Cesarean section increases the risk of respiratory adaptive disorders in healthy late preterm and two groups of mature newborns.

The rates of delivery by Cesarean section (CS) have been trending upwards in recent decades, perhaps leading to higher rates of dysfunction in respiratory adaptation in newborns. We present epidemiological data for pulmonary adaptation by mode of delivery for healthy late preterm and term infants born at a regional tertiary care center. The overall CS rate was 22% with the largest proportion of these in late preterms (39%). This drops to 30% in infants born after 37 weeks gestation and to 11% for those born after 40 weeks. Infants needing respiratory support decreased significantly as gestational age increased: 88% at 34 weeks, 67% at 35 weeks, 28% at 36 weeks, 17% at 37 weeks and 8% at 40 weeks. The risk of respiratory morbidity following CS as compared to vaginal delivery (VD) was substantially higher. 50% of infants born by CS needed respiratory support compared to only 12% following VD. 82% of all late preterm infants born by CS developed respiratory morbidity compared to 36% following VD. Comparable data for infants born after 37 and 40 weeks gestation were 33% compared to 9% and 26% compared to 6% respectively. Late preterm infants born after 36 weeks gestation showed the most marked difference by mode of birth with 66% needing respiratory support following CS as compared to only 9% following VD. Our data could be useful in counselling parents about risk associated with delivery by Cesarean section. A critical view should be taken of increasing CS rates worldwide because of a clear correlation in increased morbidity in infants, especially late preterm infants.

Influence of smoking and alcohol during pregnancy on outcome of VLBW infants.

BACKGROUND: Nicotine and alcohol consumption have been associated with premature delivery and adverse neonatal outcome. We wanted to analyze the influence of self-reported nicotine and alcohol consumption on outcome of VLBW infants. MATERIAL AND METHODS: In an ongoing multicenter study 2475 parents of former very low birth weight (VLBW) infants born between January 2009 and December 2011 answered questionnaires about maternal smoking habits and alcohol consumption during pregnancy. 2463 (99.5%) completed questions on alcohol consumption and 2462 (99.5%) on smoking habits. These infants were stratified to reported maternal smoking and alcohol consumption during pregnancy. We compared the reasons for premature delivery, neonatal outcome and parental reports on bronchitis during the first year of life, as well as growth and development at age 2 years to pregnancy exposure. RESULTS: In nicotine exposed infants intrauterine growth restriction (31 vs. 21%, p<0.01), a birth weight below the 10th percentile (26 vs. 17%, p<0.01) and placenta abruption (9.2 vs. 5.8%, p<0.05) was seen more often. Premature rupture of membranes (24 vs. 30%, p<0.05) or HELLP syndrome (6 vs. 11%, p<0.01) was less frequent. A birth weight below the 3rd percentile was seen more frequently in mothers with reported alcohol consumption (13 vs. 6%, p<0.05). We noted an increased rate of BPD and ROP if mothers reported smoking during pregnancy (p<0.05). Growth parameters and scores on Bayley Sscales of infant development at age 2 years did not differ. CONCLUSION: Smoking during pregnancy results in a high rate of growth restricted VLBW infants. Prenatal exposition to nicotine seems to increase postnatal complications such as BPD und ROP.

[Prediction of extubation failure in ELBW preterm infants]. / Prädiktion von Extubationsversagen bei ELBW-Frühgeborenen.

BACKGROUND: The accurately timed extubation of ventilated ELBW preterm infants is still a problem. With different data systems the attempt has been made to more accurately predict the successful extubation of these infants. However, there do not yet exist any satisfying solutions. PATIENTS/METHODS: We retrospectively analysed 66 ELBW preterm infants who were endotracheal intubated and ventilated within 24 h postnatal. Basic data, clinical and ventilation data immediately before planned extubation and in several intervals during the following 24 h, as well as outcome variables at discharge were interpreted. RESULTS: 51 patients were successfully extubated (EE-group), 15 (22.7%) failed extubation (reintubation within 48 h after extubation, EV-group). Immediately before extubation in the EE-group there was found a significantly higher inspiratory oxygen concentration (FiO2) in comparison to the EV-group (0.25 vs. 0.3; p=0.01). After the extubation attempt the inspiratory oxygen concentration stayed lower in the EE-group, whereas in the EV-group it rose remarkably (2 h after ext.: 0.26 vs. 0.4; p<0.001). Neither of the basic data showed any significant difference. The outcome analysis indicated a longer intensive care in the EV-group and a trend towards increased BPD and ROP. CONCLUSION: The study shows that for ELBW preterm infants the inspiratory oxygen concentration is especially important to predict a successful extubation. According to our data, the inspiratory oxygen demand before and immediately after extubation establishes the essential difference between successfully extubated and reintubated infants.

