Cerebral Oximetry Monitoring in Extremely Preterm Infants.

BACKGROUND: The use of cerebral oximetry monitoring in the care of extremely preterm infants is increasing. However, evidence that its use improves clinical outcomes is lacking. METHODS: In this randomized, phase 3 trial conducted at 70 sites in 17 countries, we assigned extremely preterm infants (gestational age, <28 weeks), within 6 hours after birth, to receive treatment guided by cerebral oximetry monitoring for the first 72 hours after birth or to receive usual care. The primary outcome was a composite of death or severe brain injury on cerebral ultrasonography at 36 weeks' postmenstrual age. Serious adverse events that were assessed were death, severe brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and late-onset sepsis. RESULTS: A total of 1601 infants underwent randomization and 1579 (98.6%) were evaluated for the primary outcome. At 36 weeks' postmenstrual age, death or severe brain injury had occurred in 272 of 772 infants (35.2%) in the cerebral oximetry group, as compared with 274 of 807 infants (34.0%) in the usual-care group (relative risk with cerebral oximetry, 1.03; 95% confidence interval, 0.90 to 1.18; P = 0.64). The incidence of serious adverse events did not differ between the two groups. CONCLUSIONS: In extremely preterm infants, treatment guided by cerebral oximetry monitoring for the first 72 hours after birth was not associated with a lower incidence of death or severe brain injury at 36 weeks' postmenstrual age than usual care. (Funded by the Elsass Foundation and others; SafeBoosC-III ClinicalTrials.gov number, NCT03770741.).

Meeting the need for effective and standardized neonatology training: a pan-European Master's Curriculum.

Neonatology is a pediatric sub-discipline focused on providing care for newborn infants, including healthy newborns, those born prematurely, and those who present with illnesses or malformations requiring medical care. The European Training Requirements (ETR) in Neonatology provide a framework for standardized quality and recognition of equality of training throughout Europe. The latest ETR version was approved by the Union of European Medical Specialists (UEMS) in April 2021. Here, we present the curriculum of the European School of Neonatology Master of Advanced Studies (ESN MAS), which is based on the ETR in Neonatology and aims to provide a model for effective and standardized training and education in neonatal medicine. We review the history and theory that form the foundation of contemporary medical education and training, provide a literature review on best practices for medical training, pediatric training, and neonatology training specifically, including educational frameworks and evidence-based systems of evaluation. The ESN MAS Curriculum is then evaluated in light of these best practices to define its role in meeting the need for a standardized empirically supported neonatology training curriculum for physicians, and in the future for nurses, to improve the quality of neonatal care for all infants. IMPACT STATEMENT: A review of the neonatology training literature was conducted, which concluded that there is a need for standardized neonatology training across international contexts to keep pace with growth in the field and rapidly advancing technology. This article presents the European School of Neonatology Master of Advanced Studies in Neonatology, which is intended to provide a standardized training curriculum for pediatricians and nurses seeking sub-specialization in neonatology. The curriculum is evaluated in light of best practices in medical education, neonatology training, and adult learning theory.

Soluble urokinase plasminogen activator receptor (suPAR) in children with obesity or type 1 diabetes as a marker of endothelial dysfunction: a cross-sectional study.

