Disrupted Seasonality of Respiratory Viruses: Retrospective Analysis of Pediatric Hospitalizations in Italy from 2019 to 2023

This multicenter study in Italian hospitals highlights the epidemiologic disruptions in the circulation of the 5 main respiratory viruses from 2019 to 2023. Our data reveal a resurgence of respiratory syncytial virus and influenza during the 2022-2023 winter season, with an earlier peak in cases for both viruses, emphasizing the importance of timely monitoring.

Neglected Populations Not to Be Forgotten: Tackling Antimicrobial Resistance in Neonatal Infections

Making further progress in reducing child mortality hinges on lowering the annual count of neonatal deaths; currently, this stands at 2 [...].

The Management of Neonates ≥34 Weeks' Gestation at Risk of Early Onset Sepsis: A Pilot Study

Early onset sepsis (EOS) is a potentially fatal condition in neonates, and its correct management is still challenging for neonatologists. Early antibiotic administration in the neonatal period may carry short- and long-term risks. Neonatal EOS calculator has been recently introduced as a new strategy to manage infants at risk of sepsis, and has shown promising results.

METHODS

In this single-center observational retrospective study, 1000 neonates ≥ 34 weeks' gestation were enrolled with the aim to evaluate our standard protocol for the management of suspected EOS compared to the EOS calculator. Outcome measures included the following: (1) incidence of EOS and (2) proportion of infants in need of sepsis evaluations and antibiotics using our standard protocol versus theoretical application of EOS calculator.

RESULTS

A total of 223/1000 infants underwent blood investigations versus 35/1000 (3.5%) if EOS calculator had been applied (p < 0.0001; k = 0.18). Furthermore, 48/1000 infants received antibiotics with our protocol versus 35/1000 with EOS calculator (p = 0.12; k = 0.58). Three infants had a positive blood culture that EOS calculator would have missed.

CONCLUSIONS

In our study, EOS calculator could have reduced investigations but not antibiotic therapy. EOS calculator is an effective and promising tool, but further studies are required to improve it.

Pressure and tidal volume delivery in extremely preterm infants at birth using different t-piece resuscitation devices

Infants <28 weeks' gestation in need of inflations at birth were recorded with Respiratory Function Monitor. Two devices were used for resuscitation. Peak Inspiratory Pressure spikes were visible in all inflations with GE Panda and in none with Neo-Puff. There was no significant difference in mean Vte/kg between GE Panda and Neo-Puff.

Italian immunization calendar implementation: Time to optimize number of vaccination appointments?

In the Italian vaccination schedule, at least six vaccination appointments are scheduled in the first year of life. This implies more discomfort for both the patient and the parents. This was particularly evident during the COVID-19 pandemic, during which several appointments were missed. A UK experience with three injectable vaccines and an oral one co-administered at the same appointment (4-in-1) at 2 and 4 months of age showed interesting results. The vaccination coverage was high, consistent with previous practice, and no relevant increase in adverse events was reported. Translating the UK experience into the Italian context would not be immediate, due to several organizational and social issues. Nevertheless, this option warrants some further considerations, which are discussed in this manuscript.

Tidal volume optimization and heart rate response during stabilization of very preterm infants

AIM

To verify the added value of respiratory function monitor (RFM) to assess ventilation and the heart rate (HR) changes during stabilization of preterm infants.

METHODS

Preterm infants <32 weeks' gestation, bradycardic at birth and in need for positive pressure ventilation (PPV) were included. The first 15 min of stabilization was monitored with RFM. Three time points were identified according to HR values (T0 the start of mask PPV; T1 the HR rise >100 bpm; T2 the delivery of the last PPV). For each inflation, PIP, PEEP, MAP, expired tidal volume/kg (Vte/kg), and mean dynamic compliance (Cdyn) were analyzed.

RESULTS

PIP and MAP values were significantly higher at T1 (27.09 ± 5.37 and 17.47 ± 3.85 cmH₂ O) and at T2 (24.7 ± 3.86 and 15.2 ± 3.78 cmH₂ O) compared to T0 (24.05 ± 2.27 and 15.85 ± 2.77 cmH₂ O). PEEP at T1 was significantly higher (6.27 ± 2.17 cmH₂ O) compared to T2 (5.61 ± 1.50 cmH₂ O). Vte/kg showed significantly lower T0 values (3.57 ± 2.14 ml/kg) compared to T1 (6.18 ± 2.51 ml/kg) and T2 (6.89 ± 2.40 ml/kg). There was a significant effect of time on Cdyn.