[Enteral feeding volume advancement by using a standardized nutritional regimen in preterm infants ≤1,750 g birth weight: a controlled randomized trial]. / Standardisierte Ernährung zum enteralen Nahrungsaufbau für Frühgeborene mit einem Geburtsgewicht ≤1,750 g - kontrollierte randomisierte Studie.

BACKGROUND: Rapid enteral feeding volume advancement in preterm infants can reduce the use of intravenous fluids. This practice may decrease the hazards of intravenous infusion solutions and potentially the morbidity rate. Several cohort trials demand the standardised nutritional regimen to reduce the complications and the time to reach full enteral feeds. AIM: to determine whether using a standardized nutritional regimen the rapid enteral feeding advancement in preterm infants is practicable without increasing the incidence of feeding complications. PATIENTS AND METHODS: A prospective, randomized, controlled trial was performed in 99 preterm infants, birth weight ≤1,750 g. Group ST (standardized nutritional regimen) received breast human milk according to a standardized nutritional regimen. Group IN (individual nutritional regimen) received breast human milk or semi-elemental nutrition (Pregomin(®) Milupa) depending on enteral problems of the infant. The feeding volume advancement in the IN-Group was decided individually. The main outcome measure was time to reach full enteral feedings. RESULTS: Infants in the ST-Group achieved full enteral feedings after 14.93±9.95 (median 12) d, infants in the IN-Group after 16.23±10.86 (median 14) d. The difference between the groups was significant only in small for gestational age (SGA) infants: ST-Group 10.20±4.78 (median 8.5) vs. IN-Group 16.73±8.57 (Median 15) days (p=0.045). The weight gain was similar in both groups. Infants in ST-Group achieved full enteral feedings having 116% of birth weight, infants in IN-Group 122% of birth weight. This difference was not significant (p=0.195). The incidence of NEC (necrotizing enterocolitis, 4%) and other complications were low in both groups. The diagnosis "feeding complications" was described in IN-Group in 14 vs. 7 infants in ST-Group. CONCLUSIONS: SGA-infants profit from the enteral feeding advancement by using a standardized nutritional regimen. These infants achieved full enteral feedings sooner then the SGA-infants, who did not feed by using a standardized nutritional regimen. A standardized nutritional regimen can be realized in clinical routine and is by strict clinical observation practicable without increasing the incidence of feeding complications.

Surfactant without intubation in preterm infants with respiratory distress: first multi-center data.

BACKGROUND: Recently in a report of a single center a method has been described to apply surfactant via a thin endotracheal catheter to very low birth weight infants spontaneously breathing with nasal continuous positive airway pressure. We now analyzed available multicenter data. PATIENTS AND METHODS: In a multicenter study investigating genetic risk factors, clinical and outcome data and data of antenatal and postnatal treatment of infants with a birth weight below 1,500 g were prospectively recorded. The measures of infants treated with the new method of surfactant application were compared to those of infants who received standard care. The analysis was restricted to infants with a gestational age below 31 weeks (n=1,541). RESULTS: 319 infants were treated with the new method and 1,222 with standard care. The need for mechanical ventilation during the first 72 h (29% vs. 53%, p<0.001), the rate of bronchopulmonary dysplasia defined as oxygen at 36 weeks of postmenstrual age (10.9 % vs. 17.5%, p=0.004) and the rate of death or bronchopulmonary dysplasia were significantly lower in the treatment group than in the standard care group. Surfactant, theophyllin, caffeine and doxapram were significantly more often and analgetics, catecholamines and dexamethasone were significantly less frequently used in the treatment group. CONCLUSIONS: A new method of surfactant application was associated with a lower prevalence of mechanical ventilation and better pulmonary outcome. A prospective controlled trial is required to determine whether this approach is superior to standard care.

Perfluorooctane sulphonate (PFOS) and perfluorooctanoic acid (PFOA) in human breast milk: results of a pilot study.

