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Background: In 2011, the Neonatal Resuscitation Program (NRP) added consideration of continuous positive airway pressure (CPAP) for spontaneously breathing infants with labored breathing or hypoxia in the delivery room (DR). The objective of this study was to determine if DR-CPAP is associated with symptomatic pneumothorax in infants 35 to 42 weeks' gestational age., Methods: We included (1) a retrospective birth cohort study of neonates born between 2001 and 2015 and (2) a nested cohort of those born between 2005 and 2015 who had a resuscitation call leading to admission to the NICU and did not receive positive-pressure ventilation., Results: In the birth cohort ( n = 200 381), pneumothorax increased after implementation of the 2011 NRP from 0.4% to 0.6% ( P < .05). In the nested cohort ( n = 6913), DR-CPAP increased linearly over time ( r = 0.71; P = .01). Administration of DR-CPAP was associated with pneumothorax (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 4.4-6.8); the OR was higher ( P < .001) in infants receiving 21% oxygen (OR: 8.5; 95% CI: 5.9-12.3; P < .001) than in those receiving oxygen supplementation (OR: 3.5; 95% CI: 2.5-5.0; P < .001). Among those with DR-CPAP, pneumothorax increased with gestational age and decreased with oxygen administration., Conclusions: The use of DR-CPAP is associated with increased odds of pneumothorax in late-preterm and term infants, especially in those who do not receive oxygen in the DR. These findings could be used to clarify NRP guidelines regarding DR-CPAP in late-preterm and term infants., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objective: Our aim was to examine the impact of a single enteral dose of vitamin E on serum tocopherol levels. The study was undertaken to see whether a single dose of vitamin E soon after birth can rapidly increase the low α-tocopherol levels seen in very preterm infants. If so, this intervention could be tested as a means of reducing the risk of intracranial hemorrhage., Methods: Ninety-three infants <27 weeks' gestation and <1000 g were randomly assigned to receive a single dose of vitamin E or placebo by gastric tube within 4 hours of birth. The vitamin E group received 50 IU/kg of vitamin E as dl-α-tocopheryl acetate (Aquasol E). The placebo group received sterile water. Blood samples were taken for measurement of serum tocopherol levels by high-performance liquid chromatography before dosing and 24 hours and 7 days after dosing., Results: Eighty-eight infants received the study drug and were included in the analyses. The α-tocopherol levels were similar between the groups at baseline but higher in the vitamin E group at 24 hours (median 0.63 mg/dL vs. 0.42 mg/dL, P = .003) and 7 days (2.21 mg/dL vs 1.86 mg/dL, P = .04). There were no differences between groups in γ-tocopherol levels. At 24 hours, 30% of vitamin E infants and 62% of placebo infants had α-tocopherol levels <0.5 mg/dL., Conclusions: A 50-IU/kg dose of vitamin E raised serum α-tocopherol levels, but to consistently achieve α-tocopherol levels >0.5 mg/dL, a higher dose or several doses of vitamin E may be needed.

Objective: Parkland Memorial Hospital (PMH) participated in Surfactant, Positive Pressure, and Oxygenation Randomized Trial (SUPPORT), an unblinded controlled trial, in which preterm neonates of 24(0/7) to 27(6/7) weeks' gestational age (GA) were randomized in the delivery room (DR) to endotracheal intubation or nasal continuous positive airway pressure. We hypothesized that DR intubation could change in nonenrolled patients at PMH and that the change would be larger than in comparable centers not participating in the trial., Methods: The PMH Cohort included eligible but nonenrolled neonates of 24(0/7) to 27(6/7) weeks (primary) and noneligible neonates of 28 to 34(6/7) weeks (confirmatory). A subset (24(0/7)-29(6/7)weeks) of that cohort was compared with a contemporaneous cohort born in centers participating in the Vermont Oxford Network (VON). We used a Poisson regression model to obtain adjusted relative risks (RRs) of DR intubation (during/after SUPPORT versus before SUPPORT) for PMH and for VON along with the ratio of these RRs., Results: In the PMH cohort (n = 3527), the proportion of DR intubation decreased during/after SUPPORT in the lower GA group (adjusted RR 0.76, 95% confidence interval [CI] 0.59-0.96) and the upper GA group (adjusted RR 0.57, 95% CI 0.46-0.70). Compared with the RR for DR intubation in VON, the RR at PMH was smaller in the lower (ratio of RR 0.76, 95% CI 0.65-0.87) and the upper GA group (ratio of RR 0.52, 95% CI 0.39-0.68)., Conclusions: A center's participation in an unblinded randomized trial may affect process of care of nonenrolled patients.

