Tobacco smoking and breastfeeding: Effect on the lactation process, breast milk composition and infant development. A critical review.

Approximately 10% of women report smoking during pregnancy. The number of breastfeeding women who relapse back to smoking is even greater. Smoking may cause adverse changes to the milk's composition by not only reducing its protective properties, but also by affecting the infant's health. The pathophysiological mechanisms underlying these adverse effects are not entirely known. This article is a review of previous reports about the effects of smoking on the lactation process, breast milk composition and infant development. A systematic search for English language articles published until 2015 was made, using a MEDLINE data. The key search terms were "smoking and breastfeeding", "smoking and lactation", "smoking and milk composition", "nicotine and breast milk". Studies have shown that nicotine levels in breast milk of women who smoke are three times higher than those in the plasma levels. Breast milk volume is reduced and the duration of lactation period is shorter. Smoking causes adverse changes to the milk's composition by not only reducing its protective properties, but also affecting infants' response to breastfeeding and to breast milk.

Late-onset bloodstream infections of Very-Low-Birth-Weight infants: data from the Polish Neonatology Surveillance Network in 2009-2011.

BACKGROUND: Late-Onset Bloodstream Infections (LO-BSI) continue to be one of the most important complications associated with hospitalization of infants born with very low birth weight (VLBW). The aims of this study were to assess the epidemiology of LO-BSI together with the risk factors and the distribution of causative pathogens at six Polish neonatal intensive care units that participated in the Polish Neonatology Surveillance Network from January 1, 2009 to December 31, 2011. METHODS: The surveillance covered 1,695 infants whose birth weights were <1501 grams (VLBW) in whom LO-BSI was diagnosed >72 hours after delivery. Case LO-BSI patients were defined according to NeoKISS. RESULTS: Four hundred twenty seven episodes of LO-BSI were diagnosed with a frequency of 25.3% and an incidence density of 6.7/1000 patient-days (pds). Results of our multivariate analysis demonstrated that surgical procedures and lower gestational age were significantly associated with the risk of LO-BSI. Intravascular catheters were used in infants with LO-BSI significantly more frequently and/or for longer duration: Central venous cathters (CVC) (OR 1.29) and Peripheral venous catheters (PVC) (OR 2.8), as well as, the total duration of total parenteral nutrition (13 vs. 29 days; OR 1.81). Occurrence of LO-BSI was significantly associated with increased the length of mechanical ventilation (MV) (OR 2.65) or the continuous positive airway pressure (CPAP) (OR 2.51), as well as, the duration of antibiotic use (OR 2.98). The occurrence of more than one infection was observed frequently (OR 9.2) with VLBW with LO-BSI. Microorganisms isolated in infants with LO-BSI were dominated by Gram-positive cocci, and predominantly by coagulase-negative staphylococci (62.5%). CONCLUSIONS: Independent risk factor for LO-BSI in VLBV infants are: low gestational age and requirement for surgery. The incidence rates of LO-BSI especially CVC-BSI were higher in the Polish NICUs surveillance than those of other national networks, similar to the central- and peripheral utilization ratio.

Heliox for mechanically ventilated newborns with bronchopulmonary dysplasia.

OBJECTIVE: We assessed the safety and studied the influence of short-term helium-oxygen (heliox) mechanical ventilation (MV) on respiratory function, gas exchange and oxygenation in infants with bronchopulmonary dysplasia (BPD) or at high risk for BPD. DESIGN: A pilot, time-series study. SETTING: Neonatal intensive care unit. PATIENTS: Infants with severe BPD who required MV. INTERVENTIONS: MV with helium-oxygen and air-oxygen mixtures. MAIN OUTCOME MEASURES: Respiratory parameters, acid-base balance, oxygenation and vital signs were recorded at five time points: initially during MV with air-oxygen, after 15 and 60 min of helium-oxygen MV, and 15 and 60 min after return to air-oxygen MV. RESULTS: 15 infants with BPD were enrolled. Helium-oxygen MV was well tolerated and was associated with a statistically significant increase in tidal volume, dynamic compliance and peak expiratory flow rate. An improvement in oxygenation and a decrease in fraction of inspired oxygen was also observed. During helium-oxygen MV there was a significant decrease in the oxygenation index and alveolar-arterial oxygen tension difference. The PaO2/fraction of inspired oxygen (FiO2) ratio increased significantly during helium-oxygen ventilation. A decrease in PaCO2 and an increase in pH were also observed during helium-oxygen administration, however this was not statistically significant. After ventilation with helium-oxygen was discontinued, the infants' respiratory function and oxygenation deteriorated and supplemental oxygen requirements increased accordingly. CONCLUSIONS: Helium-oxygen MV is safe and resulted in improvement of respiratory function and oxygenation in infants with severe BPD requiring MV.

