Maria Serenella Pignotti

Extremely preterm births: recommendations for treatment in European countries

Although there are many subtle differences among European statements addressing recommendations on treatment of extremely preterm pregnancies / neonates depending on the different cultural and social background of each country, the general recommendations are very similar. Of course, the availability of guidelines may not automatically affect physician behaviour, and we do not really know how much these recommendations influence medical practice in different countries. Studies are needed in these fields. From this review it is also evident that, despite being extremely useful, guidelines on perinatal care of peri-viable fetuses / neonates are intended as a general framework to help clinicians and parents in their decision making in this dramatic event. In respecting the dignity of every human being, they also outline the limits of modern standards of care and the medical duty to offer unconditional treatment to mothers and newborns.

Bilateral consolidation of the lungs in a preterm infant: an unusual central venous catheter complication

We describe a case of bilateral parenchymal consolidation with sudden respiratory distress in a preterm baby as a complication of peripherally inserted central catheter (PICC) dislocation. The X‐rays showed bilateral pulmonary consolidation with the catheter tip initially located in the right, and later in the left pulmonary artery. The catheter was withdrawn. As soon as the catheter was repositioned all clinical signs and symptoms disappeared. Neonatologists should consider the possibility of dramatic respiratory distress deriving from PICC dislocation. Careful tip catheter placement and conscientious monitoring may reduce morbidity.

Thoracentesis in pericardial and pleural effusion caused by central venous catheterization: a less invasive neonatal approach

An 840 g infant developed a rapid onset of shock‐like symptoms. Pericardial and pleural effusions from an indwelling central catheter were diagnosed via echocardiography. A thoracentesis was promptly performed with immediate clinical improvement. The fluid withdrawn from the pleural space was analysed as hyperalimentation. The infant survived because of early diagnosis and aggressive therapeutic intervention. A pericardial effusion should be drained if there is cardiovascular compromise and because pericardiocentesis represents a high risk technique, attempts should be made to rectify the extravasation via thoracentesis.

Consensus conference on the appropriateness of palivizumab prophylaxis in respiratory syncytial virus disease

Respiratory syncytial virus infection represents a clinical burden among young children under 24 months. Palivizumab is the only drug licensed in Italy for the prevention of serious lower respiratory tract disease requiring hospitalization caused by respiratory syncytial virus in children at high risk.

A 4-year survey on palivizumab respiratory syncytial virus (RSV)-prophylaxis: How can compliance be improved?

Objective. To identify compliance-influencing factors and to suggest strategies for overcoming barriers in a preventive medicine program. Methods. A survey was conducted to evaluate compliance in children receiving palivizumab prophylaxis for respiratory syncytial virus (RSV) infections. Demographics, neonatal variables, and parental attitudes capable of influencing the outcome of prophylaxis were studied in 216 children over a four-year period. Results. The overall compliance rate with all recommended doses of palivizumab was 87%. Among the neonatal characteristics, low birth weight and a younger age at the beginning of the program were significantly associated with good compliance (p < 0.05). The strongest factor influencing poor compliance was being foreign-born or a non-native speaker (p < 0.01). Conclusions. Compliance to RSV infection prophylaxis is reduced in infants born to foreign-born or non-native speakers. In order to enhance compliance, parents should be provided with adequate information in their own language explaining the advantages of the palivizumab prophylaxis program for RSV infections.

Perinatal asphyxia and inadvertent neonatal intoxication from local anaesthetics given to the mother during labour

In 1998, Edwards and Nelson discussed whether asphyxia at birth really is an important cause of neonatal encephalopathy and wondered how often neurological impairment in children is due to perinatal hypoxia-ischaemia and how often to entirely different causes.1 We describe two cases of neonatal intoxication resulting from the administration of local anaesthetic to the mother during labour but which we initially diagnosed as perinatal asphyxia. We analyse here the major manifestations of acute poisoning in newborns and the clinical picture that could be misdiagnosed as perinatal asphyxia. Early and correct diagnosis is recommended for allowing adequate treatment and a positive outcome and for ruling out the medicolegal aspect of perinatal asphyxias (law courts often have to decide whether a childs neurological impairment is the result of mismanagement of labour, leading to asphyxia). Within minutes of birth, two full term neonates delivered vaginally presented sudden neurological and cardiac signs such as apnoea, bradycardia, seizures, and hypotonia. In both cases no evidence of fetal distress was noted, and the fetal monitoring was normal. They were transferred to our neonatal intensive care unit with a presumptive diagnosis of perinatal asphyxia. ### Case 1 A 3550 g male infant was born after an uneventful pregnancy; episiotomy was performed after application of combined lidocaine (2.5%) and prilocaine (2.5%) cream. The Apgar score was high (9 at one minute, 9 at five minutes). Thirty minutes after birth, while still in the delivery room, the neonate suddenly developed apnoea, bradycardia, and hypotonia. He was intubated and mechanically ventilated. His cardiorespiratory function gradually improved, and he was extubated 30 minutes later. However, at this stage he began to show the first signs of neurological involvement, characterised by generalised hypertonia, which required transfer to our neonatal intensive care unit. During transport (at age one and a half hours) he had tonic …

Preterm babies at a glance

Preterm births, defined as a birth before 37.0 weeks gestation, are a main worldwide health problem. In the world, every year, about 15 million babies are born preterm, and their incidence is rising. Broadly outcomes improve with increasing gestational age; however, health care needs for preterm survivors can be extensive, both in terms of immediate postnatal support for infants and their families and in terms of lifelong support. The effect on the lifespan for the survivors especially in terms of mental health and cardiometabolic status need more attention and researches. A deeper awareness by pediatricians to the impact of preterm birth on the developing of adult diseases and pathological conditions could be of help in preserving and maintaining health once the child become an adult and in optimizing his/her impact on society.