Perfluorinated compounds (PFC) are a large group of chemicals produced for several decades and widely used for many industrial and consumer applications. Because of their global occurrence in different environmental media, their persistence and their potential to bioaccumulate in organisms they are of toxicological and public concern. In the present study, perfluorooctane sulphonate (PFOS) and perfluorooctanoic acid (PFOA) were quantified in 70 breast milk samples. Samples were obtained from Leipzig, Germany (38 archived samples), Munich, Germany (19 fresh samples) and Gyor, Hungary (13 frozen samples). PFOS could be quantified in all 70 samples. The concentration in samples from Germany ranged between 28 and 309 ng/l (median: 119 ng/l). Samples from Hungary showed significantly higher PFOS concentrations (median 330 ng/l, range 96-639 ng/l). In only 11 of 70 samples (16%) PFOA reached the LOQ (200 ng/l); values ranged from 201 to 460 ng/l. If only those samples with PFOA values above the LOQ were considered, we found a significant correlation between the PFOS and PFOA concentrations (r=0.75, p=0.008). Based on the results of the German sample, we estimated an intake of 0.10 microg PFOS/day (using median) or 0.27 PFOS microg/day (using maximum value) via breast milk for an infant of 5 kg bodyweight. Our data suggest that fully breastfed infants are unlikely to exceed the recommended tolerable daily intake of PFC. However, more target-oriented studies are needed to identify the amount and time-trend of PFOS and PFOA in maternal blood during pregnancy, after delivery, as well as in the growing infant and in its diet (e.g., breast milk and formula).

The role of elevated central-peripheral temperature difference in early detection of late-onset sepsis in preterm infants.

AIMS: The study investigated the association between clinical symptoms and late-onset sepsis (LOS) in preterm infants with the aim of identifying a non-invasive tool for the early detection of LOS. METHODS: This was a prospective study of 83 episodes of suspected LOS in 67 preterm infants. At the time LOS was suspected, we recorded a standardized set of clinical symptoms. A diagnosis of "clinical LOS" (Clin-LOS), "culture-proven LOS" (Prov-LOS) or "LOS not present" (No-LOS) was made on the basis of C-reactive protein (CrP) and blood culture results where Clin-LOS was defined as CrP>10mg/l, Prov-LOS was defined as CrP>10mg/l AND positive blood cultures, or it was established that there was no sepsis present (No-LOS). We examined univariable associations between clinical signs and LOS using odds ratio (OR) analysis and then adjusted the odds ratio (adOR) through binary regression analysis. RESULTS: Clin-LOS was diagnosed in 20/83 episodes, 19 cases were found to have Prov-LOS. Clinical signs which had a significant association with Clin-LOS were capillary refill time >2s (OR 2.9) and decreased responsiveness (OR 5.2), whereas there was a negative association between gastric residuals and LOS (OR 0.35). However, the most marked association was found for a greater central-peripheral temperature difference (cpTD) >2°C (OR 9). In Prov-LOS an increased heart rate (OR 3.1), prolonged capillary refill time (OR 3.3) and again an increased cpTD (OR 16) had a significant association with LOS, whereas gastric residuals were negatively associated (OR 0.29). Regression analysis showed that cpTD was the most striking clinical sign associated with both Clin- (adOR 6.3) and Prov-LOS (adOR 10.5). CONCLUSIONS: Prolonged capillary refill time and - more impressive - elevated cpTD were the most useful clinical symptoms for detection of LOS in preterm infants. We especially suggest using cpTD as a predictor of LOS. It is a cheap, non-invasive and readily available tool for daily routines.

Males located caudally in the uterus affect sexual behavior of male rats in adulthood.

It has been suggested that the sexual differentiation of female rats is affected by androgens from male fetuses in the uterine horn (intra-uterine position phenomenon). Effects of adjacent males, as well as of males located caudally in the uterus have been reported. The present study investigated whether male rats, like females, are affected by the presence of either caudal or adjacent male littermates. When tested in adulthood for sexual behavior, males that had male fetuses located caudally in the uterine horn showed shorter latencies to the first mount or intromission and shorter latencies to ejaculation, and exhibited more mounts and intromissions per minute than males that lacked caudal male siblings in the uterus. The presence of adjacent males did not significantly affect the parameters studied in this experiment.

The biophysical profile: antepartal assessment of fetal well-being.

The assessment of fetal well-being is a primary consideration for perinatal nurses. The biophysical profile is a clinical evaluation of the status of the fetus based on assessment of multiple discrete variables. This article describes current biophysical profile scoring systems, the physiologic basis of the fetal variables, and factors that may affect the variables. It also discusses issues related to future applications and refinement of the biophysical profile, as well as nursing implications of the technology.

A nurse-managed smoking cessation intervention during pregnancy.