Pediatric obesity and type 1 diabetes mellitus (T1DM) represent two common chronic diseases associated with chronic inflammation, endothelial dysfunction and long-term complications. The aim of the present study was to assess the possible diagnostic and prognostic value of soluble urokinase plasminogen activator receptor (suPAR), a marker of inflammation and impaired endothelial function, in children with the diseases. In this cross-sectional study, children and adolescents with T1DM (N = 41) or obesity (N = 37), aged < 18 years old, and without proteinuria were included, together with children of similar age and without evident morbidity that served as controls (N = 42). Serum samples were obtained during standard outpatient follow up and the urokinase-type plasminogen activator receptor (suPAR) concentrations were measured using a commercially available sandwich ELISA kit (DUP00, R&D systems). Clinical and biochemical indices that were also assessed include body mass index (BMI) z-score, Tanner stages, glycosylated haemoglobin (HbA1c), fasting lipid profile and serum creatinine. Mean serum suPAR levels were significantly higher in patients with obesity compared to patients with T1DM and controls, while children with T1DM had similar suPAR levels to controls. Also, serum suPAR levels showed a negative correlation with age (Spearman rho -0.359, p < 0.001) and serum creatinine levels (Spearman rho -0.334, p = 0.005), and a positive correlation with BMI z-score (Spearman rho 0.354, p = 0.009) in the whole cohort.  Conclusion: Serum suPAR may be a useful predictive marker of inflammation or endothelial dysfunction for children with obesity and T1DM, as well as a promising therapeutic target. Further studies are needed in order to clarify whether the reported differences in suPAR levels could reflect a greater impairment of the inflammation status and endothelial function in children with obesity compared to children with T1DM. What is Known: • Paediatric obesity and type 1 diabetes are characterised by chronic inflammation and metabolic dysregulation. • Urokinase plasminogen activator receptor (uPAR) has been proposed as a useful biomarker for chronic inflammation and cardiovascular risk in adults. What is New: • Serum suPAR levels were increased in children and adolescents with obesity compared to those with T1DM and healthy controls; thus, obesity may affect the inflammatory status and endothelial function to a higher degree than T1DM during childhood. • Serum suPAR may serve as a diagnostic and predictive marker of inflammation and endothelial dysfunction for children and adolescents with obesity and T1DM.

Multisystem inflammatory syndrome in children (MIS-C): A nationwide collaborative study in the Greek population.

Multisystem inflammatory syndrome in children (MIS-C) is a rare but severe hyperinflammatory condition that may occur following SARS-CoV-2 infection. This retrospective, descriptive study of children hospitalized with multisystem inflammatory syndrome in children (MIS-C) in 12 tertiary care centers from 3/11/2020 to 12/31/2021. Demographics, clinical and laboratory characteristics, treatment and outcomes are described. Among 145 patients (95 males, median age 8.2 years) included, 123 met the WHO criteria for MIS-C, while 112 (77%) had serological evidence of SARS-CoV-2 infection. Fever was present in 99%, gastrointestinal symptoms in 77%, mucocutaneous involvement in 68% and respiratory symptoms in 28%. Fifty-five patients (38%) developed myocarditis, 29 (20%) pericarditis and 19 (13%) coronary aneurysms. Among the above cases 11/55 (20%), 1/29 (3.4%) and 5/19 (26.3%), respectively, cardiac complications had not fully resolved at discharge. Underlying comorbidities were reported in 18%. Median CRP value was 155 mg/l, ferritin 535 ng/ml, PCT 1.6 ng/ml and WBC 14.2 × 109/mm3. Most patients had elevated troponin (41.3%) and/or NT-pro-BNP (49.6%). Intravenous immunoglobulin plus corticosteroids were used in 117/145 (80.6%), monotherapy with IVIG alone in 13/145 (8.9%) and with corticosteroids alone in 2/145 (1.3%). Anti-IL1 treatment was added in 15 patients (10.3%). Thirty-three patients (23%) were admitted to the PICU, 14% developed shock and 1 required ECMO. Mortality rate was 0.68%. The incidence of MIS-C was estimated at 0.69/1000 SARS-CoV-2 infections. Patients who presented with shock had higher levels of NT-pro-BNP compared to those who did not (p < 0.001). Acute kidney injury and/or myocarditis were associated with higher risk of developing shock. CONCLUSION: MIS-C is a novel, infrequent but serious disease entity. Cardiac manifestations included myocarditis and pericarditis, which resolved in most patients before discharge. Timely initiation of immunomodulatory therapy was shown to be effective. NT-pro-BNP levels may provide a better prediction and monitoring of the disease course. Further research is required to elucidate the pathogenesis, risk factors and optimal management, and long-term outcomes of this clinical entity. WHAT IS KNOWN: • MIS-C is an infrequent but serious disease entity. • Patients with MIS-C present with multi-organ dysfunction, primarily involving the gastrointestinal and cardiovascular systems. WHAT IS NEW: • NT-pro-BNP levels may provide a better prediction and monitoring of the disease course. • Acute kidney injury and/or myocarditis were associated with higher risk of developing shock.

