Giovanna Bertini

Probiotics feeding in prevention of urinary tract infection, bacterial sepsis and necrotizing enterocolitis in preterm infants: A prospective double-blind study

Background: It has been suggested that probiotics can reduce the overgrowth of pathogens in the bowels of preterm infants and contribute to the reduction of the incidence of nosocomial infections in neonatal intensive care units (NICUs). The purpose of this study was to evaluate the effectiveness of Lactobacillus GG supplementation in reducing the incidence of urinary tract infections (UTIs), bacterial sepsis and necrotizing enterocolitis (NEC) in preterm infants. Methods: A double-blind study was conducted in 12 Italian NICUs. Newborn infants with a gestational age <33 weeks or birthweight <1,500 g were randomized to receive standard milk feed supplemented with Lactobacillus GG (Dicoflor®, Dicofarm, Rome, Italy) in a dose of 6 × 109 colony-forming units (cfu) once a day until discharge, starting with the first feed or placebo. Results: Five hundred eighty-five patients were studied. The probiotics group (n = 295) and the placebo group (n = 290) exhibited similar clinical characteristics. The duration of Lactobacillus GG and placebo supplementation was 47.3 ± 26.0 and 48.2 ± 24.3 days, respectively. Although UTIs (3.4 vs. 5.8%) and NEC (1.4 vs. 2.7%) were found less frequently in the probiotic group compared to the control group, these differences were not significant. Bacterial sepsis was more frequent in the probiotics group (4.4%, n = 11) than in the placebo group (3.8%, n = 9), but the difference was not significant. Conclusion: Seven days of Lactobacillus GG supplementation starting with the first feed is not effective in reducing the incidence of UTIs, NEC and sepsis in preterm infants. Further studies are required to confirm our results in lower birthweight populations.

The role of blood transfusions and iron intake on retinopathy of prematurity

BACKGROUND The role of blood transfusions and iron intake in the pathogenesis or retinopathy of prematurity (ROP) is controversial. AIM To evaluate the influence of packed red cell (PRC) transfusions and iron intake on ROP incidence. STUDY DESIGN Prospective observational study. SUBJECTS Forty-five preterm infants with birthweight <1250 g were studied. After ophthalmological study, they were divided into group A (n=24) that included newborns without ROP, and group B (n=21) that included newborns with ROP. RESULTS Logistic regression analysis demonstrated that gestational age (OR 0.61; 95% C.I. 0.41-0.90), transfusion volume during the first week (OR 1.16; 95% C.I. 1.03-1.3) and during the first 2 months of life (OR 2.93; 95% C.I. 1.52-5.62), and iron intake during the first week of life (OR 1.15; C.I. 1.01-1.32) and during the first 2 months of life (OR 2.93; 95% C.I. 1.52-5.62) were associated with the development of ROP. CONCLUSION Our study showed that gestational age, blood transfusion volume and iron load by transfusions are associated with the risk of occurrence of ROP in infants with a birthweight of less than 1250 g.

Acute neonatal respiratory distress in Italy: a one-year prospective study

A prospective multicentre 12‐month survey of neonatal respiratory disorders in 63 537 Italian infants was performed to evaluate the incidence of acute neonatal respiratory disorders and of the main related complications. A total of 1427 developed respiratory disorders (2.2%), 208 of whom died (14.6%). The incidence of respiratory distress syndrome was 1.16%, with a case fatality rate (CFR) of 24%; that of transient tachypnoea was 0.93%, with a CFR of 1.3%. The rates of meconium aspiration syndrome, persistent pulmonary hypertension and pneumonia were 0.06%, 0.02% and 0.07%, with CFRs of 10.3%, 38.5% and 21.7%, respectively. The occurrences of the main complications in affected newborns were: bronchopulmonary dysplasia 5.6%, necrotizing enterocolitis 1.7%, patent ductus arteriosus 9.8%, 3o and 4o grade intraventricular haemorrhage 6.8% and air leak 4.9%. It was concluded that the incidence of acute neonatal respiratory disorders and the main related complications was lower than that reported two decades ago and that the CFR of acute neonatal respiratory disorders had increased. These results may be the consequences of (i) progress in the management of high‐risk pregnancies, (ii) an increased number of viable infants with extremely low birth weight and (iii) diffusion of antenatal treatment with corticosteroids which, in this series, seemed to reduce the morbidity but not the mortality in the high‐risk infants.

