Evaluation of a simple intervention to reduce exchange transfusion rates among inborn and outborn neonates in Myanmar, comparing pre- and post-intervention rates.

BACKGROUND: In Myanmar, approximately half of all neonatal hospital admissions are for hyperbilirubinaemia, and tertiary facilities report high rates of Exchange Transfusion (ET). The aim of this study was to evaluate the effectiveness of the pilot program in reducing ET, separately of inborn and outborn neonates. METHODS: The study was conducted in the Neonatal Care Units of four national tertiary hospitals: two exclusively treating inborn neonates, and two solely for outborn neonates. Prior to intervention, no high intensity phototherapy was available in these units. Intervention in late November 2011 comprised, for each hospital, provision of two high intensity LED phototherapy machines, a photo radiometer, and training of personnel. Hospital-specific data were assessed as Relative Risk (RR) ratios comparing ET rates pre- and post-intervention, and individual hospital results were pooled when appropriate. RESULTS: In 2011, there were 118 ETs among inborn neonates and 140 ETs among outborn neonates. The ET rate was unchanged at Inborn Hospital A (RR = 1.07; 95 % CI: 0.80-1.43; p = 0.67), and reduced by 69 % at Inborn Hospital B (RR = 0.31; 95 % CI: 0.17-0.57; p < 0.0001). For outborn neonates, the pooled estimate indicated that ET rates reduced by 33 % post-intervention (RRMH = 0.67; 95 % CI: 0.52-0.87; p = 0.002); heterogeneity was not a problem. CONCLUSION: Together with a photoradiometer and education, intensive phototherapy can significantly reduce the ET rate. Inborn Hospital A had four times as many admissions for jaundice as Inborn Hospital B, and did not reduce ET until it received additional high intensity machines. The results highlight the importance of providing enough intensive phototherapy units to treat all neonates requiring high intensity treatment for a full course. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615001171505 , 2 November 2015.

Minimally invasive approaches for surfactant administration.

Respiratory distress syndrome (RDS) is the most common respiratory morbidity in preterm infants. In addition to respiratory support, the current clinical treatment includes endotracheal intubation and rapid instillation of exogenous surfactant. However, this approach needs skilled operators and has been associated with complications such as hemodynamic instability and electroencephalogram abnormalities. New, less invasive methods for surfactant administration are needed. In this article, we reviewed the available noninvasive procedures for surfactant administration. In particular, we focused on aerosolized surfactant and surfactant administration through LMA.

Maintaining normothermia immediately after birth in preterm infants <34 weeks' gestation: A systematic review and meta-analysis.

AIM: To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants <34 weeks' gestation. METHODS: Medline, Embase, CINAHL and CENTRAL were searched till 22nd July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines. RESULTS: DR temperature of ≥23 °C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient. CONCLUSIONS: DR temperature of ≥23 °C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants <34 weeks' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.

Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis.

AIM: Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥34 weeks' gestation). METHODS: Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed. RESULTS: 25 RCTs and 10 non-RCTs were included. Room temperature of 23 °C compared to 20 °C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30 °C, 0.23-0.37 °C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes. CONCLUSIONS: Room temperature of 23 °C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation.

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.

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.

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.

Risk factors for acute bilirubin encephalopathy on admission to two Myanmar national paediatric hospitals.

