Teresa Farstad

First Day of Life Pulse Oximetry Screening to Detect Congenital Heart Defects

OBJECTIVE To evaluate the efficacy of first day of life pulse oximetry screening to detect congenital heart defects (CHDs). STUDY DESIGN We performed a population-based prospective multicenter study of postductal (foot) arterial oxygen saturation (SpO(2)) in apparently healthy newborns after transfer from the delivery suite to the nursery. SpO(2) < 95% led to further diagnostic evaluations. Of 57,959 live births, 50,008 (86%) were screened. In the screened population, 35 CHDs were [corrected] classified as critical (ductus dependent, cyanotic). CHDs were prospectively registered and diagnosed in 658/57,959 (1.1%) [corrected] RESULTS Of the infants screened, 324 (0.6%) failed the test. Of these, 43 (13%) had CHDs (27 critical), and 134 (41%) had pulmonary diseases or other disorders. The remaining 147 infants (45%) were healthy with transitional circulation. The median age for babies with CHDs at failing the test was 6 hours (range, 1-21 hours). For identifying critical CHDs, the pulse oximetry screening had a sensitivity rate of 77.1% (95% CI, 59.4-89.0), specificity rate of 99.4% (95% CI, 99.3-99.5), and a false-positive rate of 0.6% (95% CI, 0.5-0.7). CONCLUSIONS Early pulse oximetry screening promotes early detection of critical CHDs and other potentially severe diseases. The sensitivity rate for detecting critical CHDs is high, and the false-positive rate is low.

Comparison of broad range 16S rDNA PCR and conventional blood culture for diagnosis of sepsis in the newborn: a case control study

BackgroundEarly onset bacterial sepsis is a feared complication of the newborn. A large proportion of infants admitted to the Neonatal Intensive Care Unit (NICU) for suspected sepsis receive treatment with potent systemic antibiotics while a diagnostic workup is in progress. The gold standard for detecting bacterial sepsis is blood culture. However, as pathogens in blood cultures are only detected in approximately 25% of patients, the sensitivity of blood culture is suspected to be low. Therefore, the diagnosis of sepsis is often based on the development of clinical signs, in combination with laboratory tests such as a rise in C – reactive protein (CRP). Molecular assays for the detection of bacterial DNA in the blood represent possible new diagnostic tools for early identification of a bacterial cause.MethodsA broad range 16S rDNA polymerase chain reaction (PCR) without preincubation was compared to conventional diagnostic work up for clinical sepsis, including BACTEC blood culture, for early determination of bacterial sepsis in the newborn. In addition, the relationship between known risk factors, clinical signs, and laboratory parameters considered in clinical sepsis in the newborn were explored.ResultsForty-eight infants with suspected sepsis were included in this study. Thirty-one patients were diagnosed with sepsis, only 6 of these had a positive blood culture. 16S rDNA PCR analysis of blinded blood samples from the 48 infants revealed 10 samples positive for the presence of bacterial DNA. PCR failed to be positive in 2 samples from blood culture positive infants, and was positive in 1 sample where a diagnosis of a non-septic condition was established. Compared to blood culture the diagnosis of bacterial proven sepsis by PCR revealed a 66.7% sensitivity, 87.5% specificity, 95.4% positive and 75% negative predictive value. PCR combined with blood culture revealed bacteria in 35.1% of the patients diagnosed with sepsis. Irritability and feeding difficulties were the clinical signs most often observed in sepsis. CRP increased in the presence of bacterial infection.ConclusionThere is a need for PCR as a method to quickly point out the infants with sepsis. However, uncertainty about a bacterial cause of sepsis was not reduced by the PCR result, reflecting that methodological improvements are required in order for DNA detection to replace or supplement traditional blood culture in diagnosis of bacterial sepsis.

Hospitalisations for respiratory syncytial virus bronchiolitis in Akershus, Norway, 1993–2000: a population-based retrospective study

BackgroundRSV is recognized as the most important cause of serious lower respiratory tract illness in infants and young children worldwide leading to hospitalisation in a great number of cases, especially in certain high-risk groups. The aims of the present study were to identify risk groups, outcome and incidences of hospitalisation for RSV bronchiolitis in Norwegian children under two years of age and to compare the results with other studies.MethodsWe performed a population-based retrospective survey for the period 1993–2000 in children under two years of age hospitalised for RSV bronchiolitis.Results822 admissions from 764 patients were identified, 93% had one hospitalisation, while 7% had two or more hospitalisations. Mean annual hospitalisation incidences were 21.7 per 1.000 children under one year of age, 6.8 per 1.000 children at 1–2 years of age and 14.1 per 1.000 children under two years of age. 77 children (85 admissions) belonged to one or more high-risk groups such as preterm birth, trisomy 21 and congenital heart disease. For preterm children under one year of age, at 1–2 years of age and under two years of age hospitalisation incidences per 1.000 children were 23.5, 8.7 and 16.2 respectively. The incidence for children under two years of age with trisomy 21 was 153.8 per 1.000 children.ConclusionWhile the overall hospitalisation incidences and outcome of RSV bronchiolitis were in agreement with other studies, hospitalisation incidences for preterm children were lower than in many other studies. Age on admission for preterm children, when corrected for prematurity, was comparable to low-risk children. Length of hospitalisation and morbidity was high in both preterm children, children with a congenital heart disease and in children with trisomy 21, the last group being at particular high risk for severe disease.

