Vitamin A in prevention of bronchopulmonary dysplasia.

Bronchopulmonary dysplasia (BPD) remains one of the most serious challenges in the care of the very preterm infants, affecting approximately one-quarter of infants born < 1500g birth weight and 30% < 1000g. Oxygen toxicity may contribute to its pathogenesis. Vitamin A concentrations are lower in BPD infants which may result in a reduction of the antioxidant protection. It has been found to up regulate genes necessary for fetal lung growth and increase surfactant production in animal models and is also involved in the modulation of immunological and inflammatory responses by regulation of cytokine production. Retinoic acid plays a key role in lung development improving alveolar septation. Evidence exists that vitamin A supplementation for very low birth weight (VLBW) infants, beyond that routinely given in multivitamin preparations, is associated with a reduction in death or BPD. So, parenteral administration of vitamin A to the newborn is one of the current recommended preventive therapies for BPD (number needed to treat 12; 95% CI: 6-94; The information on long-term neurodevelopmental status suggests no evidence of either benefit or harm. Estimates for cerebral palsy range from a number needed to treat of 11 to a number needed to harm of 33. Nowadays, it seems that administration of antenatal vitamin A to the mother in late pregnancy associated with neonatal supplementation can better prevent the development of BPD in areas of endemic vitamin A deficiency. The benefits, in terms of vitamin A status, safety and acceptability of delivering vitamin A in an intravenous emulsion compared with repeat intramuscular injections, the association of vitamin A prenatal and postnatal, as well as the effectiveness and safety of administered high dose vitamin A in ELBW infants await evaluation and should be assessed in further trials.

Vitamin A in Prevention of Bronchopulmonary Dysplasia.

Bronchopulmonary dysplasia (BPD) remains one of the most serious challenges in the care of the very preterm infants, affecting approximately one-quarter of infants born <1500g birth weight and 30% <1000g. Oxygen toxicity may contribute to its pathogenesis. Vitamin A concentrations are lower in BPD infants which may result in a reduction of the antioxidant protection. It has been found to up regulate genes necessary for fetal lung growth and increase surfactant production in animal models and is also involved in the modulation of immunological and inflammatory responses by regulation of cytokine production. Retinoic acid plays a key role in lung development improving alveolar septation. Evidence exists that vitamin A supplementation for very low birth weight (VLBW) infants, beyond that routinely given in multivitamin preparations, is associated with a reduction in death or BPD. So, parenteral administration of vitamin A to the newborn is one of the current recommended preventive therapies for BPD (number needed to treat 12; 95% CI:6-94; The information on long-term neurodevelopmental status suggests no evidence of either benefit or harm. Estimates for cerebral palsy range from a number needed to treat of 11 to a number needed to harm of 33. Nowadays, is seems that administration of antenatal vitamin A to the mother in late pregnancy associated with neonatal supplementation can better prevent the development of BPD in areas of endemic vitamin A deficiency. The benefits, in terms of vitamin A status, safety and acceptability of delivering vitamin A in an intravenous emulsion compared with repeat intramuscular injections, the association of vitamin A prenatal and postnatal, as well as the effectiveness and safety of administered high dose vitamin A in ELBW infants waits evaluation and should be assessed in further trials.

[Neonatal seizures in a tertiary neonatal intensive care unit]. / Convulsões neonatais numa unidade de cuidados intensivos neonatais terciária.

INTRODUCTION: Seizures are frequent in the neonatal period. They can be idiopathic, be caused by organic brain anomalies or by metabolic disturbances. OBJECTIVE: Evaluation of the etiologic diagnosis and clinical evolution of the newborns with neonatal seizures admitted at one tertiary neonatal intensive care unit. MATERIAL AND METHODS: Retrospective review of the clinical files of the newborns with neonatal seizures, during a period of eight years. RESULTS: Neonatal seizures occurred in 91 cases. Seventy nine (86.8%) received anticonvulsant therapy during clinical seizure. Image and/or electrophysiological studies were performed in the majority of newborns (86.8%). Etiology was identified in 51.6% of the 91 cases studied, being the more frequent situations: central nervous system bleeding (11 cases), hypoxic-ischemic encephalopathy (10 cases) and electrolytes disturbances (7 cases). Mortality rate was 16.5%. The newborns followed in our hospital had good neurodevelopment, in 70.2% of cases but in 10.6% was detected important neurodevelopment impairment, including cerebral palsy. CONCLUSIONS: Anomalies in the cranial ultrasound and in the electroencephalography were correlated with clinical evolution. They still are first line exams in the initial approach to this pathology.

Respiratory outcomes and atopy in school-age children who were preterm at birth, with and without bronchopulmonary dysplasia.

