Ventilator-associated pneumonia in neonates: the role of point of care lung ultrasound.

No consensus exists regarding the definition of ventilator-associated pneumonia (VAP) in neonates and reliability of chest X-ray (CXR) is low. Lung ultrasound (LU) is a potential alternative diagnostic tool. The aim was to define characteristics of VAP in our patient population and propose a multiparameter score, incorporating LU, for VAP diagnosis. Between March 25, 2018, and May 25, 2019, infants with VAP were identified. Clinical, laboratory and microbiology data were collected. CXRs and LU scans were reviewed. A multiparameter VAP score, including LU, was calculated on Day 1 and Day 3 for infants with VAP and for a control group and compared with CXR. VAP incidence was 10.47 episodes/1000 ventilator days. LU and CXR were available for 31 episodes in 21 infants with VAP, and for six episodes in five patients without VAP. On Day 1, a VAP score of > 4, and on Day 3 a score of > 5 showed sensitivity of 0.94, and area under the curve of 0.91 and 0.97, respectively. AUC for clinical information only was 0.88 and for clinical and CXR 0.85.Conclusion: The multiparameter VAP score including LU could be useful in diagnosing VAP in neonates with underlying lung pathology. What is Known: • Ventilator associated pneumonia (VAP) is common in infants on the neonatal unit and is associated with increased use of antibiotics, prolonged ventilation and higher incidence of chronic lung disease. • Commonly used definitions of VAP are difficult to apply in neonates and interpretation of chest X-ray is challenging with poor inter-rater agreement in patients with underlying chronic lung disease. What is New: • The multiparameter VAP score combining clinical, microbiology and lung ultrasound (LU) data is predictive for VAP diagnosis in preterm infants with chronic lung disease. • LU findings of VAP in neonates showed high inter-rater agreement and included consolidated lung areas, dynamic bronchograms and pleural effusion.

Change in body composition of premature infants from parenteral nutrition discontinuation to term equivalent age.

AIM: To compare body composition (BC) of premature infants at parenteral nutrition (PN) suspension and at term equivalent age (TEA). METHODS: Body weight, fat mass (FM), fat free mass (FFM) and FM as % of body weight were measured in infants born at <32 gestational weeks by air-displacement plethysmography at PN suspension and at TEA in a tertiary level hospital. Z-scores were calculated for BC and anthropometric measurements. Nutritional and clinical data were obtained during hospital stay. BC, weight and length were measured at birth in a sample of infants born at term for comparison. RESULTS: Thirty premature infants with birth weight of 1198 ± 270 g and gestational age of 29.8 ± 1.8 weeks were included. At PN suspension, at 32.6 ± 1.6 postconceptional weeks, FFM z-score was similar to FFM z-score measured at TEA, at 39.8 ± 0.7 postconceptional weeks (-1.43 ± 1.27 vs -1.78 ± 1.64, p = 0.26), while FM z-score and %FM z-score at PN suspension were lower than those measured at TEA (FM z-score: 0.23 ± 0.62 versus 2.04 ± 1.00, p < 0.0001 and %FM z-score: 0.66 ± 0.76 versus 2.08 ± 1.07, p < 0.0001). At TEA, weight and length of premature infants were similar to those of term-born infants (3130 ± 340 g vs 3350 ± 340 g; 49.2 ± 2.4 cm vs 50.2 ± 2.5 cm, respectively), but %FM was higher (21.3 ± 4.2% vs 9.2 ± 4.4%, p < 0.001); higher exclusive enteral caloric and protein intakes were associated with a decrease in FM z-scores from PN suspension to TEA. CONCLUSION: In our sample of premature infants, fat free mass z-score was similar, while fat mass and % fat mass z-scores increased substantially from parenteral nutrition suspension to term-equivalent age. Nutritional intakes during exclusive enteral nutrition did not seem to contribute to such increase.

Phenotypic expression of 19q13.32 microdeletions: Report of a new patient and review of the literature.

