Lung Ultrasound in Bronchopulmonary Dysplasia: Patterns and Predictors in Very Preterm Infants.

INTRODUCTION: Lung ultrasound (LUS) is useful for respiratory management in very preterm infants (VPI), but little is known about the echographic patterns in bronchopulmonary dysplasia (BPD), the relation between the image findings, and the severity of the disease and its long-term outcomes. We aimed to describe LUS patterns in BPD and analyze the accuracy of LUS to predict the need for respiratory support at 36 weeks postmenstrual age (PMA) in VPI. METHODS: Preterm infants ≤30.6 weeks of gestational age were recruited. LUS was performed at admission, at 7th, and 28th day of life (DOL) with a standardized protocol (6 zones: anterior, lateral, and posterior fields). Clinical data, respiratory outcomes, and image findings were recorded. RESULTS: Eighty-nine patients were studied. Infants with BPD had significantly higher LUS score at admission, at 7th, and 28th DOL. Patients with BPD exhibited more consolidations and pleural line abnormalities at 7th and 28th DOL than those without BPD (p < 0.001), regardless of the definition used for BPD. LUS at 7th DOL predicted NICHD 2001-BPD with R2 = 0.522; AUC = 0.87 (0.79-0.94), p < 0.001, and Jensen 2019-BPD with R2 = 0.315 (AUC = 0.80 [0.70-0.90], p < 0.001). A model including mechanical ventilation >5 days, oxygen therapy for 7 days and LUS score at 7th DOL accurately predicted the need for respiratory support at 36 weeks PMA (R2 = 0.655, p < 0.001) with an AUC = 0.90 (0.84-0.97), p < 0.001. CONCLUSION: LUS score, pleural line abnormalities, and consolidations can be useful to diagnose BPD in VPI and to predict its severity after the first week of life.

Neonato afecto del síndrome del ácido valproico fetal / Newborn with fetal valproic acid syndrom

Introducción. El síndrome del ácido valproico fetal consiste en alteraciones congénitas que aparecen en el feto expuesto a tratamiento gestacional con ácido valproico. El ácido valproico, el antiepiléptico más teratogénico, es utilizado ampliamente en gestantes afectas de epilepsia. Las estrategias de prevención, sospecha y detección precoz de este síndrome son de vital importancia, ya que el inicio precoz del estudio y tratamiento permite ofrecer una mejoría en la calidad de vida del paciente. Caso clínico. Se presenta el caso clínico de un recién nacido afecto del síndrome del ácido valproico fetal. En el paciente destacaba una facies peculiar con microtia bilateral. Al alta fue seguido por Otorrinolaringología, para la realización de pruebas audiológicas y colocación de audífonos, y por Cirugía, para realizar la reconstrucción de los pabellones auriculares. Comentarios. El estudio en los casos de microtia consiste en la realización de pruebas de imagen (Tomografía computeritzada craneal), para comprobar el grado de afectación del oído medio e interno, y pruebas audiológicas para conocer el umbral auditivo del paciente, hipoacusia moderada de transmisión en la mayoría de los casos. El tratamiento persigue una estimulación precoz del oído para favorecer el lenguaje mediante la colocación de audífonos de transmisión ósea. El tratamiento quirúrgico se realiza a partir de los 10 años de vida, y consiste en la reconstrucción de un pabellón auricular en tres dimensiones a partir de cartílago costal(AU)

Introduction. The fetal valproic acid syndrome consists of congenital abnormalities occurring in the fetus exposed to gestational treatment with valproic acid; this drug is the most teratogenic antiepileptical treatment that is used in pregnant women suffering from epilepsy. Strategies for prevention and early diagnosis of this syndrome are key since early evaluation and treatment can improve significantly the quality of life of these patients. Case report. We report the case of a newborn affected by fetal valproic syndrome, who presented with an abnormal facies with severe microtia bilaterally. The patient was subsequently followed by otorhinolaryngology for audiology evaluation and placement of hearing aids, followed by reconstructive surgery of the earlobes. Comments. The diagnostic evaluation of microtia involves neuroimaging for assessing the degree of involvement of the middle and inner ear, and audiology evaluation, which shows moderate conductive hearing loss in most cases. Treatment aims to stimulating early hearing to promote language through the placement of bone transmission hearing aids. Surgical treatment is usually not recommended until 10 years of age, and it includes 3-dimensional ear reconstruction using rib cartilage(AU)

Combination of vancomycin and rifampicin for the treatment of persistent coagulase-negative staphylococcal bacteremia in preterm neonates.

