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Background Previous research shows that a lung ultrasound score (LUS) can anticipate CPAP failure in neonatal respiratory distress syndrome. Research Question Can LUS also predict the need for surfactant replacement? Study Design and Methods Multicenter, pragmatic study of preterm neonates who underwent lung ultrasound at birth and those given surfactant by masked physicians, who also were scanned within 24 h from administration. Clinical data and respiratory support variables were recorded. Accuracy of LUS, oxygen saturation to F io 2 ratio, F io 2, and Silverman score for surfactant administration were evaluated using receiver operating characteristic curves. The simultaneous prognostic values of LUS and oxygen saturation to F io 2 ratio for surfactant administration, adjusting for gestational age (GA), were analyzed through a logistic regression model. Results Two hundred forty infants were enrolled. One hundred eight received at least one dose of surfactant. LUS predicted the first surfactant administration with an area under the receiver operating characteristic curve (AUC) of 0.86 (95% CI, 0.81-0.91), cut off of 9, sensitivity of 0.79 (95% CI, 0.70-0.86), specificity of 0.83 (95% CI, 0.76-0.89), positive predictive value of 0.79 (95% CI, 0.71-0.87), negative predictive value of 0.82 (95% CI, 0.75-0.89), positive likelihood ratio of 4.65 (95% CI, 3.14-6.89), and negative likelihood ratio of 0.26 (95% CI, 0.18-0.37). No significant difference was shown among different GA groups: 25 to 27 weeks’ GA (AUC, 0.91; 95% CI, 0.84-0.99), 28 to 30 weeks’ GA (AUC, 0.81; 95% CI, 0.72-0.91), and 31 to 33 weeks’ GA (AUC, 0.88; 95% CI, 0.79-0.95), respectively. LUS declined significantly within 24 h in infants receiving one surfactant dose. When comparing F io 2, oxygen saturation to F io 2 ratio, LUS, and Silverman scores as criteria for surfactant administration, only the latter showed a significantly poorer performance. The combination of oxygen saturation to F io 2 ratio and LUS showed the highest predictive power, with an AUC of 0.93 (95% CI, 0.89-0.97), regardless of the GA interval. Interpretation LUS is a reliable criterion to administer the first surfactant dose regardless of GA. Its association with oxygen saturation to F io 2 ratio significantly improves the prediction power for surfactant need.

Respiratory care of premature neonates has witnessed substantial advances in the last two decades and has played a crucial role in decreasing early mortality in this population. This review outlines advances in techniques of synchronization and modes of synchronized invasive mechanical ventilation in neonates. The use of synchronized ventilation in the neonatal population was delayed as compared to adults, mainly because of technical reasons. Coordinating the infant's respiratory effort and the onset of mechanical ventilation in the neonatal population has requested high sensitivity instruments.

Preterm birth significantly increases the risk of developing various long-term health problems and developmental disabilities. While touch is a crucial component of many perinatal care strategies, the neurobiological underpinnings are rarely considered. C-tactile fibers (CTs) are unmyelinated nerve fibers that are activated by low-force, dynamic touch. Touch directed specifically at CTs activates the posterior insular cortex, consistent with an interoceptive function, and has been shown to reduce heart rate and increase oxygen saturation. The current research compared the effect of five minutes of CT optimal velocity stroking touch versus five minutes of static touch on autonomic markers of preterm infants between 28 and 37 weeks gestational age. CT touch induces a higher increase in heart rate variability metrics related to the parasympathetic system, which persisted for a 5-minute post-touch period. Conversely, there was no such increase in infants receiving static touch. The present findings confirmed that CTs signal the affective quality of nurturing touch, thereby arguing an additional neurobiological substrate for the evident valuable impacts of neonatal tactile interventions and improving the effectiveness of such interventions.

Congenital diaphragmatic hernia (CDH) is the most common indication for respiratory extracorporeal life support (ECLS) in neonates. The survival rate of CDH neonates treated with ECLS is 50%, and this figure has remained relatively stable over the last few decades. This is likely because the current population of CDH neonates who require ECLS have a higher risk profile [1]. The management of neonates with CDH has evolved over time to emphasize postnatal stabilization, gentle ventilation, and multi-modal treatment of pulmonary hypertension. In order to minimize practice variation, many centers have adopted CDH-specific clinical practice guidelines, however care is not standardized between different centers and outcomes vary [3]. The purpose of this review is to summarize our current understanding of issues central to the care of neonates with CDH treated with ECLS and specifically highlight how the use of the Extracorporeal Life Support Organization (ELSO) data have added to our understanding of CDH.