High flow nasal cannula therapy as respiratory support in the preterm infant

We reviewed the literature on the effects of high flow nasal cannula (HFNC) and heated, humidified, high‐flow, nasal cannula (HHHFNC) treatment in preterm infants. We found nine studies, but only two were randomized controlled trials. These studies show that: HFNC application is associated to the delivery of continuous distending pressure (CDP) in patients with closed mouth, whose value is proportional to the delivered flow only in smaller infants; the CDP delivered by HFNC is unpredictable and present large inter‐patient and intra‐patient variability; the use of recently available HHHFNC devices is effective in minimizing nasal mucosa injuries compared to traditional HFNC; the effectiveness of HHHFNC versus NCPAP for the treatment of apnoea of prematurity, respiratory distress syndrome, and the prevention of extubation failure, has been poor investigated and firm conclusions cannot be drawn on this matter. In conclusion, on the basis of published data, the routinary application of HFNC should be limited to patients requiring oxygen‐therapy, HHHFNC devices should be preferred to HFNC, but their employment as an alternative to NCPAP should wait for the conclusion of randomized controlled trials. Pediatr Pulmonol. 2009; 44:629–634.

Blood transfusions increase cerebral, splanchnic, and renal oxygenation in anemic preterm infants.

BACKGROUND: Multiprobe near infrared spectroscopy (NIRS) has been used to study regional cerebral (rSO2C), splanchnic (rSO2S), and renal (rSO2R) tissue oxygenation in newborns. We used this method to study the effects of red blood cell (RBC) transfusions in anemic preterm infants to assess if thresholds for transfusions were appropriate for recognizing a clinical condition permitting tissue oxygenation improvement.

Prophylaxis of patent ductus arteriosus with ibuprofen in preterm infants

The aim of our study was to evaluate whether the prophylactic use of ibuprofen would reduce the incidence of significant patent ductus arteriosus (PDA) and to confirm the effectiveness of ibuprofen as rescue treatment in closing PDA. Eighty preterm infants with gestational age less than 34 wk with infant respiratory distress syndrome (iRDS) were randomized to receive intravenous ibuprofen lysine (10 mg/kg, followed by 5 mg/kg after 24 and 48 h) either within 24 h of life (group A) or after echocardiographic diagnosis of PDA (group B). To evaluate the severity of RDS in each patient, we calculated the initial and highest values of Oxygenation Index (O.I. =mean airway pressure × FiO2 × 100 / PaO2) and Ventilatory Index (V.I. = O.I. × mechanical respiratory rate). Other studied variables were ventilatory support, renal function, biochemical and haematological profiles, frequency of bronchopulmonary dysplasia (BPD), intraventricular haemorrhage (IVH), necrotizing enterocolitis (NEC) and retinopathy of prematurity (ROP). On the 3rd day of life, 8% (3/40) of patients of group A and 53% of patients (21/40) of group B (p < 0.0001) developed a significant PDA. Between patients of group B who presented PDA at 3 d of life 90% (19/21) had a closure of ductus arteriosus after ibuprofen treatment. Initial and highest values of O.I. and V.I. were similar in both groups A and B. No significant differences between the groups were observed in regard to respiratory support, renal function and frequency of BPD, IVH, NEC and ROP. Ibuprofen was not associated with adverse effects.

Maternal education and the incidence and duration of breast feeding: A prospective study

Introduction Duration of breast feeding and factors possibly affecting duration were studied in a population of 2174 newborn infants, with gestational age of >37 weeks, who were born in the Department of Obstetrics and Gynaecology at the University of Florence Hospital between November 15, 1997, and November 14, 1998. Patients and Methods Nine hundred mothers agreed to participate in the study. Five questionnaires were completed at the end of the 1st, 3rd, 6th, 9th, and 12th postpartum month. These dealt with infant feeding practices, including breast feeding during the previous week. Breast feeding duration was defined as short (1 month); medium-short (>1 month–<3 months); medium (>3–<6 months); medium-long (>6–<9 months), and long (>9 months). Results The authors found that 76.3%, 64.7%, 42.3%, 26.4%, and 17% of mothers were still breast feeding at 1, 3, 6, 9, and 12 months after delivery, respectively. The multivariate analysis of the correspondence shows that lack of breast feeding is associated with a birth weight of less than 3000 g, a low level of maternal education, and maternal profession as a housewife or blue collar worker in the commercial sector. A period of breast feeding defined as short or medium-short is associated with mothers who smoke, primiparous mothers, and absence of maternal allergy. The survival curves highlight how the single factor of smoking is an element that leads to a significant difference in the duration of breast feeding. The multiple Cox regression analysis shows a significant negative influence associated with birth weight of less than 3000 g, maternal smoking, and first parity. Above all, among low–birth-weight infants of mothers who smoke, there is a strong correlation with a shorter duration of breast feeding. Discussion There is still a need for programs that support and encourage breast feeding, focusing particularly on mothers with a low level of education who give birth to a low-weight infant, primiparous mothers, and smokers.

