Lung ultrasound and postoperative follow-up of congenital diaphragmatic hernia.

Lung ultrasound (LU) has emerged as a valuable tool for assessing pulmonary aeration noninvasively, rapidly, and reliably in different neonatal conditions. However, its role in the preoperative and postoperative evaluation in congenital diaphragmatic hernia (CDH) is still poorly analyzed. We present a cohort of 8 patients diagnosed with CDH who underwent lung ultrasound examinations at various time points before and after surgical correction. The lung ultrasound patterns were compared between two groups: mechanical ventilation ≤ 7 days (MV ≤ 7) and mechanical ventilation > 7 days (MV > 7). The ultrasound findings were also compared to CT scans and chest X-ray images to assess its diagnostic capacity for identifying postoperative complications: pneumothorax, pleural effusion, and pneumonia. Group MV ≤ 7 exhibited a normal pattern even at 48 h postsurgery, while group MV > 7 presented interstitial or alveolointerstitial pattern in both lungs for prolonged periods (2-3 weeks). Furthermore, contralateral LU pattern may be predictive of respiratory evolution.  Conclusion: Lung ultrasound is a valuable tool for evaluating the progressive reaeration of the lung following surgical correction in CDH patients. It demonstrates the ability to diagnose common postoperative complications without the need for radiation exposure while offering the advantages of quick and serial assessments. These findings highlight the potential of lung ultrasound as an effective alternative to conventional imaging methods in the management of CDH. What is Known: • Lung ultrasound evaluates lung aeration and predicts respiratory outcomes in neonatal patients. What is New: • Lung ultrasound is useful in the postsurgical management of congenital diaphragmatic hernia patients, detecting reaeration and respiratory complications.

New Ventilator Strategies: High-Frequency Oscillatory Ventilation Combined with Volume Guarantee.

High-frequency oscillatory ventilation (HFOV) has been proposed as an alternative method of invasive ventilation in immature infants to prevent ventilator lung injury. To better control the size of the high-frequency tidal volume and to prevent large tidal volumes, a new strategy of controlling the tidal volume during HFOV (VThf) has been developed, HFOV-volume guarantee (VG). Data from preclinical, neonatal animal studies in normal and surfactant-depleted lungs have demonstrated the feasibility of this technique to directly control the VThf in the normal compliance and low compliance situations. Different I:E ratios also can modify the effect of CO2 washout during HFOV combined with VG in a different way as without the VG modality. Finally, clinical use of this technique in newborn infants has demonstrated the possibility of using very high frequency combined with constant very low VThf to decrease the risk of lung trauma related to the ventilator.

Electrical velocimetry for non-invasive monitoring of the closure of the ductus arteriosus in preterm infants.

Closure of a patent ductus arteriosus (PDA) in preterm infants modifies cardiac output and induces adaptive changes in the hemodynamic situation. The present study aims to analyze those changes, through a non-invasive cardiac output monitor based on blood electrical velocimetry, in preterm babies. A prospective observational study of preterm infants with a gestational age of less than 28 weeks, and a hemodynamic significant PDA, requires intravenous ibuprofen or surgical closure. All patients were monitored with electrical velocimetry before treatment and through the following 72 h. Two groups were defined, ibuprofen and surgical closure. Variations of cardiac output were analyzed from the basal situation and at 1, 8, 24, 48, and 72 h on each group. During a 12-month period, 18 patients were studied. The median gestational age in the ibuprofen group (12/18) was 26+5 weeks (25+5-27+3) with a median birth weight of 875 (670-1010) g. The cardiac output index (CI) value was 0.29 l/kg/min (0.24-0.34). Among the patients with confirmed ductus closure (50%), a significant CI decrease was shown (0.24 vs 0.29 l/kg/min; P 0.03) after 72 h (three ibuprofen doses). A statistically significant decrease in systolic volume (SVI) was found: 1.62 vs 1.88 ml/kg, P 0.03 with a decrease in contractility (ICON), 85 vs 140, P 0.02. The gestational age in the surgical group (6/18) was 25+2 weeks (24-26+3) with a median weight of 745 (660-820) g. All patients in this group showed a decrease in the immediate postoperative CI (1 h after surgery) 0.24 vs 0.30 l/kg/min, P 0.05, and a significant decrease in contractility (ICON 77 vs 147, P 0.03). In addition, a no statistically significant decrease in SVI (1.54 vs 1.83 ml/kg, P 0.06), as well as an increase in systemic vascular resistance (10,615 vs 8797 dyn/cm2, P 0.08), were detected. This deterioration was transient without significant differences in the remaining periods of time evaluated. CONCLUSION: The surgical closure of the PDA in preterm infants causes a transient deterioration of cardiac function linked to a documented decrease in the left ventricular output. The hemodynamic changes detected after pharmacological PDA closure are similar but those patients present a better clinical tolerance to changes in the cardiac output. What is Known: • Surgical ductus closure generates acute hemodynamic changes in cardiac output and left ventricular function. What is New: • The hemodynamic changes detected after pharmacological ductus closure are similar to those found in the surgical closure. Electrical velocimetry can detect those changes.

