Are high cumulative doses of erythropoietin neuroprotective in preterm infants? A two year follow-up report.

BACKGROUND: Preterm infants are at risk for neurodevelopmental sequelae even in absence of major cerebral lesions. The hypothesis that Human Recombinant Erythropoietin (rEpo) could improve the neurodevelopmental outcome in risk neonates has raised the highest interest in recent years. METHODS: A group of preterm neonates born at a gestational age ≤ 30 weeks and free from major cerebral lesions or major visual impairment, were included in the study if they had a complete neurologic evaluation for at least 24 months of postmenstrual age. They were assigned to group I in the case they had been treated with rEpo or group II if untreated. The aim was to evaluate whether rEpo, given at the high cumulative doses utilized for hematologic purposes, is able to improve the neurodevelopmental outcome in preterm infants born at a gestational age ≤ 30 weeks. A group of 104 preterm neonates were studied: 59 neonates who received rEpo for 6.9 ± 2.4 weeks at a median cumulative dose of 6300 UI/Kg (6337 ± 2434 UI/Kg), starting at a median age of 4 days and 45 neonates who were born in the period preceding the routine use of rEpo. The neurodevelopmental quotient at 24 month postmenstrual age was assessed utilizing the Griffiths' Mental Developmental Scales. RESULTS: Our results failed to show any difference in the Developmental Quotient at 24 month. Bronchopulmonary dysplasia, minor intraventricular hemorrhages and blood transfusions were the clinical features significantly related to the Developmental Quotient. CONCLUSIONS: Our results do not support the hypothesis that rEpo, administered with the schedule utilized for hematologic purposes, improve the neurodevelopmental outcome of preterm neonates, at least those preterm infants free from major impairments.

Erythropoietin and retinopathy of prematurity.

Erythropoietin (EPO) is a glycoprotein that regulates many functions of an organism: It stimulates the production of red blood cells and it has angiogenic and neuroprotective properties in newborn infants. Retinopathy of prematurity (ROP) is a frequent cause of visual impairment in preterm newborn infants and it has two distinct phases in which hypoxia-induced angiogenic factors are involved. The relationship between EPO and ROP is derived from the observation of studies done on the haematopoietic effect of EPO. The first observations suggested that a precocious treatment with EPO increases the risk of ROP, while the most recent reports suggested that the late treatment with high doses of rhEPO can increase the risk of ROP. All these studies were not designed to demonstrate the relationship between EPO and ROP. Further studies specifically designed should be performed. New ongoing studies on the neuroprotective role of EPO should consider this objective. In the mean time the use of EPO in the neonatal period should be cautious, mainly in very low birth weight infants.

Spontaneous minute ventilation is a predictor of extubation failure in extremely-low-birth-weight infants.

OBJECTIVE: To validate the percentage of time spent below a target value of spontaneous expiratory minute ventilation (< 125 ml/min per kg) during a 2-h period of continuous positive airway pressure (CPAP) via an endotracheal tube (ETT) as a predictor of failed extubation in preterm infants. METHODS: Forty-one infants intubated for at least 24 h, with birth weight between 500 and 1000 g, who were clinically stable and at ventilator setting compatible with an extubation attempt, were studied during a 2-h period of ETT CPAP. Dynamic lung compliance and total lung resistance were measured during a period of quiet breathing, while tidal volume (Vt), respiratory rate and the corresponding spontaneous expiratory minute ventilation values were calculated for the complete recording period of 2 h using a customized computer program. The time each patient spent below the target spontaneous expiratory minute ventilation value was reported as a percentage of the total recorded time (% spontaneous expiratory minute ventilation < 125 ml/min per kg). Extubation failure was defined as the need for reintubation within 72 h. RESULTS: Eleven out of 41 babies (26.8%) experienced failure of extubation (failure group) while 30 infants (73.2%) were successfully extubated (success group). There were no significant differences in dynamic lung compliance and lung resistance between the two groups, but the mean values of respiratory rate and spontaneous expiratory minute ventilation were significantly lower in the failure group than in the success group: 43 (37-56) breaths/min and 240 (160-353) ml/min per kg vs. 53 (28-67) breaths/min and 309 (223-434) ml/min per kg, respectively (p = 0.0129 and p = 0.0039). Moreover, the babies in whom extubation failed spent a longer time below the target value of spontaneous expiratory minute ventilation when compared with successfully extubated babies (p < 0.0001). Percentage of time spent with spontaneous expiratory minute ventilation < 125 ml/min per kg had a larger area than transcutaneous (Tc)PCO2, TcPO2 and pulse oxymetry saturation (SpO2) under the receiver operator characteristic curves. CONCLUSION: The measurement of spontaneous expiratory minute ventilation prior to extubation could be useful in identifying those babies who are not ready for spontaneous ventilation.