Preterm newborns exposed to early-onset preeclampsia have altered postnatal Tumor Necrosis Factor-related apoptosis-inducing ligand trends versus controls.

BACKGROUND: Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is a protein with anti-atherogenic and vasoprotective effects that has never been studied in newborns exposed to preeclampsia. Our aim was to examine TRAIL serum concentrations in such neonates after birth and during the transitional period. METHODS: Serum TRAIL levels were measured on the first and fifth day of life (DOL1 and DOL5, respectively) in 38 newborns exposed to early-onset preeclampsia and 38 controls born of normotensive mothers. RESULTS: TRAIL values on DOL1 and DOL5 did not differ between cases and controls. However, from DOL1 to DOL5 TRAIL levels increased in controls (from 20.54 ± 7.35 to 23.93 ± 11.02 pg/ml, p = 0.044) but decreased in those exposed to preeclampsia (from 25.58 ± 15.74 to 20.53 ± 10.72 pg/ml, p = 0.035). Overall, the relative change of TRAIL values from DOL1 to DOL5 was positively related to birth weight (beta coefficient 0.234, p = 0.042) and inversely related to preeclampsia (beta coefficient -0.241, p = 0.036). CONCLUSION: Newborns exposed to early-onset preeclampsia present a decrease in serum TRAIL levels during the transitional period. This pattern is exactly the opposite from what is observed in neonates born to normotensive mothers, and most likely points towards a defective mechanism of extrauterine adaptation related to preeclampsia exposure in utero. IMPACT: Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) levels during the transitional period do not differ between infants exposed to early-onset preeclampsia and controls The pattern of change of TRAIL levels after birth is different; TRAIL decreases in newborns exposed to preeclampsia but increases in controls The decrease of TRAIL levels during the transitional period points towards a defective mechanism of extrauterine adaptation and an altered cardiometabolic profile in newborns exposed to early-onset preeclampsia.

Diaphragmatic muscle function in term and preterm infants.

We aimed to assess the determinants of diaphragmatic function in term and preterm infants. 149 infants (56 term; 93 preterm, of whom 14 were diagnosed with bronchopulmonary dysplasia-BPD) were studied before discharge. Diaphragmatic function was assessed by measurement of the maximum transdiaphragmatic pressure (Pdimax)-a measure of diaphragmatic strength, and the pressure-time index of the diaphragm (PTIdi)-a measure of the load-to-capacity ratio of the diaphragm. The Pdimax was higher in term than preterm infants without BPD (90.1 ± 16.3 vs 81.1 ± 11.8 cmH2O; P = 0.001). Term-born infants also had lower PTIdi compared to preterms without BPD (0.052 ± 0.014 vs 0.060 ± 0.017; P = 0.006). In term and preterm infants without BPD, GA was the most significant predictor of Pdimax and PTIdi, independently of the duration of mechanical ventilation and oxygen support. In infants with GA < 32 weeks (n = 30), the Pdimax was higher in infants without BPD compared to those with BPD (76.1 ± 11.1 vs 65.2 ± 11.9 cmH2O; P = 0.015). Preterms without BPD also had lower PTIdi compared to those with BPD (0.069 ± 0.016 vs 0.109 ± 0.017; P < 0.001). In this subgroup, GA was the only significant independent determinant of Pdimax, while BPD and the GA were significant determinants of the PTIdi.  Conclusions: Preterm infants present lower diaphragmatic strength and impaired ability to sustain the generated force over time, which renders them prone to diaphragmatic fatigue. In very preterm infants, BPD may further aggravate diaphragmatic function. What is Known: • The diaphragm of preterm infants has limited capacity to undertake the work of breathing effectively. • The maximum transdiaphragmatic pressure (a measure of diaphragmatic strength) and the pressure-time index of the diaphragm (a measure of the load-to-capacity ratio of the muscle) have not been extensively assessed in small infants. What is New: • Preterm infants have lower diaphragmatic strength and impaired ability to sustain the generated force over time, which renders them prone to diaphragmatic fatigue. • In very preterm infants, bronchopulmonary dysplasia may further impair diaphragmatic function.