Plasma bilirubin level and oxidative stress in preterm infants

Objective: To assess the hypothesis that changes in plasma total bilirubin levels (Btot) can influence the antioxidant system and oxidative stress in preterm infants. Methods: Twenty two healthy preterm infants who presented with visible non-haemolytic hyperbilirubinaemia were studied at the mean (SD) age of 3.7 (1.5) days. Btot, plasma total hydroperoxide concentration (TH), plasma protein SH group concentration, and total antioxidant capacity of the plasma (TAC) were measured at study entry and after 24 hours. Results: Btot did not correlate with TH, TAC, or protein SH group concentration, but a significant correlation was found between TH and TAC, TH and protein SH groups, and TAC and protein SH groups, both at study entry and after 24 hours. Conclusion: The decrease in plasma bilirubin was contemporary with an increase in plasma antioxidant capacity and decrease in oxidative stress in preterm infants. This may be the result of the pro-oxidant effect of haem oxygenase, mediated by iron release, which may outcompete the antioxidant properties of bilirubin.

The INSURE method in preterm infants of less than 30 weeks' gestation

Objectives. Our aim was to identify the clinical characteristics which could distinguish infants who can be managed with INSURE (intubatio-surfactant-extubation) method for preventing mechanical ventilation (MV) and which could predict INSURE success or failure. Methods. Inborn infants with gestational age <30 weeks were Infants were categorised into three groups: (1) infants who needed MV in the delivery room; (2) infants spontaneously breathing who were treated only with NCPAP; (3) infants who were treated with INSURE method. Results. We studied 125 infants: 30 (24%) required MV, 75 (60%) received INSURE treatment, and 20 (16%) were treated with NCPAP. Sixty-eight (91%) infants were successfully treated with the INSURE method. Infants in the success group had less severe RDS and less occurrence of sepsis and pneumothorax, lower mortality, and shorter duration of stay in the NICU than infants in the failure group. A birth weight <750 g, pO2/FiO2 <218, and a/ApO2 <0.44 at the first blood gas analysis were independent risk factor for INSURE failure. Conclusions. The INSURE method can be applied to the majority of extremely preterm infants and is followed by a high percentage of success.

Brain Hemodynamic Changes in Preterm Infants after Maintenance Dose Caffeine and Aminophylline Treatment

Objective: To investigate the acute effects of low-dose caffeine and aminophylline on cerebral blood flow in preterm infants, using both near-infrared spectroscopy (NIRS) and cerebral Doppler ultrasonography. Methods: Preterm infants with a gestational age of <32 weeks and birth weight of <1,500 g were randomized to receive either caffeine or aminophylline treatment for apnea of prematurity. The study period went from 30 min before to 60 min after the administration of the maintenance dose of pure caffeine (2.5 mg/kg once a day) or aminophylline (1.25 mg/kg twice a day). NIRS was used to measure changes in oxygenated hemoglobin (O2Hb), deoxygenated hemoglobin (HHb), oxidized-reduced cytochrome aa3 (CtOx), and mean cerebral oxygen saturation (SmO2 = O2Hb/total Hb). Changes in cerebral blood volume (ΔCBV) after caffeine or aminophylline administration were calculated. Cerebral blood flow velocity (CBV) in the pericallosal artery was evaluated by cerebral Doppler ultrasounds. Results: Data collected by NIRS and cerebral Doppler ultrasounds did not show significant differences before and after caffeine treatment. We observed a significant increase in O2Hb and HHb concentration and in CBV at 30 min after the infusion of aminophylline, which tended to return to baseline at the end of the study period. Conclusion: Caffeine does not significantly affect brain hemodynamics, while aminophylline induces a significant transient increase in O2Hb and HHb concentration and CBV.