Efficacy and safety of continuous intravenous infusion of remifentanil in preterm infants undergoing laser therapy in retinopathy of prematurity: clinical experience.

BACKGROUND: Preterm infants often require surgery. As experimental evidence suggests that premature infants may experience pain and this could even result in fatal complications, the anaesthesiologist must face problems related to lowbirth weight, high risk of hypothermia, concomitant pulmonary disease and metabolic and receptor immaturity. Recently remifentanil has been considered an optimal analgesic drug in a preterm infant undergoing mechanical ventilation and frequent surgical manoeuvres, but no clinical studies have been reported in the literature. The aim of our study was to evaluate the efficacy of a continuous intravenous infusion of remifentanil in premature infants undergoing laser therapy for retinopathy of prematurity (ROP). METHODS: Six premature infants with ROP were scheduled for laser therapy. The procedure was performed in the neonatal intensive care unit. Transcutaneous carbon dioxide, pulse oximetry, respiratory rate, ECG and noninvasive blood pressure were continuously monitored. Infusion of remifentanil started with a dose of 0.75-1 microg x kg-1x min-1, 1 h before surgery. A midazolam bolus dose (0.20 mg x kg-1) was administered and the remifentanil infusion was increased to 3-5 microg x kg-1x min-1 taking into account haemodynamic and respiratory changes or spontaneous movements. RESULTS: Increased dosage was necessary only for 10 min during the procedure. No changes in temperature and ventilatory settings were observed and after 2 h from the surgical procedure the preterm infants were back to their preoperative status. CONCLUSIONS: A continuous infusion of remifentanil allowed optimal control of surgical stress and a return to preoperative status and ventilatory settings without side-effects.

Adrenocortical function and chronic lung disease of pre-maturity: an unresolved problem?

The aim of this study was to investigate the relationship between adrenocortical function and chronic lung disease (CLD) of pre-term infants. Plasma F and ACTH were measured at 7, 14, 21 and 28 days of life in 25 pre-term infants with gestational age < or = 32 weeks and birth weight < or = 1,250 g. Fourteen infants developed CLD (CLD group) and 11 recovered without CLD (NOCLD group). Response to ACTH stimulation was tested on days 7 and 28. The results show that at the 7th day of life plasma F and ACTH levels were similar in the NOCLD and CLD group. CLD group had significantly higher plasma F and ACTH concentrations at the 14th (p=0.006 for F and p=0.020 for ACTH) and at the 21st (p=0.008 for F and p=0.024 for ACTH) day of life, while no significant differences were detected at the 28th day of life. The response to ACTH stimulation test was similar between the NOCLD and CLD group. These data demonstrate the lack of any significant association between adrenal insufficiency and CLD and discourage the use of baseline or stimulated plasma F levels to predict the development of CLD in pre-term infants.

Cardiac adverse effects of early dexamethasone treatment in preterm infants: a randomized clinical trial.

This study evaluates the effects of early administration of dexamethasone on left ventricle dimensions and their clinical significance in preterm infants. Fifty preterm infants with birth weight < or = 1250 g and gestational age < or = 30 weeks were randomly assigned after 72 hours of life to the dexamethasone group (n = 25) or to the control group (n = 25). The treated infants received dexamethasone intravenously from the 4th day of life for 7 days (0.5 mg/kg/day for the first 3 days, 0.25 mg/kg/day for the next 3 days, and 0.125 mg/kg/day for the 7th day). Serial echocardiographic measurements of end systolic interventricular septum thickness, end diastolic interventricular septum thickness, end systolic left ventricle posterior wall thickness, end diastolic left ventricle posterior wall thickness, left ventricle end diastolic diameter, and left ventricle end systolic diameter were taken before starting dexamethasone, on days 3 and 7 of treatment, 7 days after the interruption of treatment, and at the 28th day of life. Five infants of each group were excluded by the final analysis because of the lack of a complete cardiac evaluation, leaving 20 treated and 20 control infants. Infants receiving dexamethasone had a significantly larger increase in mean septal and left posterior wall thickness during the treatment and 7 days after the dexamethasone weaning. The mean left ventricle diameter of treated infants was significantly lower than that of control infants from the 7th day of treatment to the 28th day of life. Four neonates (20%) in the dexamethasone group developed left ventricular myocardial hypertrophy without left ventricle outflow tract obstruction, showing signs of decreased cardiac output and ischemic changes on ECG. The daily fluid intake was increased to 200 ml/kg to ensure an adequate preload volume, and the complete resolution of left ventricle hypertrophy was obtained within the 2nd to 3rd week after dexamethasone weaning. Preterm infants receiving an early (< 96 hours of life) short course of dexamethasone develop a left ventricular myocardial hypertrophy that can be symptomatic and clinically significant. Preterm infants included in future studies with the goal to find the minimum dose and duration of dexamethasone treatment should be strictly monitored echocardiographically for this side effect.