CONCLUSIONS

A clear correspondence between HR rise and adequate Vte/kg during stabilization of very preterm infants was highlighted. RFM might be useful to tailor ventilation, following real-time changes of lung compliance.

Cranial ultrasound screening in term and late preterm neonates born by vacuum-assisted delivery: Is it worthwhile?

BACKGROUND

Vacuum extraction is the most common choice to assist vaginal delivery, but there are still concerns regarding the neonatal injuries it may cause. This study aimed to evaluate the rate of intracranial injuries assessed by cranial ultrasound (cUS) among infants born by vacuum extraction, and the relationship with maternal and perinatal factors.

METHODS

This was a single-center retrospective study carried out in a level-3 neonatal unit. A total of 593 term and late preterm infants born by vacuum-assisted delivery were examined with a cUS scan within 3 days after birth.

RESULTS

Major head injuries were clinically silent and occurred in 2% of the infants, with a rate of intracranial haemorrhage of 1.7%. Regardless of obstetric factors, the risk of cranial injury was increased in infants requiring resuscitation at birth (p = 0.04, OR 4.1), admitted to NICU (p = 0.01, OR 5.5) or with perinatal asphyxia (p < 0.01, OR 21.3). Maternal age ≥40 years correlated both with adverse perinatal outcomes (p < 0.05) and the occurrence of major injury (p = 0.02, OR 4.6).

CONCLUSION

Overall, vacuum extraction is a safe procedure for neonates. Head injuries are usually mild and asymptomatic, and with spontaneous recovery. However, the rate of major cranial injuries in our cohort warrants further investigation to support a cUS screening, particularly for infants requiring respiratory support at birth. Also, maternal age might be taken into account when evaluating the risk for neonatal complications after vacuum application.

Different Settings of Nonsynchronized Bilevel Nasal Continuous Positive Airway Pressure and Respiratory Function in Preterm Infants: A Pilot Study

OBJECTIVE

With this study, we evaluated the short-term effects of different modes and settings of noninvasive respiratory support on gas exchange, breathing parameters, and thoracoabdominal synchrony in preterm infants in the acute phase of moderate respiratory distress syndrome.

STUDY DESIGN

A feasibility crossover trial was conducted in neonates < 32 weeks' gestation on nasal continuous positive airway pressure (n-CPAP) or bilevel n-CPAP. Infants were delivered the following settings in consecutive order for 10 minutes each: • n-CPAP (5 cm H₂O) • bilevel n-CPAP 1 (Pres low = 5 cm H₂O, Pres high = 7 cm H₂O, T-high = 1 second, rate = 30/min) • n-CPAP (5 cm H₂O) • bilevel n-CPAP 2 (Pres low = 5 cm H₂O, Pres high = 7 cm H₂O, T-high = 2 second, rate = 15/min) • n-CPAP (5 cm H₂O). During each phase, physiologic parameters were recorded; the thoracoabdominal synchrony expressed by the phase angle (Φ) and other respiratory patterns were monitored by noncalibrated respiratory inductance plethysmography.

RESULTS

Fourteen preterm infants were analyzed. The mean CPAP level was significantly lower in the n-CPAP period compared with bilevel n-CPAP 1 and 2 (p = 0.03). Higher values were achieved with bilevel n-CPAP 2 (6.2 ± 0.6 vs. 5.7 ± 0.5 cm H₂O, respectively; p < 0.05). No statistical difference in the Φ was detected, nor between the three settings.

CONCLUSION

Our study did not show any superiority of bilevel n-CPAP over n-CPAP. However, nonsynchronized bilevel n-CPAP might be helpful when additional pressure is needed.

KEY POINTS

· There is currently a high degree of uncertainty about the superiority of one modality and setting of noninvasive respiratory over another.. · Our study confirmed that non-synchronized bilevel n-CPAP might be helpful when additional pressure is needed for recruitment.. · A T-high of 1 second could possibly be better tolerated in this population, but further research is needed..

