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A randomised control study comparing the Infant Flow Driver with nasal continuous positive airway pressure in preterm infants

OBJECTIVE To compare the effectiveness of the Infant Flow Driver (IFD) with single prong nasal continuous positive airway pressure (nCPAP) in preterm neonates affected by respiratory distress syndrome. DESIGN Randomised controlled study. PATIENTS Between September 1997 and March 1999, 36 preterm infants who were eligible for CPAP treatment were randomly selected for either nCPAP or IFD and studied prospectively for changes in oxygen requirement and/or respiratory rate. The requirement for mechanical ventilation, complications of treatment, and effects on mid-term outcome were also evaluated. RESULTS Use of the IFD had a significantly beneficial effect on both oxygen requirement and respiratory rate (p < 0.0001) when compared with nCPAP. Moreover, O2 requirement and respiratory rate were significantly decreased by four hours (p < 0.001 and p < 0.03 respectively). The probability of remaining supplementary oxygen free over the first 48 hours of treatment was significantly higher in patients treated with the IFD than with nCPAP (p < 0.02). IFD treated patients had a higher success (weaning) rate (94% v 72 %) and shorter duration of treatment (49.3 (31)v 56 (29.7) hours respectively; mean (SD)), although the difference was not significant. CONCLUSIONS IFD appears to be a feasible device for managing respiratory distress syndrome in preterm infants, and benefits may be had with regard to oxygen requirement and respiratory rate when compared with nCPAP. The trend towards reduced requirement for mechanical ventilation, shorter clinical recovery time, and shorter duration of treatment requires further evaluation in a multicentre randomised clinical trial.

Hennekam syndrome presenting as nonimmune hydrops fetalis, congenital chylothorax, and congenital pulmonary lymphangiectasia

We report a female infant with congenital lymphedema, facial anomalies, intestinal lymphangiectasia consistent with a diagnosis of Hennekam syndrome. At birth the patient presented with severe respiratory distress due to nonimmune hydrops fetalis, a congenital chylothorax (CC), and pulmonary lymphangiectasia. Hydrops fetalis may be present in newborns with the Hennekam syndrome. Lymphoscintigraphy can be useful in explaining pleural‐pulmonary involvement of this generalized lymph vessel malformation syndrome.

Determinants of Nosocomial Infection in 6 Neonatal Intensive Care Units: An Italian Multicenter Prospective Cohort Study

BACKGROUND Nosocomial infections are still a major cause of morbidity and mortality among neonates admitted to neonatal intensive care units (NICUs). OBJECTIVE To describe the epidemiology of nosocomial infections in NICUs and to assess the risk of nosocomial infection related to the therapeutic procedures performed and to the clinical characteristics of the neonates at birth and at admission to the NICU, taking into account the time between the exposure and the onset of infection. DESIGN A multicenter, prospective cohort study. PATIENTS AND SETTING A total of 1,692 neonates admitted to 6 NICUs in Italy were observed and monitored for the development of nosocomial infection during their hospital stay. METHODS Data were collected on the clinical characteristics of the neonates admitted to the NICUs, their therapeutic interventions and treatments, their infections, and their mortality rate. The cumulative probability of having at least 1 infection and the cumulative probability of having at least 1 infection or dying were estimated. The hazard ratio (HR) for the first infection and the HR for the first infection or death were also estimated. RESULTS A total of 255 episodes of nosocomial infection were diagnosed in 217 neonates, yielding an incidence density of 6.9 episodes per 1,000 patient-days. The risk factors related to nosocomial infection in very-low-birth-weight neonates were receipt of continuous positive airway pressure (HR, 3.8 [95% confidence interval {CI}, 1.7-8.1]), a Clinical Risk Index for Babies score of 4 or greater (HR, 2.2 [95% CI, 1.4-3.4]), and a gestational age of less than 28 weeks (HR, 2.1 [95% CI, 1.2-3.8]). Among heavier neonates, the risk factors for nosocomial infection were receipt of parenteral nutrition (HR, 8.1 [95% CI, 3.2-20.5]) and presence of malformations (HR, 2.3 [95% CI, 1.5-3.5]). CONCLUSIONS Patterns of risk factors for nosocomial infection differ between very-low-birth-weight neonates and heavier neonates. Therapeutic procedures appear to be strong determinants of nosocomial infection in both groups of neonates, after controlling for clinical characteristics.