BACKGROUND: Jaundice is the commonest neonatal ailment requiring treatment. Untreated, it can lead to acute bilirubin encephalopathy (ABE), chronic bilirubin encephalopathy (CBE) or death. ABE and CBE have been largely eliminated in industrialised countries, but remain a problem of largely undocumented scale in low resource settings. As part of a quality-improvement intervention in the Neonatal Care Units of two paediatric referral hospitals in Myanmar, hospitals collected de-identified data on each neonate treated on new phototherapy machines over 13-20 months. The information collected included: diagnosis of ABE at hospital presentation; general characteristics such as place of birth, source of referral, and sex; and a selection of suspected causes of jaundice including prematurity, infection, G6PD status, ABO and Rh incompatibility. This information was analysed to identify risk factors for hospital presentation with ABE, using multiple logistic regression. RESULTS: Data on 251 neonates was recorded over 20 months in Hospital A, and 339 neonates over 13 months in Hospital B; the number of outborn neonates presenting with ABE was 32 (12.7 %) and 72 (21.2 %) respectively. In the merged dataset the final multivariate model identified the following independent risk and protective factors: home birth, ORadj = 2.3 (95 % CI: 1.04-5.4); self-referral, ORadj = 2.6 (95 % CI: 1.2-6.0); prematurity, ORadj = 0.40 (95 % CI: 0.18-0.85); and a significant interaction between hospital and screening status because screening positive for G6PD deficiency was a strong and significant risk factor at Hospital B (ORadj = 5.9; 95 % CI: 3.0-11.6), but not Hospital A (ORadj = 1.1; 95 % CI: 0.5-2.5). CONCLUSION: The study identifies home birth, self-referral and G6PD screening status as important risk factors for presentation with ABE; prematurity was protective, but this is interpreted as an artefact of the study design. As operational research, there is likely to be substantial measurement error in the risk factor data, suggesting that the identified risk factor estimates are robust. Additional interventions are required to ensure prompt referral of jaundiced neonates to treatment facilities, with particular focus on home births and communities with high rates of G6PD deficiency.

Role of ventilation strategy on perfluorochemical evaporation from the lungs.

To study the effect of ventilation strategy on perfluorochemical (PFC) elimination profile (evaporative loss profile; E(L)), 6 ml/kg of perflubron were instilled into anesthetized normal rabbits. The strategy was to maintain minute ventilation (VE, in ml/min) in three groups: VE(L) (low-range VE, 208 +/- 2), VE(M) (midrange VE, 250 +/- 9), and VE(H) (high-range VE, 293 +/- 1) over 4 h. In three other groups, respiratory rate (RR, breaths/min) was controlled at 20, 30, or 50 with a constant VE and adjusted tidal volume. PFC content in the expired gas was measured, and E(L) was calculated. There was a significant VE- and time-dependent effect on E(L.) Initially, percent PFC saturation and loss rate decreased in the VE(H) > VE(M) > VE(L) groups, but by 3 h the lower percent PFC saturation resulted in a loss rate such that VE(H) < VE(M) < VE(L) at 4 h. For the groups at constant VE, there was a significant time effect on E(L) but no RR effect. In conclusion, E(L) profile is dependent on VE with little effect of the RR-tidal volume combination. Thus measurement of E(L) and VE should be considered for the replacement dosing schemes during partial liquid ventilation.

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.

[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.

[A case of neonatal necrotizing enterocolitis due to rotavirus]. / Un caso di enterocolite necrotizzante neonatale da rotavirus.

Recently the role of rotavirus in the etiopathogenesis of neonatal hemorrhagic gastroenteritis and necrotizing enterocolitis has been underlined. We report a case of NEC caused by rotavirus, that occurred in a term neonate born from a drug abusing mother, during an outbreak of rotavirus-associated which appeared with gastrointestinal bleeding and mild systemic signs in comparison with marked radiologic findings, rapidly evolved from the fourth day of life, after the normalization of abdominal roentgenogram.

[Skin lesions caused by oxygen saturation monitor probe: pathogenetic considerations concerning 2 neonatal cases]. / Lesioni cutanee da saturimetro: considerazioni patogenetiche su due casi neonatali.

Two cases of skin injury by a pulse oximeter probe are reported. The Authors hypothesize the local pressure as pathogenetic mechanism of the skin lesion and emphasize the importance of a careful management of critically ill patients during non-invasive monitoring.

[Resuscitation in the delivery room: experience in 3 Veneto Centers]. / La rianimazione in sala parto: esperienza in 3 Centri del Veneto.

