included benign brain tumors. To our knowledge, this is the fifth case of brain tumor associated with encephalocraniocutaneous lipomatosis and the second case of glioblastoma associated with this syndrome. The hypothesis that Haberland syndrome is associated with an increased risk of tumor development is intriguing, although the rarity of the condition is nowadays preventing us from drawing definitive conclusions about this potential link between the two entities. Further studies are needed to establish the real relationship between encephalocraniocutaneous lipomatosis and the risk of brain tumors.

Rational ideation and empiric validation of an innovative digital dermographic tester

BACKGROUND

Dermographism is a condition characterized by a weal response to a combination of pressure and traction on skin surface, and its diagnosis is based on medical history, clinical criteria and provocation test. The Dermographic Tester^® , a pen-sized tool containing a spring-loaded blunt tip, is the most widely used instrument for the provocation test, and it exerts increasing pressures on the skin surface according to an arbitrary units (AU) scale. Analysing the mechanism of function and trying to convert the AUs to SI units (g/mm² ), we found that this instrument had some defects and limits that would compromise a true and repeatable quantification of the weal response threshold. Consequently, we decided to develop a new instrument, the Digital Dermographic Tester (DDT), which is engineered with an inside force sensor to implement features lacking in the current tools, in the hope of enhancing the precision of the provocation test.

AIM

To validate the effectiveness and accuracy of the DDT.

METHODS

We tested the DDT on 213 participants purposely sampled to obtain three groups, each with a different pattern of reaction to mechanical stimuli. Based on anamnestic, diagnostic and symptomatic criteria, patients were divided into dermographic urticaria (DU), spontaneous urticaria (SU) and healthy control (HC) groups. The DDT was used to apply 12 levels of pressure to the skin surface, and a frequency distribution of positive reactions was displayed for each group.

RESULTS

A force of 36-40 g/mm² appropriately differentiated physiological from pathological conditions with high sensitivity and specificity.

CONCLUSIONS

The DDT was found to be capable of differentiating patients with DU patients from those with SU and from HCs, and was able to precisely identify the weal elicitation threshold.

Adenomas with high-grade dysplasia and early adenocarcinoma are more likely to be sessile in the proximal colon

AIM

Size and the sessile morphology of an adenoma may explain why colonoscopy is less effective in preventing proximal colonic cancer than distal cancers. We wanted to determine if advanced polypoid neoplasms (APNs, i.e. adenoma with high-grade dysplasia or early adenocarcinoma) are more likely to be sessile and/or smaller in the proximal colon.

METHOD

We searched our institution's pathology database from 2004 to 2012 and identified patients with APNs. Polyps were categorized by size, morphology and location in the colon. Average polyp size and morphology were determined for each location.

RESULTS

During the study period, 564 patients with APNs were identified. Of these, adenocarcinoma was noted in 21.6% and high-grade dysplasia in 78.4%. The average patient age was 64.4 years and 54.9% were men. The proportion of APNs that were ≤ 5 mm was 1.7%, ≤ 10 mm 19.3% and ≤ 15 mm 39%. APNs in the proximal colon were larger than those in the distal colon, but the difference was not statistically significant (27 vs 24 mm; P = 0.06). Eighty-three per cent of APNs in the proximal colon were sessile vs 57% in the distal colon (P = 0.001). APNs in the proximal colon were almost four times more likely to be sessile than in the distal colon (OR = 3.7). A similar association was noted for polyps ≤ 20 mm or polyps with high-grade dysplasia.

CONCLUSION

APNs in the proximal colon were almost four-times more likely to be sessile than those in the distal colon. No difference in the size of polyps was noted.