Fetal to neonatal transition: what additional information can be provided by cerebral near infrared spectroscopy?

This narrative review focuses on the clinical use and relevance of cerebral oxygenation measured by NIRS during fetal to neonatal transition. Cerebral NIRS(cNIRS) offers the possibility of non-invasive, continuous, and objective brain monitoring in addition to the recommended routine monitoring. During the last decade, with growing interest in early and sensitive brain monitoring, many research groups worldwide have been working with cNIRS and verified the feasibility of cNIRS monitoring immediately after birth. Cerebral hypoxia during fetal to neonatal transition, defined as cerebral oxygenation values below10th percentile, seems to have an impact on neurological outcomes. Feasibility to guide clinical support using cNIRS to reduce the burden of cerebral hypoxia has been shown. It is well known that in some cases cerebral oxygenation follows different patterns than SpO2. Cerebral oxygenation does not only depend on systemic oxygenation, hemoglobin content and cerebral blood flow, but also on cardiocirculatory condition, ventilation, and metabolic parameters. Hence, measurement of cerebral oxygenation may uncover problems not detectable by standard monitoring. Therefore, applying NIRS can provide caregivers a more complete clinical overview, especially in critically ill neonates. In this review, we aim to describe the additional information which can be provided by cNIRS during fetal to neonatal transition. IMPACT: This narrative review focuses on the clinical use and relevance of cerebral oxygenation measured by near infrared spectroscopy (NIRS) during fetal to neonatal transition. During the last decade, interest on brain monitoring is growing continuously as the measurement of cerebral oxygenation may uncover problems which are not detectable by routine monitoring. Therefore, it will be crucial to have additional information to get a complete overview, especially in critically ill neonates in need of medical and respiratory support. In this review, we offer additional information which can be provided by cerebral NIRS during fetal to neonatal transition.

Synchronized Invasive Mechanical Ventilation

Respiratory care of premature neonates has witnessed substantial advances in the last two decades and has played a crucial role in decreasing early mortality in this population. This review outlines advances in techniques of synchronization and modes of synchronized invasive mechanical ventilation in neonates. The use of synchronized ventilation in the neonatal population was delayed as compared to adults, mainly because of technical reasons. Coordinating the infant's respiratory effort and the onset of mechanical ventilation in the neonatal population has requested high sensitivity instruments.

Semi-Elemental and Elemental Formulas for Enteral Nutrition in Infants and Children with Medical Complexity-Thinking about Cow's Milk Allergy and Beyond

Children with medical complexities, such as multi-system disorders and/or neurological impairments, often experience feeding difficulties and need enteral nutrition. They frequently have impaired motility and digestive-absorbing functions related to their underlying condition. If a cow's milk allergy (CMA) occurs as a comorbidity, it is often misdiagnosed, due to the symptoms' overlap. Many of the commercialized mixtures intended for enteral nutrition are composed of partially hydrolyzed cow's milk proteins, which are not suitable for the treatment of CMA; thus, the exclusion of a concomitant CMA is mandatory in these patients for obtaining symptoms relief. In this review, we focus on the use of elemental and semi-elemental formulas in children with neurological diseases and in preterm infants as clinical "models" of medical complexity. In children with neurodisabilities, when gastrointestinal symptoms persist despite the use of specific enteral formula, or in cases of respiratory and/or dermatological symptoms, CMA should always be considered. If diagnosis is confirmed, only an extensively hydrolyzed or amino-acid based formula, or, as an alternative, extensively hydrolyzed nutritionally adequate formulas derived from rice or soy, should be used. Currently, enteral formulas tailored to the specific needs of preterm infants and children with neurological impairment presenting concomitant CMA have not been marketed yet. For the proper monitoring of the health status of patients with medical complexity, multidisciplinary evaluation and involvement of the nutritional team should be promoted.

New perspective for pain control in neonates: a comparative effectiveness research

OBJECTIVE

To compare sucrose 24% oral gel formulation to liquid formula and breastfeeding during a heel prick in neonates.