OBJECTIVE: To assess pulmonary function and the prevalence of atopy in school-age children who were very low birth weight as infants and to compare those who had bronchopulmonary dysplasia to those who did not. METHOD: We studied 85 (39 male and 46 female) at a mean age of 84 (range, 62 to 107) months who were very low birth weight infants. Bronchopulmonary dysplasia was defined as oxygen dependency at 36 weeks gestational age. We excluded 8 patients (4 for cerebral palsy and 4 for no collaboration). Detailed perinatal and clinical data were collected. Lung function was evaluated using conventional spirometry. Atopy (assessed by the allergy skin-prick test) was considered when at least one positive skin test occurred in a panel of the most common environmental allergens in the local region. Comparisons between the bronchopulmonary dysplasia and no bronchopulmonary dysplasia groups were performed using the Mann-Whitney, x2 and Fisher's exact tests. RESULTS: We compared the bronchopulmonary dysplasia (n = 13) and no bronchopulmonary dysplasia (n = 64) groups. Atopy was observed in 4 (30.8%) of the bronchopulmonary dysplasia patients and in 17 (26.6%) of the no bronchopulmonary dysplasia patients (p = 0.742). Two (15.4%) patients with bronchopulmonary dysplasia had a family history of atopy vs. 17 (26.6%) in the no bronchopulmonary dysplasia group (p = 0.5). Lung function tests showed airway obstruction in 2 (15.4%) of the bronchopulmonary dysplasia patients and in 10 (15.6%) of the no bronchopulmonary dysplasia patients (p = 1.0). Four (33.3%) of the bronchopulmonary dysplasia patients had small airway obstruction vs. 14 (22.2%) of the no bronchopulmonary dysplasia patients (p = 0.466). CONCLUSION: Our data showed no significant differences in lung function between bronchopulmonary dysplasia and no bronchopulmonary dysplasia patients at school age and no evidence of an association between atopy and bronchopulmonary dysplasia.

Prospective validation of a novel strategy for assessing risk of significant hyperbilirubinemia.

OBJECTIVE: Our aim was to validate a strategy for assessing the risk of significant hyperbilirubinemia in newborns with gestational ages of ≥35 weeks by combining predischarge bilirubin percentile data with gestational age data, for a European, predominantly white population. METHODS: We conducted a prospective cohort study with 463 newborns with gestational ages of ≥35 weeks who were admitted to the well-infant nursery. Total bilirubin levels were measured daily until discharge and once after discharge, between the third and eighth days of life, by using a Bilicheck device (Respironics, Murrysville, PA). The values obtained (<52 hours) were plotted on an hour-specific bilirubin nomogram to determine the infant's bilirubin percentile, expressed as a risk zone. Patients were assigned to 1 of 3 risk groups (very low, low, or high) on the basis of a combination of risk zone and gestational age data and were monitored prospectively for the development of significant hyperbilirubinemia. The 95% confidence interval (CI) for the prevalence of significant hyperbilirubinemia was estimated with the binomial distribution method. RESULTS: Forty-four infants (11%) developed significant neonatal hyperbilirubinemia. The risks of developing significant hyperbilirubinemia were 1.3% (95% CI: 0.2%-3.7%) for the very low risk group (n = 230 [58.1%]), 3.4% (95% CI: 0.7%-9.8%) for the low risk group (n = 86 [21.7%]), and 47.50% (95% CI: 36.2%-59.0%) for the high risk group (n = 80 [20.20%]). CONCLUSIONS: The proposed strategy, based on predischarge bilirubin level and gestational age data, was a valid method for significant hyperbilirubinemia risk assessment in our population.

Respiratory outcomes and atopy in school-age children who were preterm at birth, with and without bronchopulmonary dysplasia

OBJECTIVE: To assess pulmonary function and the prevalence of atopy in school-age children who were very low birth weight as infants and to compare those who had bronchopulmonary dysplasia to those who did not. METHOD: We studied 85 (39 male and 46 female) at a mean age of 84 (range, 62 to 107) months who were very low birth weight infants. Bronchopulmonary dysplasia was defined as oxygen dependency at 36 weeks gestational age. We excluded 8 patients (4 for cerebral palsy and 4 for no collaboration). Detailed perinatal and clinical data were collected. Lung function was evaluated using conventional spirometry. Atopy (assessed by the allergy skin-prick test) was considered when at least one positive skin test occurred in a panel of the most common environmental allergens in the local region. Comparisons between the bronchopulmonary dysplasia and no bronchopulmonary dysplasia groups were performed using the Mann-Whitney, x2 and Fisher's exact tests. RESULTS: We compared the bronchopulmonary dysplasia (n = 13) and no bronchopulmonary dysplasia (n = 64) groups. Atopy was observed in 4 (30.8 percent) of the bronchopulmonary dysplasia patients and in 17 (26.6 percent) of the no bronchopulmonary dysplasia patients (p = 0.742). Two (15.4 percent) patients with bronchopulmonary dysplasia had a family history of atopy vs. 17 (26.6 percent) in the no bronchopulmonary dysplasia group (p = 0.5). Lung function tests showed airway obstruction in 2 (15.4 percent) of the bronchopulmonary dysplasia patients and in 10 (15.6 percent) of the no bronchopulmonary dysplasia patients (p = 1.0). Four (33.3 percent) of the bronchopulmonary dysplasia patients had small airway obstruction vs. 14 (22.2 percent) of the no bronchopulmonary dysplasia patients (p = 0.466). CONCLUSION: Our data showed no significant differences in lung function between bronchopulmonary dysplasia and no bronchopulmonary dysplasia patients at school age and no evidence of an association between atopy and bronchopulmonary dysplasia.

