Noise exposure is increased with neonatal helmet CPAP in comparison with conventional nasal CPAP.

BACKGROUND: in adults, noninvasive ventilation via a helmet is associated with significantly greater noise than nasal and facial masks. We hypothesized that noise exposure could be increased with neonatal helmet continuous positive airway pressure (CPAP) in comparison with conventional nasal CPAP (nCPAP). Our primary objective was to compare the noise intensity produced by a neonatal helmet CPAP and a conventional nCPAP system. Furthermore, we aimed to evaluate the effect of the gas flow rate and the presence of the humidifier and the filter on noise levels during neonatal helmet CPAP treatment. METHODS: in this bench study, noise intensity was measured in the following settings: helmet CPAP, nCPAP, incubator and the neonatal intensive care unit. In helmet CPAP, noise measurements were performed at different gas flow rates (8, 10 and 12 l/min), while in nCPAP, the flow rate was 8 l/min. For both CPAP systems, the level of pressure was maintained constant at 5 cmH(2) O. RESULTS: during neonatal helmet CPAP, the median (interquartile range) noise levels were significantly higher than those during nCPAP: 70.0 dB (69.9-70.4) vs. 62.7 dB (62.5-63.0); P<0.001. In the helmet CPAP, the noise intensities changed with increasing flow rate and with the presence of a humidifier or a filter. CONCLUSIONS: noise intensities generated by the neonatal helmet CPAP were significantly higher than those registered while using a conventional nCPAP system. In the helmet, the noise intensity depends on the gas flow rate, and the presence of a humidifier and a filter in the system.

Comparison of the effects of two resistance training regimens on muscular and bone responses in premenopausal women.

SUMMARY: A 28-week resistance training with linear periodization was compared with an undulating model in 27 premenopausal women. In both groups, bone mineral density (BMD) was not changed but muscle strength increased, and there were changes in anthropometrical and muscle damage parameters, indicating that in this population, these models are similar concerning these variables. INTRODUCTION: This study seeks to compare the effects of resistance training with undulating versus linear periodization on BMD, muscle strength, anthropometrical variables, and muscle damage parameters in premenopausal women. METHODS: Twenty-seven females (39.6 +/- 0.41 years, mean +/- standard error), without osteopenia or osteoporosis and without calcium supplementation, were randomly assigned either to a linear periodization group (LPG, n = 14) or to an undulating periodization group (UPG, n = 13). The subjects were trained three times a week for 28 weeks. Lumbar spine and femoral neck BMDs were measured through dual-energy X-ray absorptiometry. Maximal and submaximal dynamic muscle strengths were measured through the 1-RM and 20-RM tests, respectively. Anthropometrical (body mass, skinfolds, and perimeters) and muscle damage parameters were assessed through serum creatine kinase (CK) and delayed-onset muscle soreness (DOMS). RESULTS: BMD remained unchanged in both groups, despite significant increases in maximal (LPG, 37-73%; UPG, 40-70%) and submaximal (LPG, 82-114%; UPG, 70-102%) muscle strength. The perimeter of the distal thigh was increased (about 1.7 cm) in both groups. CK and DOMS were greater in the first mesocycle than in the subsequent ones. After the 1st training session in each mesocycle, 24 and 48 h CK was increased as compared to pretraining values. CONCLUSIONS: The resistance training of 28 weeks increased muscle strength in both training groups with no difference in BMD or in the occurrence of muscle damage.

Preterm premature rupture of membranes, chorioamnion inflammatory scores and neonatal respiratory outcome.

OBJECTIVE: To evaluate whether histological chorioamnionitis (HCA), in the setting of preterm premature rupture of membranes (PPROM), affects infant respiratory outcome. DESIGN: A prospective histological study on 287 consecutive placentas was performed in preterm infants (

Prospective, randomized comparison of ProSeal and Classic laryngeal mask airways in anaesthetized neonates and infants.

