Lung UltrasouNd Guided surfactant therapy in preterm infants: an international multicenter randomized control trial (LUNG study)

BACKGROUND

The management of respiratory distress syndrome (RDS) in premature newborns is based on different types of non-invasive respiratory support and on surfactant replacement therapy (SRT) to avoid mechanical ventilation as it may eventually result in lung damage. European guidelines currently recommend SRT only when the fraction of inspired oxygen (FiO2) exceeds 0.30. The literature describes that early SRT decreases the risk of bronchopulmonary dysplasia (BPD) and mortality. Lung ultrasound score (LUS) in preterm infants affected by RDS has proven to be able to predict the need for SRT and different single-center studies have shown that LUS may increase the proportion of infants that received early SRT. Therefore, the aim of this study is to determine if the use of LUS as a decision tool for SRT in preterm infants affected by RDS allows for the reduction of the incidence of BPD or death in the study group.

METHODS/DESIGN

In this study, 668 spontaneously-breathing preterm infants, born at 25+0 to 29+6 weeks' gestation, in nasal continuous positive airway pressure (nCPAP) will be randomized to receive SRT only when the FiO2 cut-off exceeds 0.3 (control group) or if the LUS score is higher than 8 or the FiO2 requirements exceed 0.3 (study group) (334 infants per arm). The primary outcome will be the difference in proportion of infants with BPD or death in the study group managed compared to the control group.

DISCUSSION

Based on previous published studies, it seems that LUS may decrease the time to administer surfactant therapy. It is known that early surfactant administration decreases BPD and mortality. Therefore, there is rationale for hypothesizing a reduction in BPD or death in the group of patients in which the decision to administer exogenous surfactant is based on lung ultrasound scores.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05198375 . Registered on 20 January 2022.

Physiological responses and behavioural organization of very low birth weight infants during swaddled versus traditional weighing

AIM

Despite the consequences of neonatal distress and agitation, preterm infants undergo stress owing to weighing procedures. The objective of this study was to enable very low birth weight infants to maintain adequate self-regulation during weighing.

DESIGN

This prospective crossover study utilizes a within-subjects design, where intervention days were compared to control days.

METHOD

Infants were exposed to both swaddled and unswaddled weighing in an intensive care nursery setting. Nineteen very low birth weight infants were weighed on two consecutive days. Variables of heart rate, respiratory rate and ALPS-Neo score were recorded.

RESULTS

Stress score decreased significantly from 1.65 (pre-weight) to 0.23 (weight measurement) in swaddled-intervention periods; conversely, it increased significantly from 1.26 (pre-weight) to 4.97 (weight measurement) in control periods. During weight measurement, heart and respiratory rate were significantly lower for swaddled-intervention days when compared to control days. Given the significant impact of swaddled weighing in reducing stress, this method can be used as an appropriate weighing procedure in intensive care. This research has no patient or public contribution.

Human Milk Feeding Is Associated with Decreased Incidence of Moderate-Severe Bronchopulmonary Dysplasia in Extremely Preterm Infants

BACKGROUND

An increased rate of bronchopulmonary dysplasia (BPD) is reported in extremely preterm infants. A potential role of human milk feeding in protecting against this condition has been suggested.

METHODS

A retrospective descriptive study was conducted based on data about morbidity in the population of infants born between 22+0 and 26+6 weeks of gestation, included in the Spanish network SEN1500 during the period 2004-2019 and discharged alive. The primary outcome was moderate-severe BPD. Associated conditions were studied, including human milk feeding at discharge. The temporal trends of BPD and human milk feeding rates at discharge were also studied.

RESULTS

In the study population of 4341 infants, the rate of moderate-severe BPD was 43.7% and it increased to >50% in the last three years. The factors significantly associated with a higher risk of moderate-severe BPD were birth weight, male sex, high-frequency oscillatory ventilation, duration of invasive mechanical ventilation, inhaled nitric oxide, patent ductus arteriosus, and late-onset sepsis. Exclusive human milk feeding and any amount of human milk at discharge were associated with a lower incidence of moderate-severe BPD (OR 0.752, 95% CI 0.629-0.901 and OR 0.714, 95% CI 0.602-0.847, respectively). During the study period, the proportion of infants with moderate-severe BPD fed any amount of human milk at discharge increased more than twofold. And the proportion of infants with moderate-severe BPD who were exclusively fed human milk at discharge increased at the same rate.

CONCLUSIONS

Our work shows an inverse relationship between human milk feeding at discharge from the neonatal unit and the occurrence of BPD.

Active approach in delivery room and survival of infants born between 22 and 26 gestational weeks are increasing in Spain

AIM

To describe the trends in the delivery room approach and survival of extremely premature infants over the past two decades.

METHODS

Time-series analysis of infants included in the Spanish SEN1500 network from 2004 to 2019. Patients born from 22 + 0 to 26 + 6 weeks were included. The primary outcome was an active approach in the delivery room. Survival and temporal trends were also studied.