Surgical Ligation Versus Percutaneous Closure of Patent Ductus Arteriosus in Very Low-Weight Preterm Infants: Which are the Real Benefits of the Percutaneous Approach?

Percutaneous treatment of patent ductus arteriosus (PDA) in extreme premature infants is technically difficult, and therefore, often not consider as an alternative to surgery. The main objective of our work was to compare respiratory status prior and post ductal closure and morbi-mortality, in our series of preterm infants with percutaneous PDA closure versus surgical ligation in the same time-period. Retrospective review of all premature infants submitted to percutaneous and surgical PDA closure from January 2011 to December 2016. All the antenatal, perinatal, and postnatal characteristics were collected. The main outcome was the assessment of the pulmonary status before and after ductal closure using a pulmonary score. Secondary outcomes included moderate-severe disability in neurodevelopment, death before discharge, moderate-severe chronic lung disease, and morbidity at discharge. 25 patients with a mean weight of 1330 g (± 280) underwent percutaneous closure of PDA with ADO-II-AS, and a total of 53 underwent surgical ligation. 28/53 with similar gestational age, birth weight, and procedure weight to those in the percutaneous group, were selected to perform the comparative study. Ductal closure (percutaneous and surgical) resulted in improved respiratory status. However, percutaneous group achieved a fastest respiratory improvement, than surgical group. The surgical closure group associated higher morbidity among survivors (HIV, number of sepsis, need, and duration of inotropics post-interventionism). The incidence of recurrent laryngeal nerve palsy among the surgical group was 17%. Percutaneous closure of PDA in carefully selected low-weight preterm infants is a safe and reliable alternative to surgical ligation.

Cost-utility analysis of Palivizumab for Respiratory Syncytial Virus infection prophylaxis in preterm infants: update based on the clinical evidence in Spain.

BACKGROUND: This study aimed at estimating the efficiency of palivizumab in the prevention of Respiratory Syncytial Virus (RSV) infection and its sequelae in preterm infants (32day 1-35day 0weeks of gestational age -wGA-) in Spain. METHODS: A decision-tree model was developed to compare health benefits (Quality Adjusted Life Years-QALYs) and costs of palivizumab versus a non-prophylaxis strategy over 6 years. A hypothetical cohort of 1,000 preterm infants, 32day 1-35day 0 wGA (4.356 kg average weight) at the beginning of the prophylaxis (15 mg/kg of palivizumab; 3.88 average number of injections per RSV season) was analysed. The model considered the most recent evidence from Spanish observational and epidemiological studies on RSV infection: the FLIP II study provided hospital admission and Intensive Care Unit (ICU) admission rates; in-hospital mortality rate was drawn from an epidemiological study from 2004 to 2012; recurrent wheezing rates associated to RSV infection from SPRING study were adjusted by the evidence on the palivizumab effect from clinical trials. Quality of life baseline value, number of hospitalized infants and the presence of recurrent wheezing over time were granted to estimate QALYs. National Health Service and societal perspective (included also recurrent wheezing indirect cost) were analysed. Total costs (€, 2016) included pharmaceutical and administration costs, hospitalization costs and recurrent wheezing management annual costs. A discount rate of 3.0% was applied annually for both costs and health outcomes. RESULTS: Over 6 years, the base case analysis showed that palivizumab was associated to an increase of 0.0731 QALYs compared to non-prophylaxis. Total costs were estimated in €2,110.71 (palivizumab) and €671.68 (non-prophylaxis) from the National Health System (NHS) perspective, resulting in an incremental cost utility ratio (ICUR) of €19,697.69/QALYs gained (prophylaxis vs non-prophylaxis). Results derived from the risk-factors population subgroups analysed were in line with the total population results. From the societal perspective, the incremental cost associated to palivizumab decreased to an €1,253.14 (ICUR = €17,153.16€/QALYs gained for palivizumab vs non-prophylaxis). One-way and probabilistic sensitivity analyses confirmed the robustness of the model. CONCLUSIONS: The prophylaxis with palivizumab is efficient for preventing from RSV infections in preterm infants 32day 1-35day 0 wGA in Spain.