BACKGROUND: When compared with the Classic laryngeal mask airway (cLMA), the recently introduced ProSeal laryngeal mask airway (PLMA) has modified features to produce higher airway seal pressures and enable ventilation in circumstances where the cLMA might fail. The first neonatal size 1 PLMA recently became available. This study was designed to compare the effectiveness of the size 1 cLMA and PLMA during positive pressure ventilation in anesthetized neonates and infants. METHODS: Forty-six consecutive patients undergoing elective cardiac surgical procedures were randomized for initial airway management with the cLMA or PLMA. Insertion time (IT), number of placement attempts, ease of placement, quality of the initial airway, maximum tidal volume (TVmax), and airway pressure at which an audible leak in the mouth (P(leak)) occurred were collected. All data were recorded before performing tracheal intubations. RESULTS: IT and success rate were similar for both LMAs. The initial quality of the airway was significantly better for the PLMA (P<0.05). TVmax and P(leak) were significantly higher for PLMA (77 vs 58 ml, P<0.02 and 29.8 vs 24.4 cm H2O, P<0.02). No adverse events were recorded during the study. CONCLUSIONS: The size 1 PLMA forms a more effective seal than size 1 cLMA in neonates. This might allow the PLMA to be used in those newborn infants requiring high airway pressures for ventilation.

Reliability of hearing screening in high-risk neonates: comparative study of otoacoustic emission, automated and conventional auditory brainstem response.

OBJECTIVE: To compare the diagnostic reliability of automated transient evoked otoacoustic emissions (a-TEOAE), automated auditory brainstem response (a-ABR) and conventional brainstem auditory evoked potential (BAEP/ABR) for identification of hearing loss in high-risk neonates. METHODS: Two hundred and six neonatal intensive care unit (NICU) admitted neonates were tested pre-discharge. Follow-up included a-TEOAE in all children, repetition of a-ABR or BAEP if failed in NICU. Sensitivity and specificity were compared and correlated with auditory risk factors. RESULTS: BAEP had the highest sensitivity (100%) and specificity (90.8%), a-ABR the lowest (88.9% and 70.6%). A statistically significant difference in risk factors for temporary hearing loss was observed between normal and false positive a-TEOAE and BAEP, but not a-ABR outcome. Differences in specificity between a-ABR and a-TEOAE explain the pattern of "absent a-ABR/present a-TEOAE" in 13.8% of ears. CONCLUSIONS: The BAEP appears the more reliable test for hearing screening of high-risk neonates because of highest sensitivity and specificity and should be used to confirm the diagnosis of "auditory neuropathy" in high-risk neonates. The reliability of a-ABR devices in critically ill neonates needs further investigation. SIGNIFICANCE: This is, to our knowledge, the first attempt to compare the diagnostic reliability of a-TEOAE, a-ABR and BAEP in high-risk neonates.

The size 1 LMA-ProSeal: Comparison with the LMA-Classic during pressure controlled ventilation in a neonatal intubation manikin.

BACKGROUND: The classic laryngeal mask airway (cLMA) has been demonstrated to be effective for airway management during neonatal resuscitation. However, high airway pressures, when required, cannot be achieved with this device. A neonatal prototype of the LMA-ProSeal (PLMA), which might improve the oropharyngeal leak pressure, has recently been produced. The airway sealing pressures of the cLMA and the PLMA were compared in a neonatal manikin. METHODS: A neonatal PLMA and a neonatal cLMA were positioned at random in a neonatal intubation manikin (Neonate Airway Trainer; Laerdal, Norway). A Dräeger pressure controlled ventilator (Dräeger 8000; Dräegerwerk AG, Germany) was connected to the airway tubes and increasing inspiratory pressures (from 10 to 40 cm H2O) of positive pressure ventilation applied. The peak and the mean airway pressures obtained with each device were recorded. RESULTS: The airway pressures obtained with PLMA were significantly higher than those obtained with cLMA (p < 0.01) at levels of positive pressure ventilation of 25, 30, 35 and 40 cm H2O. CONCLUSIONS: The neonatal PLMA allows higher airway pressure ventilation than the cLMA, in a neonatal intubation manikin. If confirmed clinically, this may have important implications during neonatal resuscitation when high airway pressures are required.

