Umbilical cord management strategies at cesarean section.

AIM: To evaluate the effect of different strategies to improve placental transfusion in cesarean section (CS). METHODS: Retrospective analysis of all singleton term pregnancies that underwent CS over 6 months. Delayed umbilical cord clamping (dUCC) was defined as one done at least 60 s after birth. Umbilical cord milking (UCM) was an option when waiting 60 s was deemed unsafe. The two strategies were compared against early (<60 s) umbilical cord clamping (eUCC) without milking. Neonatal hematocrit (Hct) at 48 h was the main outcome variable. RESULTS: Of the 223 CS in the cohort, 100 were performed in labor and 123 were elective. dUCC was performed in 137, eUCC without milking in 53 and UCM in 33 cases. Neonatal Hct was higher in CS carried out in labor versus in elective CS (59.76% ± 6.17 vs 56.91% ± 5.95, P = 0.001). At multivariate analysis, CS performed in labor (coefficient [coeff.] 3.44, confidence interval [CI] 1.75-5.13, P < 0.001), UCM (coeff. 3.88, CI 1.61-6.14, P = 0.001) and birth weight (coeff. -0.003, CI -0.005 to -0.001, P = 0.001) were the only variables independently associated with neonatal Hct. In elective CS, UCM led to higher neonatal Hct (61.5% ± 5.5) compared to eUCC without milking (55.1% ± 5.5) and dUCC (56.4% ± 5.7, P = 0.001), while in CS performed in labor there were no significant differences among the placental transfusion strategies. CONCLUSION: In term CS, neonatal Hct is significantly higher when the CS is performed in labor or with UCM. In elective CS, UCM could be a valid option to favor placental transfusion.

Survey of PDA management in very low birth weight infants across Italy.

BACKGROUND: The optimal management of PDA in very low birth weight (VLBW) infants is still controversial. Aim of our study was to investigate the management of PDA in the Italian neonatal intensive care units (NICU). METHODS: We conducted an on-line survey study from June to September 2017. A 50-items questionnaire was developed by the Italian Neonatal Cardiology Study Group and was sent to Italian NICUs. RESULTS: The overall response rate was 72%. Diagnosis of PDA was done by neonatologists, cardiologists or both (62, 12 and 28% respectively). PDA significance was assessed by a comprehensive approach in all centers, although we found a heterogeneous combination of parameters and cut-offs used. None used prophylactic treatment. 19% of centers treated PDA in the first 24 h, 60% after the first 24 h, following screening echocardiography or clinical symptoms, 18% after the first 72 h and 2% after the first week. In the first course of treatment ibuprofen, indomethacin and paracetamol were used in 87, 6 and 7% of centers respectively. Median of surgical ligation was 3% (1-6%). CONCLUSIONS: Significant variations exist in the management of PDA in Italy. Conservative strategy and targeted treatment to infants older than 24 h with echocardiographic signs of hemodynamic significance seemed to be the most adopted approach.

Neonatologist performed echocardiography (NPE) in Italian neonatal intensive care units: a national survey.

BACKGROUND: Neonatologist performed echocardiography (NPE) has increasingly been used to assess the hemodynamic status in neonates. Aim of this survey was to investigate the utilization of NPE in Italian neonatal intensive care units (NICUs). METHODS: We conducted an on-line survey from June to September 2017. A questionnaire was developed by the Italian neonatal cardiology study group and was sent to each Italian NICU. RESULTS: The response rate was 77%. In 94% of Italian NICUs functional echocardiography was used by neonatologists, cardiologists or both (57, 15 and 28% respectively). All the respondents used NPE in neonates with patent ductus arteriosus and persistent pulmonary hypertension, 93% in neonates with hypotension or shock, 85% in neonates with perinatal asphyxia, 78% in suspicion of cardiac tamponade, and 73% for line positioning. In 30% of center, there was no NPE protocol. Structural echocardiography in stable and critically ill neonates was performed exclusively by neonatologists in 46 and 36% of center respectively. CONCLUSIONS: NPE is widely used in Italian NICUs by neonatologists. Structural echocardiography is frequently performed by neonatologists. Institutional protocols for NPE are lacking. There is an urgent need of a formal training process and accreditation to standardize the use of NPE.

Functional gastrointestinal disorders in newborns: nutritional perspectives.