STUDY DESIGN

In this comparative effectiveness research 195 neonates >36 weeks' gestation were randomised to three groups, receiving during heel stick: (i) breastfeeding, (ii) sucrose 24% liquid with non-nutritive sucking and (iii) sucrose 24% gel with non-nutritive sucking. The pain was assessed through the Neonatal Infant Pain Scale.

RESULTS

All the methods analysed has shown to be effective in reducing pain. There was an increase in odds of pain following liquid sucrose compared to breastfeeding (OR = 1.60; 95% CI: 0.82-3.3; p = 0.17). A reduction of odds of pain was showed comparing sucrose to breastfeeding (OR = 0.78; 0.38-1.6; 0.48), and comparing sucrose gel to liquid formula (OR = 0.48; 0.23-0.96; p = 0.04).

CONCLUSION

Sucrose 24% gel with non-nutritive sucking seems to be a valid alternative when breastfeeding is not possible. Further research is needed.

Antibiotic Susceptibility, Virulome, and Clinical Outcomes in European Infants with Bloodstream Infections Caused by Enterobacterales

Mortality in neonates with Gram-negative bloodstream infections has remained unacceptably high. Very few data are available on the impact of resistance profiles, virulence factors, appropriateness of empirical treatment and clinical characteristics on patients’ mortality. A survival analysis to investigate 28-day mortality probability and predictors was performed including (I) infants <90 days (II) with an available Enterobacterales blood isolate with (III) clinical, treatment and 28-day outcome data. Eighty-seven patients were included. Overall, 299 virulence genes were identified among all the pathogens. Escherichia coli had significantly more virulence genes identified compared with other species. A strong positive correlation between the number of resistance and virulence genes carried by each isolate was found. The cumulative probability of death obtained by the Kaplan-Meier survival analysis was 19.5%. In the descriptive analysis, early age at onset, gestational age at onset, culture positive for E. coli and number of classes of virulence genes carried by each isolate were significantly associated with mortality. By Cox multivariate regression, none of the investigated variables was significant. This pilot study has demonstrated the feasibility of investigating the association between neonatal sepsis mortality and the causative Enterobacterales isolates virulome. This relationship needs further exploration in larger studies, ideally including host immunopathological response, in order to develop a tailor-made therapeutic strategy.

Impact of bradycardia and hypoxemia on oxygenation in preterm infants requiring respiratory support at birth

AIM OF THE STUDY

Analysis of the impact of bradycardia and hypoxemia on the course of cerebral and peripheral oxygenation parameters in preterm infants in need for respiratory support during foetal-to-neonatal transition.

METHODS

The first 15 min after birth of 150 preterm neonates in need for respiratory support born at the Division of Neonatology, Graz (Austria) were analyzed. Infants were divided into different groups according to duration of bradycardia exposure (no Bradycardia, brief bradycardia <2 min, and prolonged bradycardia ≥2 min) and to systemic oxygen saturation (SpO₂) value at 5 min of life (<80% or ≥80%). Analysis was performed considering the degree of bradycardia alone (step 1) and in association with the presence of hypoxemia (step 2).

RESULTS

In step 1, courses of SpO₂ differed significantly between bradycardia groups (p = 0.002), while courses of cerebral regional oxygen saturation (crStO₂) and cerebral fractional tissue oxygen extraction (cFTOE) were not influenced (p = 0.382 and p = 0.878). In step 2, the additional presence of hypoxemia had a significant impact on the courses of SpO₂ (p < 0.001), crStO₂ (p < 0.001) and cFTOE (p = 0.045).

CONCLUSION

Our study shows that the degree of bradycardia has a significant impact on the course of SpO₂ only, but when associated with the additional presence of hypoxemia a significant impact on cerebral oxygenation parameters was seen (crStO₂, cFTOE). Furthermore, the additional presence of hypoxemia has a significant impact on FiO₂ delivered. Our study emphasizes the importance of HR and SpO₂ during neonatal resuscitation, underlining the relevance of hypoxemia during the early transitional phase.