Neonatal resuscitation of extremely low birthweight infants: a survey of practice in Italy.

Delivery room management of extremely low birthweight infants (ELBWIs) has been little studied. A questionnaire was sent to the heads of the 86 Italian neonatal intensive care units provided with on site delivery. The practice of and approach to the resuscitation of ELBWIs were very different among the centres surveyed, reflecting a paucity of evidence and consequent uncertainty among clinicians.

Potential risk factors for the development of acute renal failure in preterm newborn infants: a case-control study.

AIMS: To determine in a case-control study possible associations between the development of acute renal failure in preterm newborns and therapeutic interventions, particularly drug treatments. METHODS: The study population was 172 preterm infants of <38 weeks gestation; 71 had acute renal failure and 101 were controls closely matched for gestational age and birth weight. Maternal and neonatal information was collected for both groups through questionnaires and interviews. Routine data on renal variables were also collected. Univariate and multivariate logistic regression analyses were performed. RESULTS: Very low birthweight infants were at high risk of acute renal failure (79% of cases were <1500 g). However, the acute renal failure was transient. Mothers of infants with acute renal failure received more drugs during pregnancy and delivery (mainly antibiotics and non-steroidal anti-inflammatory drugs). Of the possible therapeutic interventions, intubation, catheterisation, and phototherapy were mainly applied to case subjects. A low Apgar score and patent ductus arteriosus were diagnosed in a greater percentage of neonates with acute renal failure. Moreover, in the first few days of life and before diagnosis of acute renal failure, case subjects received more drugs (antibiotics, non-steroidal anti-inflammatory drugs, and diuretics) and for a longer time. In the multivariate logistic analysis, medullary hyperechogenicity (odds ratio (OR) 4.491; 95% confidence interval (CI) 1.879 to 10.731) and ceftazidime administration (OR 5.082; 95% CI 1.493 to 17.297) were associated with a greater risk of acute renal failure. CONCLUSIONS: The results suggest the need for careful monitoring of very low birthweight infants and attention to drug treatments, as it is difficult to differentiate between normality and renal failure in the first few days of life.

Intrauterine growth and adipose tissue development.

Body fat mass (BFM), skinfold thickness (ST), and fat cell weight (FCW) have been studied in 86 newborn infants with different maturity and different intrauterine growth, and in parabiotic twins. Preterm infants (35.5 +/- 0.4 wk) with body weight appropriate for gestational age had lower values of BFM and sum of ST as compared to the control group, without differences in FCW (0.23 +/- 0.03 versus 0.22 +/- 0.02 micrograms). In infants born between 30 and 41 wk of gestation with body weights at birth appropriate for gestational age, ST and BFM progressively increase with gestational age, while the FCW remains constant. These observations suggest that fat mass growth in the last 2 months of fetal life, essentially depends on fat cell replication. In full-term large-for-date babies, bFM resulted significantly greater than in controls both in absolute values (p less than 0.001) and in percentage values of total body weight (p less than 0.001). The FCW in large for date newborns resulted significantly greater than in controls (0.50 +/- 0.06 versus 0.22 +/- 0.2 micrograms, p less than 0.001). In full-term small-for-date newborns BFM, ST, and FCW resulted significantly lower than in controls (p less than 0.001). In full-term newborns with different body weight at birth, fat cell weight was correlated to BFM (r = 0.67; p less than 0.01), to BFM as percentage of body weight (r = 0.67; p less than 0.001) and to ST (r = 0.73; p less than 0.001). In three couples of identical parabiotic twins, the larger baby of every pair showed even greater values of BFM, ST, and FCW and fat cell weight than the respective sibling. These observations suggest that in newborns with different intrauterine growth, a different triglyceride content in single adipocytes largely explains the variations in fat mass development.