School-age spirometry in survivors of chronic lung disease of prematurity in the surfactant era.

OBJECTIVE: To assess whether school-age spirometry and lung volume outcomes of preterm infants with history of moderate to severe respiratory distress syndrome (RDS), born in the surfactant era and treated with conventional mechanical ventilation (IMV) and discharged home with or without the diagnosis of BPD (chronic lung disease of prematurity), differ from those of term neonates (controls). PARTICIPANTS: The study included 148 Caucasian school-aged children (38 preterm infants without BPD, 20 preterm infants with BPD and 90 term infants). All infants were born at the Department of Pathology of Pregnancy and Labor, Pomeranian Medical University Szczecin, Poland. METHODS: Respiratory outcome in school-aged children was assessed using spirometry with the evaluation of flow and volume parameters, adjusted for age, weight and gender. The differences in spirometry were tested by the Wilcoxon or Mann-Whitney tests. Linear correlation and regression were also used. RESULTS: No statistically significant differences between the spirometric parameters in preterm infants with and without BPD were found. All investigated parameters were significantly lower in both ventilated groups compared to term controls, with the exception of ERV%, which was significantly higher CONCLUSIONS: The necessity to use assisted ventilation in preterm infants without neurological disorders most probably had an adverse effect on the lung function, assessed by spirometry at the age of 9-10 years, in the groups of children discharged home with or without BPD. Regardless of BPD, lung function parameters in prematurely born children with respiratory distress syndrome are always worse than in term controls.

The impact of second-hand tobacco smoke exposure on pregnancy outcomes, infant health, and the threat of third-hand smoke exposure to our environment and to our children.

Smoking during pregnancy is associated with various adverse effects on pregnancy and fetal development, carries a lot of serious complications such as spontaneous abortion, placental abruption, and reduced birth weight of the newborn. Children of smoking mothers have an increased risk of premature birth, low birth weight, sudden infant death syndrome and respiratory diseases during infancy. Smoking also causes long-term risk of maternal health problems such as: heart disease, cancer, emphysema, chronic obstructive pulmonary disease and higher mortality rate. Because women are more likely to quit smoking during pregnancy than at any other time, there are attempts to increase motivation and help them to stop smoking at the procreative phase of their life. The article describes interventions that are carried out in Loma Linda, where the educational program "When You Smoke Your Baby Smokes" reminds parents about the health effects of smoking during pregnancy and harmful impact on child's health caused by second-hand smoke. Another threat to health and environment of our children, is the nicotine coming from indirect exposure to tobacco smoke. Residual nicotine that persists in high concentrations on the interior surfaces, including clothing, is forming in the reaction of nitric acid carcinogenic compounds of specific nitrosamines. In addition, ozone and related atmospheric oxidants react with nicotine smoke or smoke coming from the second-hand smoke, giving the smallest particles with high risk of asthma. Efforts towards reducing exposure to tobacco smoke coming from the passive and indirect smoking should be placed at a high priority throughout the European Union.

Protecting the Vulnerable: The Importance of Effective Parental Tobacco-Dependence Treatment During Prenatal and Newborn Care.

Tobacco use among pregnant women, as well as second- and third-hand smoke exposure of their infants, translates into the startling fact that more than one third of American children live with at least one parent who smokes cigarettes daily. Maternal smoking or second-hand smoke exposure during pregnancy is deleterious to the mother's health and contributes to prematurity, low birth-weight infants, and increased risk of sudden infant death syndrome (SIDS) and recurrent wheezing during the first year of life. Pregnant women who stop tobacco use during pregnancy are at high risk for postpartum relapse frequently associated with a partner who smokes tobacco, stress, poverty, and lack of social and medical support to remain tobacco free. Enhanced efforts to identify and support pregnant women who smoke, and to implement strategies to prevent exposure of their fetus and newborn to the hazards of tobacco-smoke exposure, are paramount in our public health efforts to eliminate health disparities in the United States. We discuss the critical elements of programs to assist mothers to stop smoking during pregnancy and toward family efforts to maintain a smoke-free environment for their infant. Postpartum interventions, whether in the neonatal intensive care unit (NICU), newborn nursery, or postnatal care setting, can provide assistance that women need to remain smoke free, to educate spouses or significant others and their families, and to aide in establishing goals of maintaining a tobacco smoke-free home and car. Physicians and other perinatal healthcare providers have a duty to identify pregnant women who smoke for "meaningful use" in the electronic medical record, and to provide advice and assistance in evidence-based smoking interventions in obstetrical care settings. Pediatricians, neonatologists, and others providing postpartum, "normal" nursery or NICU care have an opportunity to protect infants and young children from second- and third-hand smoke exposure by assisting their parents and family members in maintaining a tobacco-free environment to improve the health of infants, toddlers, and young children.

