Filipa Flor-de-Lima

Failure of early nasal continuous positive airway pressure in preterm infants of 26 to 30 weeks gestation

Objective:To identify variables associated with early nasal continuous positive airway pressure (ENCPAP) failure in preterm neonates less than 30 weeks gestational age.Study Design:Multicenter prospective study including 131 preterm newborns, over a period of 2 years. Patients and respiratory variables were assessed using univariate analysis.Result:Variables associated with ENCPAP failure were: the need of resuscitation with a FiO2>0.30; a CPAP pressure of 6.4±1.2 cm H2O; the need of a FiO2 of 0.40 in the first 4 h of life; male gender maintaining the need of a FiO2>0.25 in the first 4 h of life; and respiratory distress syndrome with criteria for surfactant administration.Conclusion:The need for oxygen in resuscitation and maintained in first hours of life, male gender, a CPAP pressure over 5 cm H2O and surfactant need are predictors of ENCPAP failure in preterm neonates 26 to 30 weeks gestational age.

Severe pertussis in newborns and young vulnerable infants.

A retrospective chart review of 18 nonvaccinated newborns and infants admitted to 6 intensive care units in the north of Portugal between 2007 and 2012 revealed a high rate of admissions in 2012 along with significant rates of severe pulmonary hypertension and mortality. Hyperleukocytosis was significantly associated with a more severe clinical picture and mortality.

Impact of Changes in Perinatal Care on Neonatal Respiratory Outcome and Survival of Preterm Newborns: An Overview of 15 Years

Survival and outcomes for preterm infants with respiratory distress syndrome (RDS) have improved over the past 30 years. We conducted a study to assess the changes in perinatal care and delivery room management and their impact on respiratory outcome of very low birth weight newborns, over the last 15 years. A comparison between two epochs was performed, the periods before and after 2005, when early nasal continuous positive airway pressure (NCPAP) and Intubation-SURfactant-Extubation (INSURE) were introduced in our center. Three hundred ninety-five clinical records were assessed, 198 (50.1%) females, gestational age 29.1 weeks (22–36), and birth weight 1130 g (360–1498). RDS was diagnosed in 247 (62.5%) newborns and exogenous surfactant was administered to 217 (54.9%). Thirty-three (8.4%) developed bronchopulmonary dysplasia (BPD), and 92 (23%) were deceased. With the introduction of early NCPAP and INSURE, there was a decrease on the endotracheal intubation need and invasive ventilation (P < 0.0001), oxygen therapy (P = 0.002), and mortality (P < 0.0001). The multivariate model revealed a nonsignificant reduction in BPD between the two epochs (OR = 0.86; 95% CI 0.074–9.95; P = 0.9). The changes in perinatal care over the last 15 years were associated to an improvement of respiratory outcome and survival, despite a nonsignificant decrease in BPD rate.

Pertussis in a Portuguese Pediatric Tertiary Care Hospital.

T onset of fever or sudden worsening of a disease after the start of treatment may potentially lead one to think of misdiagnosis or adverse effects of treatment, but Jarisch-Herxheimer reaction (JHR) is also a consideration. A 3-year-old boy was referred to our Pediatric Rheumatology Department in January 2006, for chronic arthritis of the left knee of 5 months’ duration. In August 2005, he developed moderate to severe pain and functional disability of the knee, associated with intermittent fever. An arthrotomy revealed abundant cloudy liquid. No cytochemical analysis was done, and the articular fluid culture was sterile. He was treated with intravenous flucloxacillin 100 mg/kg/d for 12 days followed by oral flucloxacillin 60 mg/kg/d for 10 days. Intermittent fever remained with a persistent intense joint pain even at night, making walking impossible. After 5 months of evolution, he was sent to our Pediatric Rheumatology Department for suspicion of oligoarticular juvenile idiopathic arthritis. Examination revealed knee swelling, intense pain on any knee movement, functional disability, with 30° knee flexion and a warm joint without erythema. The remaining physical examination was normal. Serology for Brucella showed Wright reaction (1:1280) and immunofluorescence for Brucella (1:1280). The hemoglobin level was 10.8 g/dL, with no other changes, erythrocyte sedimentation rate 15 mm first hour and C-reactive protein 1.5 mg/dL. The laboratory confirmed a positive of blood culture for Brucella spp. performed on the same day as the arthrotomy. There were no risk factors for brucellosis (ingestion of nonpasteurized aliments or contact with infected animals). Treatment was initiated with intravenous gentamicin 5 mg/kg/d (7 days), oral trimethoprim-sulfamethoxazole (50 mg/kg/d of sulfamethoxazole) and oral rifampicin 20 mg/kg/d for 6 weeks. Two hours after the first dose of gentamicin, he developed high fever (40.5°C axillary), chills and prostration. The temporal relationship between beginning of the antibiotic treatment and high fever with chills suggested the