The phenotypic manifestations of microdeletions in the 19q13.32 region are still poorly known. In this paper we report a patient who presented with hypotonia, developmental delay, facial dysmorphism, micrognathia, kyphoscoliosis, and buried penis. Chromosomal microarray revealed an interstitial 327 kb de novo microdeletion in the 19q13.32 region comprising eight genes (ARGHAP35, NPAS1, TMEM160, ZC3H4, SAE1, BBC3, MIR3190, and MIR3191). Previously reported cases of microdeletions in the 19q13.32 region were reviewed and compared to our patient, highlighting the common features of a possible 19q13.32 microdeletion syndrome.

Higher growth, fat and fat-free masses correlate with larger cerebellar volumes in preterm infants at term.

AIM: Smaller cerebellar volumes in very low-birthweight (VLBW) infants at term have been related to adverse cognitive outcomes, and this study evaluated whether these volumes were associated with a growth in body composition during hospital stays. METHODS: We prospectively recruited 42 VLBW infants from an Italian neonatal unit between January 2013 and August 2015. Cerebellar volumes and body composition were measured by magnetic resonance imaging (MRI) and air-displacement plethysmography, respectively, at 40 weeks of gestational age and anthropometric and nutritional data were collected. We also included 20 term-born controls. RESULTS: The mean gestational age and birthweight of the VLBW infants were 29.4 (±1.9) weeks and 1120 (±290) g. There was a positive correlation between cerebellar volumes and daily weight gain from birth to term (R2 = 0.26, p = 0.001), weight (R2 = 0.25, p = 0.001), length (R2 = 0.16, p = 0.01), fat mass (R2 = 0.15, p = 0.01) and fat-free mass at term (R2 = 0.20, p = 0.003). In multiple regression analysis, daily weight gain, mechanical ventilation and postconceptional age at MRI were independently associated with cerebellar volumes. Anthropometric data and cerebellar volumes were similar between VLBW and control infants. CONCLUSION: Higher growth, higher fat mass and fat-free mass were associated with larger cerebellar volumes in VLBW infants at term.

Body mass index curves for Italian preterm infants are comparable with American curves for infants born before 34 weeks of gestational age.

AIM: Body mass index (BMI)-for-age curves have been developed in the USA, but not compared with other populations. This study created gender-specific intrauterine BMI-for-age curves for Italian preterm infants and compared them with the USA version. METHODS: Data on 92 262 newborn infants, born at 26-42 weeks of gestational age in the north-eastern Italian region of Friuli Venezia Giulia between 2005 and 2013, were analysed to create gender-specific BMI-for-age curves. Gender-specific and age-specific BMI Z scores for Italian infants were calculated using the parameters of the USA growth curves and the World Health Organization charts. RESULTS: Gender-specific BMI-for-age at birth curves were developed for premature Italian infants from 26 gestational weeks. The comparison with the USA charts showed no significant difference in BMI percentiles in Italian infants born at ≤33 gestational weeks, but infants born at ≥34 gestational weeks had a significantly higher BMI than the USA population, by 0.2 standard deviations. CONCLUSION: We developed the first European BMI-for-age at birth curves for premature infants. According to our findings, the Italian curves were comparable to the USA curves for the subgroup of infants born at ≤33 gestational weeks, but not ≥34 gestational weeks.

Advising Mothers on the Use of Medications during Breastfeeding: A Need for a Positive Attitude.

The use of medications by the nursing mother is a common reason for interrupting breastfeeding. Few drugs have been demonstrated to be absolutely contraindicated during breastfeeding. Excessive caution may lead health professionals to unnecessarily advise to interrupt breastfeeding, without assessing the latest evidence or considering the risk-benefit ratio of taking a medication versus terminating breastfeeding. To foster an appropriate approach toward the use of medications in breastfeeding women, the Italian Society of Perinatal Medicine created the following policy statement.

When Feeding Difficulties Are due to Genetics: The Case of Familial Partial 9q Duplication.