Surfactant lung delivery with LISA and InSurE in adult rabbits with respiratory distress

BACKGROUND

In preterm infants, InSurE (Intubation-Surfactant-Extubation) and LISA (less invasive surfactant administration) techniques allow for exogenous surfactant administration while reducing lung injury associated with mechanical ventilation. We compared the acute pulmonary response and lung deposition of surfactant by LISA and InSurE in surfactant-depleted adult rabbits.

METHODS

Twenty-six spontaneously breathing surfactant-depleted adult rabbits (6-7 weeks old) with moderate RDS and managed with nasal continuous positive airway pressure were randomized to 3 groups: (1) 200 mg/kg of surfactant by InSurE; (2) 200 mg/kg of surfactant by LISA; (3) no surfactant treatment (Control). Gas exchange and lung mechanics were monitored for 180 min. After that, surfactant lung deposition and distribution were evaluated monitoring disaturated-phosphatidylcholine (DSPC) and surfactant protein C (SP-C), respectively.

RESULTS

No signs of recovery were found in the untreated animals. After InSurE, oxygenation improved more rapidly compared to LISA. However, at 180' LISA and InSurE showed comparable outcomes in terms of gas exchange, ventilation parameters, and lung mechanics. Neither DSPC in the alveolar pool nor SP-C signal distributions in a frontal lung section were significantly different between InSurE and LISA groups.

CONCLUSIONS

In an acute setting, LISA demonstrated efficacy and surfactant lung delivery similar to that of InSurE in surfactant-depleted adult rabbits.

IMPACT

Although LISA technique is gaining popularity, there are still several questions to address. This is the first study comparing LISA and InSurE in terms of gas exchange, ventilation parameters, and lung mechanics as well as surfactant deposition and distribution. In our animal study, three hours post-treatment, LISA method seems to be as effective as InSurE and showed similar surfactant lung delivery. Our findings provide some clarifications on a fair comparison between LISA and InSurE techniques, particularly in terms of surfactant delivery. They should reassure some of the concerns raised by the clinical community on LISA adoption in neonatal units.

Respiratory Support of Neonate Affected by Bronchiolitis in Neonatal Intensive Care Unit

Acute respiratory infections are very common medical emergency in early infancy, often requiring hospitalization. The most frequent respiratory infection at this stage of life is bronchiolitis, with a benign course in the majority of cases. However, especially during neonatal period, infants are at higher risk for developing complications, and ventilatory support of various degrees is needed. The two most widespread methods to provide noninvasive respiratory support are heated humidified high-flow nasal cannula and nasal continuous positive airway pressure. They are both used in neonatal intensive care unit to treat respiratory distress syndrome of the premature infants, and the main concept of recruiting and distending alveoli is valid also for respiratory failure occurring during bronchiolitis. However, there is still ongoing debate about the superiority of one method, and their real efficacy still need to be confirmed. Once respiratory failure does not respond to noninvasive ventilation, more intensive care must be provided in the form of conventional mechanical ventilation or high-frequency ventilation. There is currently no evidence of the optimal ventilation strategy to use, and a deeper comprehension of the pulmonary mechanics during bronchiolitis would be desirable to tailor ventilation according to the degree of severity. Further research is then urgently needed to better clarify these aspects. KEY POINTS: · Guidelines on the management of bronchiolitis in neonatal population are lacking.. · Noninvasive respiratory support is mostly delivered with HHHFNC and nCPAP.. · A deeper comprehension of the pulmonary mechanics during bronchiolitis is crucial to tailor invasive ventilation..

Body temperature at nursery admission in a cohort of healthy newborn infants: results from an observational cross-sectional study

BACKGROUND

Exposure to hypothermia is somehow unavoidable when a baby comes to life. This is the reason why any possible effort should be made by every caregiver involved during birth, from labour to transfer into the maternity ward, to reduce it. Hypothermia has widely shown to be related to several neonatal problems, and the risks are more relevant when the babies are born prematurely.

METHOD

An observational study was conducted in April 2016 to assess the current practises to avoid hypothermia at birth in 20 Italian neonatal units. Each unit introduced local improvements in clinical practice and the same observational study was repeated 1 year later.