RESULTS

The study population included 8284 patients. At 22 and 23 weeks, an active approach was followed in 41.4% and 80.8%. A temporal trend toward a more active approach was observed at 23 weeks. Antenatal steroids were administered in 19.6% and 58.1% at 22 and 23 weeks. From 24 weeks, an active approach was applied in nearly all cases throughout the period, and more than 80% of patients received antenatal steroids. The rates of survival after an active approach were 8.7%, 21.6%, 40.6%, 59.9%, and 74.7% at 22, 23, 24, 25, and 26 weeks and significantly increased over the period, except for infants born at 22 weeks.

CONCLUSION

Active management and survival of infants born from 23 weeks increased over the period, but the frequency of antenatal steroid administration was lower than the intention to resuscitate.

The role of human milk feeds on inotrope use in newborn infants with sepsis

Background

Regarding neonatal hypotension, there is no certainty as to whether inotrope properties are beneficial or whether they may be harmful. However, given that the antioxidant content of human milk plays a compensatory role in neonatal sepsis and that human milk feeding has direct effects in modulating the cardiovascular function of sick neonates, this research hypothesized that human milk feeds might predict lower requirements of vasopressors in the management of neonatal septic shock.

Method

Between January 2002 and December 2017, all late preterm and full-term infants attending a neonatal intensive care unit, with clinical and laboratory findings of bacterial or viral sepsis, were identified in a retrospective study. During their first month of life, data on feeding type and early clinical characteristics were collected. A multivariable logistic regression model was constructed to determine the impact of human milk on the use of vasoactive drugs in septic newborns.

Results

322 newborn infants were eligible to participate in this analysis. Exclusively formula-fed infants were more likely to be delivered via C-section, to have a lower birth weight and a lower 1-minute Apgar score than their counterparts. Human milk-fed newborns had 77% (adjusted OR = 0.231; 95% CI: 0.07-0.75) lower odds of receiving vasopressors than exclusively formula-fed newborns.

Conclusion

We report that any human milk feeding is associated with a decrease in the need for vasoactive medications in sepsis-affected newborns. This observation encourages us to undertake further research to determine whether human milk feeds mitigate the use of vasopressors in neonates with sepsis.

Changes in perinatal management and outcomes in infants born at 23 weeks of gestational age during the last decade in Spain

INTRODUCTION

The 2021-updated guidelines of the Spanish Society of Neonatology Guidelines have moved the zone of parental discretion to 23 + 0-23 + 6 weeks. The objective of this study was to describe the changes in perinatal management at this gestational age along the last decade and to determine if a more active perinatal management has contributed to improved outcomes.

METHODS

Retrospective analysis of prospectively collected data from the 23-week infants included in the Spanish SEN 1500 neonatal network during the period 2010-2019. The main study outcomes were survival at discharge and survival without major morbidity of actively managed infants. Two periods were compared: 2010-2014 (Period 1) and 2015-2019 (Period 2). NICUs were classified into low activity NICUs (less than 50 admissions of very low birth weight infants per year) and high activity NICUs (50 or more admissions).

RESULTS

A total of 381 infants were included, 182 in Period 1 and 199 in Period 2. In Period 2 an increase in the use of intrapartum magnesium sulfate (21.5% vs 39.9%, p .002), antenatal steroids (56.6% vs 69.3%, p .011) and active neonatal approach in delivery room (76.9% vs 86.9%, p .011) were observed.The clinical outcomes of the actively managed 313 infants were similar in both periods, except for less arterial hypotension in Period 2. Survival was 27.1% in Period 1 and 25% in Period 2 (p .068) and survival without major morbidity was 2.1% and 2.3% respectively (p .914). No difference was found between low and high activity NICUs.

CONCLUSION

A change to a more active intention to treat infants born at 23 weeks is taking place in Spain. But the survival rate of the actively-managed infants has remained stable around 25-30% during the study period. A multidisciplinary effort is needed to improve outcomes in this population.

Maternal mental health and breastfeeding amidst the Covid-19 pandemic: cross-sectional study in Catalonia (Spain)

Background

Covid-19 pandemic became an unexpected stressor for the entire population and, particularly, for pregnant women and lactating mothers. The alarming infectious risk together with the lockdown period could affect the emotional state of mothers-to-be, as well as breastfeeding rates, mother-baby bonding, or neonatal weight gain. The aim of this study is to describe the impact of this world health emergency in mother-baby pairs right after the first wave of Sars-Cov-2 pandemic (from March to May 2020).

Study design

A prospective observational study was carried out in mother–child dyads from those women who gave birth between June and August 2020 in a tertiary hospital. 91 mother-baby pairs were initially enrolled and 56 of them completed the follow-up. The study design had two separate steps: i) Step one: A clinical interview plus three psychometric tests (EPDS: Edinburgh Postnatal Depression Scale, PBQ: Postpartum Bonding Questionnaire and STAI-S: State-Trait Anxiety Inventory); ii) Step two: mother–child dyads were followed using a round of three brief telephone interviews (conducted at the newborn’s 7, 14 and 28 days of age) to accurately depict the newborn’s outcome in the neonatal period.