[Successful caspofungin treatment of invasive refractory candidiasis in the extremely low birthweight neonate]. / Utilização com sucesso de caspofungina na candidíase invasiva refractária no recém-nascido de extremo baixo peso.

INTRODUCTION: Multiresistant Candida septicaemia is an increasing problem in Neonatal Intensive Care Units worldwide. Caspofungin is a new antifungal drug licensed in Portugal for use in children since September 2008, with limited experience in newborns. CASE REPORT: Preterm female, 26 weeks gestational age, born by vaginal delivery, with 780g birthweight and Apgar score 8/9. The newborn developed a mucocutaneous candidiasis at day 8 of life which was treated with oral nystatin and topic clotrimazol. Clinical and laboratory deterioration occurred at day 15 of life with Candida albicans sepsis being diagnosed. Therapy with amphotericin B liposome was started but the clinical condition and candidemia persisted. Treatment with caspofungin was initiated at day 28 of life and continued for 28 days. There was an improvement of the clinical condition and the blood cultures became negative. The child was discharged at the 80th of life with no evident clinical problems. The long term follow-up revealed bilateral deafness. COMMENT: This case reveals that caspofungin may be a useful choice for invasive refractory candidiasis in the neonate, especially in the extremely low birthweight neonate and in life-threatening situations. Long term follow-up is of great importance in order to document adverse effects not apparent at the neonatal period.

[Newborn with nonimmune hydrops fetalis - the experience of a tertiary center]. / Recém-nascido com hidrópsia fetal não imune - experiência de um centro de referência.

BACKGROUND AND AIMS: Nonimmune hydrops fetalis is a rare affection that can result from several disorders. Notwithstanding with the advances in the diagnosis and treatment, its morbidity and mortality are still very high. The purpose of this study was to characterize the newborn population with nonimmune hydrops fetalis admitted to our unit during the last ten years. METHODS: A descriptive review of the newborns with nonimmune fetalis hydrops admitted to the Neonatal Intensive Care Unit of Hospital de São João, between 1997 and 2006. Data on pregnancy, delivery, perinatal approach, etiological evaluation and outcome were collected. RESULTS: Nineteen neonates (9M/10F) with a median gestational age of 32 weeks (26-39) and a median birth weight of 2695 g (884-4270) were studied. Sixteen (84%) were preterm. Antenatal diagnosis was made in fourteen (74%) cases, and two received in uterus treatment. C-section was performed in fourteen (74%) cases. Sixteen (84%) neonates needed resuscitation in the delivery room. Aetiological diagnosis was made in 89% (n = 17): cardiovascular (n = 5), haematological (n = 5), metabolic (n = 2), infectious (n = 2), chromosomal (n = 1), lymphatic malformation (n = 1) and meconium peritonitis (n = 1). The median length of hospital stay was 17 days. Thirteen (68%) neonates were deceased. CONCLUSIONS: The occurrence and admission of newborns with nonimmune hydrops fetalis to our unit was rare. The aetiological diagnosis was made in 89% and mortality rate was 68%. The worse prognosis was related to preterm birth, anaemia, cardiac malformation, metabolic disorder, congenital infection and chromosomopathy. The prompt aetiological diagnosis and its proper ante and postnatal management are the most important steps to reduce the morbidity and mortality of this condition.

[Octreotide for conservative management of postoperative chylothorax in the neonate]. / Octreótido no tratamento conservador do quilotórax pós-cirúrgico do recém-nascido.

Chylothorax is a possible complication after thoracotomy. Treatment is initially conservative and includes drainage and correction of nutritional losses. Surgical treatment is reserved for cases not responsive to medical measures. The authors report on the clinical case of a premature neonate with a traumatic chylothorax secondary to esophageal atresia surgical correction. The use of octreotide allowed the resolution of the effusion without adverse effects and avoided the surgical treatment.