Validation of a non-invasive pressure-time index of the inspiratory muscles in spontaneously breathing newborn infants.

To validate the pressure-time index of the inspiratory muscles as a non-invasive index of inspiratory muscle function in spontaneously breathing infants by comparing it against the gold-standard pressure-time index of the diaphragm. Prospective observational cohort study of consecutive infants breathing unsupported in room air in a tertiary neonatal intensive care unit, studied prior to discharge from neonatal care. The invasive pressure-time index of the diaphragm was calculated using a transdiaphragmatic dual-pressure catheter that measured transdiaphragmatic pressure by subtraction of the oesophageal from the gastric pressure. The non-invasive pressure-time index of the inspiratory muscles was calculated using pressure measurements at the level of the mouth via a differential pressure transducer connected to a face mask. Both indices were calculated as the product of the ratio of the mean inspiratory pressure divided by the maximum inspiratory pressure and the ratio of the inspiratory time divided by the total time of a respiratory cycle. One hundred and thirty infants (79 male) were included with a mean (SD) gestational age of 35.2 (3.2) weeks, studied at a median (IQR) postnatal age of 9 (6-20) days. The mean (SD) pressure-time index of the diaphragm was 0.063 (0.019) and the mean (SD) pressure-time index of the inspiratory muscles was 0.065 (0.023). The correlation coefficient for the two indices was 0.509 (p < 0.001). The mean (SD) absolute difference between the pressure-time index of the inspiratory muscles and pressure-time index of the diaphragm was 0.002 (0.021). In convalescent infants, the non-invasive pressure-time index of the inspiratory muscles had a moderate degree of correlation with the invasively derived pressure time index of the diaphragm measured with a transdiaphragmatic catheter.

Respiratory muscle function in the newborn: a narrative review.

Our aim was to summarise the current evidence and methods used to assess respiratory muscle function in the newborn, focusing on current and future potential clinical applications. The respiratory muscles undertake the work of breathing and consist mainly of the diaphragm, which in the newborn is prone to dysfunction due to lower muscle mass, flattened shape and decreased content of fatigue-resistant muscle fibres. Premature infants are prone to diaphragmatic dysfunction due to limited reserves and limited capacity to generate force and avoid fatigue. Methods to assess the respiratory muscles in the newborn include electromyography, maximal respiratory pressures, assessment for thoraco-abdominal asynchrony and composite indices, such as the pressure-time product and the tension time index. Recently, there has been significant interest and a growing body of research in assessing respiratory muscle function using bedside ultrasonography. Neurally adjusted ventilator assist is a novel ventilation mode, where the level of the respiratory support is determined by the diaphragmatic electrical activity. Prolonged mechanical ventilation, hypercapnia and hypoxia, congenital anomalies and systemic or respiratory infection can negatively impact respiratory muscle function in the newborn, while caffeine and synchronised or volume-targeted ventilation have a positive effect on respiratory muscle function compared to conventional, non-triggered or pressure-limited ventilation, respectively. IMPACT: Respiratory muscle function is impaired in prematurely born neonates and infants with congenital anomalies, such as congenital diaphragmatic hernia. Respiratory muscle function is negatively affected by prolonged ventilation and infection and positively affected by caffeine and synchronised compared to non-synchronised ventilation modes. Point-of-care diaphragmatic ultrasound and neurally adjusted ventilator assist are recent diagnostic and therapeutic technological developments with significant clinical applicability.

The impact of COVID-19 on paediatric emergency department visits. A one-year retrospective study.