An open label, pilot study of Aerosurf® combined with nCPAP to prevent RDS in preterm neonates.

BACKGROUND: Nasal continuous positive airway pressure (nCPAP) is an accepted mode of respiratory support for preterm infants with respiratory insufficiency. To avoid potential sequelae of endotracheal (ET) intubation and mechanical ventilation, prophylactic aerosolization of surfactant delivered via nCPAP has been attempted with limited success. METHODS: To determine the feasibility and safety of prophylactic aerosolization of a peptide-containing synthetic surfactant, Aerosurf® (lucinactant for inhalation) was delivered by nCPAP to preterm infants at risk for respiratory distress syndrome (RDS). Neonates were enrolled into treatment group 1 (Aerosurf retreatment separated by at least 3 h) or treatment group 2 (Aerosurf retreatment separated by at least 1 h). A vibrating membrane nebulizer Aeroneb Pro® was used to aerosolize 20 mg/mL Aerosurf. All neonates received the initial 3-h treatment, and three retreatments were permitted within 48 h based on clinical response. RESULTS: Seventeen infants were enrolled. Aerosurf was well tolerated, with transient desaturations observed during dosing without bradycardia or hypotension. Variability in output rates of the Aeroneb Pro was observed leading to different average dispensed drug volumes per treatment per patient. All infants survived; 29.4% required subsequent ET surfactant replacement therapy, 23.5% were diagnosed with RDS at 24 h, and 11.8% with bronchopulmonary dysplasia (BPD) at 28 days of life. Mean FiO2 was 0.4 at baseline, and 0.32 at 4 h posttreatment. CONCLUSIONS: Aerosurf can be safely administered via nCPAP in preterm infants at risk for RDS and may provide an alternative to surfactant administration via an ET tube. Further studies are required to evaluate this delivery approach.

When you smoke your baby smokes: advancing maternal and child health through an academic alliance to improve health of mothers and their infants.

The detrimental effect of tobacco exposure prior to conception and during pregnancy has been receiving much worldwide attention. Maternal smoking during pregnancy is associated with early-onset wheezing, increased respiratory illnesses, and a 2-fold increased risk for Sudden Infant Death Syndrome (SIDS). Adverse effects on the infant include altered infant behaviors such as an increased occurrence of infant colic or Attention Deficit Disorders (ADD). Studies have shown that a significant number of smoking woman "quit" smoking during pregnancy. However, a majority of women, 67% by 3 months and up to 90% by 6 month, resume smoking following delivery. An infant's birth related hospitalization is a "teachable moment" to address parental smoking, and to advocate for reducing fetal exposure to tobacco smoke. Academic alliance focused on well designed educative program can further increase rate of smoking free pregnant women and decrease smoking relapse rates significantly.

The 'new' bronchopulmonary dysplasia: challenges and commentary.

Lung development is orchestrated by highly integrated morphogenic programs of interrelated patterns of gene and protein expression. Injury to the developing lung in the canalicular and saccular phases of lung development alters subsequent alveolar and vascular development resulting in simplified alveolar structures, dysmorphic capillary configuration, variable interstitial cellularity and fibroproliferation that are characteristic of the 'new' bronchopulmonary dysplasia (BPD). Fetal and neonatal infection, abnormal stretch of the developing airways and alveoli, altered expression of surfactant proteins (or genetically altered proteins), polymorphisms of genes encoding for vascular endothelial growth factors, and reactive oxygen species result in imparied gas exchange in the developing lung. However, the 'new' BPD represents only one form of neonatal chronic lung disease and the consistent use of both the physiologic definition and severity scale would provide greater accuracy in determining the impact of the disease currently defined by its treatment. Our present labelling of the clinical state of oxygen supplementation and/or ventilatory support at 36 weeks' postmenstrual age and the histopathologic severity of alveolar arrest and vascular 'simplification' may not always be predictive of the degree of altered lung development and thus longer-term pulmonary function evaluations are needed to determine the impact of this disorder in specific infants. The proposed role of novel molecular therapies, and the combined effects of currently established therapies, as well as exogenous surfactant and inhaled nitric oxide or repetitive surfactant dosing, on the severity and incidence of new BPD hold considerable promise for reducing the long-term pulmonary morbidity among infants delivered prematurely.

