[BRONCHOPULMONARY DYSPLASIA IN VERY LOW BIRTH WEIGHT INFANTS--THE OLD NEW PROBLEM].

BACKGROUND: The advances in perinatal intensive care have increased the survival rate of extremely low birthweight (ELBW) and gestational age infants. Among them the risk of developing bronchopulmonary dysplasia (BPD) remains high. AIM: To evaluate the frequency of BPD by birthweight and gestational age, to identify the main postnatal risk factors and the associated comorbidities. METHODS: 683 VLBW infants (< 1500g) were admitted in NICU from 2008 to 2010. 597 survived more than 28 days and were included in this study. BPD was diagnosed if supplemental O2 for the first 28 days was necessary; the severity was assessed by the need of O2 and/or ventilator support at 36 gestational weeks (gw). RESULTS: 27.6% (n = 164) infants were with supplemental O2 at 28d of life (BPD-group), 10.9% (n = 65) were with moderate, 3.9% (n = 23) with severe BPD (FiO2 > 30% and/or ventilator support). Infants with BPD were with significantly higher CRIB (9.9 ± 3.1) compared with those without BPD (4.0 ± 3.0), p < 0.0001. The frequency decreased progressively from almost 100% at 23gw or birthweight < 600g to single cases after 31gw and bitthweight > 1200g. Logistic regression analysis showed that each gestational week decreased the odds of BPD by 60%; each CRIB point increased the odds by 62%. Each point increment in 1/5 min Apgar-scores reduced the risk by 40%/50% respectively The need for ventilator support increased from 1.4 ± 2.7 days (no-BPD group) to 52.8 ± 5.1 days (severe-BPD infants), p < 0.05. Postnatal complications significantly increasing the odds for BPD were found to be: PDA - 19.7, Pneumothorax - 12.1 times. There was a significant correlation between BPD, severe brain injury and ROP (p < 0.000 1). CONCLUSION: The frequency of BPD strongly correlates with gestational age and birthweight and CRIB. Additional risk factors are low A pgar scores, PDA and air leak syndrome. Associated comorbidities as severe brain injury and ROP further worsen the long term prognosis.

[Pulmonary hypertension of the newborn--recent advances in the management and treatment].

Pulmonary hypertension of the newborn is a clinical syndrome with diverse etiology in which the transition from fetal circulation with high pulmonary vascular resistance to postnatal circulation with low pulmonary vascular resistance failed. The persistence of high pulmonary vascular pressure leads to right-left shunts and marked cyanosis. Despite of the advances in neonatology, the treatment of some forms of PPHN is often difficult and mortality rate remains high. In infants with PPHN appropriate interventions are critical to reverse hypoxemia, improve pulmonary and systemic perfusion and preserve end-organ function. Our understanding for management of PPHN has evaluated over decades. This review summarizes the current strategies for treatment of pulmonary hypertension of the newborn: general care, cardiovascular support, the advantages and limitations of different ventilatory strategies, oxygen therapy, extracorporal membrane oxygenation, and the evidence-based inhaled nitric oxide therapy. The balance between pulmonary vasoconstrictor and vasodilator mediators plays an important role for pulmonary vascular resistance. Recent studies are designed to develop evidence-based therapies for regulation of pulmonary vascular tone, safe medications for selective pulmonary vasodilatation effective for treatment of PPHN and other forms of pulmonary hypertension in the neonatal intensive care unit.

[Perforated neonatal appendicitis in a preterm newborn].