Normal neonatal values of ophthalmic and central retinal artery blood flow velocities.

PURPOSE: To define standard values of blood flow velocities and indices in the ophthalmic and central retinal arteries in the neonatal period. METHODS: Forty-two healthy full-term neonates comprised the study population. A color Doppler with mechanical sector probe was used for measuring blood flow velocity in the ophthalmic and central retinal arteries. Systolic, end diastolic, and mean-enveloped velocities were measured, and the resistance index and pulsatility index were calculated. RESULTS: Ophthalmic artery Doppler velocities were similar on the first and third days of life, but increased significantly on the fifth and seventh days of life; resistance index significantly increased during the first week of life, whereas pulsatility index did not change significantly. Doppler velocities of the central retinal artery were similar on the first and third days; they show a delayed increase compared to the ophthalmic artery. Central retinal artery blood flow velocities increased significantly from the third to seventh postnatal day. Resistance index also increased between the first two days and on the fifth and seventh postnatal days, while pulsatility index did not change. CONCLUSION: These data constitute a starting point for studying the possible relationship between eye circulation and pathogenesis of retinopathy of prematurity.

Prophylactic ibuprofen therapy of patent ductus arteriosus in preterm infants.

UNLABELLED: This study was aimed at evaluating the efficacy of ibuprofen in the prophylaxis of patent ductus arteriosus (PDA) in very preterm neonates and at detecting eventual side-effects. A total of 46 preterm neonates with gestational age under 31 weeks were randomly assigned at 2 h of life: 23 to the prophylaxis group and 23 to the control group. The prophylaxis group received intravenous treatment with ibuprofen lysine (10 mg/kg), followed by 5 mg/kg after 24 h and 48 h. No placebo was given to the control group. No PDA was demonstrated at 72 h of life in 20 of the 23 babies in the ibuprofen group (87%) nor in 7 of the 23 control neonates (30.4%). All neonates with PDA received treatment with indomethacin. One neonate in the prophylaxis group and three in the control group underwent surgical ligation. Prophylaxis with ibuprofen was not associated with any significant side-effect except for food intolerance. CONCLUSION: Ibuprofen prophylaxis seems to be efficient in closing patent ductus arteriosus and in reducing indomethacin treatment. No significant early side-effects were found due to ibuprofen.

Effects of prophylactic ibuprofen on cerebral and renal hemodynamics in very preterm neonates.

OBJECTIVE: To evaluate the effects on cerebral and renal blood flow velocities of ibuprofen when used as prophylaxis for patent ductus arteriosus in preterm neonates (gestational age <30 weeks). METHODS: Blood flow velocities in the anterior cerebral artery and the renal artery were measured with Doppler ultrasonography in 17 neonates before, during, and 10, 30, and 60 minutes after administration of 10 mg/kg ibuprofen lysine. RESULTS: In four (23.6%) neonates without echocardiographic patency of the ductus, no significant modifications in blood flow velocities and Doppler indexes were found either in the anterior cerebral artery or in the renal artery. In 13 (76.4%) neonates, cardiac echocardiographic Doppler showed patency of the ductus and left-to-right shunt. In these neonates diastolic and mean blood velocities rapidly increased both in the anterior cerebral artery and the renal artery (P < .0001). Resistance and pulsatility index decreased during the study period (P < .0001 and P < .001, respectively, in the anterior cerebral artery; P < .0001 in the renal artery). CONCLUSIONS: Data suggest that ibuprofen does not determine any direct effect on cerebral and renal blood flow velocities; hemodynamic modifications observed in neonates with patency of ductus can be related to closure of the ductus induced by the drug.