BACKGROUND: The number of paediatric emergency department (ED) visits and hospital admissions was recorded in a tertiary referral centre during the first year of the COVID-19, March 2020-February 2021, and compared with those of the preceding year. METHODS: The number of visits and admissions and the reason of visit and admission were prospectively recorded from 15,087 patients' files. RESULTS: A substantial decline in the total number of visits and increase in the admission rate were documented during the COVID-19 year compared to the preceding year (10691 vs 4396 patients, 22.59% vs 18.15% (OR: 1.316, CI 95%: 1.208-2.242, p < 0.0001), respectively). Fever and/or respiratory symptoms were the commonest reported symptoms in both periods. Possible explanations include: (i) restricted overall infection transmission due to confinement and self-protective measures, (ii) avoidance of unnecessary hospital visits in the absence of severe symptoms and (iii) reduced or delayed access to medical care due to parental fear of children's exposure to COVID-19. CONCLUSION: This study is the first worldwide to investigate the impact of COVID-19 on ED visits and admissions throughout the whole year of the pandemic, and to highlight the need for re-evaluation of future protective strategies to infections, adjustment of health-care systems and parental education so that medical care in a health-care setting is sought in a more appropriate manner. IMPACT: A significant decline in paediatric ED visits and increase in the admission rate was observed during the first year of COVID-19 in a tertiary referral centre, possibly due to reduced overall infection transmission, limited ED overuse, but also ED underuse due to parental fear of children's exposure to SARS-CoV-2. COVID-19 may serve as an opportunity for societies to re-evaluate future strategies to infections, adjust health-care systems accordingly, and reinforce parents to seek medical care more appropriately. Although the incidence of critical illness in children due to COVID-19 and in general is low, special attention should be devoted to identifying children at risk early.

Potential benefit from the implementation of the Kaiser Permanente neonatal early-onset sepsis calculator on clinical management of neonates with presumed sepsis.

To assess the potential benefit from the implementation of the Kaiser Permanente early-onset sepsis calculator (EOS-C), in terms of antibiotic use and requested laboratory tests, in a network of neonatal intensive care units (NICUs) in Greece, and to determine the incidence of early-onset sepsis (EOS) in Greek NICUs, a prospective surveillance study was conducted in 7 NICUs between April 2018 and June 2019. Data were collected for all newborns ≥ 34 weeks' gestation receiving empiric antibiotic therapy within the first 3 days of life. The number of live births and positive blood or cerebrospinal fluid cultures within the first 3 days of life were used for calculation of EOS incidence. Evaluation of possible impact of implementing the calculator was done by comparing the clinicians' recorded management to the calculator's suggested course of action. The unit-specific incidence of culture-proven EOS ranged between 0 and 2.99/1000 live births. The weighted incidence rate for all 7 units was 1.8/1000 live births. Management of EOS guided by the calculator could lead to a reduction of empiric antibiotic initiation up to 100% for the group of "well-appearing" neonates and 86% for "equivocal," lowering exposure to antibiotics by 4.2 and 3.8 days per neonate, respectively. Laboratory tests for blood cultures drawn could be reduced by up to 100% and 68%, respectively. Sensitivity of the EOS-C in identifying neonates with positive blood cultures was high.Conclusion: Management strategies based on the Kaiser Permanente neonatal sepsis calculator may significantly reduce antibiotic exposure, invasive diagnostic procedures, and hospitalizations in late preterm and term neonates. What is Known: • Neonates are frequently exposed to antibiotics for presumed EOS. • The Kaiser Permanente sepsis calculator can reduce antibiotic exposure in neonates.. What is New: • EOS calculator can be an effective antibiotic stewardship tool in a high prescribing country and can reduce invasive diagnostic procedures and mother-baby separation. • Incidence of EOS in Greece is higher compared to other European countries.

Influenza vaccination among caregivers and household contacts of children with congenital heart disease before and during COVID-19 pandemic.