UNLABELLED: Abstract: Appendicitis is common in paediatric surgical praxis, but extremely rare in newborn infants. CASE REPORT: We report a premature male newborn from a twin pregnancy with gestational age of 31(+4) weeks, birth-weight 1580g, who underwent a laparotomy because of perforation. The baby was admitted to NICU after birth with transitory respiratory failure and early onset neonatal sepsis. MS-Staphylococcus epidermidis was isolated from blood culture, gastric contents and all peripheral specimens, C-reactive protein values were elevated after birth and significantly increased before surgery; thrombocytopenia and mild anemia were found. The control blood culture showed Candida albicans. At day 25 after birth life threatening deterioration occurred: feculent vomiting, progressing distension and palpable rigidity of the abdomen, absence of peristalsis, respiratory distress. Abdominal radiograph showed significantly distension of the intestines, air liquid levels, and discrete signs of pneumoperitoneum. The baby was transferred to the surgery with the diagnosis NEC with perforation. Appendicitis acuta gangrenosa perforativa and peritonitis fibrinopurulenta totalis were found intra-operatively but without signs of NEC. Appendectomy and sanitation of the abdominal cavity were carried out. The histological result confirmed gangrenous perforative appendicitis and purulent necrotic peritonitis. The postoperative course was unremarkable. The boy was transferred to the neonatology on day 33 of life and discharged home 12 days later. CONCLUSIONS: Despite of the low incidence of neonatal appendicitis, it should be taken into consideration if unclear abdominal symptoms occur in the neonatal period. Early surgical intervention contribute to a reduction of potential complications.

[Neonatal bacteremia--frequency, spectrum of organisms and correlation between clinical symptoms and laboratory data for early onset sepsis].

UNLABELLED: Improved obstetrical management and evidence-based peripartum antimicrobial therapy in the last decades reduce the frequency of early-onset neonatal sepsis (EONS) and improve the outcome. The spectrum of the microrganisms is different according to regions, countries and periods of time. Appropriate diagnosis and treatment improve the outcome. However dissociation often occurs between clinical manifestation, laboratory and microbiological findings. AIMS: To determine the incidence of neonatal bacteremia in our hospital, to identify the spectrum of organisms from positive blood cultures (BC), to analyze the correlation between clinical manifestation of EOS and/or laboratory abnormalities. PATIENTS AND METHODS: This study was carried out at the University Hospital of Obstetrics and Gynecology "Maichin dom"- Sofia for 2012. From all 4081 inborn babies 848 were at risk for maternal-fetal infection. In the first two hours after birth they were screened for EONS using a panel of microbiological probes and laboratory blood tests, followed up the next days. According the guidelines of the Neonatology clinic a standard antibiotic therapy was started. 43 of the screened infants (1.05% of all inborn babies) had positive BC and were enrolled in this study. RESULTS: Sixteen from the 43 babies with positive BC were with birthweight > 2500g (0.48% from all 3316 life born term infants), 27--with birthweight < 2500g (3.5% from all 765 low birthweight babies), 24 were patients of the NICU (3.8% of all 635 babies admitted at the NICU for 2012). No one died. The following groups of organisms in BC were isolated: 24 BC with coagulase-negative Staphylococci, Methicilline sensitive (MSCoNS)--11 of them without any clinical symptoms and laboratory abnormalities were interpreted as result of contamination, 1 BC with Staphylococcus aureus MS (MSSA), 8 with alpha-Streptococci, 5 with Enterococcus faecalis (1 in combination with MSCoNS), 2 with GBS, 2 with Aerococcus urinae and 2 BC with Listeria monocytogenes. Gram-negative organisms were not found in BC after birth. 30 from the infants with positive BC didn't show any clinical symptom of EONS. 20 of them were without laboratory criteria for infection and were discharged after negative BC control. 10 newborns were with transient elevation of CRP but without clinical symptoms. 13 babies showed clinical symptoms of EOS, 3 of them had transient respiratory failure, but negative laboratory criteria. 10 babies met the clinical and laboratory criteria for EONS; in 8 of them the CRP was significantly elevated. Most critically ill were 3 ELBW and ELGA babies: 2 twins with Listeria and 1 baby with MSSA-EONS. CONCLUSIONS: In our study, CoNS were found to be the most common cause of EONS or bacteremia, low incidence of GBS sepsis was established. Almost the half of the babies with positive BC were asymptomatic and without laboratory data for infection. Elevation of the CRP-value was the most frequent laboratory abnormality in symptomatic infants.

[Osteopenia of prematurity--prophylaxis, diagnostics and treatment].