Chromosomal abnormalities may cause growth failure before or since birth. 9q duplication is reported as a cause of intrauterine growth restriction, mild dysmporphism, and intellectual disabilities. We report a case of a maternally inherited 9q21.31q21.33 duplication causing prenatal and postnatal growth restriction with feeding refusal and mild facial dysmorphisms, prenatally diagnosed by single-nucleotide polymorphism array analysis. Hypothesis of the possible pathogenic mechanisms are discussed.

Impact of Surgery for Neonatal Gastrointestinal Diseases on Weight and Fat Mass.

OBJECTIVE: To compare growth, fat mass (FM), and fat-free mass in surgical infants vs matched controls at similar postconceptional age (PCA). STUDY DESIGN: Anthropometric and body composition measurements by air-displacement plethysmography (PeaPod-Infant Body Composition System; LMI, Concord, California) were performed at the same PCA in 21 infants who received gastrointestinal surgery and in 21 controls matched for gestational age, birth weight, and sex. RESULTS: Despite similar anthropometry at birth, postsurgical infants were shorter (50.4 [4.7] cm vs 53.2 [4.1] cm, P = .001), lighter (3516 [743] g vs 3946 [874] g, P < .001), and had lower FM content (%FM 14.8 [4.7]% vs 20.2 [5.8]%, P < .0001) than their peers at similar PCA (43 [4] weeks). All surgical infants but 1 (20/21) received parenteral nutrition (PN). Mean PN duration was 40 (30) days. Five infants in the control group received PN because of prematurity for 15 (9-30) days. Nine infants in the surgical group and 1 in the control group had PN-associated cholestasis. CONCLUSIONS: Neonates having surgery for gastrointestinal diseases were shorter, had lower weight, and lower FM content than their peers, despite receiving more PN. Body composition evaluation and monitoring may help optimize growth in these newborns.

Making the first days of life safer: preventing sudden unexpected postnatal collapse while promoting breastfeeding.

Early and prolonged skin-to-skin contact (SSC) after birth between a mother and her newborn has been shown to generate beneficial effects on the mother-infant relationship and breastfeeding. Close mother-infant body contact immediately after birth positively enhances exclusive breastfeeding during the hospital stay, with a dose-response relationship. Skin-to-skin contact may ease the infant's transition to extra-uterine life and helps regulate the infant's body temperature and nursing behavior. However, reports of sudden unexpected postnatal collapse (SUPC) soon after birth, in healthy term neonates, in association with SSC, have raised concerns about the safety of this practice. Based on available evidence, we developed a surveillance protocol in the delivery room and postnatal ward of the Institute for Maternal and Child Health of Trieste (Italy). The aim of our protocol is (a) to promote safe mother and infant bonding and (b) to establish successful breastfeeding, without increasing the risk of SUPC. As there is no known effective intervention to prevent SUPC, our protocol has been conceived as a potential best practice.

From tube to breast: the bridging role of semi-demand breastfeeding.

Determination of the optimal timing of breastfeeding initiation for preterm infants is still a challenge for health professionals. Often unjustified delays and restrictions of breastfeeding occur due to non-evidence-based current opinions about preterm infants' feeding capacity. Semi-demand feeding has been proposed for preterm infants during the transition from scheduled to full demand feeding, to promote the establishment of self-regulated oral feeding. Although semi-demand feeding has been shown to be safe and effective in reducing time to reaching oral feeding, the implementation of this feeding pattern for preterm infants in the neonatal intensive care unit (NICU) is still limited. We developed a protocol for the application of semi-demand feeding in preterm infants based on the existing knowledge of preterm infant neurodevelopment and NICU organization and staff experience. The protocol's aim is to attain successful transition from tube feeding to breastfeeding. In this article, we describe the protocol used in the neonatal unit of the Maternal and Child Health Institute of Trieste, a third level care center in northeastern Italy.

Can body mass index accurately predict adiposity in newborns?