[Parental alienation syndrome (PAS): unknown in medical settings, endemic in courts].

A purposed syndrome of so-called parental alienation (PAS), unsupported by any evidence-based data, unknown in medical settings, unquoted in medical books, absent in DSM and ICD, never demonstrated by controlled studies published in high scientific level journals, is rampant in Courts where it can lead to loose parental custody. During a divorce trial, almost always the mothers and the children, become joint in a sort of folie au deux, in a denigration campaign of ex-husband/father. From a review on this issue it seems evident its theoretical roots lie on a theory that justify gender violence and children sexual abuse. The bias that both of them are layers and that he children have not autonomy block their possibility of any defence in front of a Court. In severe cases, PAS becomes a new and efficient tool of intra-familiar violence. The treatment of severe cases is to stop any contact between mother and children. The resort to PAS in Courts must be strongly rejected.

Regulation of treatment of infants at the edge of viability in Italy: the role of the medical profession?

In the last few years there has been intense debate in Italy on administration of life-prolonging treatment to premature babies at the edge of viability. In 2006, a group of experts based in Florence drafted recommendations known as Carta di Firenze (CdF) for responsible use of intensive care for premature infants between 22 and 25 weeks of gestational age (GA). The CdF was later endorsed by several medicoprofessional associations, but was followed by recommendations by the Ministry of Health mandating resuscitation for all premature babies regardless of GA and parental consent. Recent statements from medicoprofessional bodies seem to show that the ‘always resuscitate rule’ is not supported by many Italian doctors. We argue that ethically sensitive issues in medicine should be regulated with, and not against, the medical profession and its representative bodies.

Aseptic meningitis in neonatal varicella complicated by Escherichia coli sepsis

We describe a 10-day-old infant with aseptic meningitis caused by varicella zoster virus, a very rare neonatal condition, associated with Escherichia coli sepsis. A 3420 g male neonate was delivered by caesarean section at 36 weeks after spontaneous rupture of the membranes. Apgar score was 91–95. Twenty hours later the previously healthy mother experienced an erythematous, vesicular pustular rash with high fever (40 C). Without any specific diagnosis, claritromicine was administered. The infant was breast-fed and discharged on day 4. On day 9, an erythematous rash appeared on the infant’s scalp and face and then extended in a craniocaudal direction. Treatment with claritromicine was commenced. On day 12, the newborn suddenly became pale, lethargic, subfebrile and cyanotic. He was admitted to another hospital where he experienced generalised tonic-clonic seizures. Phenobarbital was administered just before transferral to our neonatal intensive care unit (NICU). On inspection, a diffuse erythematous maculopapular eruption, more evident in the caudal region, was noted (Fig. 1). The infant, who was lethargic, irritable, hypotonic and had a temperature imbalance, required 40% oxygen administration. A slight neck stiffness was noted; however, the anterior fontanelle was not bulging. Laboratory studies showed a white blood cell count of 3700 cells/mm with an automated differential cell count of 40% neutrophils, 56% lymphocytes, 3% monocytes, and 2% eosinophils. C-reactive protein was 12 mg/dl. Serum electrolytes and arterial blood gas analysis were within the reference range, as were the CSF parameters (3 cells/mm, glucose level 86 mg/dl with serum glucose 156 mg/dl, protein level 64 mg/dl). The CSF was clear and no bacteria were observed on gram-stained smears. A chest X-ray film demonstrated bilateral interstitial pneumonia. Electroencephalograms showed inconstant interhemispheric asymmetry and a cerebral ultrasound failed to reveal any specific abnormalities. Ampicillin, gentamicin, acyclovir and varicella zoster virus (VZV) specific antibodies were administered. Further laboratory studies included bacterial cultures, serum antibody titres and polymerase chain reaction (PCR) in CSF for some human herpes viruses (cytomegalovirus, herpes simplex virus, VZV), coxackie and parvovirus. Blood, urine and skin grew Escherichia coli, whereas the CSF culture was negative. VZV DNA was detected in CSF by PCR. Seroconversion of anti-VZV IgG and IgM was positive in both the infant’s and the maternal peripheral blood. Antimicrobial and antiviral treatment was continued for 14 days. Within 24 h, lethargy and hypotonia resolved M. S. Pignotti (&) AE G. Indolfi AE G. Donzelli Neonatal Intensive Care Unit, Anna Meyer Children’s Hospital, via Luca Giordano 13, 50132 Firenze, Italy E-mail: m.pignotti@meyer.it Tel.: +39-55-5662432 Fax: +39-55-702856