Comparison of the effectiveness of different high-flow devices in neonatal care

OBJECTIVE

To evaluate the success rate of high-flow nasal cannula (HFNC) therapy using an adapted obsolete mechanical ventilator (MV), Optiflow™ and Vapotherm™ in newborns (NBs).

METHOD

This was a retrospective observational study conducted in the neonatal intensive care unit (NICU). The sample comprised NBs who underwent HFNC therapy due to ventilatory dysfunction, for weaning from non-invasive ventilation (NIV), or post-extubation. The three groups, stratified according to gestational age (GA) and birth weight, and corrected GA and weight at the beginning of HFNC use, were as follows: Optiflow ™, Vapotherm ™, and obsolete Mechanical Ventilator (MV) adapted for high flow therapy. Subsequently, the NBs were divided into a success group (SG) and a failure group (FG). HFNC success was defined as a therapy duration exceeding 72 h.

RESULTS

A total of 209 NBs were evaluated, with 31.1 % using HFNC due to ventilatory dysfunction, 2.4 % after extubation, and 66.5 % after NIV weaning. HFNC success rate was observed in 90.9 % of the NBs, with no difference between equipment types (Vapotherm ™, Optiflow ™, and adapted VM).

CONCLUSION

Different types of HFNC equipment are equally effective when used in neonatology for respiratory dysfunction, as a method of weaning from NIV and post-extubation. Adapted obsolete MV can be an alternative for HFCN therapy in resource-constrained settings.

Less invasive surfactant administration versus intubation-surfactant-extubation in the treatment of neonatal respiratory distress syndrome: a systematic review and meta-analyses

OBJECTIVES

To compare LISA with INSURE technique for surfactant administration in preterm with gestational age (GA) < 36 weeks with RDS in respect to the incidence of pneumothorax, bronchopulmonary dysplasia (BPD), need for mechanical ventilation (MV), regional cerebral oxygen saturation (rSO2), peri‑intraventricular hemorrhage (PIVH) and mortality.

METHODS

A systematic search in PubMed, Embase, Lilacs, CINAHL, SciELO databases, Brazilian Registry of Randomized Clinical Trials (ReBEC), Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed. RCTs evaluating the effects of the LISA technique versus INSURE in preterm infants with gestational age < 36 weeks and that had as outcomes evaluation of the rates of pneumothorax, BPD, need for MV, rSO2, PIVH, and mortality were included in the meta-analysis. Random effects and hazard ratio models were used to combine all study results. Inter-study heterogeneity was assessed using Cochrane Q statistics and Higgin's I2 statistics.

RESULTS

Sixteen RCTs published between 2012 and 2020 met the inclusion criteria, a total of 1,944 preterms. Eleven studies showed a shorter duration of MV and CPAP in the LISA group than in INSURE group. Two studies evaluated rSO2 and suggested that LISA and INSURE transiently affect brain autoregulation during surfactant administration. INSURE group had a higher risk for MV in the first 72 h of life, pneumothorax, PIVH and mortality in comparison to the LISA group.

CONCLUSION

This systematic review and meta-analyses provided evidence for the benefits of the LISA technique in the treatment of RDS, decreasing CPAP time, need for MV, BPD, pneumothorax, PIVH, and mortality when compared to INSURE.

Endoscopic evaluation of neonates with signs of upper airway obstruction in the neonatal unit of a tertiary hospital

INTRODUCTION

The aim of the study is to evaluate major causes of upper airway obstruction in newborns receiving healthcare at our institution, their method of endoscopic assessment and the rate of complications related to these procedures.

MATERIALS AND METHODS

This is a case series study of patients from institutional neonatal intensive care unit (NICU) presenting signs of ventilatory dysfunction for whom an endoscopic airway assessment was warranted. Information of interest was collected from medical records according to a Clinical and Endoscopic Assessment Protocol created for the study. The protocol included clinical manifestations needing ENT evaluation, clinical signs of ventilatory dysfunction, comorbidities (pulmonary, cardiac, neurological, and gastrointestinal), examination method (airway endoscopy under general anesthesia or awake), exam complications, and final diagnosis.

RESULTS

One hundred sixty-nine newborn patients who underwent airway endoscopy (awake bedside flexible fiberoptic laryngoscopy (FFL) or direct laryngoscopy and bronchoscopy (DLB) in the surgical ward) were included. Thirty-nine patients (23.07%) underwent bedside FFL. For the remaining 130 who underwent DLB under general anesthesia, the median procedure time was 30 min (20-44). Only 9 (5.32%) patients presented complications: desaturation (4), laryngospasm without desaturation with spontaneous resolution (2), apnea with resolution after stimulation (1), seizures (1), nasal bleeding (1). The most frequent diagnoses found were glossoptosis, posterior laryngeal edema, and laryngomalacia.

CONCLUSION

This retrospective case series describes the prevalence of different pathologies that cause upper airway obstruction in neonates. Airway endoscopy seems an effective and safe diagnostic tool in neonatal airway obstruction. Glossoptosis was the most prevalent cause of obstruction in our center.

Association between preterm infant size at 1 year and ADHD later in life: data from 1993 and 2004 Pelotas Birth Cohorts

The objective of this study is to examine the association between preterm infants' size at 1 year and attention-deficit/hyperactivity disorder (ADHD) assessed categorically and dimensionally in childhood and adolescence. We studied infants born < 37 weeks' gestation from two Brazilian birth cohorts (n = 653). ADHD was evaluated using the Development and Well-Being Assessment (DAWBA) interview at the age of 6 years in one cohort and by a structured interview according to DSM-5 criteria at 18 years in the other one. The presence of child attention difficulties was measured by the Strengths and Difficulties Questionnaire (SDQ) at 6 and 11 years in the 2004 and 1993 cohorts, respectively. We estimated associations of weight, length, head circumference, and BMI z-scores at 1-year chronological age with ADHD using Poisson Regression Model; and with attention difficulties using Linear Regression, adjusting for covariates. Mean birth weight was 2500 g and gestational age was 34.5 weeks. The aggregated ADHD prevalence in the two cohorts was 2.7%, and the median score for attention difficulties was 3.0. We found that increased head circumference at 1 year was associated with a lower risk of ADHD diagnosis (RR = 0.7, 95% CI 0.4, 0.9; p = 0.04 per standard deviation difference) and with fewer dimensional attention symptoms. In sensitivity analysis with other mental disorders, head circumference was associated with depression, but not with anxiety. Our findings emphasize poor head growth in the first year of life as a potential determinant of attentional difficulties in the preterm infant population.