Body mass index (BMI) is correlated with body fatness and risk of related diseases in children and adults. Proportionality indexes such as BMI and ponderal index (PI) have been suggested as complementary measures in neonatal growth assessment. Yet, they are still not used in neonates and their correlation with fatness is unknown. The aim of the study was to test the hypothesis that BMI z-score would predict neonatal adiposity. Body composition measurements (ie, fat mass, fat-free mass) by air displacement plethysmography (PEA POD, LMI, Concord-USA), weight and length were obtained in 200 infants ≥36 weeks' gestational age (GA) at birth. Linear regression analysis showed a direct association between BMI z-score and %fat mass (r(2)=0.43, p<0.0001). This association was confirmed independently from sex, GA and maternal prepregnancy BMI. BMI z-score predicted adiposity better than PI. However, both BMI z-score and PI were poor predictors of adiposity at birth.

Intermittent kangaroo mother care: a NICU protocol.

The practice of kangaroo mother care (KMC) is steadily increasing in high-tech settings due to its proven benefits for both infants and parents. In spite of that, clear guidelines about how to implement this method of care are lacking, and as a consequence, some restrictions are applied in many neonatal intensive care units (NICUs), preventing its practice. Based on recommendations from the Expert Group of the International Network on Kangaroo Mother Care, we developed a hospital protocol in the neonatal unit of the Institute for Maternal and Child Health in Trieste, Italy, a level 3 unit, aimed to facilitate and promote KMC implementation in high-tech settings. Our guideline is therefore proposed, based both on current scientific literature and on practical considerations and experience. Future adjustments and improvements would be considered based on increasing clinical KMC use and further knowledge.

To feed or not to feed? Case presentation and best practice guidance for human milk feeding and group B streptococcus in developed countries.

Group B Streptococcus (GBS) is the most frequent cause of neonatal invasive disease. Two forms of GBS are recognized: early-onset and late-onset disease. The average incidence of late-onset disease is 0.24 per 1000, a figure that has remained substantially unchanged over time. Exposure to breast milk represents a potential source of infection, especially in late-onset and/or recurrent GBS disease. As a result, both breastfeeding and the use of breast milk have been questioned. We report for the first time the case of both simultaneous and recurrent infection in newborn preterm twins, born 3 weeks apart, resulting from ingestion of GBS positive breast milk. A genetically identical strain was found in both breast milk and her newborn infants. Transmission of GBS through breast milk should be considered in late-onset GBS sepsis. An eradicating antibiotic treatment of GBS positive mothers with ampicillin plus rifampin and temporary discontinuation of breastfeeding and/or the use of heat processed breast milk may represent preventive measures, although outcomes are inconsistent, for recurrent GBS disease. Guidelines on breastfeeding and prevention of recurrent neonatal GBS disease are needed. It is unfortunate that existing scientific literature is scarce and there is no general consensus. As a consequence, we propose a best practice approach on the topic.

Under pressure.

Physical urticaria is a rare but challenging subset of chronic urticaria. Wheals of pressure urticaria are typically delayed in appearance. A pressure test can easily be done to confirm the diagnosis.

Longitudinal growth and body composition of twins versus singletons in the first month of life.

BACKGROUND: Although twin gestation is well recognized to be associated with impaired fetal and postnatal growth, specific data about body composition of twins in the first month of life are scarce. OBJECTIVE: The aim of this study was to compare the body composition of twins, evaluated with air-displacement plethysmography, to that of singletons of similar gestational age and adequacy of growth, during the first month of life. We tested the hypothesis that the quality of growth would be similar. METHODS: Anthropometric and air-displacement plethysmography measurements were performed in 18 pairs of twins and in 36 singleton neonates, longitudinally, from birth to the 30th day of life. Each twin was matched to a singleton infant of similar gestational age and birth weight z-score. RESULTS: With regard to anthropometric measures, the only difference was a lower weight in twins versus singletons on the 15th day of life. With regard to body composition, we did not find any difference between groups at any time point. Fat mass increased significantly from day 1 to day 30 in both twins and singletons. CONCLUSION: In terms of body composition, twins do not differ from singletons of similar gestational age and weight, either at birth or in early postnatal life.