Intraventricular hemorrhage: past, present and future, focusing on classification, pathogenesis and prevention.

The improvement in the survival rate of infants born at the limit of viability, i.e. < 26 weeks of gestational age, raises concern about the risk of neurodevelopmental disabilities. The relevance of intraventricular hemorrhage (IVH), which is the most frequent cerebral lesion diagnosed in extremely low birth weight neonates, cannot then be underestimated. Pharmacological interventions designed to prevent the occurrence of IVH and its complications have not been entirely conclusive. The understanding of pathogenetic factors involved in the genesis of IVH is the key to planning of new strategies and meanwhile of implementing care guidelines aimed at its prevention.

Effect on growth of two different dexamethasone courses for preterm infants at risk of chronic lung disease. A randomized trial.

A randomized study was designed to evaluate the effects of two different dexamethasone courses on the growth of preterm infants. The first phase included 30 preterm infants at high risk for chronic lung disease (CLD). 15 babies (moderately early dexamethasone group) were treated with dexamethasone for 14 days, from the 10th day of life, and received a total dose of 4.75 mg/kg; 15 babies were assigned to the control group. The second phase included 30 preterm infants at high risk for CLD. 15 babies (early dexamethasone group) were treated with dexamethasone for 7 days, from the 4th day of life, and received a total dose of 2.38 mg/kg; 15 babies were assigned to the control group. All the main clinical baseline characteristics were similar between the groups both in the first and in the second phase. Infants given the two dexamethasone courses showed significantly reduced weight gain during the period of treatment when compared to the respective control group, but they had a weight catch-up soon after the end of treatment. At 30 days of life the weight and length gain of each treated group were similar to those of control infants, but the moderately early dexamethasone group showed a significantly poorer head growth. No differences between the groups were observed at discharge. Dexamethasone treatment induces a slower weight gain which is time-limited to the period of treatment and is followed by a body weight catch-up. However, the poorer head growth detected at 30 days of life in the infants who received a higher dose of dexamethasone could indicate important adverse effects, possibly dose-related, on postnatal brain growth and development.

Early postnatal dexamethasone for the prevention of chronic lung disease in high-risk preterm infants.

OBJECTIVE: The purpose of this study was to evaluate the effect of early administration of dexamethasone on the incidence of chronic lung disease (CLD) in high risk preterm infants and to evaluate the side effects of the early steroid administration. DESIGN: Randomised clinical trial. SETTING: Neonatal intensive care unit. PATIENTS: 50 infants at high risk of CLD were randomly assigned after 72 h of life to the dexamethasone group (n = 25) or to the control group (n = 25). The treated infants received dexamethasone intravenously from the 4th day of life for 7 days (0.5 mg/kg per day for the first 3 days, 0.25 mg/kg per day for the next 3 days and 0.125 mg/kg per day on the 7th day). The control group received no steroid treatment. RESULTS: The incidence of CLD at 28 days of life and at 36 weeks' postconceptional age was significantly lower in the dexamethasone group than in the control group (p < 0.001). Moreover, infants in the dexamethasone group remained intubated and required oxygen therapy for a shorter period than those in the control group (p < 0.001). Hyperglycaemia, hypertension, growth failure and mainly hypertrophy of the left ventricle were the transient side effects associated with early steroid administration. CONCLUSIONS: Early dexamethasone administration may be useful in preventing CLD, but its use should prudently be restricted to preterm infants at high risk of CLD.

Doppler ultrasound of blood flow velocities in ophthalmic and central retinal arteries during the early neonatal period.