A preterm infant with benign neonatal hemangiomatosis and persistent patent ductus arteriosus: a curious comorbidity

A female infant had been delivered prematurely at 33 weeks to a gravida 1, para 0, 32-year-old mother following normal spontaneous vaginal delivery. Because of persistent patent ductus arteriosus the new born underwent surgery after 30 days. Four months later, when the infant arrived at our observation, approximately 13 red, nodular hemangiomas ranging from 0.5 to 30 mm in diameter were scattered over the scalp, trunk, abdomen, and extremities. Laboratory and instrumental tests investigating visceral involvement were all negative. Our diagnosis was of benign neonatal hemangiomatosis. Benign neonatal hemangiomatosis is a condition with multiple congenital hemangiomas limited to the skin. The incidence in the newborn population is between 1.0% and 4% with females 4 times more affected than males. Solitary hemangiomas occur more frequently in premature neonates with a reported incidence, inversely proportional to birth weight. Although the exact mechanism for hemangioma development remains unknown, vascular growth factors seem to play a role in the pathogenesis. Proliferation most likely results from an imbalance between positive and negative angiogenic factors expressed by the hemangioma and adjacent normal tissue. Patency of the ductus arteriosus is a common complication of preterm birth. During the immediate postpartum period, a loss of vasodilatory stimuli and activation of intrinsic contractile mechanisms facilitates ductus lumen occlusion. The imbalance of these forces, linked to premature birth, interrupts the normal maturation process, leaving the immature ductus patent. Our case is the first one of benign neonatal hemangiomatosis and patency ductus arteriosus described.

[A case of neonatal lupus syndrome and congenital atrioventricular block associated with maternal antibodies antiRo/SS-A]

The neonatal lupus erythematosus syndrome (LEN) is a disease due to the transplacental passage of maternal antiextractable nuclear antigens (ENA) antibodies, particularly anti-Ro/SS-A and anti-La/SS-B. The disease affects neonates born from mothers with autoimmune diseases. It is characterized by erythematous annular polycylic skin lesions, slightly scaling with prevalent face localization, hematologic and liver diseases and only in 2% of cases with extracutaneous lesions including complete atrioventricular block. The Authors describe a case of LEN characterized by isolated atrioventricular block at birth and endocardial fibroelastosis without skin lesions in a preterm infant female. She was born from asymptomatic, ANA (Anti-Nuclear Antibodies) and ENA (anti-Extractable Nuclear Antigen) positive mother, with a previous miscarriage at the 5th week of gestation.

Effect of red wine on adipocytokine expression and vascular alterations in fructose-fed rats

BACKGROUND

Imbalance in adipocytokines secretion is related to the development of metabolic syndrome (MS). In addition, moderate consumption of red wine (RW) decreases the risk of cardiovascular disease. The aim of this study was to evaluate the effects of moderate consumption of RW or ethanol (E) on adiponectin and resistin expression, and vascular alterations in fructose-fed rats (FFRs) as an experimental model of MS.

METHODS

Thirty-day-old male Wistar rats were assigned to control (C), F (10% fructose in drinking water), F+E (4.5 ml/kg), and F+RW (35 ml/kg of Malbec RW containing 4.5 ml/kg E). E and RW were administered during the last 4 weeks of a 10-week period.

RESULTS

RW administration to F rats was able to significantly decrease insulin resistance, mesenteric adipose tissue weight, and systolic blood pressure (SBP) compared to F group. F+E only reduced the SBP (P < 0.05 vs. F). F+RW also reduced aortic NAD(P)H-oxidase activity, NAD(P)H subunits Nox4 expression in mesenteric tissue, plasma thiobarbituric acid reactive substances (TBARS), and recovered plasma total antioxidant activity (TAA) compared to F and F+E groups (P < 0.05). Adiponectin expression decreased, whereas resistin, vascular cell adhesion molecules-1 (VCAM-1), and nuclear factor-κB (NF-κB) expression and vascular remodeling in mesenteric arteries were higher in F than in C group (P < 0.05). Only RW was able to partially reverse the aforementioned alterations.

CONCLUSION

In this study, Malbec RW, but not alcohol alone, improved the balance of adipocytokines and attenuated the oxidative stress and vascular inflammation in a model of MS, suggesting that nonalcohol components of RW are responsible for the beneficial effects.

