Neonatal SARS-CoV-2 immunoglobulin G antibodies at delivery and their impact on COVID-19.

OBJECTIVE: To assess neonatal SARS-CoV-2 anti-spike IgG antibody levels after maternal mRNA COVID-19 vaccination and/or infection during pregnancy and evaluate their protective effect. METHODS: Prospective observational study, conducted from January 2021 to December 2022. Infants were tested for anti-spike IgG antibodies at birth and then every 3 months until disappearance of titer. A follow-up was done for SARS-CoV-2 infection up to 12 months. RESULTS: In total, 147 newborns were enrolled with a median (IQR) gestational age of 39.60 weeks (38.3-40.4). Median (IQR) titers in UA/ml at 2 days were higher (P < .001) in newborns of vaccinated 7063.7 (2841.4-14,448.1), than of infected mothers 372.7 (158.00-884.90). Titers dropped significantly during the follow-up but 50% still had a detectable titer at 6 months. A high antibody titer at 2 days led to a longer persistence (HR 0.89, IC 95% 0.83-0.96, P = .004). In total, 36 infants were infected during the first months of life coinciding with the Omicron variant. Fifty percent had detectable antibodies during the infection period. Relationship between high IgG titers and month of infection was inverse (RHO - 0.52, P = .009). CONCLUSION: Though a high antibody titer at birth led to longer persistence, no protective effect against infection was found. As newborns are a high risk group for COVID-19, avoiding transmission during the first year of life is important.

The Role of Manganese in Very Low Birth Weight Infants.

OBJECTIVES: High manganese (Mn) levels during fetal growth or prolonged parenteral nutrition (PN) may have adverse effects on neurodevelopment. We aim to report on Mn levels and their short-term impact on clinical course in very low birth weight infants. METHODS: An observational study including newborns with a gestational age (GA) ≤32 weeks and/or ≤1500 g of birth weight (BW). Newborns received intravenous supplementation of Mn at 1 µg/kg/day (Peditrace ® ) in PN and continued with fortified breast milk. Mothers answered surveys about dietary and other habits and blood levels of Mn in newborns were analyzed at days 1, 15, and 30 of life. Associations of Mn levels with mothers' and newborns' data were evaluated and adjusted for multiple comparisons. RESULTS: One hundred and sixty premature infants were recruited. Median blood Mn levels at birth were 43.0 and 24.5 µg/L at day 30. No important association with mothers' data was found. Median [interquartile range (IQR)] duration of PN was 8 days (7-14). A prolonged PN and late oral feeding showed a nonsignificant association with lower blood Mn levels at day 30 ( P = 0.010, P threshold 0.003). Mn levels at day 15 and 30 were associated with increasing GA ( P < 0.001). Low Mn was not a significant predictor of adverse outcomes such as retinopathy of prematurity, bronchopulmonary dysplasia, or respiratory distress syndrome after adjusting for potential confounders and multiple testing. CONCLUSIONS: Mn showed lower levels with decreasing GA and prolonged PN. Using a low Mn PN solution may not raise blood Mn levels in premature infants.

Diagnosis and management of aspiration using fiberoptic endoscopic evaluation of swallowing in a Pediatric Pulmonology Unit.

BACKGROUND AND OBJECTIVES: Swallowing disorders lead to chronic lung aspiration. Early detection and treatment of aspiration in children with dysphagia are important to prevent lung damage. Diagnosis of aspiration, which may be silent, requires an instrumental study such as fiberoptic endoscopic evaluation of swallowing (FEES). Despite its usefulness, it is rarely practiced by pediatric pulmonologists. This study aimed to evaluate the feasibility and utility of FEES performed in the pediatric respiratory unit of a tertiary hospital, analyze the clinical characteristics, endoscopic findings and proposed treatments, and identify the factors associated with penetration or aspiration. METHODS: Medical records of 373 children with suspected aspiration who were referred to the pediatric respiratory unit for FEES were reviewed retrospectively. Clinical characteristics, FEES findings, and the proposed treatments were analyzed. RESULTS: Laryngeal penetration/aspiration was seen in 47.9% of the patients. The most common associated conditions were neurological disease and prematurity. The most frequently observed endoscopic finding was altered laryngeal sensitivity (36.5%). Intervention was recommended in 54.2% of the patients. Complications were not seen during any of the procedures. The multivariate logistic regression model revealed an independent association between aspiration and alterations in laryngeal sensitivity (odds ratio [OR], 5.68), pharyngeal pooling (OR, 11.47), and post-swallowing food residues (OR, 8.08). CONCLUSIONS: The FEES procedure performed by pediatric pulmonologists is a reliable method for diagnosing aspiration in children. It can be safely executed by trained pulmonologists, and significant endoscopic signs other than aspiration can guide in the diagnosis and management recommendations.