Heterotaxy Syndrome with Esophageal Atresia

newborn presented with a prenatal diagnosis of hy-dramnios, dysplastic kidney, and congenital heart dis-ease and suspected heterotaxy syndrome. His 38-week gestation was complicated by maternal cholestasis. Anamniocentesiswasperformedandkaryotypewas46,XY.Thirdtrimesterserologieswerenegativeandthemotherwasimmuneto rubella and not immune to toxoplasmosis. There was norelevantfamilyhistory.Thedeliverywasbycesarean,theApgarscoreat1st/5thminutewas8/9andbirthweightwasadequatefor gestational age. After birth, he presented mild respiratorydistress withheart sounds inthe rightthoraxand left cryptor-chidism.Hypersalivationwasobservedwithnoprogressionofthe orogastric tube. A thoraco-abdominal radiograph showedesophageal atresia with right sided stomach bubble (Figure).Cardiac evaluation confirmed dextrocardia and dextroapex,large oval foramen, an atrioventricular septal defect withatrial septal defect, total abnormal pulmonary venous returnto one of the left atria located in the right position,interrupted inferior vena cava, right aortic arch, and patentductus arteriosus. To better understand the heterotaxysyndrome, a thoracic tomography angiogram was performedand the presence of bilateral hyparterial bronchi suggestedleft isomerism. Abdominal ultrasound showed rightpolysplenia and a liver in median position; malrotation wasexcluded. Renal ultrasound showed dysplastic left kidneywith no other relevant abnormalities. The esophageal atresiawith tracheoesophageal fistula was corrected on day 1 withmechanical ventilation required until day 5. He wasdischarged at day 28 and no relevant complications aroseduringhospitalstay.Hehadafavorableshorttermfollow-up.Heterotaxy syndrome is associated with congenital heartdefects and multiple systems may be involved; however,esophageal atresia is rarely found.

Red blood cells transfusions in very low birth weight neonates

Introduction: Very low birth weight preterm infants are associated with a greater risk of morbidity and mortality and are more susceptible to therapy with red blood cells transfusions. The aim of this study is to analyse the frequency and factors associated with red blood cells transfusions in very low birth weight infants. Material and methods: This retrospective study included neonates with very low birth weight admitted between November 1, 2011 and October 31, 2015. Demographic, perinatal and clinical data during hospitalization were obtained through medical records. Statistical tests were used to compare neonates with and without need for red blood cells transfusion and multivariate regression analysis to find predictor factors. Results: Seventy-nine patients were studied, median birth weight of 1,190 grams and mean gestational age of 29 ± 2 weeks. Forty-nine (62%) received transfusion support with red blood cells. Higher need for red blood cells transfusions was significantly associated with low birth weight (OR = 0.99, 95% CI 0.990-0.999) and total millilitres of phlebotomy losses (OR = 1.17, 95% CI 1.07-1.28). Birth weight (B = -0.01, 95% CI -0.008 to -0.003), hemoglobin at admission (B = -0.33, 95% CI -0.53 to -0.13) and sepsis (B = 1.85, 95% CI 0.72-2.98) were predictive factors for the number of red blood cells transfusions. Regarding the treatment with erythropoietin, there were no differences for all outcomes. Conclusions: Phlebotomy losses are one of the major factors for the need of transfusion in preterm infants, and therefore sampling should be minimized to the maximum.