AIM: We aimed to investigate the influenza immunisation status of caregivers and household contacts of children with congenital heart disease (CHD) and potential barriers to vaccine uptake. METHODS: Prospective questionnaire-based survey over two influenza seasons (2019-2020 and 2020-2021) on 161 children with CHD attending a tertiary paediatric cardiology clinic and their families. Logistic regression and factor analysis were performed to identify factors associated with influenza vaccine uptake. RESULTS: Influenza vaccination coverage of children was 65%, whereas that of their fathers and mothers was 34% and 26%, respectively. Children with unvaccinated siblings represented 43% and those with unvaccinated adults in the household 79% of our study population. No statistically significant differences were found before and during COVID-19 pandemic on vaccine uptake. Logistic regression analysis showed that higher education level, understanding the risk of contracting the disease and vaccination status of the child determined the vaccination status of parents, regardless of their age, age of their child, severity of CHD, beliefs about vaccine safety and efficacy and risk of transmission if not vaccinated. Factor analysis revealed distinct groups among unvaccinated parents (76.3% of the variation in the responses). CONCLUSIONS: Vaccination coverage of caregivers and household contacts of children with CHD is suboptimal. Influenza vaccination campaigns should take into consideration the specific characteristics of parental groups and target interventions accordingly to increase their vaccine uptake and indirectly protect children with CHD.

Anxiety levels in parents of asymptomatic neonates and young infants referred for echocardiography.

INTRODUCTION: Previous studies in children with innocent murmurs have shown that parental concern is common. METHODS: We assessed the anxiety levels among parents of asymptomatic neonates or infants up-to 6 weeks referred for cardiologic consultation because of a heart murmur. A six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI) was completed by the parents before and after consultation. RESULTS: The average STAI score decreased from 14.42 ± 4.54 on arrival to 9.69 ± 4.26 after the consultation (p < 0.001). Overall, the parents felt more calm, less tense, less upset, more relaxed, more content and less worried after the consultation (p < 0.001). Multivariable linear regression analysis showed that the STAI score prior to consultation was related to infants age (coefficient ß = - 0.172; P = 0.046) and STAI score post consultation was related to the final diagnosis (ß = 0.312; P < 0.001). CONCLUSION: In conclusion, parents of asymptomatic neonates and young infants with a murmur exhibit moderate levels of anxiety which can be ameliorated after consultation. Parental education in the field is of paramount importance and the role of both paediatric cardiologists as well as primary care physicians is crucial and decisive.

Seasonal variation and epidemiological parameters in children from Greece with type 1 diabetes mellitus (T1DM).

BACKGROUND: A positive correlation between T1DM onset and winter has been suggested by several studies. We investigated the seasonal variation of T1DM diagnosis and epidemiological parameters in children from Western Greece with T1DM. METHODS: One hundred and five patients, 44 males, aged 1-16 years were studied. The month of the diagnosis, the order of birth, gestational age, birth weight, the mode of delivery, parental age and pubertal status were recorded from the patients' files. RESULTS: The mean age at diagnosis was 8.1 ± 4.0 years. The majority of the studied patients were diagnosed during the period of October-March. The majority were born at full term, 11.7% were preterm babies and 52.3% were first born. The mean birth weight was 3266 ± 596 g. 60% were born by vaginal delivery. The majority of the patients were prepubertal at diagnosis. CONCLUSIONS: Our results are in agreement with the reported seasonal variation of T1DM onset in other regions of Greece and Europe. The positive correlation between T1DM presentation and colder temperatures may be explained by factors such as viral infections. This is the first report on epidemiological parameters that may be related to T1DM presentation in Western Greece. The study of such parameters extends the understanding on the disease as a whole. IMPACT: A seasonality of the T1DM diagnosis is shown, with a predominance of the colder months of the year. This is in agreement with previous reports from other countries. Our findings confirm previously reported data and add to the existing knowledge on T1DM in general. Additionally, this is one of the few reports on the incidence and epidemiology of T1DM in Greece and the first in the region of Western Greece. Safer and more accurate conclusions can be drawn with regards to the possible causes and predisposing factors of T1DM by the assessment of statistical data from different populations throughout the world. This offers a better understanding of T1DM and may also contribute to the identification of factors that may reduce the incidence of the disease in the future.

Parental anxiety and misperceptions in children with innocent murmurs.