Utility of fiberoptic bronchoscopy for difficult airway in neonates.

BACKGROUND: Newborns diagnosed with craniofacial malformations or laryngeal and tracheal alterations may often need advanced airway-management for airway stabilization. Although fiberoptic bronchoscopy (FB) is currently the gold standard for difficult airway management, there is a scarcity of published data on the application of FB in newborns for intubation and controlled extubation (CE). OBJECTIVES: This study describes a case series where FB is used for intubation and/or extubation to manage newborns with difficult airway in either urgent procedures or scheduled ones. METHODS: All FB were carried out on newborns with difficult airway in the neonatal unit over the period January 2005 to December 2018. Patient characteristics were collected from clinical reports, description of the technique from the procedure report. RESULTS: 66 FBs were performed from a total of 40 newborns, a median age of 25 days and a weight of 3217 g. Eighteen were ex-premature babies (45%). Six (15%) had craniocervical malformations. 17 (25.7%) FBs were performed for tracheal intubation (TI), 6 in emergency situations, 34 (51.5%) for CE, and 15 (22.7%) for precise tube placement. Clearing of the airway was achieved in all cases and thus there were no failed TIs. In 32 cases (94.1%), CE was successfully performed. In 6 cases, withdrawal of the ET midprocedure was decided to postpone as 4 of these required extra treatment prior to renewed extubation attempt and 2 needed a tracheostomy. 2 patients required subsequent FB reintubation due to airway pathology. Complications during the procedure were mild desaturations (3%) and deep desaturations (7.5%). CONCLUSIONS: FB is very safe and highly useful when performing intubation in neonates with difficult airway but is essential during extubation to avoid any risk of failure with a potentially fatal outcome. Neonatal units of tertiary hospitals should provide equipment and training to manage these neonates. WHAT IS ALREADY KNOWN?: A failed intubation or extubation can lead to cardiac arrest and anoxic brain damage and/or to death in a neonate. Fiberoptic bronchoscopy is recommended as the safest tool for neonates with difficult airway. However, there is little concrete data published in the current literature to support the recommendations. WHAT IS NEW: Fiberoptic bronchoscopy is an essential tool to avoid the risk of a failed extubation in neonates with difficult airway.

Assessment of portable oxygen concentrators in infants undergoing hypoxic challenge testing. A randomised controlled crossover trial.

AIM: Due to reduced PaO2 , aircrafts at cruising altitudes are pressurised to a cabin altitude of 2438 m, equivalent to breathing FiO2 0.15. Portable oxygen concentrators (POCs) are approved for onboard oxygen supply with lack of evidence, especially in infants. We assessed POCs (continuous-flow cPOC vs. pulsed-flow pPOC) under simulated altitude conditions performing Hypoxic Challenge Testing (HCT). METHODS: In a randomised controlled crossover trial, we included patients <1 year born prematurely. In incidents of hypoxia (SpO2  ≤ 85%), oxygen was administered through POC. In patients with a positive hypoxia reversal, HCT was repeated 24 hours later. If hypoxia occurred during the second testing, oxygen was given using the alternative POC. RESULTS: We randomised 26 patients; 22 patients received allocated intervention (4 dropped out). Mean gestational age 30.4 weeks, mean corrected age 38.2 weeks. Both POCs achieved immediate hypoxia reversal in all cases (SpO2 cPOC/pPOC 98%/99.4% (95%CI -2.91, 0.01)) without any adverse events. No significant difference was observed in patients with BPD. CONCLUSION: Both POCs generated sufficient oxygen to reverse HCT induced hypoxia. Although pPOCs are not recommended in paediatric age, our data suggest their effectiveness even in neonates without any associated adverse events. Future research on pPOCs safety is required to establish recommendations for their use.