Apendicitis abdominal neonatal. Experiencia en un hospital terciario y revisión de la literatura / Neonatal appendicitis. Our experience and review

Introducción: La apendicitis neonatal (AN) es una enfermedad poco frecuente, cuyo diagnóstico diferencial con otras entidades, como la enterocolitis necrosante, es muy difícil de realizar. Casos clínicos: Presentamos tres casos de AN en nuestro centro atendidos en los últimos 12 años. Resultados: Todos eran recién nacidos prematuros de menos de 1.500 g, con distensión abdominal y signos radiológicos de perforación. Todos sobrevivieron tras la realización de una laparotomía y una apendicectomía. No se encontraron en ningún caso otras enfermedades asociadas, como enfermedad de Hirschsprung (EH) o fibrosis quística (FQ). Conclusiones: La AN es un cuadro poco frecuente, y en nuestra experiencia no parece estar relacionado con la EH ni la FQ. Con un diagnóstico precoz, puede tener buen pronóstico (AU)

Introduction: Neonatal appendicitis (NA) is a rare disease, and differential diagnosis with necrotizing enterocolitis is hard to do. Clinical cases: We present three cases of NA found in our centre in the last 12 years. Results: All of them were premature infants less than 1,500 g, with physical findings of abdominal distention and perforation. All of them survived after laparotomy and appendectomy. No other diseases were associated (Hirschsprung disease, cystic fibrosis). Conclusions: We find neonatal appendicitis to be rare, and in our experience is not related to Hirschsprung disease or cystic fibrosis. With early diagnoses, prognosis seems to be good (AU)

Servicio de Neonatología del Hospital General Universitario Gregorio Marañón / Neonatology Department of the Hospital General Universitario Gregorio Marañón

El Servicio de Neonatología del Hospital General Universitario Gregorio Marañón es un servicio de nivel IIIC, integrado en un hospital perteneciente al sistema público de salud de la Comunidad de Madrid, que presta servicios de atención sanitaria especializada. Es un hospital universitario adscrito a la Universidad Complutense de Madrid y realiza actividades docentes, pre y posgrado e investigadoras. Es un servicio cuyo objetivo es la calidad asistencial centrada en el paciente y en la familia (AU)

The Neonatology division of the University General Hospital 'Gregorio Marañón' is a service level IIIC, integrated into a hospital belong to the public health system of the Community of Madrid, which provides specialized health care services. It is associated with the Complutense University of Madrid and performs grade and postgrade teaching and training and research. It is a service whose objective is the quality of care focused on the family centered care (AU)

Using very high frequencies with very low lung volumes during high-frequency oscillatory ventilation to protect the immature lung. A pilot study.

OBJECTIVE: High-frequency oscillatory ventilation (HFOV) has been described as a rescue therapy in severe respiratory distress syndrome (RDS) with a potential protective effect in immature lungs. In recent times, HFOV combined with the use of volume guarantee (VG) strategy has demonstrated an independent effect of the frequency on tidal volume to increase carbon-dioxide (CO2) elimination. The aim of this study was to demonstrate the feasibility of using the lowest tidal volume on HFOV+VG to prevent lung damage, maintaining a constant CO2 elimination by increasing the frequency. STUDY DESIGN: Newborn infants with RDS on HFOV were prospectively included. After adequate and stable ventilation using a standard HFOV strategy, the tidal volume was fixed using VG and decreased while the frequency was increased to the highest possible to maintain a constant CO2 elimination. Pre- and post-PCO2, delta pressure and tidal volume obtained in each situation were compared. RESULT: Twenty-three newborn infants were included. It was possible to increase the frequency while decreasing the tidal volume in all patients, maintaining a similar CO2 elimination, with a tendency to a lower mean PCO2 after reaching the highest frequency. High-frequency tidal volume was significantly lower, 2.20 ml kg(-1) before vs 1.59 ml kg(-1) at the highest frequency. CONCLUSION: It is possible to use lower delivered tidal volumes during HFOV combined with VG and higher frequencies with adequate ventilation to allow minimizing lung injury.