OBJECTIVE: To evaluate the effectiveness of a nurse-managed smoking cessation intervention in an outpatient setting among pregnant women who smoked. DESIGN: Prospective; control group participants' cessation rates were assessed 6-12 weeks after clinic contact. They were compared to cessation rates for subsequent intervention participants 6-12 weeks after receiving a nurse-managed smoking cessation intervention. SETTING/PARTICIPANTS: One hundred seventy-eight women who were daily smokers, during their first visit after confirmation of pregnancy at a teaching hospital prenatal clinic. INTERVENTION: Fifteen-minute individualized intervention delivered by an advanced-practice nurse, combined with a telephone contact by an advanced-practice nurse 7-10 days after the clinic visit. MAIN OUTCOME MEASURES: Self-report of smoking, confirmed by saliva cotinine. RESULTS: Intervention group participants had a self-reported abstinence rate of 19% compared with 0% among control group participants. The cotinine-validated abstinence rate for the intervention group was 15.5%, compared with 0% in the control group. African Americans were more likely to quit, compared with white participants who received the intervention. CONCLUSION: A nurse-managed intervention combined with a telephone contact may be an effective strategy for intervening with pregnant smokers, especially African Americans.

Changes in regional tissue oxygenation saturation and desaturations after red blood cell transfusion in preterm infants.

OBJECTIVE: The study investigated the ability of near-infrared spectroscopy (NIRS) to detect subgroups of preterm infants who benefit most from red blood cell (RBC) transfusion in regard to cerebral/renal tissue oxygenation (i) and the number of general oxygen desaturation below 80% (SaO(2) <80%) (ii). STUDY DESIGN: Cerebral regional (crSO(2)) and peripheral regional (prSO(2)) NIRS parameters were recorded before, during, immediately after and 24 h after transfusion in 76 infants. Simultaneously, SaO(2) <80% were recorded by pulse oximetry. To answer the basic question of the study, all preterm infants were divided into two subgroups according to their pretransfusion crSO(2) values (<55% and ≥55%). This cutoff was determined by a k-means clustering analysis. RESULT: crSO(2) and prSO(2) increased significantly in the whole study population. A stronger increase (P<0.0005) of both was found in the subgroup with pretransfusion crSO(2) values <55%. Regarding the whole population, a significant decrease (P<0.05) of episodes with SaO(2) <80% was observed. The subgroup with crSO(2) baselines <55% had significant (P<0.05) more episodes with SaO(2) <80% before transfusion. During and after transfusion, the frequency of episodes with SaO(2) <80% decreased more in this group compared with the group with crSO(2) baselines ≥55%. CONCLUSION: NIRS measurement is a simple, non-invasive method to monitor regional tissue oxygenation and the efficacy of RBC transfusion. Infants with low initial NIRS values benefited most from blood transfusions regarding SaO(2) <80%, which may be important for their general outcome.

[Use of herbal medicine in German children - prevalence, indications and motivation]. / Phytotherapie in der Kinderheilkunde - Prävalenz, Indikationen und Motivation.

BACKGROUND AND OBJECTIVES: Herbal medicine (phytotherapy) is increasingly used by the German population. But its use for children has been rarely analysed. This study determined prevalence, motivations and indications for the use of herbal medicine use. It also investigated parent-related variables associated with its use. METHODS: An anonymized questionnaire was filled in by parents of children and adolescents who attended the general pediatric out-patient department of two German university children's hospitals and the practice of two general pediatricians. RESULTS: 413 of 600 parents (68.8%) completed the questionnaire. Mean age of the children was 6.7 +/- 4.7 years. 353 (85.5%) were given one or more herbal products, chamomile (85.5%), fennel (81.3%), eucalyptus (43.9%). Bronchipret 43.1%) (thyme and primrose [tablets] or thyme with ivy [syrup] and Prospan (43.1%) (a syrup of ivy leaf extract) were the most commonly used, in the treatment of cough. Parents who give phytotherapeuticals to their children were significantly more often women, living in a large city, of good education and financially better off (p< 0.05). CONCLUSION: Herbal medicine is widely used in Germany during childhood and adolescence. To achieve high therapeutic safety it is important to ask parents explicitly about such use.

Polymorphisms in the Renin-Angiotensin system and outcome of very-low-birthweight infants.