Effect of various phototherapy regimens on bilirubin decrement.

Continuous phototherapy in full-term newborns was found to be more effective than intermittent illumination. Treatment efficacy was also related to age and the initial bilirubin level of the infants. In fact, the reported data indicate an increased therapeutic effect in newborns affected with nonhemolytic hyperbilirubinemia who had an initial bilirubin level greater than 15 mg/dl as compared to neonates with an initial bilirubin level less than 15 mg/dl. The light treatment was also more effective in infants older than 3 days, possibly because of an increased ligandin and conjugating capacity. Shielding the hepatic area during illumination significantly decreases the efficiency of this treatment, suggesting that the liver could also be a phototherapeutic action site.

Postnatal development of adipose tissue in normal children on strictly controlled calorie intake.

The relations between adipose tissue development at birth, later expansion of fat mass and the behavior of fat mass and fat cell growth from birth to 12 mo of age have been studied in normal children born to normal, obese or diabetic mothers and maintained on strictly controlled calorie intake. A simple method for fat cell size determination on microsamples of fat tissue, specifically designed for small children, is reported. In the first 3 mo of life, a marked increase of fatty tissue from 13.4 +/- 0.4 to 20.3 +/- 0.8 percent of total body mass was observed. Subsequently, a sharp decrease in the relative amount of fat mass occurs, probably related to an increased energy expenditure or to a slightly higher protein content in the diet. No sex related differences in body weight, body fat mass, sum of skinfold thickness or fat cell weight were found throughout the study. No significant differences in body fat mass, sum of skinfold thickness and body fat mass as percent of body weight was observed at birth and at 3 or 6 mo of age in children of obese or gestational diabetic mothers, in comparison with children of normal mothers, and no significant correlation was found between maternal adiposity (sum of skinfold thickness or pre-gravidic overweight) or glucose tolerance (blood glucose area after OGTT) and adipose tissue development in the first 6 mo of life. Thus, in children on strictly controlled intake, obesity or diabetes in the mother do not relate to the rate of fat accumulation. Moreover, no relations were found between adipose tissue development at birth and subsequent rate of fat enlargement in the first year of life. Thus, when the interference of a different calorie intake is excluded, adiposity at birth has no predictive value for possible fatness later in infancy.

Lysosomal enzymes in preterm infants with bronchopulmonary dysplasia: a potential diagnostic marker.

Some lysosomal glycohydrolases (N-acetyl-beta-D-glucosaminidase and their major isoenzymes, beta-D-glucuronidase, alpha-D-galactosidase, beta-D-galactosidase and alpha-D-glucosidase) were investigated in the plasma of 36 preterm infants with respiratory distress, 11 of whom developed bronchopulmonary dysplasia (BPD), in order to evaluate the role of the lysosomal apparatus in the disease. Enzyme activity was assayed fluorimetrically; the major N-acetyl-beta-D-glucosaminidase (NAG) isoenzymes were separated using a routine chromatofocusing procedure; the diagnostic efficiency was evaluated by Bayes theorem. The mean levels of almost all glycohydrolases considered were significantly higher in BPD than in non-BPD infants. Among NAG major isoenzymes, an increase was found only in form A. No variation was evident in the plasma levels of glycohydrolases during dexamethasone therapy. Data from a retrospective analysis performed in all preterms considered, show that alpha-D-galactosidase and beta-D-galactosidase differentiate a posteriori BPD and non-BPD subjects. These enzymes, after a priori verification of their diagnostic potential in preterm infants at risk of BPD development, could acquire an important predictive value.

Enzymes of lysosomal origin in plasma of twin neonates.