PURPOSE: To obtain standard values of blood flow velocity in the ophthalmic artery and central retinal artery in the neonatal period and to compare blood flow velocity of orbital vessels with that of the anterior cerebral artery and middle cerebral artery. METHODS: Forty-five healthy neonates (gestational age, 39.2 +/- 1.2 weeks; birth weight, 3,210 +/- 567 g) on the first and third postnatal days (90 eyes each time) and on the fifth day of life (34 eyes) were included in a clinical trial. A duplex scanner with mechanical sector probe was used for measuring blood flow velocity in the ophthalmic artery, central retinal artery, anterior cerebral artery, and middle cerebral artery. A nominal imaging frequency of 7.5 MHz, a transmitted Doppler frequency of 5 MHz, and a wall filter setting of 50 Hz were used in each case. Systolic, end-diastolic, and mean-enveloped velocities were measured for the studied vessels and the resistance and pulsatility indices were calculated. RESULTS: On the first postnatal day, blood flow velocities and indices in the ophthalmic artery were systolic 14 +/- 2.4 cm/sec, end-diastolic 3.8 +/- 0.6 cm/sec, mean-enveloped 7.3 +/- 1.3 cm/sec, resistance index 0.73 +/- 0.03, and pulsatility index 1.5 +/- 0.2. Central retinal artery blood flow velocities and indices were systolic 8.7 +/- 1.8 cm/sec, end-diastolic 2.7 +/- 0.7 cm/sec, mean-enveloped 5.0 +/- 1.1 cm/sec, resistance index 0.70 +/- 0.04, and pulsatility index 1.3 +/- 0.1. There were no significant differences in ophthalmic artery and central retinal artery flow velocities between right and left eyes. Doppler values of the central retinal artery were significantly lower (P = .0005) than those of the ophthalmic artery for each day studied. The Doppler data for the central retinal artery and ophthalmic artery were significantly lower (from P = .005 to .0001) than those observed in the anterior cerebral artery and middle cerebral artery at the same postnatal age. No significant differences in flow variables were found in the central retinal artery and ophthalmic artery from the first to third day, whereas blood flow velocities in the anterior cerebral artery and middle cerebral artery increased significantly (P = .01 to .0001) from day 1 to day 3. On the fifth day of life a significant increase in blood flow velocities and indices was observed in the ophthalmic artery, whereas only systolic velocity significantly increased in the central retinal artery. CONCLUSIONS: We report blood flow data of the ophthalmic artery and central retinal artery in healthy neonates and suggest that a delay of arterial blood flow changes occurs for the ophthalmic artery and central retinal artery with respect to the anterior cerebral artery and middle cerebral artery in the early prenatal period.

Doppler evaluation of renal blood flow velocity as a predictive index of acute renal failure in perinatal asphyxia.

UNLABELLED: Aim of our study was to evaluate Doppler renal blood flow velocity in asphyxiated neonates and to correlate renal function to Doppler findings. Doppler renal blood flow velocity was evaluated in 23 severely asphyxiated neonates born at a gestational age > 32 weeks and compared to our standard Doppler data obtained in 25 healthy neonates comparable for gestational age and birth weight. Renal Doppler ultrasound was performed on the 1st and 3rd days of life. Renal function was investigated in the first 2 weeks of life. Asphyxiated neonates showed mean values of systolic velocity and mean velocity significantly reduced (P < 0.001) compared with our standard Doppler values on the 1st day of life. Seven out of the 23 asphyxiated neonates were affected by acute renal failure and 14 showed no renal involvement. Two neonates were oliguric but did not develop acute renal failure. On the 1st day of life, neonates with acute renal failure had significantly lower mean values of systolic velocity and mean velocity than the asphyxiated neonates without renal involvement (P < 0.01). All 7 neonates affected by acute renal failure showed a systolic velocity more than 2SD below the mean standard value, while only 4 of the 16 asphyxiated neonates (25%) without acute renal failure had low systolic velocity values on the 1st day of life. Doppler velocities in asphyxiated neonates were similar to standard values on the 3rd day of life. Renal failure recovered before the 11th day of life in all cases. CONCLUSION: Our findings indicate that decreased Doppler renal flow systolic velocity observed in asphyxiated neonates on the st day of life is a useful predictive index for subsequent development of acute renal failure, with 100% sensitivity and 63.6% specificity.

Furosemide does not prevent indomethacin-induced renal side effects in preterm infants.