Results

In terms of maternal mental health, 25% of the sample screens positively in the EPDS, requiring further evaluation to rule out depressive symptoms. STAI-state and PBQ detect no abnormalities in either anxiety levels or mother–child bonding in our sample, as 100% of the mothers score below the cut-off points in each test (34 and 26 respectively). When comparing feeding practices (breast/bottle feeding) in 2020 to those practices during pre-pandemic years (2017–2019), a significant increase in breastfeeding was found in pandemic times. All newborns in the sample showed an adequate weight gain during their first month of life.

Conclusion

Women and newborns in our sample did not experience an increase in adverse outcomes in the neonatal period in terms of maternal mental health, breastfeeding rates, bonding and further neonatal development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05036-9.

Human Milk Feeding for Septic Newborn Infants Might Minimize Their Exposure to Ventilation Therapy

Background. It has been well established that human milk feeding contributes to limiting lung diseases in vulnerable neonates. The primary aim of this study was to compare the need for mechanical ventilation between human milk-fed neonates with sepsis and formula-fed neonates with sepsis. Methods. All late preterm and full-term infants from a single center with sepsis findings from 2002 to 2017 were identified. Data on infant feeding during hospital admission were also recorded. Multivariate logistic regression analyses were performed to assess the impact of feeding type on ventilation support and main neonatal morbidities. Results. The total number of participants was 322 (human milk group = 260; exclusive formula group = 62). In the bivariate analysis, 72% of human milk-fed neonates did not require oxygen therapy or respiratory support versus 55% of their formula-fed counterparts (p < 0.0001). Accordingly, invasive mechanical ventilation was required in 9.2% of any human milk-fed infants versus 32% of their exclusively formula-fed counterparts (p = 0.0085). These results held true in multivariate analysis; indeed, any human milk-fed neonates were more likely to require less respiratory support (OR = 0.44; 95% CI:0.22, 0.89) than those who were exclusively formula-fed. Conclusion. Human milk feeding may minimize exposure to mechanical ventilation.

Inadequate Weight Gain According to the Institute of Medicine 2009 Guidelines in Women with Gestational Diabetes: Frequency, Clinical Predictors, and the Association with Pregnancy Outcomes

Background: In the care of women with gestational diabetes mellitus (GDM), more attention is put on glycemic control than in factors such as gestational weight gain (GWG). We aimed to evaluate the rate of inadequate GWG in women with GDM, its clinical predictors and the association with pregnancy outcomes. Methods: Cohort retrospective analysis. Outcome variables: GWG according to Institute of Medicine 2009 and 18 pregnancy outcomes. Clinical characteristics were considered both as GWG predictors and as covariates in outcome prediction. Statistics: descriptive, multinomial and logistic regression. Results: We assessed 2842 women diagnosed with GDM in the 1985–2011 period. GWG was insufficient (iGWG) in 50.3%, adequate in 31.6% and excessive (eGWG) in 18.1%; length of follow-up for GDM was positively associated with iGWG. Overall pregnancy outcomes were satisfactory. GWG was associated with pregnancy-induced hypertension, preeclampsia, cesarean delivery and birthweight-related outcomes. Essentially, the direction of the association was towards a higher risk with eGWG and lower risk with iGWG (i.e., with Cesarean delivery and excessive growth). Conclusions: In this cohort of women with GDM, inadequate GWG was very common at the expense of iGWG. The associations with pregnancy outcomes were mainly towards a higher risk with eGWG and lower risk with iGWG.

Breastfeeding Disparities between Multiples and Singletons by NICU Discharge

Multiple pregnancy increases the risk of a range of adverse perinatal outcomes, including breastfeeding failure. However, studies on predictive factors of breastfeeding duration in preterm twin infants have a conflicting result. The purpose of this observational study was to compare feeding practices, at hospital discharge, of twin and singleton very low birth weight infants. The study is part of a prospective survey of a national Spanish cohort of very low birth weight infants (SEN1500) that includes 62 neonatal units. The study population comprised all infants registered in the network from 2002 to 2013. They were grouped into singletons and multiples. The explanatory variables were first analyzed using univariate models; subsequently, significant variables were analyzed simultaneously in a multiple stepwise backward model. During the twelve-year period, 32,770 very low birth weight infants were included in the database, of which 26.957 were discharged alive and included in this analysis. Nine thousand seven hundred and fifty-eight neonates were multiples, and 17,199 were singletons. At discharge, 31% of singleton infants were being exclusively breastfed, 43% were bottle-fed, and 26% were fed a combination of both. In comparison, at discharge, only 24% of multiple infants were exclusively breastfed, 43% were bottle-fed, and 33% were fed a combination of both (p < 0.001). On multivariable analysis, twin pregnancy had a statistically significant, but small effect, on cessation of breastfeeding before discharge (OR 1.10; 95% CI: 1.02, 1.19). Risks of early in-hospital breastfeeding cessation were also independently associated with multiple mother-infant stress factors, such as sepsis, intraventricular hemorrhage, retinopathy, necrotizing enterocolitis, intubation, and use of inotropes. Instead, antibiotic treatment at delivery, In vitro fertilization and prenatal steroids were associated with a decreased risk for shorter in-hospital breastfeeding duration. Multiple pregnancy, even in the absence of pathological conditions associated to very low birth weight twin infants, may be an impeding factor for in-hospital breastfeeding.