The levels of some enzymes of lysosomal origin were assayed during days 2 and 5 of life in plasma from 11 sets of twin neonates and from 25 neonates from single pregnancies (13 of weight appropriate for gestational age and 12 small for their gestational age) as controls. The plasma enzyme levels were also determined in the correspondent twin and control mothers 2 days after delivery. N-Acetyl-beta-D-glucosaminidase isoenzymes were assayed after chromatofocusing separation. All the plasma enzyme levels were higher in the group of twin neonates and of their mothers than in the respective control groups with differences highly statistically significant for two enzymes, beta-D-galactosidase and alpha-D-glucosidase. In neonate plasma lysosomal enzymes are increased at the fifth day of life with respect to the second day. Full term control neonates showed the same enzyme trend. For the N-acetyl-beta-D-glucosaminidase the more significant differences concerned the isoenzyme I2-P (pregnancy). The pattern of the lysosomal enzymes in the twins resembled that of neonates of diabetic mothers who had had no insulin therapy. Since lysosomal enzymes are considered to be particularly sensitive indicators of carbohydrate metabolism abnormalities, we conclude that twin pregnancies are more at risk for these abnormalities than single ones.

The laryngeal mask airway: potential applications in neonates.

The laryngeal mask airway is a safe and reliable airway management device. This review describes the insertion techniques, advantages, limitations, and potential applications of the laryngeal mask airway in neonates.

Home oxygen therapy in infants with bronchopulmonary dysplasia: assessment of parental anxiety.

BACKGROUND: It is conceivable that a complicated recovery course in a high-risk premature infant managed at home generates apprehension and anxiety in parents. AIMS: We attempted to define the evolution of anxiety levels in a population of parents of low-birth-weight premature infants with bronchopulmonary dysplasia enrolled in a prospective home O(2) therapy program. STUDY DESIGN: In the immediate pre-discharge [mean postnatal age 95 (45-158) days], a questionnaire (State-Trait Anxiety Inventory form Y) was given to all parents of the premature infants [mean birth weight 1106 (0.610-1.770) kg; mean gestational age 27.1 (24-31) weeks] present for the discharge. Subsequently, the parents were assessed twice, initially after a week from the discharge of their infants and then at the end of the oxygen therapy phase [mean postnatal age 185 (60-361) days]. They included 10 mothers and 10 fathers, aged 33.5+/-0.5 and 37+/-0.2 years, respectively. RESULTS: Our results indicate that these parents present an increased state anxiety level upon hospital discharge of their oxygen-dependent premature infants, which decreases as the improvement of respiratory status and the cessation of oxygen-dependency become evident [mean+/-S.D. related to age (T) maternal values 47.1+/-7.0, 41.8+/-5.6, 39.1+/-4.7, respectively; mean+/-S.D. related to age (T) paternal values 42.2+/-8.5, 41.1+/-8.1, 40.5+/-8.2, respectively]. When assessed separately by parental gender, in the maternal group, state anxiety decreased significantly (ANOVA, p<0.05). CONCLUSIONS: These data indicate that although neonatologists generally define the discharge of prematures with chronic lung disease based upon the acquired stabilization of vital parameters, in the oxygen-dependent group, they should also pay special attention to the emotional support of the parents who we have identified as being at increased risk for pre-discharge anxiety.

[High-frequency ventilation in the newborn infant]. / La ventilazione ad alta frequenza nel neonato.