RESULTS

A total of 4722 babies were analysed. An overall increase in adherence to local and international recommendations emerged from our study. Significant differences between 2016 and 2017 were found in regard to neonatal temperature at nursery entry (36.3 °C vs 36.5 °C, respectively, p < 0.0001), delayed cord clamping practice > 60″ (48.1% vs 68.1%, respectively, p < 0.0001) and skin-to-skin practice > 60' (56.3% vs 60.9, respectively, p = 0.03). Statistical correlations with the risk of hypothermia were found for delivery room (OR 0.88 (CI 95%0.83-0.94), p < 0.0001) and maternal temperature (OR 0.57 (CI 95% 0.48-0.67), p < 0.0001).

CONCLUSION

Periodical assessment of the delivery room practice has shown to be effective in improving adherence to the international recommendations. Relationship between neonatal hypothermia and several other variables including the delivery room and mother temperature underlines how neonatal thermoregulation starts immediately after birth. Hence, a multi-disciplinary approach is needed to provide the optimal environment for a safe birth.

Interventions to reduce occupational stress and burn out within neonatal intensive care units: a systematic review

Occupational stress is an emerging problem among physician and nurses, and those working in intensive care settings are particularly exposed to the risk of developing burnout. To verify what types of interventions to manage occupational stress and burn out within neonatal intensive care units (NICUs) have been introduced so far and to verify their efficacy among caregivers. PsycINFO (PsycINFO 1967-July week 3 2019), Embase (Embase 1996-2019 week 29) e Medline (Ovid MEDLINE(R) without revisions 1996-July week 2 2019) were systematically searched combining MeSH and free text terms for "burn out" AND "healthcare provider" AND "NICU". Inclusion criteria were interventions directed to healthcare providers settled in NICUs. Only English language papers were included. Six articles were included in the final analysis. All the studies reported an overall efficacy of the interventions in reducing work-related stress, both when individual focused and organisation directed. The analysis revealed low quality of the studies and high heterogeneity in terms of study design, included populations, interventions and their evaluation assessment. There is currently very limited evidence regarding the management of occupational stress and burn out within NICUs. The quality of available studies was suboptimal. The peculiarities of the NICUs should be considered when developing strategies for occupational stress management. Training self-awareness of workers regarding their reactions to the NICU environment, also from the pre-employment stage, could be an additional approach to prevent and manage stress.

Acute ulceronecrotic adverse reaction to potassium hydroxide 5% solution in the treatment of molluscum contagiosum

Molluscum contagiosum is a common childhood condition, and although it is self-limited, treatments are often prescribed. Several medications are available, but there is no consensus regarding the optimal choice in the pediatric population. We report a child who underwent potassium hydroxide 5% treatment resulting in superficial diffuse erosions caused by the inappropriate application. This underlines the importance of parent education before use of this medication with well-known caustic properties.

Feasibilty of Transcutaneous pCO2 Monitoring During Immediate Transition After Birth-A Prospective Observational Study

Background: According to recommendations, non-invasive monitoring during neonatal resuscitation after birth includes heart rate (HR) and oxygen saturation (SpO₂). Continuous transcutaneous monitoring of carbon dioxide partial pressure (tcpCO₂) may further offer quantitative information on neonatal respiratory status. Objective: We aimed to investigate feasibility of tcpCO₂ measurements in the delivery room during immediate neonatal transition and to compare the course of tcpCO₂ between stable term and preterm infants. Methods: Neonates without need for cardio-respiratory intervention during immediate transition after birth were enrolled in a prospective observational study. In these term and preterm neonates, we measured HR and SpO₂ by pulse oximetry on the right wrist and tcpCO₂ with the sensor applied on the left hemithorax during the first 15 min after birth. Courses of tcpCO₂ were analyzed in term and preterm neonates and groups were compared. Results: Fifty-three term (gestational age: 38.8 ± 0.9 weeks) and 13 preterm neonates (gestational age: 34.1 ± 1.5 weeks) were included. First tcpCO₂ values were achieved in both groups at minute 4 after birth, which reached a stable plateau after the equilibration phase at minute 9. Mean tcpCO₂ values 15 min after birth were 46.2 (95% CI 34.5-57.8) mmHg in term neonates and 48.5 (95%CI 43.0-54.1) mmHg in preterm neonates. Preterm and term infants did not show significant differences in the tcpCO₂ values at any time point. Conclusion: This study demonstrates that tcpCO₂ measurement is feasible during immediate neonatal transition after birth and that tcpCO₂ values were comparable in stable term and preterm neonates.