Spanish survey on follow-up programmes for children born very preterm

AIM

To describe variations in practice between follow-up programmes for very preterm children born at less than 32 weeks' gestation or with very low birth weight of less than 1,500 g.

METHODS

A survey on follow-up practices was electronically distributed to level II and III units among hospitals of the Spanish National Health Service in 2016. The survey included 70 questions covering issues such as follow-up organisation and resources, routine assessments, relationships with other services and families, information management and training.

RESULTS

The response rate was 91.5% (141/154). Among respondents, 70.9% (100/141) reported that they do provide follow-up and 42% do so up to six years of age. Routine neurological and ophthalmological follow-up is not performed in 60% and 37% of hospitals, respectively, and a second hearing assessment is not given in 62%. Just 38% of units have psychologist. In 41% of hospitals, training in follow-up skills is not included in Paediatric Residency training programme.

CONCLUSION

Although Spain has a nationwide health system that provides universal health coverage, we found that follow-up care for children born very preterm/very low birth weight is not equitable. Nearly half of paediatric residents receive no training in follow-up for this high-risk population.

Variation in the Protein Composition of Human Milk during Extended Lactation: A Narrative Review

The aim of this review is to evaluate changes in protein parameters in the second year postpartum. There is considerable agreement among authors about the declining trend of human milk protein concentrations, but most research on protein content in breast milk focuses on the first year of life and comes from developed countries. Whereas this is the case for exclusive breastfeeding or for breastfeeding into the first year of life, the opposite applies to weaning or extended breastfeeding. This review is predominantly based on observational epidemiological evidence and on comparative research linking breast milk composition with cutting down on breastfeeding. Studies dating back several decades have shown an increase in the proportion of immunoglobulins, lactoferrin, and serum albumin during weaning. According to the limited data available, it seems likely that the regulation of milk protein composition during involution can be ascribed to alterations in tight junctions. In studies on humans and other mammalian species, offspring suckle more from mothers that produce more dilute milk and the increase in milk protein concentration is positively correlated to a decrease in suckling frequency during weaning. High milk protein contents were first reported in nonindustrial communities where breastfeeding is sustained the longest, but recent papers from urbanized communities have taken credit for rediscovering the increase in protein content of human milk that becomes evident with prolonged breastfeeding. This review presents an overview of the changes in breast milk protein parameters in the second year postpartum to enable milk banks' practitioners to make informed nutritional decisions on preterm infants.

Morbidity and mortality of very low birth weight multiples compared with singletons

BACKGROUND

Previous studies comparing the neonatal outcome of very low birth weight (VLBW) multiples and singletons have suggested a worse outcome for multiples at gestational ages on the limits of viability.

OBJECTIVES

The objective of this study is to determine the neonatal mortality and morbidity of VLBW multiples compared to singletons.

METHODS

This is a retrospective study including all infants registered in the Spanish network for infants under 1500 g (SEN1500), over a 12-year period (from 2002 to 2013). Mortality and major morbidities were compared between singletons and multiples.

RESULTS

About 32,770 infants were included: 21,123 singletons (64.5%) and 11,647 multiples (35.5%), with a mean gestational age of 29.5 weeks (22-38), and mean birth weight of 1115 g (340-1500). When adjusted by other perinatal factors, multiple pregnancy has a significantly higher risk of mortality than singleton pregnancy (odds ratio (OR) 1.15; IC 95% 1.05-1.26, p = .002), but not a higher risk of major morbidity or composite adverse outcome. In the subgroup of infants born before 26 weeks, multiples showed a higher risk of mortality (63.9% versus 51%, OR 1.7; 95% CI 1.47-1.96) and a higher risk of composite adverse outcome (88.9% versus 81.5%, OR 1.82, 95% CI 1.28-2.24).

CONCLUSIONS

In preterm infants born with less than 1500 g, multiple pregnancy is a prognostic factor that can slightly increase mortality. Extremely preterm infants born before 26 weeks have a greater risk of mortality and major morbidity if they come from a multiple pregnancy.