Incidence of nasal pressure injury in preterm infants on nasal mask noninvasive ventilation

OBJECTIVE

The aim of this study was to evaluate the incidence of nasal injury in preterm newborns (NB) using the Neonatal Skin Condition Score within 7 days of noninvasive ventilation (NIV) and to compare the incidence of injury in NB weighing ≥1,000 g and those weighing <1,000 g at the time of initiation of NIV support.

METHODS

This is a prospective, observational study carried out in a neonatal intensive care unit of a public hospital in Rio Grande do Sul from July 2016 to January 2021. Patients were stratified into two groups at the time of NIV initiation: group 1 (weight ≥1,000 g) and group 2 (weight <1,000 g). To assess the condition of nasal injury, a rating scale called the Neonatal Skin Condition Score was applied during the first seven consecutive days on NIV. Kaplan-Meier, log-rank test, and Cox proportional hazards regression were used to estimate the hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

In total, 184 NB were evaluated. Nasal injury was reported in 55 (30%) NB. The risk of nasal injury was 74% higher in group 2 (19/45) than in group 1 (36/139) (HR: 1.74; 95%CI 0.99-3.03, p=0.048).

CONCLUSION

The incidence of nasal injury in infants submitted to NIV by nasal mask was high, and the risk of this injury was greater in preterm infants weighing <1,000 g.

Risk Factors for cognitive, motor and language development of preterm children in the first year of life

Abstract Objective: To perform a longitudinal investigation of risk factors in premature infants’ cognitive, motor, and language development. Methods: Thirty-three preterm infants were assessed at 4, 8, and 12 months of corrected age, using the Bayley-III Scales. Parents completed questionnaires regarding development opportunities at home, parenting practices and knowledge. Results: Significant associations were found (1) at 4-months between cognitive scores and family income, variety of stimuli, availability of toys, parenting practices and knowledge; language and parenting practices; and motor skills and parenting practices; (2) at 8-months between cognitive score and length of stay in the Neonatal Intensive Care Unit (NICU), gestational age, birth weight, toys, and parenting knowledge; language and toys; and motor skills and toys and parenting knowledge; (3) at 12-months between cognitive scores and length of stay in the NICU, family income, breastfeeding, toys, and parenting knowledge; language and income and toys; and motor scores and length of stay in the NICU, gestational age, income, stimuli, toys, and parenting knowledge. Regression analyses indicated that: for (1) cognitive development, stimulus variety explained 72% of the model variance at 4 months of age; time at the NICU explained 67 and 43% at 8 and 12 months of age, respectively, and breastfeeding time explained 41% of the model variance at 12 months; (2) for language development, family income explained 42% of the model variance at 12 months; and for motor development (3), time at the NICU explained 80% of the model variance at 12 months. Conclusions: The development over the first year of life is not explained by the severity of birth conditions and associated morbidities only, but also by parenting practices.

The impact of an early intervention home-based program on body composition in preterm-born preschoolers with very low birth weight

Background and aims

Early child interventions focused on the family prevented neurodevelopmental and behavioral delays and can provide more knowledge regarding responsive feeding, thus creating learning opportunities to promote better quality nutrition and preventing failure to thrive. The aim is to verify the impact of a continuous program of early home-based intervention on the body composition of preschool infants who were born preterm with very low birth weight (VLBW).

Methods

This is a longitudinal analysis from a randomized controlled trial, including VLBW preterm children, born in a tertiary hospital in Southern Brazil and followed up at the high-risk institutional ambulatory clinic. Participants were divided into the intervention group (IG): skin-to-skin care with the mother (kangaroo care), breastfeeding policy, and tactile-kinesthetic stimulation by mothers until hospital discharge. Subsequently, they received a program of early intervention with orientation and a total of 10 home visits, independently from the standard evaluation and care that was performed following the 18 months after birth; conventional group (CG): standard care according to the routine of the newborn intensive care unit (NICU), which includes kangaroo care, and attending to their needs in the follow-up program. Body composition estimation was performed using bioelectrical impedance analyses (BIA), and physical activity and feeding practices questionnaires were evaluated at preschool age, as well as anthropometric measurements and biochemical analysis.

Results

Data of 41 children at 4.6 ± 0.5 years old were evaluated (CG n = 21 and IG n = 20). Body weight, height, body mass index, waist and arm circumferences, and triceps and subscapular skinfold did not differ between groups. The IG presented higher segmented fat-free mass (FFM) when compared to the CG (right arm FFM: 0.74 vs. 0.65 kg, p = 0.040; trunk FFM: 6.86 vs. 6.09 kg, p = 0.04; right leg FFM: 1.91 vs. 1.73 kg, p = 0.063). Interaction analyses showed that segmented FFM and FFM Index were associated with higher iron content in the IG. In the CG, interaction analyses showed that increased visceral fat area was associated with higher insulin resistance index.

Conclusion

An early intervention protocol from NICU to a home-based program performed by the mothers of VLBW preterm children of low-income families presents a small effect on FFM.

Motor development in the first year of life predicts impairments in cognition and language at 3 years old in a Brazilian preterm cohort of low-income families

Purpose

Early identification of impairments is crucial to providing better care for preterm children, especially those from low-income families. The early motor assessment is the first step in monitoring their neurodevelopment. This study investigates if motor development in the first year of life predicts impairments in cognition and language at 3-year-old in a Brazilian preterm cohort.

Materials and methods

Data were collected in a follow-up clinic for high-risk infants. The Bayley Scales were used to assess children at 4, 8, 12, and 36 months of age, considering composite scores. Cognitive and language impairments were considered if scores were ≤85. Children (N = 70) were assessed at 4 and 36 months, 79 were assessed at 8 and 36 months, and 80 were assessed at 12 and 36 months. Logistic regressions were used to analyze the predictability of cognitive and language impairments, and receiver-operating characteristics (ROC) curves were used to analyze the sensibility and specificity of motor assessment and cognitive and language impairments.