High-frequency ventilation (HFV), currently under investigation in three categories: high-frequency positive pressure ventilation (HFPPV), high-frequency jet ventilation (HFJV), and high-frequency oscillation (HFO), is a new form of mechanical ventilation that employs small tidal volumes in relation to dead space and extremely rapid rates, ranging from 1 to 40 Hz. It has a number of theoretical advantages when compared with current methods of conventional ventilation, and provides adequate gas exchange using minimal proximal airway pressure with little circulatory interference. Reports of successful application of the principles of the HFV in the treatment of infants with respiratory distress syndrome and particularly those with severe interstitial emphysema have raised hopes that this technique might prevent barotrauma to the lungs and have stimulated physicians and engineers to develop new equipment that might be useful in ventilating small infants. Approximately 80 infants are known to have been treated with HFV, mostly for short periods of time. In some with pulmonary interstitial emphysema, the only means of ventilating the infant have been with HFV. There is evidence that the technique can produce adequate gas exchange in infants, primarily when employed for a short period of time. As more knowledge is gained about the etiology of chronic neonatal lung disorders and as the questions of serious adverse effects of HFV are answered, it seems likely that a controlled, randomized, clinical trial might be needed in the future to determine whether HFV can decrease the incidence of complications such as air leak, lessen the morbidity, shorten the duration of dependency on the ventilator, and decrease the requirement for oxygen.

[Hypoxic-ischemic brain damage in the newborn]. / Il danno ipossico-ischemico cerebrale nel neonato.

The condition referred to as "birth asphyxia" occurs as the result of a hypoxic-ischaemic insult during the process of labour and delivery. There is no standard clinical definition for birth asphyxia, but its incidence in term infants has been differently reported to be between 2.9 and 9.0 cases per 1000 deliveries. In term infants the risk of death appeared to be closely related to the duration that the Apgar score is severely depressed. The best predictor of disability in surviving infants is abnormal neurological behavior in the neonatal period referred to as hypoxic-ischaemic encephalopathy. Unfortunately, there are no generally accepted treatment regimens for birth asphyxia and traditional methods for treating hypoxic-ischaemic encephalopathy have not been shown to improve outcome.

[Follow-up of children in obstetrical clinical trials: research experience in Italy]. / Il follow-up dei bambini nei trial clinici ostetrici: esperienze di ricerca in Italia.

The effectiveness of treatments for the mother exposed to adverse events in pregnancy is not always interpreted in the light of possible effects on the child. The follow-up of infants is an important component of obstetric and perinatal audit not only in randomised clinical trials but as part of routine health care. The results of the 18 month's follow-up of children born from women recruited in the Italian Study of Aspirin in Pregnancy and in the Italian Trial on Nifedipine in Pregnancy are discussed. No significant differences emerged between treatment and no-treatment groups with respect to indicators of development and health status. Malformations, diseases, and other health problems showed no specific patterns and were much the same in the groups. Our findings suggest that the use of low-dose aspirin and calcium channel blocker nifedipine in pregnancy is safe with respect to the risks of malformation and of major impairment in development at 18 months of age.

[Urinary tract infections in newborns: sensitivity, specificity, and predictive value of urinary screening with the reagent strip test]. / Le infezioni delle vie urinarie nel neonato: sensibilità, specificità e valore predittivo dello screening urinario con striscia reattiva.

Important considerations in evaluating newborn urine examinations by dip-stick method are: ease of performance, the volume of the specimen required for test, the time required to perform the test and the cost. In considering the dip-stick test for the early diagnosis of Urinary Tract Infections (U.T.I.), it has never been tested with later follow-up to evaluate its sensitivity and specificity, also in regard to reduce the risk of further complications for urinary tract and kidney.

[Epidemiology of identical twin pregnancy]. / Epidemiologia della gravidanza gemellare.

On the basis of MEDLINE and manual search, we looked at the main papers in English literature published from 1976, regarding risk factors for spontaneous (i.e. not related to fertility drug use) multiple births. The constant frequency of monozygotic (MZ) pregnancies over time and in different geographic areas suggests that determinants of MZ twins are largely unchanged over time and that genetic mechanism may act a role. On the contrary, temporal and geographic trends observed in dizygotic (DZ) pregnancies suggest that environmental factors play a role in determining this condition. At present maternal age and hereditary components are the better defined determinants for spontaneous multiple births.