Objectives: To assess whether targeted short-term fluconazole prophylaxis reduces late-onset (>3 days of age) invasive fungal infection (IFI) among very low birth weight infants and extremely low birth weight (ELBW) infants and to assess mortality rates, toxicity, and costs associated with this intervention., Methods: An observational study of 2 subsequent epochs of inborn infants with birth weight of <1500 g or gestational age of <32 weeks, 1 before (control) and 1 after (fluconazole) initiation of routine targeted fluconazole prophylaxis in March 2003, was performed. Targeted fluconazole (3 mg/kg) prophylaxis was administered to infants for whom a decision was made to administer broad-spectrum antibiotics for >3 days., Results: IFI was observed for 13 (6.3%) of 206 infants in the control epoch and 2 (1.1%) of 178 in the fluconazole epoch, with a common odds ratio of 0.166. Logistic regression analysis taking into account all published factors (except for fungal colonization) showed that the fluconazole epoch was associated significantly with lower IFI rates. We observed no change in late (>3 days) mortality rates (11 of 206 infants in the control epoch vs 8 of 178 infants in the prophylaxis epoch). The mortality rate for ELBW infants with IFI was low (15%) in our study. Fluconazole was administered to 81% of ELBW infants, who received a median of 8 doses, and 41% of larger infants, who received a median of 5 doses. The intervention was cost-effective, and the effective number needed to treat to prevent 1 IFI was 10., Conclusions: This study suggests that targeted short-course fluconazole prophylaxis in very low birth weight and ELBW infants may be efficacious and cost effective.

The incidence of congenital syphilis has increased rapidly over the past few years. Most infected mothers and their newborns are asymptomatic at birth and diagnosis depends on serologic testing during pregnancy and at delivery. This study was initiated to compare maternal sera, cord blood, and neonatal sera for detecting presumptive congenital syphilis and to assess the role of maternal treatment (administration of penicillin to the mother at least 1 month before delivery) on the serologic results at the time of delivery. The serologic results from all live deliveries complicated by a positive maternal and/or neonatal test for syphilis during a 12-month period were compared using chi 2 analysis and multiple comparisons for proportions. Of 3306 livebirths, 73 (2.2%) were complicated by a positive maternal or neonatal serology. At delivery, the serologic test was positive in 68 (94%) of 72 maternal sera, 30 (50%) of 60 cord sera, and 43 (63%) of 68 neonatal sera. In the absence of maternal treatment, 95% of the maternal sera, 66% of the cord blood samples, and 86% of the neonatal sera were positive. If the mother had been treated, 94% of maternal sera, 36% of cord sera, and 39% of neonatal sera were positive. Cord blood and neonatal sera appear to be inferior to maternal sera for detecting prenatal exposure to syphilis. Cord serology is also inferior to neonatal serology at 2 to 3 days of age. The most effective way to identify newborns at risk for congenital syphilis is to obtain a maternal serologic diagnosis during pregnancy and to test maternal and neonatal sera at delivery.

Metaphyseal abnormalities are present in greater than 90% of infants with symptomatic congenital syphilis. The incidence of these lesions in asymptomatic newborns in the present epidemic is not known. To determine the incidence of bone lesions at birth in asymptomatic congenital syphilis, long-bone films were obtained for all babies born during a 9-month period with a positive perinatal serology. Of 2544 newborns, 61 had a positive maternal serology and 40 also had a positive cord serology. Two symptomatic babies had abnormal radiographs and 12 of 59 asymptomatic newborns had metaphyseal changes consistent with congenital syphilis. It is concluded that long-bone radiographs are abnormal in approximately 20% of asymptomatic newborns with positive perinatal treponemal serology. With the increasing incidence of congenital syphilis, radiologic studies should be included in the assessment of all newborns with a positive serology. Indeed, those patients with any sign of active disease should be carefully followed because even treated infants remain at some risk for developing the late sequelae of congenital syphilis.