National surveys of UK and Italian neonatal units highlighted significant differences in the use of non-invasive respiratory support

AIM

This study compared how non-invasive respiratory support (NRS) was provided in neonatal units in Italy and the UK.

METHODS

An NRS questionnaire was sent to tertiary neonatal centres, identified by national societies, from November 2015 to May 2016.

RESULTS

Responses were received from 49/57 (86%) UK units and 103/115 (90%) Italian units. NRS was started in the delivery room by 61% of UK units and 85% of Italian units. In neonatal intensive care units, 33% of UK units used nasal high-flow therapy (HFT) as primary support, compared to 3% in Italy. Nasal continuous positive airway pressure (CPAP) was used in 57% of UK units and 90% of Italian units. The commonest starting flow rate on nasal HFT for term and preterm infants was 6 L/min in the UK, while Italian units mainly used this flow for term infants. In the UK, 67% of units decreased nasal HFT by 1 L/min per day. In Italy, infants on nasal CPAP were weaned by 1 cm H₂ O per day in 39% of units.

CONCLUSION

The way that NRS was managed for very preterm infants differed between the UK and Italy, reflecting a lack of evidence on optimal NRS and the use of local protocols.

Full oral feeding is possible before discharge even in extremely preterm infants

AIM

This study described the steps needed to achieve full oral feeding before discharge in a group of very and extremely preterm (EPT) infants. We analysed the effects of oral feeding skills on discharge timing and on weight gain during their neonatal intensive care unit (NICU) stay.

METHODS

A prospective cross-sectional observational study of 100 infants who were <32 weeks of gestation (GA) was conducted at the Division of Neonatology, Graz, Austria, from March 2014 to February 2015. Patients were stratified into two groups: those who were <28 weeks at birth and those who were 28 weeks and over. Velocity of oral feeding skills attainment and weight gain were analysed.

RESULTS

All infants successfully acquired oral feeding skills during hospitalisation. The median GA at which full oral feeding skills were reached was 37 + 1 weeks in EPT and 34 + 5 weeks in very preterm infants. More immature neonates showed worse feeding performances and lower weight increments during oral feeding steps.

CONCLUSION

Our study confirmed the role of GA in the development of oral feeding skills in the most premature babies. It also raises the question of whether expected daily weight gain should be targeted according to GA.

Is Less Invasive Surfactant Administration Necessary or "Only" Helpful or Just a Fashion?

In the 1990s, the most relevant pillars in the treatment of neonatal respiratory distress syndrome (RDS) have been improvements in ventilation strategies, the introduction of exogenous surfactant replacement therapy, and the use of antenatal steroids. Lately, in addition to the standard INSURE (INtubation-SURfactant administration-Extubation) method to administer surfactant, a new technique has been gaining increasing popularity. It is the so-called less invasive surfactant administration (LISA) method, which has shown promising results in preventing bronchopulmonary dysplasia development and in reducing mortality in preterm neonates. The rationale behind this technique is to avoid positive pressure ventilation and the endotracheal tube, being surfactant delivered through a thin catheter while the neonate is maintained on continuous positive airway pressure. Given the paucity of large-scale randomized trials on LISA method to prove its effects on short- and long-term outcomes, some questions still remain unanswered. Then, uncertainty regarding the feasibility of this maneuver needs to be better clarified before gaining wide acceptance in routine clinical practice. In our report, we aim at hypothesizing the main mechanisms behind the efficacy of LISA, considering it as a single maneuver in a comprehensive approach for RDS management in the delivery room.

Nutritional problems of children with bronchopulmonary dysplasia after hospital discharge

The last decades have seen significant improvements in the care of premature infants. The introduction of new approaches, especially in the ventilatory management, have led to significant increase of survival rate of low and extremely low gestational age infants. These populations of neonates, however, often experience prolonged mechanical ventilation, which is widely recognized to be closely related to bronchopulmonary dysplasia (BPD) development. The management of BPD, which is a multifactorial disease, requires a multidisciplinary approach and remains challenging for all the physicians involved. In fact, short and long-term sequelae are not only related to pulmonary performances but include neurological impairment and growth deficiency. A proper nutrition management since the very first days has shown to significantly contribute to the optimal maturation and functionality of the lung. In this paper, we aim to give an overall of the main principles of nutrition in infants born prematurely, with specific regard to the interventions, which could be relevant in infants affected by BPD.