Results

Poor motor scores at 8 and 12 months increased the chances of cognitive and language impairment at 3-year-old. The chance of cognitive impairment at 3-year-old increases by 6–7% for each point that the motor composite score decreases, and the chance of language impairment at 3-year-old increases by 4–5% for each point that the motor composite score decreases. No-significant results were found at 4-months. Adequate sensibility and specificity were found for language impairments considering 12 months scores and for cognitive impairments as soon as 8 months scores.

Conclusion

Monitoring preterm motor development in the first year of life helps to identify preterm children at risk for impairment in other developmental domains. Since preterm children from low-income families tend to demonstrate poorer neurodevelopment outcomes, these children need early assessment and referral to intervention to prevent school failures and support from public policies.

Development of a risk calculator to predict attention-deficit/hyperactivity disorder in very preterm/very low birth weight newborns

BACKGROUND

Very preterm/very low birth weight (VP/VLBW) newborns can have lifelong morbidities, as attention-deficit/hyperactivity disorder (ADHD). Clinicians have no markers to discriminate which among those individuals will develop later ADHD, based only on the clinical presentation at birth. Our aim was to develop an individualized risk calculator for ADHD in VP/VLBW newborns.

METHODS

This retrospective prognostic study included a consecutive sample of all VP/VLBW children (gestational age <32 weeks and/or birth weight <1.5 kg) born between 2010 and 2012 from a clinical cohort in a Brazilian tertiary care hospital. Children were clinically assessed at 6 years of age for ADHD using the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). The least absolute shrinkage and selection operator (LASSO) method was used for model-building.

RESULTS

Ninety-six VP/VLBW children were assessed at 6 years of age (92% follow-up), of whom 32 (33%) were diagnosed with ADHD. The area under the ROC curve (AUC) for ADHD prediction based on seven parameters (late-onset sepsis confirmed by blood culture, necrotizing enterocolitis, neonatal seizures, periventricular leukomalacia, respiratory distress syndrome, length of hospital stay, and number of maternal ADHD symptoms) was .875 (CI, 0.800-0.942, p < .001; AUC corrected for optimism with bootstrapping: .806), a performance that is comparable to other medical risk calculators. Compared to approaches that would offer early intervention to all, or intervention to none, the risk calculator will be more useful in selecting VP/VLBW newborns, with statistically significant net benefits at cost:benefits of around 1:2 to around 10:6 (range of ADHD risk thresholds of 32%-62%, respectively). It also showed specificity for ADHD compared to other prevalent child psychopathologies.

CONCLUSIONS

The risk calculator showed good performance for early identification of VP/VLBW newborns at high risk of future ADHD diagnosis. External validity in population-based samples is needed to extend clinical usefulness.

Temporal trends in intraventricular hemorrhage in preterm infants: A Brazilian multicenter cohort

BACKGROUND

Intraventricular hemorrhage (IVH) is a serious problem in preterm infants. Brazilian national data are unknown.

OBJECTIVE

To evaluate the incidence and temporal trend of IVH in very low birth weight (VLBW) preterm infants of 18 centers of the Brazilian Network on Neonatal Research.

STUDY DESIGN

National prospective multicenter cohort study including inborn VLBW preterm infants aged 23^0/7- 33^6/7 weeks' gestation, admitted between 2013 and 2018. The center with the mean incidence rate was used as reference. We applied two adjustments models using perinatal variables, and perinatal + neonatal diseases.

RESULTS

Of 6,420 infants, 1951/30.4% (range 27.1-33.8%) had IVH and the disease showed a significant trend towards an overall increase in incidence over time (p = 0.003), especially in three centers. Severe IVH (grade III or IV) occurred in 32.2% (range 29.2-34.5%) of those affected by IVH, with a stable incidence. After adjustments for perinatal variables, the differences persisted among centers: for global IVH, 7 centers had significantly lower rates (OR ranging from 0.31 to 0.62), and 2 presented rates higher than the reference center (OR ranging from 2.00 to 12.46) for severe HIV. Considering perinatal and neonatal variables, 6 centers had significantly lower rates (OR ranging from 0.36 to 0.60) for global IVH than the reference center and 3 had statistically higher rates (OR 1.72, 1.86 and 11.78) for severe forms.

CONCLUSION

The incidence rate of IVH in this Brazilian cohort was high and it revealed an increasing trend towards over time. The severe IVH rate was also worrisome.

Risk Perception and Decision Making about Early-Onset Sepsis among Neonatologists: A National Survey

OBJECTIVE

Many newborns are investigated and empirically treated for suspected early-onset sepsis (EOS). This study aimed to describe neonatologists' self-identified risk thresholds for investigating and treating EOS and assess the consistency of these thresholds with clinical decisions.

STUDY DESIGN

Voluntary online survey, available in two randomized versions, sent to neonatologists from 20 centers of the Brazilian Network on Neonatal Research. The surveys included questions about thresholds for investigating and treating EOS and presented four clinical scenarios with varying calculated risks. In survey version A, only the scenarios were presented, and participants were asked if they would order a blood test or start antibiotics. Survey version B presented the same scenarios and the risk of sepsis. Clinical decisions were compared between survey versions using chi-square tests and agreement between thresholds and clinical decisions were investigated using Kappa coefficients.

RESULTS

In total, 293 surveys were completed (145 survey version A and 148 survey version B). The median risk thresholds for blood test and antibiotic treatment were 1:100 and 1:25, respectively. In the high-risk scenario, there was no difference in the proportion choosing antibiotic therapy between the groups. In the moderate-risk scenarios, both tests and antibiotics were chosen more frequently when the calculated risks were included (survey version B). In the low-risk scenario, there was no difference between survey versions. There was poor agreement between the self-described thresholds and clinical decisions.

CONCLUSION

Neonatologists overestimate the risk of EOS and underestimate their risk thresholds. Knowledge of calculated risk may increase laboratory investigation and antibiotic use in infants at moderate risk for EOS.

KEY POINTS

· Neonatologists overestimate the risk of EOS.. · There is wide variation in diagnostic/treatment thresholds for EOS.. · Clinical decision on EOS is not consistent with risk thresholds.. · Knowledge of risk may increase investigation and treatment of EOS..

The challenges of neonatal sepsis management

OBJECTIVES

To present current evidence on the etiology, risk factors, diagnosis, and management of early and late neonatal sepsis.