Towards a New Strategy for Diagnosis of Congenital Trypanosoma cruzi Infection

The immigration of Latin American women of childbearing age has spread the congenital transmission of Chagas disease to areas of nonendemicity, and the disease is now a worldwide problem. Some European health authorities have implemented screening programs to prevent vertical transmission, but the lack of a uniform protocol calls for the urgent establishment of a new strategy common to all laboratories. Our aims were to (i) analyze the trend of passive IgG antibodies in the newborn by means of five serological tests for the diagnosis and follow-up of congenital Trypanosoma cruzi infection, (ii) assess the utility of these techniques for diagnosing a congenital transmission, and (iii) propose a strategy for a prompt, efficient, and cost-effective diagnosis of T. cruzi infection. In noninfected newborns, a continuous decreasing trend of passive IgG antibodies was observed, but none of the serological assays seroreverted in any the infants before 12 months. From 12 months onwards, serological tests achieved negative results in all the samples analyzed, with the exception of the highly sensitive chemiluminescent microparticle immunoassay (CMIA). In contrast, in congenitally infected infants, the antibody decline was detected only after treatment initiation. In order to improve the diagnosis of congenital T. cruzi infection, we propose a new strategy involving fewer tests that allows significant cost savings. The protocol could start 1 month after birth with a parasitological test and/or a PCR. If negative, a serological test would be carried out at 9 months, which if positive, would be followed by another at around 12 months for confirmation.

Formula Feeding Is Independently Associated With Acute Kidney Injury in Very Low Birth Weight Infants

BACKGROUND

Successful strategies to prevent neonatal acute kidney injury are lacking. Nevertheless, it is well known that in breastfed babies the excretory needs of the kidney are low because the intake of most nutrients is just above the nutritional requirement.

OBJECTIVES

This study aimed to determine whether feeding type predicts acute kidney injury in the very low birth weight infant.

METHODS

One hundred and eighty-six infants were enrolled in this pre-post cohort study (114 infants were included in the only human milk-fed group and 72 in the formula-fed group). Routine biological markers of acute kidney injury were collected in both groups from birth to discharge.

RESULTS

Compared with formula feeding, human milk feeding was associated with almost 80% lower odds of acute kidney injury (odds ratio [OR] = 0.2; 95% confidence interval [CI], 0.05-0.77). After confounding variables had been controlled for, formula feeding was independently associated with acute kidney injury in very low birth weight infants.

CONCLUSION

The study showed that, at our institution, acute kidney injury in the neonatal period is frequently associated with the avoidable procedure of formula feeding. Further prospective multicenter studies are needed to determine the generality of this association.

Human milk feeding protects very low-birth-weight infants from retinopathy of prematurity: a pre-post cohort analysis

OBJECTIVES

To examine the effect of early human milk (HM) feeding on the incidence of retinopathy of prematurity (ROP) among very low-birth-weight (VLBW) infants.

METHODS

Observational cohort research in a Level III neonatal intensive care unit. A total of 186 infants were enrolled in this pre-post cohort study (114 infants were included in the HM-fed group and 72 in the formula-fed group). ROP, type of feeding (early exclusive HM versus any formula), and potential confounding variables were measured. Differences between groups were explored.

RESULTS

The clinical characteristics of the neonates did not differ between the two groups. By bivariate analysis, HM feeding was associated with 75% lower odds of Stage 2 or 3 ROP (OR = 0.25, 95% CI: 0.091 to 0.705; p = 0.009) At multivariate logistic regression, type of milk feeding retained significance, exclusive HM being protective with p = 0.002.

CONCLUSIONS

This study found an association between early exposure to formula in VLBW infants and ROP. An initial HM diet, devoid of cow milk-containing products before achieving full enteral feeding, may help prevent ROP.

Hospital outcomes of extremely low birth weight infants after introduction of donor milk to supplement mother's milk

AIM

This study evaluated the impact of an exclusive human milk diet to nourish extremely low birth weight infants in the neonatal intensive care unit.

MATERIALS AND METHODS

This multicenter pre-post retrospective study included all inborn infants <1,000 g admitted to four Level IV neonatal intensive care units either before or after implementing a donor human milk policy. The feeding protocol was unchanged in both periods. Collected data included maternal/infant demographics, infant clinical data, and enteral intake as mother's own milk, donor milk, and formula.

RESULTS

Two hundred one infants were enrolled. Infant growth and other clinical outcomes were similar in both groups. Exposure to mother's own milk at discharge was not different. Median time in oxygen and duration of mechanical ventilation were significantly higher among formula-fed infants (63 versus 192 hours [p=0.046] and 24 versus 60 hours [p=0.016], respectively).

CONCLUSIONS

Our results add evidence supporting the safety of donor milk. This study also found an association between exposure to formula in preterm infants and the requirement for respiratory support, a finding that warrants further investigation.

Blood biochemical profile of very preterm infants before and after trophic feeding with exclusive human milk or with formula milk

OBJECTIVES

To determine whether feeding type of trophic feeds affect haematological and biochemical markers in the very preterm infant.

DESIGN AND METHODS

Fifty-six very preterm infants were enrolled in this retrospective study (30 infants were included in the only human milk-fed group and 26 in the formula-fed group). Routine haematological and biochemical variables were collected in both groups on days 1 and 4 of life and fourteen serum markers were measured.

RESULTS

There were no significant differences between the two groups before starting trophic feeds. After starting trophic feeds, sodium and lactate levels were significantly higher in the human milk-fed group compared with those measured in the formula-fed group.

CONCLUSION

The study demonstrates that supplementation of minimal enteral feeding with human milk does affect biochemical profiles in very preterm infants. Small amounts of enteral feedings of formula and/or human milk may result in different metabolic responses; these differences are reflected by different serum biochemistries.