BACKGROUND: Previous studies in children with innocent murmurs have shown that parental concern is common. Our aim was to assess the level of anxiety among parents of children referred for cardiology evaluation because of an innocent heart murmur and investigate their perceptions about innocent murmurs. METHODS: A questionnaire was completed by parents before and after consultation. The questionnaire included a six-item short form of the state scale of the Spielberger State-Trait Anxiety Inventory. After the echocardiogram, a detailed consultation was offered including a thorough explanation that the results were normal, as well as a written report. RESULTS: A total of 417 questionnaires were completed by parents of 340 children. Almost half of the parents believed that a heart murmur signifies heart disease or may interfere with child's ability to exercise; 21% of them stated that the siblings should also be investigated irrespective of the presence of a murmur. The mean Spielberger State-Trait Anxiety Inventory questionnaire score before pediatric cardiology consultation was 17.1 ± 4.3 and increased to 22.6 ± 2.8 after the consultation (Wilcoxon P < 0.001). CONCLUSIONS: Parents of infants and children with innocent murmurs exhibit moderate levels of anxiety and this condition can be ameliorated significantly after pediatric cardiology consultation. Focused parental education is of paramount importance and the role of pediatric cardiologists is crucial and decisive.

Antenatal vaccination for influenza and pertussis: a call to action.

Pregnant women should receive influenza and pertussis vaccines according to the National Immunisation Schedule in Greece. The purpose of this study was to assess the knowledge, attitudes and factors associated with antenatal vaccination of women in Greece. A cross-sectional prospective survey was conducted involving 432 pregnant women and women who had recently given birth in Western Greece. Although the majority of women were aware of both diseases (289, 66.9%), they admitted lack of knowledge about antenatal vaccination (317, 73.4%). Overall, there was poor awareness that the vaccination is safe during pregnancy (95, 22%). Only 26 (6%) of women have been offered the vaccines during current pregnancy. Prior vaccination and obstetrician`s recommendation were the stronger predictors of antenatal vaccine uptake. There is substantial room for improvement among antenatal care providers in both patient education and the provision of the vaccines.Impact StatementWhat is already known about the topic? Maternal vaccination has been recognised as an important public health intervention to protect both pregnant women and their offspring from various infectious diseases. Pregnant women should receive influenza and pertussis vaccines according to the National Immunisation Schedules in many countries worldwide. However, scepticism still exists upon vaccine uptake during pregnancy.What do the results of this study add? The purpose of the study was to assess the knowledge, attitudes and factors associated with antenatal vaccination of women in Greece. We found that the knowledge and uptake of influenza and pertussis vaccine among pregnant women in Greece is poor.What the implications are of these findings for clinical practice and/or further research? There is substantial room for improvement among antenatal care providers in both patient education and the provision of the vaccines.

Effect of Early-Onset Preeclampsia on Offspring's Blood Pressure during the First Month of Life.

OBJECTIVE: To explore the effect of early-onset preeclampsia on the blood pressure of offspring during the first month of life. STUDY DESIGN: This prospective case-control study included 106 neonates of mothers with early-onset preeclampsia (developing at <34 weeks of gestation) and 106 infants of normotensive mothers, matched 1-to-1 for sex and gestational age. Serial blood pressure measurements were obtained on admission, daily for the first postnatal week, and then weekly up to the fourth week of life. RESULTS: There were no differences in blood pressure values on admission and the first day of life between cases and controls. Conversely, infants exposed to preeclampsia had significantly higher systolic (SBP), diastolic (DBP), and mean blood pressure (MBP) on the subsequent days up to the fourth postnatal week (P <.001-.033). Multiple regression analyses with adjustment for sex, gestational age, antenatal corticosteroid use, and maternal antihypertensive medication use confirmed the foregoing findings (P <.001-.048). Repeated-measures ANOVA also identified preeclampsia as a significant determinant of trends in SBP, DBP, and MBP during the first month of life (F = 16.2, P < .001; F = 16.4, P < .001; and F = 17.7, P < .001, respectively). CONCLUSIONS: Infants of mothers with early-onset preeclampsia have elevated blood pressure values throughout the neonatal period compared with infants born to normotensive mothers.

Work of Breathing in Mechanically Ventilated Preterm Neonates.