SOURCE OF DATA

Non-systematic review of the Medline (PubMed), Scopus, Web of Science, Cochrane, and Google Scholar databases regarding the following terms: neonatal sepsis, early neonatal sepsis, late neonatal sepsis, empirical antibiotic therapy, sepsis calculator, vancomycin, newborn, preterm newborn.

DATA SYNTHESIS

Neonatal sepsis is a frequent cause of neonatal morbidity and mortality. Its diagnosis is difficult. Continuous observation of the patient is critical to diagnostic suspicion. When neonatal sepsis is suspected, bacteriological tests should be collected. Vancomycin should not be routinely using in the empirical antibiotic regimen in late neonatal sepsis, and the main protective mechanisms against neonatal sepsis are handwashing and the use of breast milk.

CONCLUSIONS

Newborns constitute a group that is more vulnerable to sepsis. Knowledge of risk factors and etiological agents allows a better approach to the newborn with sepsis.

Systemic Arterial Hypertension in Childhood: A Challenge Related to the Increasing Survival of Very Low Birth Weight Preterm Infants

OBJECTIVE

To verify the prevalence of systemic arterial hypertension (SAH) and to identify possible early predictors of SAH at ages 2 and 4 years in very low birth weight (VLBW) infants.

STUDY DESIGN

This is a prospective cohort study including inborn children with birth weight (BW) <1,500 g. Arterial blood pressure measurements were performed at 2 and 4 years. Model 1 compared children with and those without SAH at age 4. Model 2 compared children who had SAH at ages 2 and 4 with the others. SAH was diagnosed if the systolic or/and diastolic pressures were above the 95th percentile.

RESULTS

A total of 198 patients were included during the 5-year study period, of whom 56% had SAH at age 4. In model 1, white matter injury (WMI) and catch-up growth at age 2 were predictors of SAH at age 4. In model 2, bronchopulmonary dysplasia, WMI, catch-up growth at age 2, and BW were predictors of SAH at 2 and 4 years. SAH at age 2 was an independent risk factor for SAH at age 4. After a multivariate analysis of model 2, BW and catch-up growth were associated with SAH.

CONCLUSION

Prevalence of SAH was high in VLBW infants; it was associated with low BW and catch-up growth at age 2.

Preterm newborn's postnatal growth patterns: how to evaluate them

OBJECTIVES

There are several factors that influence the postnatal growth of preterm infants. It is crucial to define how to evaluate the growth rate of each preterm child and its individual trajectory, the type of growth curve, either with parameters of prescriptive curves for healthy preterm infants with no morbidities or, in the case of preterm infants and their "bundle of vulnerabilities", growth curves that may represent how they are actually growing, with the aim of directing appropriate nutritional care to each gestational age range.

DATA SOURCES

The main studies with growth curves for growth monitoring and the appropriate nutritional adjustments that prioritized the individual trajectory of postnatal growth rate were reviewed. PubMed and Google Scholar were searched.

DATA SYNTHESIS

The use of longitudinal neonatal data with different gestational ages and considering high and medium-risk pregnancies will probably be essential to evaluate the optimal growth pattern.

CONCLUSIONS

Prioritizing and knowing the individual growth trajectory of each preterm child is an alternative for preterm infants with less than 33 weeks of gestational age. For larger preterm infants born at gestational age >33 weeks, the Intergrowth 21st curves are adequate.

EVALUATION OF USABILITY OF A NEONATAL HEALTH INFORMATION SYSTEM ACCORDING TO THE USER'S PERCEPTION

Objective:

To measure the level of satisfaction regarding the usability of a neonatal health information system and identify if demographic factors can influence the usability of a health information system.

Methods:

A cross-sectional, exploratory study was carried out with a convenience sample of 50 users of the Brazilian Neonatal Research Network. The instrument chosen for the usability evaluation was the System Usability Scale between February and March 2017. The statistical analysis of the collected variables was carried out in order to describe the sample, to quantify the level of satisfaction of the users and to identify the variables associated with the level of satisfaction.

Results:

The female gender represented 75% of the sample. The mean age was 52.8 years; 58% had a doctoral degree, average time of graduation was 17 years, with area of practice in medicine (neonatology), with intermediate knowledge in computer science (74%) and mean system use time of 52 months. Regarding usability, 94% rated the system as “good”, “excellent” or “better than imaginable”. The usability of the system was not associated with age, gender, education, profession, area of practice, knowledge in computer science and time of system use.

Conclusion:

The level of satisfaction of the computerized health system user was considered good. No demographic factors were associated with the satisfaction of the users.

Association between human breast milk and retinopathy of prematurity

PURPOSE

To evaluate the possible protective effect of breast milk against retinopathy of prematurity by comparing the amount of breast milk received by patients who developed retinopathy of prematurity and those who did not and to determine both the required minimum amount of breast milk and the time of life during which neonates need to receive breast milk for this effect to be significant.

METHODS

Cohort study of newborns with a birth weight of <1500 g or gestational age of <32 weeks, or both, born between January 2011 and October 2014 and hospitalized within the first 24 h of life in the Hospital Criança Conceição Neonatal Intensive Care Unit in Porto Alegre, RS, Brazil.

RESULTS

The prevalence of retinopathy of prematurity of any degree was 31% (100 of 323 patients) and that of severe retinopathy of prematurity was of 9% (29 of 323 patients). The median amounts of breast milk received daily by patients with and without retinopathy of prematurity were 4.9 mL/kg (interquartile range, 0.3-15.4) and 10.2 mL/kg (1.5-25.5), respectively. The amount of breast milk received in the first 6 weeks of life was inversely associated with the incidence of both retinopathy of prematurity of any degree and severe retinopathy of prematurity in the univariate analyses. However, the statistical significance was maintained only during the sixth week of life in a per-period multivariate analysis controlling for confounding factors.

CONCLUSIONS

Small amounts of breast milk are inadequate to prevent retinopathy of prematurity in premature newborns at risk for the disease.

Attention-Deficit/Hyperactivity Disorder and Very Preterm/Very Low Birth Weight: A Meta-analysis

CONTEXT

Although very preterm (VP), extremely preterm (EP), very low birth weight (VLBW), and extremely low birth weight (ELBW) newborns seem to have a higher risk of later attention-deficit/hyperactivity disorder (ADHD), the magnitude of the risk is not well-defined.