Maternal body mass index is a predictor of neonatal hypoglycemia in gestational diabetes mellitus

CONTEXT

In diabetic pregnancy, neonatal hypoglycemia (NH) is usually attributed to insufficient regulation of maternal glycemic control. Recent data suggest that maternal body mass index (BMI) could have an influence.

OBJECTIVE

Our objective was to determine whether an association exists between maternal prepregnancy BMI category and occurrence of NH among infants born to women with gestational diabetes mellitus (GDM).

DESIGN AND SETTING

This was a retrospective study including all GDM pregnancies delivered between 1986 and 2006 at a tertiary care center (Hospital de la Santa Creu i Sant Pau, Barcelona). PATIENTS AND OUTCOMES: GDM was diagnosed using universal screening and National Diabetes Data Group criteria. Two thousand ninety-two newborns (1925 singletons, 85% of total GDM offspring) were studied. NH was defined according to Cornblath criteria. In addition to maternal BMI, we considered other variables such as glucose values at diagnosis or third-trimester glycated hemoglobin as potential predictors of NH. We explored whether the association between maternal BMI and NH could be due to intermediate steps such as cesarean section or abnormal birth weight.

RESULTS

The rate of NH was 3%. In the bivariate analysis, prepregnancy BMI was higher in the NH group (24.45 vs. 23.19 kg/m(2), P < 0.02). In the logistic regression analysis, prepregnancy BMI of at least 25 kg/m(2) was independently associated with NH whether the analysis included intermediate variables (odds ratio = 2.11; 95% confidence interval = 1.10-4.03) or not (odds ratio = 2.66; 95% confidence interval = 1.44-4.92).

CONCLUSIONS

Pregestational BMI should be considered among the predictors of NH in offspring of women with GDM.

Diagnostic accuracy of a 16S ribosomal DNA gene-based molecular technique (RT-PCR, microarray, and sequencing) for bacterial meningitis, early-onset neonatal sepsis, and spontaneous bacterial peritonitis

The diagnostic accuracy of a 16S ribosomal DNA (rDNA) gene-based molecular technique for bacterial meningitis (BM), early-onset neonatal sepsis (EONS), and spontaneous bacterial peritonitis (SBP) is evaluated. The molecular approach gave better results for BM diagnosis: sensitivity (S) was 90.6% compared to 78.1% for the bacterial culture. Percentages of cases correctly diagnosed (CCD) were 91.7% and 80.6%, respectively. For EONS diagnosis, S was 60.0% for the molecular approach and 70.0% for the bacterial culture; and CCD was 95.2% and 96.4%, respectively. For SPB diagnosis, the molecular approach gave notably poorer results than the bacterial cultures. S and CCD were 48.4% and 56.4% for the molecular approach and 80.6% and 89.1% for bacterial cultures. Nevertheless, bacterial DNA was detected in 53.3% of culture-negative samples. Accuracy of the 16S rDNA PCR approach differs depending on the sample, the microorganisms involved, the expected bacterial load, and the presence of bacterial DNA other than that from the pathogen implied in the infectious disease.

[Interhospital transportation of the severe pediatric patient in Catalonia]

OBJECTIVE

To describe the organization of the interhospital transport of the pediatric patients in Catalonia.

DESIGN

Description of the different phases of organization, of the organizational structure, both of the bases and of the coordinating center, and of the evolution of the model.

SCOPE

System of medical emergencies and hospital net of Catalonia.

PERIOD

between 1996 and 2003.

PATIENTS

Patients moved by the pediatric teams.

INTERVENTIONS

Analysis of the documentation used in the transports realized by the system of medical emergencies.

VARIABLES OF INTEREST

Clinical information, hours and times of transport, as well as the way used for the transport. RESULTS. A total of 6,110 pediatric transports were realized by an annual average of 777. The 94% of the movements carried out for ambulances and 6% with helicopter. The number of transport was growing to lengths of the years of study.

CONCLUSIONS

The model followed in the last years in Catalonia bases on the specialization of the pediatric interhospital transport. The pediatric teams contribute a value added to the own transport.

Poorer perinatal outcome in male newborns of women with pregestational diabetes mellitus

AIMS

  To assess perinatal outcome in women with pregestational diabetes mellitus according to the sex of the fetus.

METHODS

  A retrospective review of all singleton pregnancies of women with pregestational diabetes progressing to a gestational age of 22 weeks or more who attended the diabetes and pregnancy clinic from 1981 to 2006 (n=455). We compared maternal characteristics and perinatal outcomes (perinatal mortality, major congenital malformations, small and large for gestational age newborns, preterm birth and a composite of the former) according to the sex of the fetus. A logistic regression analysis was performed using the composite perinatal outcome as the dependent variable and all maternal variables and sex of fetus as potential predictors.

RESULTS

  Maternal characteristics did not differ in mothers of male and female newborns. In the whole cohort, the composite perinatal outcome was significantly higher in male fetuses; adjusted OR 1.61 (95% CI 1.04-2.50).

