Use of Fibrin Glue in the Treatment of Persistent Pneumothorax in Premature Infants at the Limit of Viability: Ethical Issues and Two and A Half Years Follow-Up.

INTRODUCTION: Due to the extreme immaturity of many internal organs, including lungs, infants at the limit of viability are more predisposed to a pneumothorax (PTX). In some cases, PTX becomes persistent. Previously, only a few attempts of PTX treatment with fibrin glue were reported. However, its impact on further lung development is unknown. CASE REPORT: We present a case of an extremely preterm infant with persistent PTX who was successfully treated with fibrin glue. In addition, we present a two-and-a-half-year corrected age follow-up focusing on respiratory problems, motor development and sensory organs. Furthermore, we touch upon the related ethical issues. CONCLUSIONS: Fibrin glue should be used to treat persistent PTX even in an extremely preterm infant. No adverse effects were observed. At the two-and-a-half-year corrected age follow-up, despite severe bronchopulmonary dysplasia development, no serious pulmonary problems were observed. However, the child's development is uncertain. This situation raises important ethical issues concerning saving the lives of infants at the limit of viability.

[The assessment of influence of the diet in the early life, with regard to the effect of protein hydrolysates, on bone mineralization in preterm infants]. / Ocena wplywu sposobu zywienia w pierwszych miesiacach zycia, z uwzglednieniem wplywu hydrolizatów bialkowych, na mineralizacje kosci u noworodków urodzonych przedwczesnie.

UNLABELLED: The aim of the study was to evaluate the influence of the neonatal diet on bone mineralization. We studied 21 neonates (M-10, F-11) in gestational age 27-35 weeks with body birth weight ranging from 860 to 1800 g (mean 1343 g). 12 children received breast milk with fortifier (BMF--group 1) and 9 children were fed with hydrolysate formulas (group 2). The feeding was modified after child body weight reached 3500 g. The bone mineral density measured by densitometry (DPX) technique and body weight gain were evaluated. RESULTS: Mean TBBMD (total body bone mass density--g/cm2) at week 40 of postconceptual age in group 1 was 0.450 +/- 0.021 and in group 2 0.457 +/- 0.049. At 3rd month TBBMD was respectively 0.496 +/- 0.034 and 0.478 +/- 0.016, and at 6 month of corrected age 0.546 +/- 0.055 and 0.564 +/- 0.021. The differences were not statistically significant. There were no differences in body weight gain between both groups. At month 7-9 of corrected age body weight were 8650 g and 8475 g respectively. CONCLUSION: We did not demonstrate the differences in TBBMD and body weight gain between children fed with breast milk and BMF or hydrolysate formulas in the first months of life. The low number of children does not allow to generalize this conclusion.

[Surgical treatment of neonates with very low (VLBW) or extremely low (ELBW) birth weight].

UNLABELLED: Progress in perinatology and neonatal intensive care led to surgical treatment of premature infants born with low (<1500 g) and extremely low (<1000 g) birth weight. AIM: Evaluation of surgical treatment in the group of neonates with very low birth weight (<1500 g) and extremely low birth weight (<1000 g). MATERIAL AND METHODS: In the years 2000-2009 in the Department of Paediatric Surgery in the Institute of Mother and Child, 617 neonates underwent surgical treatment, 101 of them (16%) were born with very low or extremely low birth weight. In the analyzed group the birth weight ranged from 450 g to 1500 g (mean 952 g), gestational age ranged from 23 weeks to 32 weeks (mean 27 weeks). Fifty four patients (53%) were operated with the weight <1000 g. Indications for surgery were of two categories: pathologies related to prematurity and congenital defects. The extend of surgical intervention is presented. Additional pathologies influencing prognosis such as respiratory distress syndrome, haemodynamic ductus arteriosus, intraventricular haemorrhagia, multiple congenital defects and genetic disorders were also taken into consideration. Mortality in the entire group of patients was evaluated in relation to the birth weight, gestational age, reasons for surgical treatment and additional risk factors. RESULTS: Pathologies related to prematurity were indications for surgical treatment in 70 patients: perforation of the bowel in the course of necrotizing enterocolitis - NEC (28 patients), spontaneous intestinal perforation - SIP (32), gastric perforation - GP (4), meconium obstruction - MO (3) posthemorrhagic hydrocephalus - PH (3). In the remaining 31 neonates the following congenital defects were operated: inguinal hernia (10 patients), oesophageal atresia (8), anal atresia (2), torsion of the bowel (2), bowel atresia (3), hernia of the umbilical cord (3), ruptured omphalocele (1), myelomeningocele (2). In the entire group of 101 premature infants, 99 patients (98%) had respiratory distress syndrome, 56 (56%) required the closure of ductus arteriosus , in 55 patients (55%) intraventricular haemorrhage from II to IV degree was confirmed. In total thirty patients died. Twenty one of them were ELBW neonates. None of the patients died during the operation or within the first postoperative day. Mortality rate in the group with the weight <1000 g was 38%, in the group with the weight 1000 g-1500 g it was 19%. Highest mortality was observed in the patients with oesophageal atresia (62%) In this group the biggest number of additional anomalies or other genetic disorders was found. Twenty infants died (31%) in the group of 64 neonates with perforations. Mortality rate in the groups with the weight <1000 g and 1000 g-1500 g it was 34% and 26% respectively. Our results confirmed the significant difference between mortality in NEC - 65% and in SIP - 19.5% . The remaining 5 deaths were related both to extreme multiorgan prematurity and severe congenital defects. CONCLUSION: The most frequent indications for surgery in premature neonates (VLBW and ELBW) are acquired pathologies which are related to premature multiorgan insufficiency: perforations in the course of ischaemic or inflamatory changes in the bowel (NEC, SIP), intestinal obstruction related to functional insufficiency of alimentary tract (MO) and posthaemorrhagic hydrocephalus. Congenital anomalies constitute 30% of indications for surgical treatment in this group of patients. Neonates born with low or extremely low birth weight are in the group of patients with the highest intraoperative risk. There is herefore a need to create well equipped, interdisciplinary centres employing paediatric surgeons, anaesthesiologists and neonatologists experienced in treatment of extremely premature neonates.