OBJECTIVE: To determine whether furosemide could prevent renal side effects of indomethacin (INN, indometacin) used for the pharmacologic closure of the patent ductus arteriosus (PDA) in preterm infants. METHODS: Thirty-six preterm infants with birth weights < 1750 gm affected by hemodynamically significant PDA were randomly assigned to one of two study groups. Group 1 consisted of 18 infants treated with three doses of indomethacin (0.20 mg/kg every 12 hours); each dose was followed by a dose of furosemide (1 mg/kg). Group 2 consisted of 18 infants treated only with the same doses of indomethacin. Body weight, urine output, glomerular filtration rate (GFR), fractional excretion of sodium (FENa+) and potassium (FEK+), and osmolal and free water clearance were evaluated in both groups before, during, and after treatment. RESULTS: The body weight trend, serum sodium, chloride and potassium concentrations, plasmatic and urinary osmolality were similar during the treatment in both the groups. A significant reduction of urine output (p < 0.01) was detected in group 2 but not in group 1. A significant increase of blood urea nitrogen and serum creatinine was detected at the end of treatment in group 1 compared with group 2. During the treatment, a significantly higher GFR (p < 0.05) was found in group 2 than in group 1. FENa+ and FEK+ were significantly higher (p < 0.05 and p < 0.001, respectively) in group 1 than in group 2 during and after the treatment. The osmolol clearance and free water clearance were significantly higher during and after treatment (p < 0.01 and p < 0.001, respectively) in group 1 than in group 2. CONCLUSIONS: Our findings show that furosemide cannot prevent the indomethacin-induced renal failure, but it does not have any negative influence on its therapeutic effectiveness.

Failure of fibrinolytic endoventricular treatment to prevent neonatal post-haemorrhagic hydrocephalus. A case-control trial.

Post-haemorrhagic hydrocephalus is assumed to result from obstruction of the cerebrospinal fluid (CSF) pathways by blood clots and subsequent chronic infiltration with collagen. The aim of this work was to evaluate the possibility of preventing permanent shunt dependence by enhancing the endoventricular fibrinolysis by means of an endoventricular streptokinase infusion in babies affected by posthaemorrhagic ventricular dilation. A case-control trial was carried out in 12 neonates affected by intraventricular haemorrhage and subsequent progressive ventriculomegaly. Six of them were treated with 20,000 U/day of streptokinase infused over 96 h through a percutaneous ventricular catheter. Our results show that the percentage of shunted babies was identical in treated and control patients despite the enhancement of endoventricular fibrinolysis obtained in all treated patients. On the basis of our results we do not recommend intraventricular streptokinase infusion for routine use in post-haemorrhagic ventricular dilatation.

[A new device for phototherapy of neonatal jaundice]. / Un nuovo sistema di fototerapia nel trattamento dell'ittero neonatale.

The effectiveness of a new device for phototherapy in the treatment of nonhemolytic hyperbilirubinemia (Wallaby Phototherapy System) was evaluated. 46 healthy term infants, appropriate for gestational age and with serum bilirubin > 12 mg/dl in the first 3 days of life or > 15 mg/dl after 3rd day were randomly assigned to a treatment group (24 hours of light exposure with Wallaby Phototherapy System) and to a control group (any treatment for hyperbilirubinemia). Body temperature, weight, feeding and hydration were recorded during the study period. Serum bilirubin and haematocrit were done every 12 hours in all babies. In the treated group we found a decrease of 5.1% and of 7.8% at 12 and 24 hours, while an increase of 3.37% and of 2.9% at 12 and 24 hours was found in the control group. After 24 hours the serum bilirubin level was significantly lower in the treated group than in the control group (p < 0.05). No newborn of the treated group needed conventional phototherapy versus 4 control infants (17.4%). The conclusion of our study is that the Wallaby System is useful in the treatment of neonatal nonhemolytic hyperbilirubinemia even if its effectiveness for higher bilirubin levels has still to be tested.

[Weight gain in the first 2 months of life in neonates with a birth weight less than or equal to 1500 g. A comparison between parenteral nutrition and orogastric feeding]. / Accrescimento ponderale dei primi due mesi di vita in neonati con PN meno di od uguale a 1500 g. Confronto tra nutrizione parenterale e alimentazione orogastrica.

This study was designed to verify the effectiveness of parenteral nutrition (NP) and continuous nasogastric feeding (AOG) in providing a good caloric intake and a good growth in the very low birth weight infants during the first 60 days of life. The study included 108 preterm babies with birth weight less than or equal to 1500 g: 26 received parenteral nutrition, 82 nasogastric feeding. Infants in NP showed a smaller postnatal weight loss and regained birth weight earlier than the AOG group. Caloric intake greater than 120 kcal/kg/die was achieved in 10.2 days of life in the NP group and in 14.1 days in the AOG group. Full enteral feeding was achieved later in the NP than in the AOG group (25.7 days vs 20.7 days). Weight gain at 60 days of life was better in the NP group (23.2 g/die vs 18.2 g/die), while there was no difference in the head circumference gain. The study shows the efficacy of NP in providing a good caloric intake in the very low birth weight infants in the first weeks of life.