Neonatal swallowing assessment using fiberoptic endoscopic evaluation of swallowing (FEES).

OBJECTIVES: Swallowing disorders which lead to aspiration are common in premature infants with a postmenstrual age (PMA) of >36 weeks. Aspiration is often silent and the unique symptom is desaturation during feeding. The aim of this study was 1) to determine the number of prematures with desaturations during feeding due to aspiration, using Fiberoptic Endoscopic Evaluation of Swallowing (FEES); 2) to relate clinical factors and FEES findings to aspiration; and 3) to describe type and efficacy of suggested treatments. METHODS: A retrospective review of 62 ex-premature babies with a median PMA of 40 weeks which underwent FEES due to persistent feeding desaturations. Aspiration was related to other FEES findings and to clinical and demographic data. The efficacy of the treatment was evaluated during the FEES and by comparing recorded desaturations during feeding 7 days before and after FEES. RESULTS: A total of 44 (71%) infants were diagnosed with aspiration and/or penetration. No relation was found to demographic or clinical data. The accumulation of saliva and residues post-swallowing were related to aspiration (P < 0.01). In 77.3% of the infants, use of a thickener seemed to reduce aspiration during FEES and was suggested as a treatment. 13.6% of infants received anti-reflux treatment after FEES and 9.1% required gastrostomy. CONCLUSIONS: Aspiration is very frequent in premature infants who present desaturations during feeding and FEES is a useful method for diagnosing and suggesting treatments.

Hypoxia Challenge Testing in Neonates for Fitness to Fly.

BACKGROUND: Preflight hypoxia challenge testing (HCT) in a body plethysmograph has previously been done only on infants >3 months of corrected gestational age (CGA). This study aims to determine the earliest fit-to-fly age by testing neonates <1 week old. METHODS: A prospective observational study was carried out on 3 groups of infants: healthy term infants ≤7 days old, preterm infants (≥34 weeks CGA) 2 to 3 days before discharge, and preterm infants with bronchopulmonary dysplasia (BPD). HCT was conducted using a body plethysmograph with a 15% fraction of inspired oxygen. The oxygen saturation (Spo2) test fail point was <85%. RESULTS: Twenty-four term (mean CGA 40 weeks), 62 preterm (37 weeks), and 23 preterm with BPD (39.5 weeks) infants were tested. One term infant (4.2%) and 12 preterm infants without BPD (19.4%) failed. Sixteen (69.3%) preterm infants with BPD failed (P < .001), with a median drop in Spo2 of 16%. At 39 weeks CGA, neither preterm infants without BPD nor term infants had an Spo2 <85%. However, 7 of 12 term infants with BPD failed the HCT. CONCLUSIONS: Term and preterm infants without BPD born at >39 weeks CGA do not appear to be likely to desaturate during a preflight HCT and so can be deemed fit to fly according to current British Thoracic Society Guidelines.

Digestive tract symptoms in congenital langerhans cell histiocytosis: a fatal condition in an illness usually considered benign.

INTRODUCTION: Congenital Langerhans cell histiocytosis is usually limited to cutaneous lesions and has a good prognosis. In rare cases of gut involvement, mortality is high and early and aggressive treatment essential. MATERIALS AND METHODS: We report a case of histiocytosis in a newborn with bowel involvement, and performed a literature review of 13 similar cases worldwide documented between 1973 and 2008. RESULTS: Skin eruptions are usually the initial symptoms at birth. Bloody stools or protein-losing enteropathy are the first signs of bowel involvement that appear mostly in the first 4 weeks of life. Risk organs (hematopoietic system, liver, spleen) are often affected in the newborns with intestinal Langerhans cell histiocytosis. Prognosis is usually poor, with 78.5% mortality. CONCLUSIONS: Even if histiocytosis in a neonate appears limited to autoinvoluting skin lesions, it is important to exclude all other organ involvement, including the bowel and stomach, as early treatment is vital.