[Risk factors, frequency and severity of bronchopulmonary dysplasia (BPD) diagnosed according to the new disease definition in preterm neonates]. / Czynniki ryzyka, czestosc wystepowania i stopien ciezkosci dysplazji oskrzelowo-plucnej (BPD) rozpoznawanej na podstawie nowej definicji choroby u noworodków przedwczesnie urodzonych.

BACKGROUND: Bronchopulmonary dysplasia (BPD) is a chronic lung disease of prematurity. The new definition of BPD was introduced in 2001. It combined two existing BPD definitions - oxygen dependency at 28 days of life and at 36 weeks of postmenstrual age. New definition divided BPD into three forms: mild, moderate and severe. Despite significant progress in neonatal intensive care and increasing survival of extremely immature infants the incidence of BPD is not decreasing. The etiopathology of new disease is still discussed. OBJECTIVE: The aim of the study was to assess the frequency and severity of BPD in very low birth weight (VLBW) neonates (<28 GA) and to determine peri- and postnatal risk factors according to the new BPD definition. PATIENTS AND METHODS: We retrospectively analyzed the case records of 244 neonates boys - 112; girls - 132) at gestational age weeks 23-28 (26.4+/-1.4) treated at the Institute of Mother and Child in Warsaw between 1999 and 2004. Of these 166 (68%) infants were evaluable at 36 weeks of postmenstrual age and had BPD evaluation according to the new definition. The following variables were analyzed according to BPD status: sex distribution, gestational age, body weight at birth severity, of respiratory distress syndrome (RDS), intrauterine or late infections, congenital or late pneumonia, patent ductus arteriosus (PDA) and intraventricular haemorrhage (IVH) grade III or IV. RESULTS: BPD was present in 126 (76%) neonates including: severe BPD in 23 (18%), moderate 19 (15%) and mild BPD in 84 (67%) of children. Neonates with BPD had lower gestational age (26.4+/-1.3 vs 27.4+/-0.9 week, p<0.001) and lower birth weight (887+/-186 vs 1038+/-183 g, p<0.001) than children without BPD. The rates of late onset sepsis, late pneumonia and PDA were statistically higher in children with BPD than in those without BPD (respectively 70 vs 33%, 72 vs 35% and 51 vs 20% p<0.001). Logistic regression with adjustment for gestational age did not change these results. Children with severe BPD had higher rate of late infections (p<0.05) and PDA (p<0.05). CONCLUSIONS: 1. The frequency of BPD in VLBV neonates is high (76%) but in the majority of cases the disease is mild (67%); 2. Severe BPD was more common in neonates with late onset sepsis and IVH grade III or IV; 3. The BPD risk factors are: low gestational age, low birth weight, as well as late onset sepsis, late pneumonia and PDA.

[Inguinal hernia in preterm infants - therapeutic problem for neonatologist, anaesthesiologist and paediatric surgeon]. / Przepuklina pachwinowa u przedwczesnie urodzonego noworodka- wspólny problem leczniczy dla neonatologa, anestezjologa i chirurga.

UNLABELLED: Inguinal hernia in preterm infants is a difficult therapeutic problem because of the risk of anaesthesia and the immaturity of the baby. Despite of high risk of perioperative complications surgical repair of the hernia should be considered before discharge. AIM: evaluation of the perioperative problems in the preterm infants with inguinal hernia. MATERIAL AND METHODS: evaluation was performed in 21 preterm infants (gestational age 23-36 weeks, birth weight 450-1370 g) operated because of inguinal hernia between 2002-2007. Various problems related to prematurity were confirmed in all patients. Incarcerated hernia were operated on in 5 patients, in 16 neonates hernia repair was performed as elective surgery. In two of them, few weeks after unilateral hernia repair, operation on the other side was performed because of incarceration. Nine infants were qualified for general anaesthesia, fourteen for spinal anaesthesia. Indications for surgical treatment, method of anaesthesia and early postoperative results were analysed with reference to various problems connected with prematurity such as intraventricular haemorrhage and chronic lung disease. RESULTS: inclusively 23 operations were performed in 21 infants (gestational age 36-47 weeks, weight 1130 -2750 g). Four of fourteen infants preliminary qualified for spinal anaesthesia turned into general anaesthesia. There were not any problems during the operations. Two patients required short ventilatory support (both with general anaesthesia because of incarcerated hernia). During a follow up examination recurrence of the hernia was not observed in any of the patients. CONCLUSION: despite of high risk of perioperative complications in preterm infants, surgical repair of the inguinal hernia should be considered before discharge. Spinal anaesthesia is a safe alternative for general anaesthesia in preterm infants especially for infants with chronic lung disease.