Respiratory Care for the Ventilated Neonate

Invasive ventilation is often necessary for the treatment of newborn infants with respiratory insufficiency. The neonatal patient has unique physiological characteristics such as small airway caliber, few collateral airways, compliant chest wall, poor airway stability, and low functional residual capacity. Pathologies affecting the newborns lung are also different from many others observed later in life. Several different ventilation modes and strategies are available to optimize mechanical ventilation and to prevent ventilator-induced lung injury. Important aspects to be considered in ventilating neonates include the use of correct sized endotracheal tube to minimize airway resistance and work of breathing, positioning of the patient, the nursing care, respiratory kinesiotherapy, sedation and analgesia, and infection prevention, namely, the ventilator-associated pneumonia and nosocomial infection, as well as prevention and treatment of complications such as air leaks and pulmonary hemorrhage. Aspects of ventilation in patients under ECMO (extracorporeal membrane oxygenation) and in palliative care are of increasing interest nowadays. Online pulmonary mechanics and function testing as well as capnography are becoming more commonly used. Echocardiography is now a routine in most neonatal units. Near infrared spectroscopy (NIRS) is an attractive tool potentially helping in preventing intraventricular hemorrhage and periventricular leukomalacia. Lung ultrasound is an emerging tool of diagnosis and can be of added value in helping monitoring the ventilated neonate. The aim of this scientific literature review is to address relevant aspects concerning the respiratory care and monitoring of the invasively ventilated newborn in order to help physicians to optimize the efficacy of care.

Neonatal dilated cardiomyopathy

Cardiomyopathies are rare diseases of the heart muscle, of multiple causes, that manifest with various structural and functional phenotypes but are invariably associated with cardiac dysfunction. Dilated cardiomyopathy is the commonest cardiomyopathy in children, and the majority present before one year of age. Its etiology may be acquired or genetic. Myocarditis is an important cause and is responsible for the majority of acquired cases. Inherited (familial) forms of dilated cardiomyopathy may occur in 25-50% of patients. Echocardiographic and tissue Doppler studies are the basis for diagnosis of dilated cardiomyopathy in most patients. Marked dilatation of the left ventricle with global hypokinesis is the hallmark of the disease. This review will cover the classification, epidemiology and management of newborns with dilated cardiomyopathy. In particular, a comprehensive and up-to-date review of the genetic study of dilated cardiomyopathy and of detailed echocardiographic assessment of these patients will be presented.

Severe bronchopulmonary dysplasia with large pneumatoceles in an extreme preterm newborn

Bronchopulmonary dysplasia (BPD) is a major complication of extreme prematurity. The lungs are characterized by areas of emphysema, and fibrosis.1 Large pneumatoceles due to acquired localized emphysema over-inflation are recognized but are relatively rare in advanced BPD.2--4 A male newborn of 580 g birthweight was born at 26 weeks of gestation by c-section to a 33 years old 4G, 3P, gipsy mother, after a full cycle of corticosteroids. The pregnancy was regularly followed, and was complicated by gestational diabetes, preeclampsia and intrauterine growth restriction. The 1st/5th/10th minutes Apgar score were 3/5/7. He was intubated after birth and received synchronized conventional mechanical ventilation from the 2nd minute of life. He needed surfactant administration three times, because of severe respiratory distress syndrome (RDS). On day (D) two of life he presented a pulmonary hemorrhage. On D17 he was moved from SIPPV+ volume guarantee (maximum settings: InspP = 24 cmH2O; frequency = 60 min--1; PEEP = 5 cmH2O; FiO2 = 0.6; VG = 6.5 ml/kg) to high frequency oscillatory ventilation (maximum settings: MAP = 18; DeltaP = 38; iT = 33%; Freq = 15 Hz; FiO2 = 1). Blood cultures were negative as was reactive C protein. A 10 days course of systemic dexamethasone was started. Large cystic pneumatoceles appeared in the right and left lower lobe on D19 (Figs. 1 and 2). Taking a wait and see attitude, the pneumotoceles spontaneously regressed on D32 (Fig. 3).2 Serial cultures of tracheal aspirates from D15 became positive for an extended-spectrum beta-lactamase (ESBL) Klebsiella pneumonia strain, only sensitive to amikacin. Overall, during the neonatal intensive care unit admission the baby was under mechanical ventilation for 90 days, suffered from two episodes of hypertensive pneumothorax (D14 and D25), two episodes of nosocomial sepsis without isolation of agent on blood cultures (D48 and D80) treated

Correspondence: predictors of prognosis in neonates with congenital diaphragmatic hernia – Authors' reply

We would like to start by thanking the author for his kind correspondence and his comments on our paper. This corrispondence refers to the following article: Granjo Morais C, Rocha G, Flor-de-Lima F, Eden P, Fragoso AC, Guimaraes H. Predictors of prognosis in neonates with congenital diaphragmatic hernia: experience of 12 years. J Pediatr Neonat Individual Med. 2017;6(1):e060126. doi: 10.7363/060126 . Comments can be found in the following article: Kumar J. Correspondence: predictors of prognosis in neonates with congenital diaphragmatic hernia. J Pediatr Neonat Individual Med. 2017;6(1):e060139. doi: 10.7363/060139 .