CONCLUSIONS

  In women with pregestational diabetes, perinatal outcome was poorer in male newborns despite similar maternal characteristics.

Glycemic control and perinatal outcomes of pregnancies complicated by type 1 diabetes: influence of continuous subcutaneous insulin infusion and lispro insulin

AIMS

This study compared glycemic control and maternal and fetal outcomes in pregnant women with type 1 diabetes mellitus (T1DM) treated with multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) using regular (RI) or lispro (LP) insulin.

METHODS

Three hundred fifteen consecutive singleton pregnancies of T1DM women using the same insulin program since before pregnancy (196 MDI with NPH + RI, 16 MDI with NPH + LP, 44 CSII with RI, 59 CSII with LP) were studied. Variables of glycemic control assessed included glycated hemoglobin, mean blood glucose (MBG), and insulin doses in each trimester, diabetic ketoacidosis, and hypoglycemic comas. Variables of pregnancy outcome included miscarriage, preterm birth, large or small for gestational age (LGA or SGA, respectively) newborns, and perinatal mortality. Multiple linear regression and logistic regression analysis were used.

RESULTS

Groups differed in baseline and glycemic control but not in maternal or fetal outcomes. In multivariate analysis, LP was associated with higher second trimester MBG and lower rate of hypoglycemic coma, CSII with higher third trimester MBG, and CSII + LP with lower insulin requirements and lower rate of hypoglycemic coma. As to pregnancy outcomes, LP was associated with lower risk of preterm birth and higher risk of SGA, CSII with lower risk of SGA and higher risk of LGA and perinatal mortality, and CSII + LP with higher risk of miscarriage.

CONCLUSIONS

Pregnant women with T1DM using LP and/or CSII had different characteristics. LP with or without CSII was independently associated with fewer hypoglycemic comas, whereas impact of LP/CSII on the fetus had a favorable or an unfavorable influence depending on the specific outcome.

Period of gestational diabetes mellitus diagnosis and maternal and fetal morbidity

BACKGROUND

The aim of the study was to analyze the association between the period of diagnosis of gestational diabetes mellitus (GDM) and maternal and neonatal outcome.

METHODS

In this retrospective study, 1708 offspring (1571 singleton, 119 twins, and 18 triplets) born to women with GDM who attended the Diabetic and Pregnancy Clinic were included. Pregnancies were divided into three groups according to the gestational age at GDM diagnosis. The association of the period of diagnosis with maternal and fetal outcome was assessed adjusting for potentially confounding variables (logistic regression analysis).

RESULTS

The period of diagnosis was a predictor in two out of three maternal outcomes (pregnancy-induced hypertension and insulin treatment) and in four out of 12 fetal outcomes (preterm birth, 5-min Apgar <7, perinatal mortality, and hyperbilirubinemia). Whereas pregnancy-induced hypertension was higher in women diagnosed with GDM in the second period, the other outcomes displayed higher occurrences with earlier diagnosis.

CONCLUSIONS

Diagnosis of GDM earlier in pregnancy is a predictor of adverse maternal and neonatal outcome.

In human gestational diabetes mellitus congenital malformations are related to pre-pregnancy body mass index and to severity of diabetes

AIMS/HYPOTHESIS

This study analysed the relationship between congenital malformations (CM) and severity of gestational diabetes mellitus.

METHODS

A cohort of 2060 infants of mothers with gestational diabetes was studied. Universal screening and 3(rd) Workshop-Conference criteria were used to diagnose gestational diabetes. The severity of diabetes was assessed on the basis of previous hyperglycaemia, blood glucose values in diagnostic OGTT, area under the glucose curve, gestational age and HbA(1)c at diagnosis, insulin requirements during pregnancy, and OGTT after delivery. Potentially confounding variables (age, pre-pregnancy BMI, smoking) were considered. The relationship of potential predictors with CM was analysed with several multivariate logistic regression analyses.

RESULTS

The rate of CM was 6% for minor and 3.8% for major malformations (1.4% heart, 0.8% renal/urinary, 0.7% skeletal, 0.3% hypospadias, 0.2% central nervous system, 0.2% cleft lip/palate, 0.1% digestive tract, 0.3% other). In the final models, forward logistic regression analysis identified pre-pregnancy BMI as the predictor of CM (area under receiver operating characteristic curve 0.616); in the backward analysis additional predictors were 1-h blood glucose in diagnostic OGTT and gestational age at diagnosis (area under receiver operating characteristic curve 0.646). Both BMI and severity of gestational diabetes were predictors of heart and minor CM, whereas BMI predicted renal/urinary CM and severity of diabetes predicted skeletal CM.

CONCLUSIONS/INTERPRETATION

In these infants of mothers with gestational diabetes, severity of diabetes and pre-pregnancy BMI were predictors of CM, in accordance with the well-documented pathogenic role of BMI (in the general population) and hyperglycaemia (in diabetic pregnancy). BMI was the main predictor of more prevalent CM.