Functional nutrients in infants born by vaginal delivery or Cesarean section

The development of a proper neonatal microbiota is of great importance, especially for the effects that dysbiosis has in acute and chronic diseases' onset. The microbiota, particularly the intestinal one, plays a crucial role in maintaining the health of the host, preventing colonization by pathogenic bacteria and significantly influencing the development and maturation of a normal gastrointestinal mucosal immunity. Several factors may interfere with the physiological development of microbiota, such as diseases during pregnancy, type of delivery, maternal nutrition, type of neonatal feeding, use of antibiotics, exposition to hospital environment (e.g., neonatal intensive care unit) and genetic factors. Thanks to a proper maternal and neonatal supplementation with specific functional nutrients, it is now possible to correct dysbiosis, thus reducing the risks for the newborn's health. In this review of the literature, we give an overview of the studies highlighting the composition of the maternal, fetal and neonatal microbiota, the factors potentially responsible for dysbiosis and the use of functional nutrients to prevent diseases' onset.

Efficacy of lung volume optimization maneuver monitored by optoelectronic pletismography in the management of congenital diaphragmatic hernia

Newborns affected by congenital diaphragmatic hernia (CDH) need cardio-respiratory stabilization before undergoing surgical repair. Open lung strategy is a well-established approach to optimize lung volume in preterm infants with Respiratory Distress Syndrome (RDS), using both High Frequency Oscillatory Ventilation (HFOV) and Conventional Mechanical Ventilation (CMV).

We report a case of left CDH with severe lung hypoplasia, managed applying open lung strategy in HFOV (pre-surgery period) and in Assist-Control with Volume Guarantee (post-surgery period), guided by SpO₂ changes, TcPO₂ and TcPCO₂ monitoring. Opto-electronic plethysmography was used to measure end-expiratory chest wall volume changes (ΔEEcw) related to lung volume variations occurring during pressure changes. OEP confirmed the efficacy of using SpO₂ and transcutaneous gas monitoring during this recruitment maneuver.

Effects of Breathing and Apnoea during Sustained Inflations in Resuscitation of Preterm Infants

BACKGROUND

A sustained inflation (SI) at birth in preterm babies may be ineffective unless the infants breathe. Gain in lung volume is associated with breathing during delivery room non-invasive management.

OBJECTIVE

To describe the breathing patterns of preterm infants during an SI and correlate to a calculated gain in lung volume.

METHODS

Retrospective observational study. Data collected from a respiratory function monitor during SI (25 cmH2O for 15 s then PEEP at 5 cmH2O) through a face mask in preterm infants (gestational age [GA] ≤31 weeks). Spontaneous breaths, inspiratory time (TI), inspiratory/expiratory tidal volume (Vti/Vte), and gain in lung volume were determined.

RESULTS

30 SIs in 20 infants (mean GA 27 weeks; birth weight 825 g) were analysed and stratified in 2 groups according to spontaneous breathing: SIs without spontaneous breaths (apnoea: n = 11) and SIs with spontaneous breaths (breathing: n = 19). Mean GA was lower in the apnoea group versus the breathing group (25 vs. 27+5 weeks; p = 0.01). Mean birth weight was lower in the apnoea group versus the breathing group (683 vs. 860 g; p = ns). In the breathing group, the mean number of spontaneous breaths was 4 with a mean TI of 0.52 min, the mean Vti/kg was 5.9 mL/kg, and the mean Vte was 2.7 mL/kg. The calculated mean gain in lung volume was 7.5 mL/kg in the apnoea group and 17.8 mL/kg in the breathing group (p = 0.039).

CONCLUSIONS

Actively breathing infants during an SI at birth showed a gain in lung volume higher than apnoeic infants. Spontaneous breathing during SI seems to be related to GA.