Cribado universal de infección por citomegalovirus en prematuros de menos de 1.500g / Universal cytomegalovirus infection screening in premature newborns less than 1500g

No disponible

Atención del parto en el agua. Consenso de la Sociedad Española de Neonatología y de la Sección de Medicina Perinatal de la Sociedad Española de Obstetricia y Ginecología / Underwater delivery. Consensus of the Spanish Neonatology Society and the Perinatal Section of the Spanish Obstetrics and Gynecology Society

La atención del trabajo de parto en el agua como alternativa al parto tradicional es una práctica que se ha incrementado en muchos países. Se ha constatado que esta modalidad de parto es un método eficaz para disminuir el dolor y acortar el tiempo de dilatación. La American Academy of Pediatrics y The American College of Obstetricians and Gynecologists han publicado un informe clínico en el cual señalan los potenciales beneficios maternos durante la primera parte del parto pero ponen en entredicho la realización de esta técnica durante el expulsivo y el nacimiento del recién nacido. En este informe, la Sociedad Española de Neonatología y la Sociedad Española de Obstetricia y Ginecología analizan la evidencia científica disponible en la actualidad sobre la realización del parto bajo agua y el impacto que puede tener esta práctica en la madre y sobre todo en la salud del recién nacido

Immersion in water during labor and delivery as an alternative to traditional delivery is a practice that has increased in many countries. This technique is effective in reducinge pain and duration of labor. The American Academy of Pediatrics and The American College of Obstetricians and Gynecologists have published a clinical report which indicates the potential maternal benefits during the first stage of labor but, questions the performance ofthis technique during delivery and birth of the newborn. In this report, the Spanish Society of Neonatology and the Spanish Society of Obstetrics and Gynecology analyze the current scientific evidence on water immersion delivery, and the impact this practice could have in the mother and especially in the wellbeing of newborn

[Underwater delivery. Consensus of the Spanish Neonatology Society and the Perinatal Section of the Spanish Obstetrics and Gynecology Society]. / Atención del parto en el agua. Consenso de la Sociedad Española de Neonatología y de la Sección de Medicina Perinatal de la Sociedad Española de Obstetricia y Ginecología.

Immersion in water during labor and delivery as an alternative to traditional delivery is a practice that has increased in many countries. This technique is effective in reducing pain and duration of labor. The American Academy of Pediatrics and The American College of Obstetricians and Gynecologists have published a clinical report which indicates the potential maternal benefits during the first stage of labor but, questions the performance of this technique during delivery and birth of the newborn. In this report, the Spanish Society of Neonatology and the Spanish Society of Obstetrics and Gynecology analyze the current scientific evidence on water immersion delivery, and the impact this practice could have in the mother and especially in the wellbeing of newborn.

Uso de las nuevas tecnologías y telemedicina en el seguimiento del recién nacido sano / Use of the new technologies and Telemedicine, in the healthy newborn follow up