In vivo evaluation of a Poly-2p barrier cream protective effect

AIM

Theoretically, skin barrier creams reduce or even prevent the penetration into the skin by building up a physical barrier, like a thin film between the skin and the irritant. Practically, controversial experiences concerning the effectiveness of barrier creams exist. For this, we propose an in vivo method to evaluate the efficacy of barrier creams trough clinical scoring and instrumental analysis.

METHODS

Nineteen housewives with hand dermatitis in remission phase were enrolled in the study. Every patient was evaluated clinically and an arbitrary score was assigned by the investigator considering erythema, exudation, lichenification and xerosis. A score was also assigned by every patient to itching and burning. As measurement of the functional state of the skin and of the effectiveness of the barrier cream, transepidermal water loss (TEWL), corneometry, colorimetry and visco-elasticity determination were performed. To investigate the protection properties against irritant products, the 24-h irritancy patch test with sodium lauryl sulphate 1% in water was used.

RESULTS

Through the patch test technique the efficacy of the barrier cream was tested compared to other topical products containing corticosteroids, lipids, humectants or urea, with already known anti-inflammatory, lenitive or protective properties. The results showed this methods easy and fast in handling, non-invasive, standardized, and in vivo applicable for evaluation and ranking of barrier creams.

CONCLUSION

The study preparation demonstrated high tolerability and indubitable efficacy in improving the skin barrier function even towards a very well known irritant.

Porokeratosis: Two Faces, One Family

Porokeratosis is a disorder of keratinisation whose pathogenesis is yet unclear. It has been postulated that it results from the proliferation of an abnormal clone of keratinocytes, triggered by several factors, such as immunosuppression or prolonged ultraviolet exposure. Various clinical forms are recognized whose common denominator is a keratotic ring surrounding a central zone of atrophy. The histological hallmark is the cornoid lamella, a thin column of hyperproliferative abnormal keratinocytes. We describe two cases of porokeratosis. A 67-year-old woman with an erythematous purplish round plaque surrounded by a keratotic border that had appeared 6 years previously on the left sural region was diagnosed as ‘giant’ porokeratosis. A 49-year-old man presented with small papules coalescent in an erythematous oval plaque on the lateral side of the left foot consistent with linear porokeratosis.

[Development and use of quality control program in magnetic resonance]

In 1992, two identical 0.5 Magnetic Resonance units were installed in Policlinico S. Orsola-Malpighi in Bologna. A Quality Assurance (QA) protocol was designed by the Medical Physics Department to monitor both systems as of Acceptance Test. Our main goals in drawing up the QA protocol were: 1) Completeness--to check all the most significant physical parameters; 2) Efficiency--to reduce examination time of the QC Protocol; 3) Reliability--to achieve good repeatability of results. The QA protocol consists of two QC programs: 1) Daily check of Variable Echo image SNR of a homogeneous phantom, Eddy Current compensation, laser printer test; 2) Monthly check of SNR of Spin Echo and Fast Scan images, integral uniformity, B0 uniformity, B1 uniformity, T2 stability, ghosts, slice thickness, slice profile, geometrical distortion, resolution power. SNR dependence on FOV, NEX, matrix and slice thickness, and resolution dependence on slice thickness and position were tested as Acceptance test. The daily checks provide continual monitoring of the performance of both systems and laser printer and have shown: 1) strong fluctuations in image reproduction probably due to film emulsion instability; 2) a "warning" of imminent malfunction. The monthly checks were in line with acceptance test data and have shown: 1) different behavior of the two systems that should perform analogously; 2) greater result stability in one system with better results also in terms of diagnostic images. The main aim of our QA protocol is to optimize diagnostic accuracy by checking several physical parameters that act as good "indicators" for possible malfunctioning. We believe this can be done with simple but useful daily QC supporting a routine more complex QC program and can be achieved through continual application of both protocols.