Objective The aim of our study was to determine the outcome of fetuses with isolated mild ventriculomegaly, with prenatal imaging work-up, prenatal consultation, delivery and clinical follow-up performed in a single tertiary referring center. Methods Fetuses with isolated and non-progressive mild ventriculomegaly (10–15 mm) were included in the study. Inclusion criteria were as follows: singleton pregnancies, normal chromosomal analysis, normal serological evaluation of TORCH, fetal ultrasound and MRI excluding additional CNS or extra-CNS malformations. The prenatal consultation consisted in discussing the prognosis of ventriculomegaly, according to the literature. The postnatal follow-up protocol included a neuroradiological investigation (cranial ultrasound or MRI), neurological and pediatric examinations. The Griffiths Scales were used to assess the neurodevelopmental outcome. Results Thirty newborns were included in follow-up. The postnatal neuroradiological investigations confirmed the ventriculomegaly as an isolated finding in all cases except one. Nineteen children were available for formal neurodevelopmental testing. In our case series, 93.3% of the children had a favorable outcome or mild anomalies. Two children (6.6%) with mild ventriculomegaly were diagnosed as having rare genetic conditions. The Griffiths developmental quotients were normal (mean General Quotient 98.3) at the latest assessment (mean age 20.8 months) in all but one case. Discussion Most children in our case series had a favorable outcome, as described in the literature. Even though a large quantity of data is now available on ventriculomegaly, fetal consultation remains challenging and requires caution. The diagnostic work-up of pregnancies diagnosed with mild ventriculomegaly must be very meticulous and include TORCH evaluation, microarray, serial ultrasounds to exclude progression, and a fetal MRI. However, despite accurate screening, there are more complex conditions in which ventriculomegaly can be the only non-specific finding in fetal life, making postnatal follow up mandatory.

Background: Few studies evaluated the efficacy of pharmacological therapy for gastro-esophageal reflux disease (GERD) in newborns, whose safety has been questioned. Esophageal basal impedance (BI) is a marker of mucosal integrity, and treatment with proton pump inhibitors significantly increases BI in infants; however, no correlation with clinical improvement was reported. Aims: To evaluate the relationship between BI and other esophageal pH-impedance parameters and clinical response to therapy in newborns with GERD. Study design: Multicenter retrospective study. Subjects: Infants who received omeprazole or ranitidine for GERD. Outcome measures: Complete response to therapy was defined as symptom decrease by ≥50% compared to baseline, partial response as symptom decrease

Premature infants often experience difficulties adapting to postnatal life. The most relevant ones are related to establishing an adult type cardiorespiratory circulation and acquiring hemodynamic stability, aerating the lung and attaining a functional residual capacity, performing an adequate gas exchange and switching to an oxygen enriched metabolism, and keeping an adequate body temperature. In recent years a body of evidence supports a trend towards gentle management in the delivery room aiming to reduce damage especially to the lungs in the so-called first golden minutes. Herewith, we describe and update four of the most relevant interventions performed in the delivery room: delayed cord clamping, non-invasive ventilation, individualized oxygen supplementation, and maintaining an adequate body temperature so as to avoid hyperthermia and/or hypothermia.