UNLABELLED: Coagulase-negative staphylococci are the most common cause of late-onset sepsis in premature neonates. The optimal approach in persistent coagulase-negative staphylococcal bacteremia, despite adequate treatment with glycopeptides, is not well established. A retrospective study was conducted on preterm neonates with persistent coagulase-negative staphylococcal bacteremia treated with the combination of vancomycin-rifampicin. Ten cases were included, with a median gestational age of 26 weeks (range 24 weeks + 3 days-31 weeks + 4 days, interquartile range 25 weeks + 3 days-29 weeks + 3 days) and a median birth weight of 715 g (range 555-2,030). The median age at the onset of infection was 9 days (range 5-37). The most frequent clinical presentation was apnea or increased ventilatory support. Bacteremia persisted for a median of 9 (range 6-19) days until rifampicin initiation. Bacteremia was resolved in all cases on vancomycin-rifampicin with no serious side effects. CONCLUSION: Our study provides data supporting the safety and efficacy of vancomycin-rifampicin combination for the treatment of persistent coagulase-negative staphylococcal bacteremia in preterm neonates.

Trends in survival among extremely-low-birth-weight infants (less than 1000 g) without significant bronchopulmonary dysplasia.

OBJECTIVE: The aim of this study was to analyze the evolution from 1997 to 2009 of survival without significant (moderate and severe) bronchopulmonary dysplasia (SWsBPD) in extremely-low-birth-weight (ELBW) infants and to determine the influence of changes in resuscitation, nutrition and mechanical ventilation on the survival rate. STUDY DESIGN: In this study, 415 premature infants with birth weights below 1000 g (ELBW) were divided into three chronological subgroups: 1997 to 2000 (n = 65), 2001 to 2005 (n = 178) and 2006 to 2009 (n = 172).Between 1997 and 2000, respiratory resuscitation in the delivery room was performed via a bag and mask (Ambu®, Ballerup, Sweden) with 40-50% oxygen. If this procedure was not effective, oral endotracheal intubation was always performed. Pulse oximetry was never used. Starting on January 1, 2001, a change in the delivery room respiratory policy was established for ELBW infants. Oxygenation and heart rate were monitored using a pulse oximeter (Nellcor®) attached to the newborn's right hand. If resuscitation was required, ventilation was performed using a face mask, and intermittent positive pressure was controlled via a ventilator (Babylog2, Drägger). In 2001, a policy of aggressive nutrition was also initiated with the early provision of parenteral amino acids. We used standardized parenteral nutrition to feed ELBW infants during the first 12-24 hours of life. Lipids were given on the first day. The glucose concentration administered was increased by 1 mg/kg/minute each day until levels reached 8 mg/kg/minute. Enteral nutrition was started with trophic feeding of milk. In 2006, volume guarantee treatment was instituted and administered together with synchronized intermittent mandatory ventilation (SIMV + VG). The complications of prematurity were treated similarly throughout the study period. Patent ductus arteriosus was only treated when hemodynamically significant. Surgical closure of the patent ductus arteriosus was performed when two courses of indomethacin or ibuprofen were not sufficient to close it.Mild BPD were defined by a supplemental oxygen requirement at 28 days of life and moderate BPD if breathing room air or a need for <30% oxygen at 36 weeks postmenstrual age or discharge from the NICU, whichever came first. Severe BPD was defined by a supplemental oxygen requirement at 28 days of life and a need for greater than or equal to 30% oxygen use and/or positive pressure support (IPPV or nCPAP) at 36 weeks postmenstrual age or discharge, whichever came first. Moderate and severe BPD have been considered together as "significant BPD". The goal of pulse oximetry was to maintain a hemoglobin saturation of between 88% and 93%. Patients were considered to not need oxygen supplementation when it could be permanently withdrawn. The distribution of the variables was not normal based on a Kolmogorov-Smirnov test (p < 0.05 in all cases). Therefore, quantitative variables were expressed as the median and interquartile range (IQR; 25th-75th percentile). Statistical analysis of the data was performed using nonparametric techniques (Kruskal-Wallis test and Mann-Whitney U test). A chi-square analysis was used to analyze qualitative variables. Potential confounding variables were those possibly related to BPD in survivors (p between 0.05 and 0.3 in univariate analysis). Logistic regression analysis was performed with variables related to BPD in survivors (p < 0.05) and potential confounding variables. The forward stepwise method adjusted for confounding factors was used to select the variables, and the enter method using selected variables was used to obtain the odds ratios. RESULTS AND CONCLUSION: There was an increase in the rate of SWsBPD (1997 to 2000: 58.5%; 2001 to 2005: 74.2%; and 2006 to 2009: 75.0%; p = 0.032). In survivors, the occurrence of significant BPD decreased after 2001 (9.5% vs. 2.3%; p = 0.013). The factors associated with improved SWsBPD were delivery by caesarean section, a reduced endotracheal intubation rate and a reduced duration of mechanical ventilation.While the mortality of ELBW infants has not changed since 2001, the frequency of SWsBPD has significantly increased (75.0%) in association with increased caesarean sections and reductions in the endotracheal intubation rate, as well as the duration of mechanical ventilation.