A novel mutation associated with congenital hyperinsulinism.

Congenital hyperinsulinism is an important cause of persistent hypoglycemia in neonates. We present a term large-for-gestation neonate with congenital hyperinsulinism, who was found to have a novel sporadic missense mutation in the ABCC8 gene. The clinical phenotype of our case is described along with results of genetic testing. Our patient had an early onset of persistent hypoglycemia, which responded to diazoxide and octreotide. The echocardiogram revealed diffuse hypertrophy of the ventricular walls and septum, which regressed spontaneously by 8 months of age. The specific ABCC8 missense mutation has not been previously reported in association with congenital hyperinsulinism. Our case highlights the need for genetic evaluation in this condition. The unraveling of new mutations with unique phenotypic features may have diagnostic and prognostic utility.

Evolution of pulmonary surfactants for the treatment of neonatal respiratory distress syndrome and paediatric lung diseases.

UNLABELLED: This review documents the evolution of surfactant therapy, beginning with observations of surfactant deficiency in respiratory distress syndrome, the basis of exogenous surfactant treatment and the development of surfactant-containing novel peptides patterned after SP-B. We critically analyse the molecular interactions of surfactant proteins and phospholipids contributing to surfactant function. CONCLUSION: Peptide-containing surfactant provides clinical efficacy in the treatment of respiratory distress syndrome and offers promise for treating other lung diseases in infancy.

A multicenter, randomized, masked, comparison trial of lucinactant, colfosceril palmitate, and beractant for the prevention of respiratory distress syndrome among very preterm infants.

BACKGROUND AND OBJECTIVE: Evidence suggests that synthetic surfactants consisting solely of phospholipids can be improved through the addition of peptides, such as sinapultide, that mimic the action of human surfactant protein-B (SP-B). A synthetic surfactant containing a mimic of SP-B may also reduce the potential risks associated with the use of animal-derived products. Our objective was to compare the efficacy and safety of a novel synthetic surfactant containing a functional SP-B mimic (lucinactant; Discovery Laboratories, Doylestown, PA) with those of a non-protein-containing synthetic surfactant (colfosceril palmitate; GlaxoSmithKline, Brentford, United Kingdom) and a bovine-derived surfactant (beractant; Abbott Laboratories, Abbott Park, IL) in the prevention of neonatal respiratory distress syndrome (RDS) and RDS-related death. METHODS: We assigned randomly (double-masked) 1294 very preterm infants, weighing 600 to 1250 g and of < or =32 weeks gestational age, to receive colfosceril palmitate (n = 509), lucinactant (n = 527), or beractant (n = 258) within 20 to 30 minutes after birth. Primary outcome measures were the rates of RDS at 24 hours and the rates of death related to RDS during the first 14 days after birth. All-cause mortality rates, bronchopulmonary dysplasia (BPD) rates, and rates of other complications of prematurity were prespecified secondary outcomes. Primary outcomes, air leaks, and causes of death were assigned by an independent, masked, adjudication committee with prespecified definitions. The study was monitored by an independent data safety monitoring board. RESULTS: Lucinactant reduced significantly the incidence of RDS at 24 hours, compared with colfosceril (39.1% vs 47.2%; odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.52-0.89). There was no significant difference in comparison with beractant (33.3%). However, lucinactant reduced significantly RDS-related mortality rates by 14 days of life, compared with both colfosceril (4.7% vs 9.4%; OR: 0.43; 95% CI: 0.25-0.73) and beractant (10.5%; OR: 0.35; 95% CI: 0.18-0.66). In addition, BPD at 36 weeks postmenstrual age was significantly less common with lucinactant than with colfosceril (40.2% vs 45.0%; OR: 0.75; 95% CI: 0.56-0.99), and the all-cause mortality rate at 36 weeks postmenstrual age was lower with lucinactant than with beractant (21% vs 26%; OR: 0.67; 95% CI: 0.45-1.00). CONCLUSIONS: Lucinactant is a more effective surfactant preparation than colfosceril palmitate for the prevention of RDS. In addition, lucinactant reduces the incidence of BPD, compared with colfosceril palmitate, and decreases RDS-related mortality rates, compared with beractant. Therefore, we conclude that lucinactant, the first of a new class of surfactants containing a functional protein analog of SP-B, is an effective therapeutic option for preterm infants at risk for RDS.