On the basis of the classical USA guidelines for neonatal resuscitation, we examined the personnel activity in delivery room in 3 Veneto's Centres of different level (level I, II, III). Totally, we studied 3492 neonates in the period January, 1-December, 31, 1994. Three hundred and seven (8.7%) of them needed resuscitation at birth; respectively 5.6%, 4.6% and 14.2% in the level I, II and III Centres. The management of the first neonatal resuscitation's step was similar in the 3 studied Hospitals, while the second phases (ventilation) was different among the Centres. In fact, in the level I and II Hospitals the most part of the neonates were treated by ventilation bag (81.8% and 74.6%, respectively), while only a little part of them received endotracheal intubation (18.2% and 25.4%, respectively). In the level III Centre, endotracheal intubation (87.4%) was more frequently used respect to ventilation bag (12.6%). The third phases, chest compressions, was performed in many resuscitated infants in the level I (54.5%) and II (22.8%) Hospitals, while no infant needed it in the 3th Centre. The last step, drug and fluid administration, interested few patients in every Centre. Furthermore, the physicians of the 3 examined Institutions followed no protocol for neonatal resuscitation. The differences in neonatal resuscitation policy among the 3 studied Centres demonstrate the absence of a protocol and an educational program for the personnel. Theoretical and practical guidelines for correct neonatal resuscitation have to be implemented in our Region.

Effect of prolonged dexamethasone on oxygen-dependency in infants with chronic lung disease.

To determine the effect of prolonged dexamethasone therapy on oxygen-dependency clinical phase of prematures with bronchopulmonary dysplasia, we examined a consecutive group of 27 infants (birth weight, < 1500 g and gestational age, < 32 weeks), who remained with a static or deteriorating oxygen-dependency after weaning from the respirator [pre-treatment FiO2, mean +/- SEM over three days (31 +/- 2)%, range (27-73)%]. Twenty five out of 27 infants were weaned from supplemental oxygen during the 42-day steroid treatment period, with a mean (+/- SEM) duration of oxygen supplementation of 16 +/- 4 days. The distribution of the ratios of successive post-treatment FiO2 values with respect to pre-treatment FiO2 shows, on average, a progressive reduction with time. The percentage of the FiO2 decrease is statistically significant at a level of 2 and 3 SD after 3 days and 7 days, respectively and the average FiO2 fall, as function of time, follows an exponential law. It follows that the time spent in oxygen for a single patient may be determined, accounting for the individual severity of pre-treatment FiO2.

Prenatal theophylline and necrotizing enterocolitis in premature newborn infants.

To determine whether prenatal theophylline therapy would increase the incidence of neonatal necrotizing enterocolitis (NEC) we studied bowel dysfunction in 59 consecutive premature infants (g.s. < 34 weeks), whose mothers were treated with theophylline as a tocolytic during the last trimester, or as surfactant synthesis inductor, for at least three days prior to premature labor (Group A). As case-control we considered the premature, matched for gestational age born immediately before, and whose was untreated with theophylline (Group B). NEC occurred in one patient from group A during the second postnatal week, and surgery was performed. First passage of meconium and start of enteral feeding were comparable in groups A and B, while gastric residuals lasting more than 4 days were found statistically increased (p < 0.03) in antenatally treated group A prematures. Furthermore, 18 out of 49 prematures postnatally treated with theophylline had gastric residuals (36%) with respect to 5 out of 69 untreated (7%) (p < 0.001). Also the premature infants treated ante and postnatally with theophylline showed a statistically significant increase of lasting gastric residuals with respect to the untreated, 13/16 vs 5/7, respectively (p < 0.03). Antenatal theophylline administered to high risk mothers, when maternal diseases do not allow the use of steroids, does not appear to later increase the risk of NEC in premature infants, and provides a chance to avoid the risks related to premature birth. Inhibitory activity on gut motility and gastric irritability are only detectable during the first postnatal days, enhanced by gut immaturity of preterm infants.

[The micro-ESR with the capillary tube inclined to 45 degrees in the "sepsis screen" of neonatal infection due to beta-hemolytic B-group Streptococcus]. / MicroVES con capillare inclinato a 45 gradi nello "sepsis screen" dell'infezione neonatale da streptococco beta emolitico gruppo B.

The authors describe the advantages of a new method to determinate the erythrocyte sedimentation rate (micro-ESR) during neonatal GBS infections. They utilize a capillary tube placed at a 45 degrees angle and have the results of this test only after 15 minutes. The micro-ESR is proposed as a simple and quick method of sepsis screen in term and preterm newborns.