Functional gastrointestinal disorders (FGIDs) definition in children has changed over the years trying to facilitate clinicians, because the diagnostic process is complicated by the interpretation variability of symptoms described by children or by their caregivers for newborns and toddlers. This review refers to the Rome IV classification system, drafted in 2016. FGIDs pathophysiology is multifactorial and still poor understood, with limitations for the therapeutic process, which results often in unnecessary and alternative treatments trying to reduce the relevant caregiver distress, but with increased costs for families and for the National Health Service. This study reports the most recent evidence-based treatments for FGIDs in newborns: though in most cases the first action is an educational and behavioral intervention, reassuring caregivers about the transient and self-limiting natural history of FGIDs, there is now more evidence to recommend probiotics in some infant FGIDs.

Breastfeeding promotion: evidence and problems.

Although breastfeeding is associated with many health benefits in children and mothers, and World Health Organization (WHO) recommends exclusive breastfeeding until 6 months of age and continued breastfeeding until 2 years of age, overall breastfeeding rates remain low. Italian rates of exclusive breastfeeding do not differ from international data. The aim of this review is to evaluate evidence of breastfeeding promotion interventions and the remaining problems to achieve them. We found that breastfeeding support is a complex system of interventions, including individual, structural and environmental factors. Many systematic reviews report evidence that breastfeeding support offered to women increases duration and exclusivity of breastfeeding, both in full term healthy newborns and in preterm infants. Political and economic efforts should be made to ensure breastfeeding support to all women in the different settings, assuming it as a collective target.

Mother-To-Child Transmission of KPC Carbapenemase-Producing Klebsiella Pneumoniae at Birth.

We report on a mother-to-child transmission of KPC carbapenemase-producing Klebsiella pneumoniae at birth followed by subsequent cases in the neonatal intensive care unit. Molecular analysis of isolates showed production of KPC-3 enzyme. The only potential risk factor identified for the mother was previous activity as a caregiver. Present findings suggest consideration of proactive surveillance in pregnant women with risk factors for colonization.

Echocardiographic assessment of ductal significance: retrospective comparison of two methods.

BACKGROUND: Patent ductus arteriosus (PDA) in preterm infants is often assessed with echocardiographic parameters, especially colour Doppler ductal diameter and pulsed Doppler flow pattern. Clinical algorithms have been proposed in which PDA treatment is indicated by either large diameter or a particular flow pattern, however it is unknown whether ductal diameter and flow pattern provide equivalent stratification of infants. AIM: Retrospectively assess both parameters in 197 echocardiograms from 104 infants (gestational age <31 weeks). METHODS: Echocardiograms were independently reviewed and the internal colour Doppler diameter of the PDA and the pulsed Doppler flow pattern were characterised for each study (169 records had both parameters recorded). RESULTS: Diameter varied widely within each group but was significantly associated with flow pattern: mean diameter was greatest in the pulmonary hypertension (PH) group (2.6 mm), progressively narrowed across growing and pulsatile groups, and was smallest in the closing group (1.3 mm). When echocardiograms were categorised using previously published diameters, 82.4% of the PH group had diameters >2.0 mm, large diameters predominated in the growing and pulsatile groups but to a progressively smaller extent, and 98.1% of closing group had diameters <2.0 mm. CONCLUSION: Ductal diameter and flow patterns are significantly associated, consistent with a narrowing of the ductus until closure. Overall, the two parameters are in good agreement but will result in different treatment decisions in some cases. Clinicians might consider using both methods as a cross check against each other, to assist in the management of preterm infants with a clinically detectable PDA.

Blood pressure or blood flow: which is important in the preterm infant? A case report of twins.

There is a poor association between systemic blood flow and blood pressure in preterm infants in the first days of life. Very preterm babies can have early low systemic blood flow with poor myocardial contractility but normal blood pressure. Superior vena cava flow measured by echocardiography can be used to determine systemic blood flow. Low superior vena cava flow is a risk factor for mortality and morbidity in preterm infants. We report the case of preterm twins with contrasting relationships among systemic blood flow, myocardial contractility and blood pressure. The first twin with normal blood pressure, but low superior vena cava flow and poor myocardial contractility in the first hours of life developed a severe intraventricular haemorrhage and died, despite cardiovascular support. The second twin with low blood pressure but normal superior vena cava flow did not develop adverse outcomes in the first days of life. These cases underline the usefulness of neonatal functional echocardiography in early understanding and management of the preterm infant, and the inaccuracy of other clinical parameters used to assess cardiovascular function.