Impact of chorioamnionitis on exhaled nitric oxide and endotracheal aspirate levels of nitrites-nitrates and interleukin-8 in mechanically ventilated preterm neonates.

OBJECTIVES: To assess the influence of maternal chorioamnionitis on early exhaled nitric oxide (NO) and levels of nitrites-nitrates and interleukin (IL)-8 in endotracheal aspirate fluid in mechanically ventilated preterm neonates. STUDY DESIGN: Cross-sectional study. PATIENT-SUBJECT SELECTION: Between September 2007 and August 2009, 54 mechanically ventilated preterm neonates were included. Patients were divided into two groups according to the presence or absence of maternal chorioamnionitis, and those without chorioamnionitis (controls) were further stratified into two subgroups by birth weight < or ≥ 2,000 g. METHODOLOGY: The ventilator used was a Babylog 8000. The NO level assessed was the plateau value given by the software of the Sievers NOA apparatus. Collection of endotracheal aspirate fluid samples was performed coinciding with routine aspirations and using the dry technique. RESULTS: The two groups of control neonates showed statistically significant differences in exhaled NO expressed as nl/min and normalized exhaled NO expressed as either nl/min or nl/min/kg, so they are not homogeneous and cannot be used in clinical practice. Serum C-reactive protein and endotracheal aspirate levels of nitrites-nitrates were significantly higher in the chorioamnionitis group than in controls (3.6 vs. 1.07 µmol/L; P = 0.035). Nitrites-nitrates levels were positively correlated with exhaled NO in ppb (ρ = 0.367; P = 0.006). Minute exhaled endogenous NO was significantly higher in the chorioamnionitis group (0.48 vs. 0.27 nl/min/kg; P = 0.021). CONCLUSIONS: In mechanically ventilated preterm infants weighing <2,000 g, maternal chorioamnionitis was associated with an increase of early exhaled NO (nl/min/kg) and serum levels of C-reactive protein and levels of nitrites-nitrates in endotracheal aspirate fluid.

Nonimmune hydrops fetalis due to congenital xerocytosis.

Hereditary xerocytosis is a rare hemolytic anemia in which erythrocytes are dehydrated due to a loss of potassium and water through their cell wall membrane. In adults, this condition leads to a mild-to-moderate hemolysis. We report a case of hydrops fetalis secondary to hereditary xerocytosis. Management with intrauterine erythrocyte and albumin transfusions resulted in a favorable postnatal course.