OBJECTIVE

To systematically review and meta-analyze the risk of VP/VLBW and EP/ELBW individuals to develop a ADHD categorical diagnosis or dimensional symptomatology compared with controls with normal weight and/or birth age.

DATA SOURCES

We used PsycINFO, Medline, Embase, and Cochrane databases.

STUDY SELECTION

We selected cross-sectional, prospective, or retrospective studies with no time or language restriction.

DATA EXTRACTION

Independent reviewers screened and extracted data using predefined standard procedures.

RESULTS

In 12 studies (N = 1787), researchers relying on a categorical diagnosis showed that both VP/VLBW and EP/ELBW subjects have a higher ADHD risk (odds ratio [OR] = 3.04 higher than controls; 95% confidence interval [CI] 2.19 to 4.21). In subgroup analyses, we demonstrated that the more extreme the cases, the higher the ORs (VP/VLBW: OR = 2.25 [95% CI 1.56 to 3.26]; EP/ELBW: OR = 4.05 [95% CI 2.38 to 6.87]). We drew data from 29 studies (N = 3504) on ADHD symptomatology and found significant associations with inattention (standardized mean difference [SMD] = 1.31, 95% CI 0.66 to 1.96), hyperactivity and impulsivity (SMD = 0.74, 95% CI 0.35 to 1.13), and combined symptoms (SMD = 0.55, 95% CI 0.42 to 0.68) when compared with controls.

LIMITATIONS

Heterogeneity was significantly high for all analyses involving the 3 ADHD dimensions.

CONCLUSIONS

With our results, we provide evidence that VP/VLBW subjects have an increased risk of ADHD diagnosis and symptomatology compared with controls, and these findings are even stronger in the EP/ELBW group. Future researchers should address which risk factors related to prematurity or low birth weight lead to ADHD.

Comparison of two dose regimens of ibuprofen for the closure of patent ductus arteriosus in preterm newborns

OBJECTIVE

To compare the efficacy of intravenous ibuprofen at high (20-10-10mg/kg/dose) and low doses (10-5-5mg/kg/dose) the closure of patent ductus arteriosus in preterm newborns.

METHODS

A cohort study with historical control of newborns that received high- and low-dose intravenous ibuprofen, from 2010 to 2013 in a neonatal intensive care unit, for closure of the patent ductus arteriosus, documented by echocardiography. Secondary outcomes included the number of ibuprofen cycles, incidence of bronchopulmonary dysplasia, necrotizing enterocolitis, changes in renal function, and death.

RESULTS

Seventy-seven patients received three doses of ibuprofen for the treatment of patent ductus arteriosus, with 33 receiving high-dose and 44 low-dose therapy. The ductus closed after the first cycle in 25 (56.8%) low-dose patients and in 17 (51.5%) high-dose patients (p>0.99). Sixteen patients received a second cycle of ibuprofen, and the ductus closed in 50% after low-dose and in 60% after high-dose therapy (p>0.99). Seven patients required surgery for ductus closure, 13.6% in the low-dose group and 3% in the high-dose group (p=0.22). Thirty-nine patients developed bronchopulmonary dysplasia, 50% in the low-dose group and 51.5% in the high-dose group (p>0.99). Twenty-two (50%) low-dose patients died vs. 15 (45.5%) high-dose patients (p=0.86).

CONCLUSIONS

There was no difference in closure of the ductus arteriosus or occurrence of adverse effects between the two dose regimens.

Ventilator-induced lung injury in preterm infants

In preterm infants, the need for intubation and mechanical ventilation is associated with ventilator-induced lung injuries and subsequent bronchopulmonary dysplasia. The aim of the present review was to improve the understanding of the mechanisms of injury that involve cytokine-mediated inflammation to contribute to the development of new preventive strategies. Relevant articles were retrieved from the PubMed database using the search terms "ventilator-induced lung injury preterm", "continuous positive airway pressure", "preterm", and "bronchopulmonary dysplasia". The resulting data and other relevant information were divided into several topics to ensure a thorough, critical view of ventilation-induced lung injury and its consequences in preterm infants. The role of pro-inflammatory cytokines (particularly interleukins 6 and 8 and tumor necrosis factor alpha) as mediators of lung injury was assessed. Evidence from studies conducted with animals and human newborns is described. This evidence shows that brief periods of mechanical ventilation is sufficient to induce the release of pro-inflammatory cytokines. Other forms of mechanical and non-invasive ventilation were also analyzed as protective alternatives to conventional mechanical ventilation. It was concluded that non-invasive ventilation, intubation followed by early surfactant administration and quick extubation for nasal continuous positive airway pressure, and strategies that regulate tidal volume and avoid volutrauma (such as volume guarantee ventilation) protect against ventilator-induced lung injury in preterm infants.

Plasma cytokine levels fall in preterm newborn infants on nasal CPAP with early respiratory distress

Introduction

Early nCPAP seems to prevent ventilator-induced lung injury in humans, although the pathophysiological mechanisms underlying this beneficial effect have not been clarified yet.

Objective

To evaluate plasma levels IL-1β, IL-6, IL-8, IL-10, and TNF-α immediately before the start of nCPAP and 2 hours later in preterm infants.

Methods

Prospective cohort including preterm infants with 28 to 35 weeks gestational age with moderate respiratory distress requiring nCPAP. Extreme preemies, newborns with malformations, congenital infections, sepsis, surfactant treatment, and receiving ventilatory support in the delivery room were excluded. Blood samples were collected right before and 2 hours after the start of nCPAP.

Results

23 preterm infants (birth weight 1851±403 grams; GA 32.3±1.7 weeks) were treated with nCPAP. IL-1β, IL-10, TNF-α levels were similar, IL-8 levels were reduced in 18/23 preterm infants and a significant decrease in IL-6 levels was observed after 2 hours of nCPAP. All newborns whose mothers received antenatal steroids had lower cytokine levels at the onset of nCPAP than those whose mothers didn’t receive it; this effect was not sustained after 2 hours of nCPAP.

Conclusion

Early use nCPAP is not associated with rising of plasma pro-inflammatory cytokines and it seems to be a less harmful respiratory strategy for preterm with moderate respiratory distress.