Purpose To evaluate amplitude-integrated EEG (aEEG) in comparison with conventional (cEEG) for the identification of electrographic seizures in neonates with acute neonatal encephalopathies. Methods Thirty-one conventional cEEG/aEEG long-term recordings from twenty-eight newborns were reviewed in order to assess the electrographic seizure detection rate and recurrence in newborns. Two paediatric neurologists and one neonatologist, blinded to the raw full array cEEG, were asked to mark any events suspected to be an electrographic seizures on aEEG. They were asked to decide if the displayed aEEG trace showed the pattern of a single seizure (SS), repetitive seizures (RS) or status epilepticus (SE). Their ability to recognize electrographic seizures on aEEG was compared to seizures identified on full array cEEG. Results 25 of the 31 long-term cEEGs recordings showed electrographic seizures. The two paediatric neurologists and the neonatologist identified SE in 100% of the reviewed traces using aEEG alone while they identified 49.4% and 37.5% of electrographic seizures using aEEG alone. Overall, the correct identification ranged from 23.5% to 30.7% for SS and 66% for RS. The inter-observer agreement ( k ) for the identification of SE for the two paediatric neurologists and the neonatologist was 1.0. Overall the inter-observer agreement ( k ) for the detection of SS, RS and SE of the two paediatric neurologists was 0.91. Conclusions In our study the observers identified SE in 100% of the reviewed traces using raw aEEG alone, thus aEEG might represent a useful tool to detect SE in the setting of NICU. SS may not be reliably identified using aEEG alone. Simultaneous recording of the raw cEEG/aEEG provides a good level of sensitivity for the detection of neonatal electrographic seizures.

Early myoclonic encephalopathy is an epileptic syndrome with different etiologies. Nonketotic hyperglycinemia is one cause. We describe two cases of early myoclonic encephalopathy, secondary to nonketotic hyperglycinemia, with fatal evolution in the neonatal period. These two cases may better clarify clinical findings that can be associated with impairment of glycine metabolism. Distinguishing features include agenesis of the corpus callosum in patient 1, and weight loss exceeding 10%, associated with metabolic acidosis, in patient 2. The burst-suppression electroencephalography pattern is relatively common in neonatal encephalopathies, and is frequently associated with seizures. Nonketotic hyperglycinemia is an inborn error of metabolism caused by mutations in genes encoding protein in the mitochondrial glycine cleavage system. The neonatal form is a severe, frequently lethal neurologic disease. When associated with electro-clinical features, progressive lethargy and hypotonia occur in the first days of life, progressing to apnea and often death. Prospective treatment with oral sodium benzoate, the N-methyl-d-aspartate receptor antagonist ketamine, and dextromethorphan can favorably modify the early neonatal course of severe nonketotic hyperglycinemia, but does not prevent poor long-term outcomes.

Background: Probiotics are important in restoring gut normal microbiota, and/or in preventing its disturbances. Several data from neonatal studies disclose efficacy of certain mixtures of probiotics in preventing NEC, ameliorating feeding tolerance, and preventing gut fungal colonization. Nevertheless, concerns still exist about safety and tolerability of routinary, long-lasting administration of living microorganisms in immature patients. We report a 6-year clinical experience from two large tertiary NICUs in Italy. Design/methods: Retrospective study by review of patient charts on infants with birth weight Standard protocol of administration of Lactobacillus GG in the two NICUs consisted of 3 × 10 9 CFU/day, in a single oral dose, since the 4th day of life, for 3 to 4 week courses. Nutritional policy in the two NICUs relied on administration of fresh, expressed maternal milk, whenever possible, and supplementation of premature formaulae when needed. Data about safety and tolerance to probiotic administration, concomitant sepsis, feeding tolerance, and microbiological clinical and surveillance cultures, were retrieved and analysed. Results: During the study period, 811 VLBW infants (mean birth weight 1056 g [± 88]; mean gestational age 29.5 weeks [± 1.1]) were born at the two facilities and survived till discharge. Complete data were obtained for 743 of them. A total number of 17,108 doses of the probiotic LGG were administered (mean 23.1 per infant). No adverse effects or intolerances putatively attributable to LGG occurred. Over the study period, 5350 clinical and surveillance cultures from 13 different sites or devices were performed (7.2 mean cultures from 6.5 mean different sites per infant). None of these cultures ever grew Lactobacillus GG, or other Lactobacilli; no episode of sepsis was attributable to LGG. Full enteral feeding was achieved at 19.2 mean days-of-life [± 8]; 73% of the infants were fed exclusive or partial maternal milk. 14 cases of NEC occurred (1.9%), among them 5 (0.7%) were > stage 2b. Conclusions: Routinary use of probiotic Lactobacillus GG in two large Italian NICUs over a 6-year period was safe and well tolerated. No isolation of Lactobacillus GG from clinical and surveillance cultures occurred. No clinical episode of sepsis attributable to Lactobacillus GG was recorded.