Acute bronchiolitis in infancy as risk factor for wheezing and reduced pulmonary function by seven years in Akershus County, Norway

BackgroundAcute viral bronchiolitis is one of the most common causes of hospitalisation during infancy in our region with respiratory syncytial virus (RSV) historically being the major causative agent. Many infants with early-life RSV bronchiolitis have sustained bronchial hyperreactivity for many years after hospitalisation and the reasons for this are probably multifactorial. The principal aim of the present study was to investigate if children hospitalised for any acute viral bronchiolitis during infancy in our region, and not only those due to RSV, had more episodes of subsequent wheezing up to age seven years and reduced lung function at that age compared to children not hospitalised for acute bronchiolitis during infancy. A secondary aim was to compare the hospitalised infants with proven RSV bronchiolitis (RS+) to the hospitalised infants with non-RSV bronchiolitis (RS-) according to the same endpoints.Methods57 infants hospitalised at least once with acute viral bronchiolitis during two consecutive winter seasons in 1993–1994 were examined at age seven years. An age-matched control group of 64 children, who had not been hospitalised for acute viral bronchiolitis during infancy, were recruited from a local primary school. Epidemiological and clinical data were collected retrospectively from hospital discharge records and through structured clinical interviews and physical examinations at the follow-up visit.ResultsThe children hospitalised for bronchiolitis during infancy had decreased lung function, more often wheezing episodes, current medication and follow-up for asthma at age seven years than did the age matched controls. They also had lower average birth weight and more often first order family members with asthma. We did not find significant differences between the RSV+ and RSV- groups.ConclusionChildren hospitalised for early-life bronchiolitis are susceptible to recurrent wheezing and reduced pulmonary function by seven years compared to age-matched children not hospitalised for early-life bronchiolitis. We propose that prolonged bronchial hyperreactivity could follow early-life RSV negative as well as RSV positive bronchiolitis.

Incidence of Kawasaki disease in northern European countries.

Background:  The aim of the present study was to compare the epidemiologic features of Kawasaki disease (KD) in three northern European countries and Japan.

Cardiopulmonary function in premature infants with bronchopulmonary dysplasia--a 2-year follow up.

Twenty-three premature infants (GA 28.8±0.5 weeks) with bronchopulmonary dysplasia (BPD) and 14 premature infants (controls, GA 33.0±1.2 weeks) with moderate respiratory distress syndrome or with mild respiratory disturbances, were evaluated for impairment of cardiopulmonary function at 50 and 120 weeks corrected age. Respiratory system compliance was reduced in both groups, but improved with advancing age. Respiratory system resistance was initially increased, especially in the BPD group, but improved gradually. Maximum flow at functional residual capacity (VmaxFRC ml/s) indicated, nevertheless, severe peripheral obstruction (flow <84 ml/s) in 16/20 of infants with BPD and in 7/12 of control infants at 50 weeks corrected age. At 120 weeks corrected age none of the control patients had severe peripheral pulmonary obstruction (flow <120 ml/s), while this was still found in 5/13 infants with BPD. Doppler echocardiography indicated cardiac involvement (shortened pulmonary acceleration time) in patients with the most severe peripheral pulmonary obstruction. Pulmonary morbidity was also higher in the BPD group, and these infants were shorter and weighed less than the control infants.ConclusionMeasurements of maximum flow at functional residual capacity as well as cardiac evaluation are essential elements in follow up of infants with severe BPD.

Predictors of RSV LRTI Hospitalization in Infants Born at 33 to 35 Weeks Gestational Age: A Large Multinational Study (PONI)