Late-onset sepsis in very low birth weight infants: a Brazilian Neonatal Research Network Study

BACKGROUND

Late-onset sepsis (LOS) is an important cause of morbidity and mortality in very low birth weight (VLBW) infants.

AIM

To determine the incidence, risk factors and etiology of LOS.

METHODS

LOS was investigated in a multicenter prospective cohort of infants at eight public university neonatal intensive care units (NICUs). Inclusion criteria included inborn, 23-33 weeks of gestational age, 400-1499 g birth weight, who survived >3 days.

RESULTS

Of 1507 infants, 357 (24%) had proven LOS and 345 (23%) had clinical LOS. Infants with LOS were more likely to die. The majority of infections (76%) were caused by Gram-positive organisms. Independent risk factors for proven LOS were use of central venous catheter and mechanical ventilation, age at the first feeding and number of days on parenteral nutrition and on mechanical ventilation.

CONCLUSION

LOS incidence and mortality are high in Brazilian VLBW infants. Most risk factors are associated with routine practices at NICU.

Association of late-onset neonatal sepsis with late neurodevelopment in the first two years of life of preterm infants with very low birth weight

OBJECTIVE

To establish the influence of late-onset sepsis on neurodevelopment of preterm infants with very low birth weight (VLBW), according to the etiologic agent.

METHOD

This was a cohort of newborns with birth weight<1,500 g and gestational age less than 32 weeks, admitted to the institutional intensive care unit (ICU) with up to 48 hours of life, and followed-up at the outpatient follow-up clinic for preterm infants with VLBW until 2 years of corrected age.

EXCLUSION CRITERIA

death within the first 72 hours of life, congenital malformations and genetic syndromes, children with congenital infection by the human immunodeficiency virus (HIV), congenital infection (STORCH), presence of early-onset sepsis and cases with more than one pathogen growth in blood cultures. Septic and non-septic infants were compared regarding neonatal outcomes and mortality. Neurodevelopment was assessed using the Bayley Scale (BSDI-II) at 18 to 24 months of corrected age.

RESULTS

411 preterm infants with VLBW were eligible; the mean gestational age was 29 ± 2.2 weeks and mean birth weight was 1,041 ± 281 grams. Late-onset sepsis occurred in 94 preterm infants with VLBW (22.8%). VLBW infants with Gram-positive infection showed motor deficit when compared to the non-septic group, 68.8% vs. 29.3%, respectively (OR 6; 1.6-21.8, p=0.006); the cognitive development was similar between the groups. The overall mortality rate from infection was 26.7%; considering the pathogens, the rates were 18.7% for coagulase-negative Staphylococcus, 21.8% for Gram-positive bacteria, and 50% for Gram-negative bacteria and fungi.

CONCLUSION

Neonatal sepsis has a significant influence on late neurodevelopment at 2 years of corrected age in preterm infants with VLBW, and Gram-positive infections are associated with motor deficit.

Incidence and main risk factors for severe retinopathy of prematurity in infants weighing less than 1000 grams in Brazil

OBJECTIVES

This study evaluated the incidence and risk factors for severe retinopathy of prematurity (ROP) in babies <1000 g at Porto Alegre, Brazil.

METHODS

Prospective cohort study including premature children with birth weight ≤1000 g was conducted. Main outcome was the occurrence of severe ROP needing treatment.

RESULTS

A total of 157 infants were included. Severe ROP occurred in 20 infants (12.7%). Nineteen patients were treated by laser photocoagulation. Main risk factors for severe ROP were gestational age (P = 0.029), infant's weight measured at sixth week of life (P < 0.001) and number of days of oxygen therapy under mechanical ventilation (P < 0.001). After logistic regression, infant's weight at sixth week of life and number of days in mechanical ventilation were associated to severe ROP.

CONCLUSIONS

We reported the incidence of 12.7% of severe ROP among babies born ≤ 1000 g in our institution. Laser photocoagulation was effective to stabilize the disease among 19 treated patients.

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

OBJECTIVE

To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death.

STUDY DESIGN

Prospective cohort of 484 infants with 23(0/7) to 26(6/7) weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of ≥1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24  h of life.

RESULT

Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/neonatal clinical conditions.

CONCLUSION

In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day.

Postconceptional age at the treatment of retinopathy of prematurity in inborn and referred preterm infants from the same institution

PURPOSE

The outcomes of the treatment of retinopathy of prematurity (ROP) seem to be better in inborn patients than in those patients who were referred for ROP treatment. This study aims to investigate the timing of treatment and the outcomes in inborn patients and in patients referred for treatment to the Hospital de Clínicas de Porto Alegre, Brazil.

METHODS

An institutional prospective cohort study was conducted from 2002 to 2010 and included in group 1 all inborn preterm neonates treated for retinopathy of prematurity and in group 2 all babies referred for treatment to the same institution. All of the included patients presented birth weight (BW) ≤1,500 g and/or gestational age (GA) ≤32 weeks. Main outcomes were postconceptional age at the treatment and one year follow-up outcomes in both groups. The considered variables were: BW, GA, stage and location of retinopathy of prematurity at treatment.

RESULTS

Group 1 comprised 24 inborn patients. Mean BW and GA at birth were 918 ± 232 g and 28.2 ± 2.1 weeks, respectively, and median post-conceptional postconceptional age at treatment was 37 weeks. Group 2 comprised 14 infants transferred for treatment. Mean BW and GA at birth were 885 ± 188 g and 28.2 ± 2.4 weeks, respectively, and median postconceptional age at treatment was 39 weeks. Mean BW and GA were similar in both groups (P=0.654 and P=0.949, respectively), but the difference among the postconceptional age was significant (P=0.029).

CONCLUSIONS

Inborn patients were treated for retinopathy of prematurity during the 37(th) week of postconceptional age while transferred patients were treated, usually, after the 39(th) week postconceptional age. The worst outcomes observed among referred patients could be partially explained by the delayed time for treatment.

Prevention of retinopathy of prematurity

Retinopathy of prematurity (ROP) is related to oxygen-regulated vascular endothelial growth factor and to insulin-like growth factor-I. After premature birth, supplemental oxygen induces a retinal hyperoxic condition with vasoconstriction and to a definitive interruption of retinal vasculogenesis. Peripheral ischemia may stimulate retinal neovascularization and the onset of additional ROP-related complications. The natural course of the disease may result in irreversible blindness if not promptly diagnosed and attended. Recently, a significant increase in the prevalence of ROP has been observed in survival rates of preterm infants, especially in emerging-economy countries in Latin America, Asia, and Eastern Europe. This article addresses the main preventive measures in ROP.