Introducción: la implementación de la telemedicina es cada vez mayor; sin embargo, no existen estudios controlados en nuestro medio que demuestren su efecto en Atención Primaria (AP). Nuestro objetivo es analizar si la implementación de prácticas tecnológicas puede ir encaminada al asesoramiento de las familias. Materiales y métodos: estudio piloto de intervención, prospectivo, controlado no aleatorizado, muestreo consecutivo, con seguimiento longitudinal de seis meses, realizado en un centro de AP pediátrica. Seguimiento a través de web, redes sociales y telemedicina, entre las revisiones del niño sano, 1-2, 2-4 y 4-6 meses. Charlas grupales por telemedicina: vacunas, lactancia materna e introducción alimentos. El grupo control recibió el seguimiento habitual de AP. Resultados: la distribución sociodemográfica, revisiones presenciales del niño sano, detección de patologías fueron homogéneas en los dos grupos. En el grupo de intervención, se objetivó una disminución de la frecuentación de visita pediátrica/enfermería (p<0,05); se reforzó la lactancia materna exclusiva hasta el sexto mes, control 18,6% e intervención 36%. Seguimiento: web 72,5%; redes sociales 58,8%, telemedicina 88,3% y charlas 78,4%. Satisfacción 86,2%. Encuesta pre- y posintervención: cambio de actitud en desplazarse a urgencia/hospital por dudas del 58,62% al 0% (p<0,05). Posición de seguridad al dormir: boca arriba/lado del 73,68% al 100% (p<0,05). Conclusiones: la telemedicina ha demostrado ser eficaz y eficiente en AP en el control, seguimiento y prevención de los problemas habituales de los lactantes sanos en los primeros seis meses de vida. Una web especializada, redes sociales y telemedicina resuelven dudas sobre lactancia materna, alimentación y vacunas. La telemedicina fortalece la atención médica continuada, disminuyendo la frecuentación Pediatría/enfermería (AU)

Background: new technologies, as, websites, social networks and telemedicine are increasingly used for the community to improve and promote health. The aim of this study was to demonstrate the impact of the e-Health in primary care medicine of healthy infants during their first 6 months of age. Methods: pilot prospective intervention, controlled non randomised study, healthy newborn until they're 6 months old, in a primary care medical centre. Website was developed and also a e-Health already established website was used for, visiting between standard, revisions of face to face newborn care: 1-2, 2-4, 4-6 months old; and telemedicine discussions group of vaccines, breastfeeding and introducing solid food. Results: the use of new technologies, demonstrated a decreased of face to face pediatrics and nursing consultant, p<0.05. Increased of exclusive breastfeeding until six months old: control 18,5%, case 36%. Tracker website 72,5%, social networks 58,8%, telemedicine 88,3% and telemedicine patients groups 78,4%. Survey: a changing the attitudes to go to the emergency hospital by questions about the newborn care, before 58,62% after 0%, p<0.05. Safe sleeping position, to sleep on his back, before 73,68% after 100% p<0.05. Conclusions: telemedicine is effective and efficient in improving child health at pediatric primary care. Website, social networks and telemedicine, resolves questions of breastfeeding, introducing solid food and vaccines. Telemedicine benefits the continuous improvement in health care. Decrease the face-to-face pediatrics and nursery consultant (AU)

Cribado universal de infección por citomegalovirus en prematuros de menos de 1.500 g / Universal cytomegalovirus infection screening in premature newborns less than 1500 g

INTRODUCCIÓN: La infección por citomegalovirus es una infección endémica y los niños que acuden a guardería constituyen el foco de infección más importante para las gestantes. OBJETIVO: Establecer una recomendación para el diagnóstico basada en la evidencia médica sobre la infección de trasmisión vertical por citomegalovirus en prematuros menores de 1.500g al nacer. ANTECEDENTES: La infección en la gestante puede ser primaria o secundaria. Aunque exista infección fetal, el 85% de los recién nacidos serán asintomáticos. Los síntomas de infección son: bajo peso al nacer, hepatoesplenomegalia, trombocitopenia, microcefalia y trastornos neurológicos. El pronóstico de los niños sintomáticos suele ser grave, con elevada mortalidad y secuelas neurológicas. El virus se puede reactivar durante la lactancia y es posible la infección precoz a través de la leche materna, probablemente con poca repercusión en niños a término, aunque en prematuros puede afectar al neurodesarrollo a largo plazo. El método diagnóstico de elección es la identificación del citomegalovirus en orina; la determinación en las 2 primeras semanas de vida indica infección congénita. Un diagnóstico posterior sugiere que puede haber sido adquirida en el parto o a través de la leche materna o transfusión de sangre contaminada. Conclusión y recomendación: Determinar el ADN viral por reacción en cadena de la polimerasa a las 4-6 semanas de vida. En caso positivo, investigar en muestras obtenidas los primeros días de vida y en leche materna. Ello debe permitir clasificar al recién nacido en 3 estados: «no infectado», «infección congénita» e «infección adquirida»