OBJECTIVES: To compare the imposed work of breathing by means of pressure-time product of the diaphragm in newborn infants receiving different modes of mechanical ventilation. DESIGN: Prospective observational crossover study. SETTING: Tertiary care neonatal unit. PATIENTS: Forty preterm newborns (gestational age ≤ 37 wk) in the phase of weaning from mechanical ventilation. INTERVENTIONS: Participants were ventilated in assist control, synchronized intermittent mandatory ventilation, and intermittent mandatory ventilation mode, in a crossover manner. The combination synchronized intermittent mandatory ventilation-pressure support (SIMV-PS) at 50% (SIMV-PS50) and 75% (SIMV-PS75) of the difference between peak inflating and positive end-expiratory pressure, was also applied in a subset of infants (n = 11). Each mode was maintained for 30 minutes. Transdiaphragmatic pressure was obtained by digital subtraction of esophageal from gastric pressure (both measured using a dual pressure-tipped catheter), and pressure-time product of the diaphragm was computed by integration of transdiaphragmatic pressure over inspiratory time. MEASUREMENTS AND MAIN RESULTS: The pressure-time product of the diaphragm was 224.2 ± 112.8 in the intermittent mandatory ventilation mode, 165.8 ± 58.8 in the synchronized intermittent mandatory ventilation mode, and 125.5 ± 61.8 cm H2O × s × min in the assist control mode; all values were significantly different to each other (p < 0.0001). The pressure-time product of the diaphragm difference between assist control and intermittent mandatory ventilation, and assist control and synchronized intermittent mandatory ventilation was negatively related to postmenstrual age (regression coefficient, -0.365; p = 0.020 and -0.341; p = 0.031, respectively). In the SIMV-PS subcohort, the pressure-time product of the diaphragm was significantly higher in the intermittent mandatory ventilation mode as compared with assist control (p < 0.0001) or SIMV-PS75 (p = 0.0027), and in the synchronized intermittent mandatory ventilation mode as compared with assist control (p = 0.0301). CONCLUSIONS: In preterm infants, patient-triggered ventilation modalities result in lower work of breathing than intermittent mandatory ventilation, while the assist control mode is also associated with lower pressure-time product of the diaphragm compared with synchronized intermittent mandatory ventilation. The difference in the imposed diaphragmatic workload between these ventilation modalities was inversely related to postmenstrual age, implying that less mature infants benefit more from assist control-based ventilation strategies.

Cesarean section delivery and development of food allergy and atopic dermatitis in early childhood.

BACKGROUND: Delivery by Cesarean section (CS) may predispose to allergic disorders, presumably due to alterations in the establishment of normal gut microbiota in early infancy. In this study, we sought to investigate the association between CS and physician-diagnosed food allergy and atopic dermatitis during the first 3 years of life, using data from a homogeneous, population-based, birth cohort. METHODS: A total of 459 children born and cared for in the same tertiary maternity unit were examined at birth and followed up at 1, 6, 12, 18, 24, 30 and 36 months of age. Participants with symptoms suggestive of food allergy or atopic dermatitis were evaluated by a pediatric allergy specialist to confirm the diagnosis based on well-defined criteria. RESULTS: The rate of CS was 50.8% (n = 233). Food allergy was diagnosed in 24 participants (5.2%) while atopic dermatitis was diagnosed in 62 children (13.5%). Cesarean section (OR 3.15; 95% CI 1.14-8.70), atopic dermatitis of the child (OR 3.01; 95% CI 1.18-7.80), parental atopy (OR 4.33; 95% CI 1.73-12.1), and gestational age (OR 1.57; 95% CI 1.07-2.37) were significant and independent predictors of food allergy. Children with at least one allergic parent delivered by CS had higher probability of developing food allergy compared with vaginally delivered children of non-allergic parents (OR 10.0; 95% CI 3.06-32.7). Conversely, the effect of CS on atopic dermatitis was not significant (OR 1.35; 95% CI 0.74-2.47). CONCLUSIONS: Delivery by CS predisposes to the development of food allergy but not atopic dermatitis in early childhood. Cesarean section delivery seems to upregulate the immune response to food allergens, especially in children with allergic predisposition.