BACKGROUND: The insertion/deletion polymorphism of the angiotensin-converting enzyme (ACE-ins/del) and the angiotensin II type 1 receptor 1166A/C polymorphism (ATR1166A/C) were reported to be associated with several unfavorable outcome parameters in preterm infants like bronchopulmonary dysplasia, persistent ductus arteriosus and impaired insulin sensitivity. OBJECTIVE: To confirm the above-mentioned associations in a large cohort of very-low-birthweight (VLBW) infants. METHOD: Clinical data of VLBW infants were prospectively recorded. The ACE-ins/del polymorphism and the ATR1166A/C polymorphism were determined by polymerase chain reaction in 1,209 and 1,168 infants, respectively. RESULTS: There was no significant association between ACE-ins/del or ATR1166A/C genotype and outcome parameters (death, intraventricular hemorrhage, sepsis, bronchopulmonary dysplasia, ventilation, supplemental oxygen at discharge, postnatal treatment with insulin, surgery for intestinal perforation/necrotizing enterocolitis/retinopathy of prematurity/persistent ductus arteriosus. CONCLUSION: Both known functional polymorphisms of the renin-angiotensin system do not seem to be associated with the outcome of VLBW infants.

Analgosedation with low-dose morphine for preterm infants with CPAP: risks and benefits.

BACKGROUND: CPAP is widely used in preterm infants on NICUs but it poses a stressful stimulus to the patient, sometimes requiring the use of analgosedative drugs. AIM: The aim of this study is to evaluate the risks and benefits associated with the use of low-dose morphine in preterm infants with CPAP, especially apnea. METHODS: Sixty-four CPAP-treated preterm infants, who received a low single dose of morphine (recommended 0.01 mg/kg), were included in this prospective study. Observation-time was 4 h prior to injection, directly before injecting, until 15 min and 15-30 min, 30 min-1 h, 1-2 h, 2-3 h, 3-4 h, 4-5 h and 5-6 h after injection. For all observation periods incidence of apnea, heart rate, respiratory rate and a score for analgesia and for sedation were recorded. RESULTS: Sixty-four preterm infants (29.6+/-3.3 weeks gestational age (GA), birth weight 1401+/-735 g) received 0.025+/-0.012 mg/kg morphine i.v. on the day 10-13 of life. The decrease in heart and respiratory rate, scores for analgesia and sedation were significant. The overall incidence of apnea did not increase compared to the 4 h pre-morphine period. Six patients (9.3%) experienced considerable delayed apnea. This group was significantly younger in GA (p<0.001) and lighter in birth weight (p=0.002). CONCLUSION: Morphine in dosage less than half of recommended dosage has a high analgetic and sedative potential. The danger of delayed severe apnea has to be taken into consideration in the clinical situation, especially in patients<28 weeks.

[Contribution to aetiology by the primary pulmonary sarcoma in comparison to the pulmonary carcinoma (author's transl)]. / Zur Atiologie des primären Lungensarkoms in Gegenüberstellung zum Lungenkarzinom.

On 41 primary pulmonary sarcomas in the years 1957 till 1974 and on 192 pulmonary carcinomas in the year 1969 cancerogene noxes and endogene factors were analysed, compared and discussed with literature. Smoking of cigarettes, chronic bronchitis and radioactive radiation at underground mining are also significantly accumulated in our study and are recognized as cancerogenes. There is no correlation between pulmonary sarcomas and these exogene factors. The constant frequency in the last decades, the non-existing sex disposition, the ten till fifteen years lower sarcoma manifestation with a continuous increase already in the second decade of life and the protected position of the mesenchyme do not suggest a causal connexion between exogene cancerogene influence and pulmonary sarcoma formation. Rather make us suppose an endogene tumour disposition. Pulmonary sarcomas correlate as to localisation, sex relation and not provable exogene cancerogena with the adenocarcinoma of the lungs. The causal connexion between trauma and sarcoma formation in a thoracotomy cicatrice as well as the possibility of a sarcomatous degeneration are discussed.

[The special position of primary lymphosarcoma of the lung (author's transl)]. / Die Sonderstellung primärer Lymphsarkome der Lunge.

There has been made a comparison between a total of 121 primary lymphatic sarcomas of the lungs with 314 other histomorphological forms of primary sarcomas of the lungs found in the literature from 1957 to 1972. Histomorphology, clinic and prognosis are discussed. Beside a higher average age and a predominating right-hand localization, the favourable postoperative prognose is impressing.

[Sarcoma metastases in the lung]. / Sarkommetastasen der Lunge.

It is reported on 15 metastases of sarcomas of the lung, of which 7 were treated by operation and 8 were inoperable. The diagnostic and therapeutic parameters of these relatively rare sarcomas are described and discussed in connection with the prognosis. A well-considered active therapy is justified. There were obtained one five-year and one 16-year survival time postoperatively, four out of seven operatively treated cases had a postoperative life longer than two years, whereas all conservatively treated eight cases died within two years. Our results correspond with the actual literature. The influence of prognostically significant parameters is discussed.