Nurse-based management in patients with gestational diabetes

OBJECTIVE

To compare the rate of insulin treatment and perinatal outcome in women with gestational diabetes mellitus (GDM) under endocrinologist-based versus diabetes nurse-based metabolic management.

RESEARCH DESIGN AND METHODS

In a retrospective analysis, maternal characteristics, rate of insulin treatment, and perinatal outcome of patients with GDM delivering between 1 January 1995 and 30 June 1997 (n = 244) receiving endocrinologist-based care were compared with those delivering between 1 July 1997 and 31 December 1999 (n = 283) who received diabetes nurse-based care. The diabetes nurse's role was similar to that of an advanced practice nurse in the U.S. There were no changes in the metabolic goals and instruments or in obstetric and neonatal management. Quantitative data were compared with the Mann-Whitney U test and categorical data, with Fisher's exact test.

RESULTS

Maternal characteristics (age, BMI, family history of diabetes, prior glucose intolerance, gestational age, and blood glucose at diagnosis of GDM) did not differ between groups treated during the two periods. Rates of insulin treatment and perinatal outcome (hypertension, preterm delivery, cesarean section, low Apgar score, macrosomia, small- and large-for-gestational-age newborns, obstetric trauma, major malformations, hypoglycemia, hypocalcemia, polycythemia, jaundice, respiratory distress, and mortality) were also similar in both groups.

CONCLUSIONS

Comparison of periods of endocrinologist-based and diabetes nurse-based metabolic management of women with GDM showed no differences in the rate of insulin treatment and perinatal outcome. This supports a more active role of nurses in the management of women with GDM.

Peritoneal drainage as primary management in necrotizing enterocolitis: a prospective study

BACKGROUND/PURPOSE

The use of peritoneal drainage (PD) in neonates with necrotizing enterocolitis (NEC) is controversial. The authors began to perform it successfully in infants with pneumoperitoneum, and subsequently they extended its use to infants with peritonitis and advanced NEC before radiologic evidence of peritoneal free air. To analyze the efficacy of PD they began a prospective study.

METHODS

A prospective study was conducted in 6 neonatal intensive care units (NICU) in Spain: neonates with pneumoperitoneum or peritonitis and advanced NEC were all included, whatever the birth weight and gestational age (GA).

RESULTS

PD was performed in 47 infants, but 3 of them were excluded because pneumoperitoneum was caused by pathologies other than NEC. In a cohort of 44 infants, 86% improved after PD, and 64% survived after only PD. After PD, 54% of infants needed delayed surgery. Overall survival rate was 82%; 57% infants with birth weight under 1,000 g, and 95% in infants over 1,000 g at birth. The main cause of mortality was massive NEC in the tiniest babies. Only one infant had a short bowel syndrome.

CONCLUSIONS

From the authors' point of view, PD is the first step in treating neonates with pneumoperitoneum or overwhelming NEC, regardless of birth weight and GA. Laparotomy, if it is necessary, always must be performed after clinical stability is achieved. Mortality rates remain higher in the tiniest babies because of massive NEC.

Hydrops fetalis-associated congenital dyserythropoietic anemia treated with intrauterine transfusions and bone marrow transplantation

Hydrops fetalis is rarely caused by congenital dyserythropoietic anemia (CDA). We report a patient with hydrops fetalis as a result of severe anemia. This patient needed intrauterine transfusions from 21 weeks of gestation until birth. The hematologic study showed an atypical CDA (hydrops fetalis-associated CDA) characterized by features resembling CDA type II, but negative acidified serum lysis test (HEMPAS negative). The patient was regularly transfused for a year, after which an allogeneic bone marrow transplantation (BMT) from an HLA-identical sibling was successfully carried out. His actual hemoglobin is 127 g/L, and he has not received transfusions for more than a year. In conclusion, intrauterine transfusions and BMT could cure an otherwise lethal atypical CDA.

Outbreaks of influenza A virus infection in neonatal intensive care units

BACKGROUND

Outbreaks of nosocomial influenza virus infections have been described rarely during childhood and even less so in the neonatal period.

METHODS

We report 30 neonates admitted to 2 neonatal intensive care units with nosocomial influenza A virus infection, which occurred in 2 outbreaks during 1999. Risk factors for infection were evaluated, and control measures were adopted. Virus was detected by indirect immunofluorescence antibody screen. Any infant with nasopharyngeal aspirate positive for influenza A virus was considered infected.

RESULTS

Of 95 infants screened 30 were positive for influenza A virus (31.5%). Mean birth weight was 1622 g, and mean gestational age was 31 weeks in the infected group. In the noninfected group mean birth weight was 2594 g and mean gestational age was 36.4 weeks. Low birth weight, short gestational age, twin pregnancy and mechanical ventilation were identified as risk factors for infection. Clinical symptoms were seen in 22, and 8 were asymptomatic. Clinical features were predominantly respiratory and digestive. The outcome was favorable in all cases.

CONCLUSIONS

Infection by influenza virus has to be considered as a possible cause of nosocomial infection in the neonatal period. Control measures and prevention are important.