Cerebellar growth in very low birth weight infants

OBJECTIVE

The aim of this study was to assess cerebellar growth of very low birth weight infants from birth to discharge and compare it with term infants.

STUDY DESIGN

Very low birth weight infants were matched by gender, adequacy of weight to gestational age at birth and postmenstrual ages at hospital discharge to term newborns. Exclusion criteria were central nervous system malformation, peri-intraventricular hemorrhage, cerebellar hemorrhage and meningitis. Transverse cerebellar diameter was measured by cranial ultrasound at birth and at hospital discharge in cases, and at birth in matched controls. Very low birth weight infants had magnetic resonance imaging done in the first year.

RESULT

Cerebellar growth was similar in very low birth weight infants without periventricular leukomalacia and controls, and smaller in cases with periventricular leukomalacia than in controls.

CONCLUSION

We suggest that cerebellar growth is normal in the absence of supratentorial injury.

Predicting proliferative retinopathy in a Brazilian population of preterm infants with the screening algorithm WINROP

OBJECTIVE

To retrospectively validate the WINROP (weight, insulinlike growth factor I, neonatal, retinopathy of prematurity [ROP]) algorithm in a Brazilian population. WINROP aims to predict ROP and is based on longitudinal weight measurements from birth until postmenstrual age 36 weeks. WINROP has predicted 100% of severe ROP in 3 neonatal intensive care unit settings in the United States and Sweden.

METHODS

In children admitted to the neonatal intensive care unit at Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil, from April 2002 to October 2008, weight measurements had been recorded once a week for children screened for ROP, 366 of whom had a gestational age of 32 weeks or less. The participating children had a median gestational age of 30 weeks (range, 24-32 weeks) at birth and their median birth weight was 1215 g (range, 505-2000 g).

RESULTS

For 192 of 366 children (53%), no alarm or low-risk alarm after postmenstrual age 32 weeks occurred. Of these, 190 of 192 did not develop proliferative disease. Two boys with severe sepsis who were treated for ROP received low-risk alarms at postmenstrual age 33 and 34 weeks, respectively. The remaining 174 children (47%) received high- or low-risk alarms before or at 32 weeks. Of these infants, 21 (12%) developed proliferative ROP.

CONCLUSIONS

In this Brazilian population, WINROP, with limited information on specific gestational age and date of weight measurement, detected early 90.5% of infants who developed stage 3 ROP and correctly predicted the majority who did not. Adjustments to the algorithm for specific neonatal intensive care unit populations may improve the results for specific preterm populations.

Neonatal sepsis and septic shock: concepts update and review

The nonspecific presentation of neonatal sepsis and systemic inflammatory response syndrome preceding septic shock delay the early diagnosis of septic shock and increase its mortality rate. Early diagnosis involves suspecting septic shock in every newborn with tachycardia, respiratory distress, difficult feeding, altered tonus and skin coloration, tachypnea and reduced perfusion, specially in case of maternal peripartum infection, chorioamnionitis or long-term membranes rupture. This article aims to review current knowledge on neonatal period peculiarities, fetal circulation dynamics, and the pregnancy age variable. Newborn septic shock is not just a small adult shock. In the newborn, the septic shock is predominantly cold and characterized by reduced cardiac output and increased systemic vascular resistance (vasoconstriction). Time is fundamental for septic shock reversion. The indexed-databases literature review provides subside for the newborn management.

Score for Neonatal Acute Physiology and Perinatal Extension II as a predictor of retinopathy of prematurity: study in 304 very-low-birth-weight preterm infants

AIM

To evaluate the use of the Score for Neonatal Acute Physiology and Perinatal Extension (SNAPPE-II) at admission to predict the development of retinopathy of prematurity (ROP) among very-low-birth-weight preterm babies.

METHODS

A prospective cohort study included 304 infants screened for ROP from July 2004 to October 2007. The main outcomes were the development of any stage ROP and severe ROP. The main variable was the SNAPPE-II obtained at admission. Seventeen risk factors for ROP were studied by univariate analysis (chi(2) and Student's t test). A simple descriptive analysis was used for the SNAPPE-II (mean, median, standard deviation and interquartile range: p25-p75). Logistic regression and receiver-operating characteristic (ROC) curve were calculated for SNAPPE-II. Ophthalmological examinations started at the 6th week of life and were repeated until the 45th week of corrected gestational age (GA).

RESULTS

The mean GA and mean birth weight of the whole cohort were 30.3 weeks (+/-2.2) and 1,209.2 g (+/-277.7), respectively. The median SNAPPE-II among non-ROP and ROP patients were 6.0 and 15.0, respectively (p = 0.001). When compared with severe ROP patients (25.0) there was also a significant difference (p = 0.003). After logistic regression, the SNAPPE-II adjusted odds ratio for ROP was 1.024. The area under the ROC curve was 0.62 (95% confidence interval: 0.55-0.70, p < 0.001). The best discriminative cutoff value was 8.5 (sensitivity: 68%; specificity: 54%; positive predictive value: 37.3%; negative predictive value: 80.6%).

CONCLUSIONS

The SNAPPE-II values at admission were significantly higher among babies with ROP, suggesting a positive association between higher scores with the development of ROP, but after adjusted logistic regression and ROC curve results, the SNAPPE-II scores at admission did not enhance the assessment of risk for ROP.

Is being small for gestational age a risk factor for retinopathy of prematurity? A study with 345 very low birth weight preterm infants

OBJECTIVE

To analyze prevalence and risk factors for retinopathy of prematurity (ROP) among preterm infants born small for gestational age (SGA) and appropriate for gestational age (AGA).

METHODS

A prospective cohort study included preterm infants with birth weight (BW) < or = 1,500 grams and gestational age (GA) < or = 32 weeks, divided into two groups: AGA or SGA. Prevalences and risk factors for ROP were determined in both groups. Logistic regression was used for the significant variables after univariate analysis.