Lymphoscintigraphic evaluation of congenital lymphedema of the newborn

The authors present a case of the Hennekam syndrome diagnosed in a newborn. Lymphedema is usually present in this syndrome, and the lymphoscintigraphic imaging findings for its detection are discussed. This case confirms the utility of lymphoscintigraphy in providing important physiologic and anatomic information for presurgical planning. An etiologic diagnosis could possibly be obtained. The procedure is relatively easy to perform, safe, reliable, minimally invasive, and not uncomfortable for the patient. It should be considered a valuable diagnostic tool, especially in newborns, in whom conventional contrast lymphoangiography is difficult to perform.

Pulmonary interstitial emphysema in preterm twins on continuous positive airway pressure.

Unilateral pulmonary interstitial emphysema (uPIE) is a well-known condition that is usually observed as a complication in infants who undergo mechanical ventilation (MV). It is rather unusual for uPIE to occur during nasal continuous positive airway pressure (n-CPAP) [1]. We report herein preterm twins with uPIE on n-CPAP who were successfully managed by a conservative approach. Female, monochorionic twins were born at 31 weeks of gestation to a 28-year-old mother by cesarean section following premature rupture of the membranes. A course of betamethasone had been administered to the mother one week prior to delivery. Case 1 Apgar scores were 5 and 9 at 1 and 5 minutes, respectively. Mild tachydyspnea at birth was treated by n-CPAP (3 cmH2O) in the delivery room. Birth weight was 1200 g (510 centile), length was 36 cm (510 centile), and head circumference was 26.5 cm (10 centile). Due to persisting mild respiratory distress, n-CPAP (Infant Flow Driver, Electro Medical Equipment Ltd, Brighton, UK) was continued (FiO2 0.30; 4 cmH2O), with stable and satisfactory gas values during the first 24 hours. Echocardiography showed a patent ductus arteriosus, which was successfully treated with ibuprofen. A chest radiograph was taken at 24 hours of age and showed interstitial emphysema involving the left lung with herniation across the midline and a rightward shift of the mediastinum compressing the quite normal appearing right lung (Figure 1, panel A). The patient’s O2 dependency concomitantly worsened up to 0.5, and there was a mild increase in tachydyspnea. Radiography was again performed 2 hours later and showed that the lesions were gradually enlarging and were associated with a progressive worsening of the mediastinal shift to the right. A few hours later, severe respiratory deterioration abruptly occurred and an X-ray showed left pneumothorax (Figure 1, panel B). The infant was placed on MV and a chest tube was inserted into the left hemithorax. Antibiotic therapy was also started. Due to the evidence of uPIE, the patient was selectively intubated in the right mainstem bronchus and was positioned left side-down. An X-ray taken 8 hours later showed a substantial improvement in the affected lung (Figure 1, panel C). Twenty-four hours later the uPIE had almost completely resolved. At 5 days of age the chest drainage tube was removed and she was extubated (Figure 1, panel D). Case 2 Apgar scores were 5 and 8 at 1 and 5 minutes, respectively. Mild tachydyspnea at birth was treated by n-CPAP (3 cmH2O) in the delivery room. Birth weight was 1170 g (510 centile), length was 36 cm (510 centile), and head circumference was 24.5 cm (510 centile). Early respiratory distress syndrome (RDS) was treated in the neonatal intensive care unit (NICU) by n-CPAP (FiO2 0.3; 4 cmH2O) (Infant Flow Driver, Electro Medical Equipment Ltd, Brighton, UK). Clinical status remained stable over the next 36 hours. Echocardiography showed a patent ductus arteriosus, which was successfully treated with ibuprofen. On account of an increase in oxygen requirement (FiO2 up to 0.5), a slight worsening of tachypnea, and slow, progressive deterioration of blood gases, we took a chest X-ray at 36 hours of age, which revealed marked left interstitial emphysema with mediastinal shift to the right, while mild antero-lateral The Journal of Maternal-Fetal and Neonatal Medicine, October 2006; 19(10): 671–673