Background Preterm infants are at high risk of developing respiratory syncytial virus (RSV)-associated lower respiratory tract infection (LRTI). This observational epidemiologic study evaluated RSV disease burden and risk factors for RSV-associated LRTI hospitalization in preterm infants 33 weeks+0 days to 35 weeks+6 days gestational age not receiving RSV prophylaxis. Methods Preterm infants ≤6 months of age during RSV season (1 October 2013–30 April 2014) were followed at 72 sites across 23 countries from September 2013–July 2014 (study period). RSV testing was performed according to local clinical practice. Factors related to RSV-associated hospitalization for LRTI were identified using multivariable logistic regression with backward selection. Results Of the 2390 evaluable infants, 204 and 127 were hospitalized for LRTI during the study period and RSV season, respectively. Among these subjects, 64/204 and 46/127, respectively, were hospitalized for confirmed RSV LRTI. Study period and RSV season normalized RSV hospitalization rates (per 100 infant years) were 4.1 and 6.1, respectively. Factors associated with an increased risk of RSV-related LRTI hospitalization in multivariable analyses were smoking of family members (P<0.0001), non-hemodynamically significant congenital heart disease diagnosis (P = 0.0077), maternal age of ≤25 years at delivery (P = 0.0009), low maternal educational level (P = 0.0426), household presence of children aged 4 to 5 years (P = 0.0038), age on 1 October ≤3 months (P = 0.0422), and presence of paternal atopy (P<0.0001). Conclusions During the 2013–2014 RSV season across 23 countries, for preterm infants 33–35 weeks gestation ≤6 months old on 1 October not receiving RSV prophylaxis, confirmed RSV LRTI hospitalization incidence was 4.1 per 100 infant years during the study period and 6.1 per 100 infant years during the RSV season. This study enhances the findings of single-country studies of common risk factors for severe RSV infection in preterm infants and suggests that combinations of 4–6 risk factors may be used to accurately predict risk of RSV hospitalization. These findings may be useful in the identification of infants most at risk of severe RSV infection.

Pulmonary Effects after Surfactant Treatment in Premature Infants with Severe Respiratory Distress Syndrome

To understand the mechanisms behind the improved oxygenation after intratracheal surfactant instillation, the immediate effects of lung volume and pulmonary mechanics were analyzed. All infants studied were enrolled in multicenter trials in which surfactant therapy was instituted according to a rescue protocol. Infants received either synthetic surfactant (Exosurf) or modified porcine surfactant (Curosurf). Measurements of lung volume and pulmonary mechanics were successfully performed in 12 patients with a birth weight of 1.3 +/- (SD) 1.4 weeks. Functional residual capacity (FRC) and pulmonary mechanics were measured during mechanical ventilation. The FRC increased significantly by 70% (median), from 7.10 +/- (SD) 2.8 ml/kg to 11.5 +/- 3.3 ml/kg after surfactant instillation. However, a concomitant decrease in specific compliance was also seen. These findings could suggest that this immediate increase in FRC is initially nonuniform. However, since no significant correlation between changes in FRC and improvement in arterial-to-alveolar oxygen tension ratio is seen, other effects of surfactant must also be considered. These could include local and/or systemic changes in hemodynamics, such as decreased shunting as well as various effects on gas diffusion.

Patent ductus arteriosus in premature infants

BACKGROUND Patent ductus arteriosus in premature infants has often been treated because of its association with worsening of pulmonary disease and complications such as bronchopulmonary dysplasia. This view has now been challenged. MATERIAL AND METHODS Relevant publications have been identified from review articles in international peer-reviewed journals. The articles have been retrieved through searches in the PubMed and Cochrane-databases. RESULTS Recent research has led to a new understanding of patent ductus arteriosus - a shift of paradigm has occurred. The condition implies that a shunt enables blood to flow from right to left in the first postnatal days (when pulmonary arterial pressure is high), and left to right in cases where significant pulmonary disease is present. The increased pulmonary blood flow improves oxygenation, and the condition should be considered as physiological in small premature infants. A patent ductus arteriosus does not worsen concomitant pulmonary disease or increase the risk of bronchopulmonary dysplasia, intraventricular hemorrhage, necrotising enterocolitis or other complications. INTERPRETATION Treatment of a patent ductus arteriosus with COX-inhibitors such as indomethacin and ibuprofen, increases the risk for bronchopulmonary dysplasia without reducing other complications or death. A large patent ductus arteriosus has significant hemodynamic effects and should be treated with fluid restriction, diuretics and inotropic drugs before closure is considered. Surgical closure of a patent ductus arteriosus is linked to neurosensory impairment in survivors.

EFFECT OF INTRATRACHEAL INSTALLATION OF SURFACTANT OH LUNG FUNCTION AND FUNCTIONAL RESIDUAL CAPACITY (FRC) IN PREMATURE INFANTS WITH RESPIRATORY DISTRESS SYNDROME (RDS)

To understand the mechanism behind improved oxygenation after surfactant in infants with RDS we analysed changes in lung compliance (CL, ml/cmH2O), lung resistance (RL, cmH2O/l/s/cm), overdistention (C20/C1), FRC (ml) and oxygen need (FiO2). Data were collected serially in nine infants (CurosurfR two, ExosurfR seven) (BW: 1389 ± 540 g) prior to and post surfactant treatment. Lung mechanics were determined by a differential pressure transducer and pneumotachography (PEDSR). FRC was measured by a helium dilution technique (PANDAR) with correction for gas leakage. Ventilator settings (except FiO2) were if possible kept constant during the study. (Data given as mean±SEM).Surfactant significantly increases FRC, while lung compliance and resistance (during mechanical breath) do not improve. The improved oxygenation after surfactant treatment is probably related to increased lung volume.