RESULTS

A total of 345 patients were examined: 199 included in the AGA group and 146 in the SGA. Mean BW and GA in the whole cohort (345 patients) were 1,128.12 grams (+/-239.9) and 29.7 weeks (+/-1.9), respectively. The prevalence of any stage ROP and severe ROP (needing treatment) was 29.6 and 7.0%, respectively. ROP in any evolutive stage developed in 66 AGA (33.2%) and in 36 SGA (24.7%) (p = 0.111). Severe ROP occurred in 15 AGA (7.5%) and in nine SGA (6.2%) (p = 0.779). After adjusted logistic regression, weight gain from birth to sixth week of life and need for blood transfusions were found to be significant risk factors for ROP in both groups.

CONCLUSIONS

This study has shown that being SGA was not a significant risk factor for any stage ROP or for severe ROP in this cohort and, also, that the risk factors for ROP were similar among SGA and AGA very-low-birth-weight preterm babies.

Cortisol and 17-alpha-hydroxy-progesterone levels in infants with refractory hypotension born at 30 weeks of gestation or less

Refractory hypotension is frequent in very low-birth weight infants, whose hypothalamic-pituitary-adrenal axis has been suggested to be immature. The objective of the present study was to evaluate basal cortisol and 17-alpha-OH-progesterone in the first 36 h of life in preterm infants with and without refractory hypotension (mean arterial blood pressure below the lower limit for gestational age throughout the study despite aggressive volume expansion and use of vasopressors). Thirty-five infants with <or=30 weeks of gestation and a birth weight <or=1250 g, with no postnatal use of corticosteroid or death in the first 48 h were studied. Mean arterial pressure was measured every 4 h during the first 48 h. Cortisol and 17-alpha-OH-progesterone were determined at 12 and 36 h and patients were divided into refractory hypotensive (N = 15) and control (N = 20) groups. The groups were not different regarding type of delivery, use of prenatal corticosteroid, requirement of mechanical ventilation, use of vasopressor drugs, morphine, fentanyl, prophylactic indomethacin, and mean sample timing. Although refractory hypotensive newborns were more immature, were smaller, suffered more deaths after 48 h of life and had a higher SNAPPE-2 score, their cortisol and 17-alpha-OH-progesterone levels were not different from controls at 12 h and at 36 h. The increase of cortisol in newborns with refractory hypotension 36 h after birth was significantly higher than in controls. Despite the fact that refractory hypotensive very low-birth weight neonates were submitted to a very stressful condition, their cortisol and 17-alpha-OH-progesterone levels were similar to controls.

Incidence and risk factors for retinopathy of prematurity in very low and in extremely low birth weight infants in a unit-based approach in southern Brazil

AIMS

To analyse the incidence and risk factors for retinopathy of prematurity (ROP) and survival rates among extremely low birth weight (ELBW) and very low birth weight (VLBW) preterm infants.

METHODS

A prospective cohort study of 352 infants admitted at a teaching hospital, Hospital de Clinicas de Porto Alegre, Brazil, between October 2002 and December 2006, was screened for ROP. The ELBW group comprised infants whose birth weight (BW) was < or = 1000 g and the VLBW group comprised those infants whose BW were > 1000 g and < or = 1500 g. Perinatal risk factors for ROP were assessed using univariate and multivariate analysis.

RESULTS

Of the 352 neonates screened, 88 were ELBW babies. Survival rates among ELBW and VLBW were 47.8 and 88.7%, respectively. ROP affected 48.9% of ELBW infants and 18.2% of VLBW babies. Threshold disease occurred in 21 patients, 15 of whom were born weighing < 1000 g. Only 2.3% of the neonates born with more than 1000 g developed treatable disease. Univariate analysis showed that gestational age (GA), BW, use of indomethacin and erythropoietin, blood transfusions, and intraventricular haemorrhage were associated with ROP. After logistic regression, the most important adjusted risk factors were BW (OR: 1.002;95% CI: 1.001-1.003; P=0.003), GA (OR: 1.254;95% CI: 1.082-1.455; P=0.003), and use of erythropoietin (OR: 2.486;95% CI: 1.182-5.231; P=0.016).

CONCLUSION

This study showed reduced survival rates, high incidence of ROP, and a greater need of treatment among ELBW infants as compared to VLBW babies admitted in this institution.

[Bathing and the colonization of the preterm newborn skin]

This article aims at determining the bathing role in skin colonization of preterm newborn by reviewing the literature from MEDLINE database. Clinical researches have demonstrated that bathing with soap triggers pH increase interfering with the skin physiological protection and provoking changes in the cutaneous microflora composition. Preterm neonates in NICU tend to acquire nosocomial skin flora from the action of bathing with cleansing products on the epidermal barrier function with direct consequences on the skin colonization.

Umbilical cord blood and neonatal endothelin-1 levels in preterm newborns with and without respiratory distress syndrome

Increased pulmonary vascular resistance in preterm newborn infants with respiratory distress syndrome is suggested, and endothelin-1 plays an important role in pulmonary vascular reactivity in newborns. We determined umbilical cord blood and neonatal (second sample) levels of endothelin-1 in 18 preterm newborns with respiratory distress syndrome who had no clinical or echocardiographic diagnosis of pulmonary hypertension and 22 without respiratory distress syndrome (gestational ages: 31.4 +/- 1.6 and 29.3 +/- 2.3 weeks, respectively). Umbilical cord blood and a second blood sample taken 18 to 40 h after birth were used for endothelin-1 determination by enzyme immunoassay. Median umbilical cord blood endothelin-1 levels were similar in both groups (control: 10.9 and respiratory distress syndrome: 11.4 pg/mL) and were significantly higher than in the second sample (control: 1.7 pg/mL and respiratory distress syndrome: 3.5 pg/mL, P < 0.001 for both groups). Median endothelin-1 levels in the second sample were significantly higher in children with respiratory distress syndrome than in control infants (P < 0.001). There were significant positive correlations between second sample endothelin-1 and Score for Neonatal Acute Physiology and Perinatal Extension II (r = 0.36, P = 0.02), and duration of mechanical ventilation (r = 0.64, P = 0.02). A slower decline of endothelin-1 from birth to 40 h of life was observed in newborns with respiratory distress syndrome when compared to controls. A significant correlation between neonatal endothelin-1 levels and some illness-severity signs suggests that endothelin-1 plays a role in the natural course of respiratory distress syndrome in preterm newborns.