15 Determinants of Nosocomial Infection (NI) in Six Italian Neonatal Intensive Care Units (NICUs).

As care improves many neonates with life-threatening disorders now survive. Nonetheless Nosocomial Infections (NI) are still a major cause of morbidity and mortality in NICUs. A prospective multicentric surveillance study was conducted in six Italian NICUs to describe the epidemiologic profile and determinants of NI in NICU. 1692 neonates, consecutively admitted to the NICUs from July 2000 to October 2002 and monitored for the development of NI were enrolled into the study. The standard definition criteria for NI formulated by the Centers for Disease Control in Atlanta were used. The cumulative probability and hazard ratios (HR) for the first episode of infection were estimated by the Kaplan-Meier method and the Cox model. A total of 217 neonates had 255 episodes of NI. The incidence rate of NI was 7 per 1000 patient-days. The cumulative probability of first infection was 20% (95% CI, 7.50–23.30) and 27.6% (95 CI, 23.20–32.80) at 30 and 60 days after admission to the NICU. After adjustment for the severity of illness, the main risk factors related to NI in very-low-birth-weight neonates (VLBW) were surgical procedures (HR 2.69;95% CI 0.60–12.08), nasal ventilation (CPAP) (HR, 2.51; 95% CI, 0.93–6.76), continuous enteral feeding (HR 1.89; 95% CI, 0.20–17.50), mechanical ventilation (HR, 1.70; 95%CI, 0.72–4.00) and intravenous infusions (HR 1.46; 95% CI, 0.32–6.52). Among neonates with a birth weight over 1500 g, risk factors for NI were parenteral nutrition with lipid emulsion (HR, 12.41; 95% CI, 4.19–36.78), surgical procedures (HR 2.78; 95% CI, 0.82–9.44), and intravenous infusions (HR, 2.63; 95% CI, 0.27–25.53). Risk factors for NI were related more to the severity of illness than to healthcare procedures in VLBW babies and more to medications among neonates weighing more than 1500 g at birth.Supported by a Grant from the Italian Ministry of Health, N 99010661

Lack of effect of dietary nucleotide supplementation on erythrocyte 2,3-diphosphoglycerate concentration. A study on preterm neonates

Background. Recently we demonstrated an increased 2,3-diphosphoglycerate (2,3-DPG) erythrocyte concentration in rat pups subjected to nucleotide-enriched artificial feeding. Design. The present study was carried out to test the hypothesis that a possible increase in 2,3-DPG concentration can also be obtained in human neonates who are fed nucleotide-enriched formula. Preterm neonates born or referred to the neonatal intensive care unit of the G. Gaslini Hospital, Genoa University, with a gestational age >30 weeks and <37 weeks were enrolled in our randomized trial. Recruitment took place within 48–72 hours from birth. Only newborns of mothers deciding not to breast-feed were eligible to be randomized for the supplemented group (FN) or non-supplemented group (RF). Breast-fed newborns were considered the control group (C). The study window (for supplementation and blood samples) was restricted to the first two weeks following birth (from the 2nd (t1) to the 16th (t2) day of life). At the end of our study, only 21 neonates were eligible for statistical analysis. Results. The stimulating action of dietary nucleotides on 2,3-DPG concentration failed to be demonstrated; increases in 2,3-DPG concentration that were observed in newborns fed with nucleotide supplemented formula (FN) were comparable to those observed in newborns fed with regular formula (RF) and breast-fed newborns. Conclusions. The EC recommendation for the amount of nucleotides allowed in formula milk does not seem to be high enough to have positive effects on 2,3-DPG synthesis. Whether this possible ‘pharmacological’ effect can be achieved by a higher intake of ingested nucleotides and/or a change in the proportions of single nucleotides contained in milk formulas remain interesting end points to be elucidated.

Persistent left superior vena cava in a preterm newborn

P. Tomà (&) Department of Radiology, Institute G. Gaslini, 5 Largo G. Gaslini, 16147, Genoa, Italy E-mail: paolotoma@ospedale-gaslini.ge.it Tel.: +39-010-5636572 Fax: +39-010-385599 A premature infant (gestational age 26 weeks; birth weight 900 g) presented with mild respiratory distress shortly after birth. Following a preset protocol at our unit, an Epicutaneo-Cava-Katheter (Vygon Medical Products, Germany), containing a 19-gauge needle and a 24-F Silastic catheter (0.3 mm internal diameter and 0.6 mm external diameter), was inserted percutaneously via a left-sided antecubital vein and advanced to the superior vena. A chest radiograph demonstrated the course of the catheter (Fig. 1). Cardiac US confirmed persistent leftsided superior vena cava (PLSVC) and showed the absence of congenital cardiac anomalies; 24-h Holter recording was normal. PLSVC is an embryological remnant and is the most common thoracic venous anomaly [1]. It results from the abnormal persistent patency of an embryological vessel. During embryological development, venous return from the head and arms normally drains to the right atrium via the left and right anterior cardinal veins. At approximately 8 weeks’ gestation, the left brachiocephalic vein develops as a bridge between the left and right anterior cardinal veins. The caudal part of