INTRODUCTION: Cytomegalovirus (CMV) infection is endemic, and children who attend day care are the most important source of infection. OBJECTIVE: To establish recommendations based on the medical evidence on the vertical transmission of cytomegalovirus in preterm infants weighing less than 1500g at birth. BACKGROUND: Infection in pregnant women may be primary or secondary. Although there is fetal infection, 85% of newborn infants are asymptomatic. Symptoms of infection include low birth weight, hepatosplenomegaly, thrombocytopenia, microcephaly and neurological disorders. The prognosis of symptomatic children is very poor, with high mortality and neurological disorders. The virus can be reactivated during breast feeding, and early infection is possible through breast milk, probably with little impact in term infants, although the long-term neurological outcome worsens in preterm infants. The diagnostic method of choice is the identification of CMV in urine; the determination in the first two weeks of life suggests congenital infection; later it can be acquired at birth or through breast milk or contaminated blood transfusion. Conclusion and recommendation: Determine viral DNA at 4-6 weeks of life by protease chain reaction. If it is positive, monitoring of samples from the first days of life and breast milk are mandatory. This should allow the newborn to be classified into three states: «Without CMV infection», «Congenital CMV infection», «Acquired CMV infection»

"Límite de la viabilidad" en la actualidad / Current "limit of viability"

No disponible

Bringing back the old: time to reevaluate the high-frequency ventilation strategy.

OBJECTIVE: To examine the role of frequency in high-frequency ventilation (HFV) on carbon-dioxide (CO2) elimination and lung injury, independent of its effect on tidal volume. STUDY DESIGN: An anatomically representative lung model was attached to a mechanical ventilator capable of providing HFV with a constant volume. CO2 was infused directly into the lung, and a commercially available end-tidal CO2 detector was used to determine CO2 elimination. CO2 elimination and amplitude of pressure transmissions were evaluated using frequencies ranging from 5 to 15 Hz. The pressure-volume index (PVI) was described as the product of the volume and pressures delivered to the lung, a surrogate for lung injury. RESULT: The use of increasing frequencies directly correlated with improved CO2 clearance when keeping the tidal volume fixed, expressed as percent CO2 remaining in the lung at 25 s (66.5 (±1.1)%, 50.5 (±0.1)% and 37.8 (±0.3)% at 5, 10 and 15 Hz, respectively, P<0.05). With a fixed tidal volume, there was a decrease in pressure amplitudes transmitted to the lung with a decline in the PVI (53.9 (±2.7) mmHg ml(-1), 41.1 (±0.9) mmHg ml(-1) and 23.4 (±3.6) mmHg ml(-1), at 5, 10 and 15 Hz, respectively, P<0.05). CONCLUSION: Frequency has a direct relationship with CO2 elimination when tidal volume is fixed. Using low delivered tidal volumes and high frequencies may allow for improved ventilation efficacy, while minimizing lung injury.

[Universal cytomegalovirus infection screening in premature newborns less than 1500 g]. / Cribado universal de infección por citomegalovirus en prematuros de menos de 1.500 g.

INTRODUCTION: Cytomegalovirus (CMV) infection is endemic, and children who attend day care are the most important source of infection. OBJECTIVE: To establish recommendations based on the medical evidence on the vertical transmission of cytomegalovirus in preterm infants weighing less than 1500g at birth. BACKGROUND: Infection in pregnant women may be primary or secondary. Although there is fetal infection, 85% of newborn infants are asymptomatic. Symptoms of infection include low birth weight, hepatosplenomegaly, thrombocytopenia, microcephaly and neurological disorders. The prognosis of symptomatic children is very poor, with high mortality and neurological disorders. The virus can be reactivated during breast feeding, and early infection is possible through breast milk, probably with little impact in term infants, although the long-term neurological outcome worsens in preterm infants. The diagnostic method of choice is the identification of CMV in urine; the determination in the first two weeks of life suggests congenital infection; later it can be acquired at birth or through breast milk or contaminated blood transfusion. CONCLUSION AND RECOMMENDATION: Determine viral DNA at 4-6 weeks of life by protease chain reaction. If it is positive, monitoring of samples from the first days of life and breast milk are mandatory. This should allow the newborn to be classified into three states: "Without CMV infection", "Congenital CMV infection", "Acquired CMV infection".