UNLABELLED: Osteopenia of prematurity is a metabolic bone disease of premature infants with birth weight < 1500 g and gestational age < 32 weeks. Sub-optimal bone matrix, poor skeletal support and an increased risk of fractures characterized the disease. Its importance is determined by relatively high frequency--between 30-70% of infants at risk, multifactorial etiology and impact on early and late morbidity of the newborns. The prevention and treatment of bone disorders are important aspects of the care of preterm babies. OBJECTIVE: To identify of the risk factors, to determine early diagnostic criteria and to create a prevention program for osteopenia in infants with very low and extremely low birth weight. MATERIALS AND METHODS: The prospective study includes 39 preterm babies with birth weight below 1500 gr. and < 32 g. w who were admitted to the NICU from September 2011-January 2012. Bone metabolism was monitored by calcium, phosphate and alkaline phosphatise at 2-weeks intervals. Vitamin D levels of the neonates were registered at birth, and at 8th week. PTH was measured at the second and the 8th weeks. RESULTS: The following biochemical abnormalities were found. Hypophosphatemia in two weeks (P < 1,6 mmol/l), a gradual increase in phosphorus levels and normalization at eight weeks of age. There was a significant positive correlation between 25OHD/phosphorus at eight weeks/r = 0.353/. Significantly elevated levels of parathyroid hormone in eight weeks, correlating with low levels of vitamin D (negative correlation between 25OHD/parathormone r = -0.581). Blood levels of calcium and alkaline phosphatase were in normal limits. IN CONCLUSION: Risk factors for osteopenia are: the low gestational age and low levels of vitamin D at birth. Biochemical markers of osteopenia are: changes in levels of parathyroid hormone, phosphorus and vitamin D at eight weeks of age. Prevention includes: early supplementation of vitamin D in the risk neonates with individual dose adjustment. Upon biochemical evidence of osteopenia treatment should begin in the second week of life with supplementation of phosphorus, and vitamin D 1320 IU/daily and appropriate physiotherapy.

[Vitamin D levels in maternal--VLBW infants pairs].

UNLABELLED: Normal foetal growth depends on sufficient mother's vit D intake. Premature birth interrupts vit D and mineral mother-to-foetus transfer and leads to vit D deficiency and disturbs newborn mineral bone metabolism. OBJECTIVES: To determine vit. D plasma levels in mothers and their very low birth weight- (VLBW) newborns and the prevalence of vit D deficiency in this population, to investigate seasonal variation and analyse babies' vit D levels from birth to the 8 postnatal week. PATIENTS AND METHODS: The study has been carried out in the University hospital "Maichin dom" Sofia for the period 09.2011-01.2012 and there have been investigated 32 women and their 39 VLBW infants as a target group. 25-OHD level has been measured in maternal and newborn cord blood samples. The ECLIA method has been used. 25-OHD level has been tested second time at eight weeks of age in 34 infants. According to the maternal vit D levels the patients have been divided into 3 groups: Group. 1--vit D reference range level (> 30 ng/ml); Group. 2--vit D insufficiency (21-29 ng/ml), Group. 3--vit D deficiency (< 20 ng/ml). RESULTS: Low Vit. D levels have been estimated in 62.5% of mothers' group. Nevertheless, only 38.6% of all babies have been Vit. D deficient. In 61.4% of them vit D has been in normal range (32.4-35.7 ng/ml). A significant positive correlation between maternal and infants' vit D level at birth has been established (r = 0.516; p = 0.002). There have been found a significant seasonal dependence of vit D level at birth in the group too: vit D plasma levels have been estimated higher in September-October group compared to those in November-January group. Most of the blood samples in winter months showed lower vit. D levels than the autumn group. At 8 weeks of age 67.6% of the babies have been with vit D insufficiency. There has been a significant positive correlation between 25-OHD levels at birth and at weeks (r = 0.425; p = 0.012). CONCLUSION: Vit. D insufficiency has been found in 62.5% of the mothers at birth. Maternal vit. D deficiency is a significant risk factor for neonatal vit D deficiency. There is a clear seasonal dependency with a significantly lower 25-OHD level in the mothers and their VLBW babies in winter months.