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Background Cerebral hemodynamics is supposed to be influenced by the different ventilation approach. Ventilation support can be classified as non-invasive (N-CPAP) or invasive (SIMV and HFV), the last known to induce endotrauma. Our aim was the non-invasive NIRS assessment of neonatal absolute cerebral blood flow (CBF) and relative cerebral blood volume changes (ΔCBV) during synchronized intermittent ventilation (SIMV), or high frequency ventilation (HFV) and nasal continuous positive airways pressure (CPAP). Methods An observational study in a tertiary referral NICU. CBF and ΔCBV changes were assessed in 41 preterm newborn infants with respiratory distress syndrome treated using mechanical ventilation or the CPAP device. Results Basal chromophore traces enabled ΔCBV (mL/100 g) changes to be calculated. CBF was calculated in mL/100 g/min from the saturation rise integral and rate of rise [O2Hb-HHb]. Median ΔCBV was 0.07 (range 0.01–0.13) in SIMV group, 0.07 (0.01–0.19) in HFV group and 0.13 (0.10–1.28) in CPAP group. Median CBF was 14.44 (2.70–32.10), 9.20 (2.94–19.58) and 31.69 (13.59–34.93) respectively. A multiple regression model showed a significant correlation between ΔCBV or CBF and ventilation approach. Conclusion In the light of our results, we might speculate that, assuming that hemodynamic autoregulation is safe and arterial blood pressure is preserved, ventilation per se influences brain circulation.

Background The availability of a score for predicting neonatal outcome prior to discharge may help us to define the risk of developmental disorders in very low birth weight infants. Aim To compare Scheiner's Perinatal Risk Inventory (PERI) with Brazy's Neurobiological Risk Score (NBRS) when applied at discharge, in predicting developmental delay at 24 months of age. Study design To evaluate the predictive power of the two tests, we measured their sensitivity and specificity in predicting outcome (Mental Development Index, MDI, Psychomotor Development Index, PDI, and Amiel–Tison Neurological Examination) in an observational study. Subjects 102 very low birth weight infants (BW Results In the cohort studied, 75.5% of the patients had a normal MDI, while 24.5% showed a delayed performance (8.8% mildly and 15.7% severely so); the PDI was normal in 74.5% patients, whilst 25.5% had a delayed performance (9.8% mildly and 15.7% severely so). According to the Amiel–Tison test, neurological performance was normal in 66% patients, impaired without disability in 19% and impaired with disability in 15%. NBRS showed a sensitivity and specificity respectively of 0.96 and 0.23 (MDI), 0.96 and 0.24 (PDI), 0.94 and 0.25 (Amiel–Tison test); for PERI were 0.88 and 0.54 (MDI), 0.77 and 0.51 (PDI), 0.82 and 0.57 (Amiel–Tison test). The PERI and NBRS can predict the MDI with an AUC > 0.8 and the PDI or Amiel–Tison findings with an AUC of 0.7–0.8. No significant differences were found between the areas under the ROC curves using the NBRS and the PERI. Conclusions : In assessing the prognosis for individual babies, the physician can choose either the PERI or the NBRS to predict PDI, MDI or Amiel–Tison performance.

Background In the debate on the best cord clamping time in newborn infants, we hypothesized that late cord clamping enables an increased volemia due to blood transfer to the newborn from the placenta. Aim To assess whether clamping time can affect limb perfusion and heart hemodynamics in a group of 22 healthy term newborn infants. Study design A case-control study. Subjects Eleven early-clamped (at 30 s) vaginally-delivered newborn infants were compared with eleven late-clamped (at 4 min) newborns. Outcome measures The two groups were studied using near-infrared spectroscopy and M-mode echocardiography. Results Late cord clamping coincided with a higher hematocrit (median 62% versus 54%) and hemoglobin concentration (median 17.2 versus 15 g/dL), whilst there were no changes in bilirubin level. Echocardiography showed a larger end-diastolic left ventricle diameter (1.7 cm median value versus 1.5) coupled with unvaried shortening and ejection fraction values. There were no changes in calf blood flow, oxygen delivery, oxygen consumption or fractional oxygen extraction calculated from the NIRS measurements, or in foot perfusion index. Conclusions Our results demonstrated that late cord clamping coincides with an increased placental transfusion, expressed by higher hematocrit and hemoglobin values, and larger left ventricle diameter at the end of the diastole, with no changes in peripheral perfusion or oxygen metabolism.

Background : It is conceivable that a complicated recovery course in a high-risk premature infant managed at home generates apprehension and anxiety in parents. Aims : We attempted to define the evolution of anxiety levels in a population of parents of low-birth-weight premature infants with bronchopulmonary dysplasia enrolled in a prospective home O 2 therapy program. Study design : In the immediate pre-discharge [mean postnatal age 95 (45–158) days], a questionnaire (State–Trait Anxiety Inventory form Y) was given to all parents of the premature infants [mean birth weight 1106 (0.610–1.770) kg; mean gestational age 27.1 (24–31) weeks] present for the discharge. Subsequently, the parents were assessed twice, initially after a week from the discharge of their infants and then at the end of the oxygen therapy phase [mean postnatal age 185 (60–361) days]. They included 10 mothers and 10 fathers, aged 33.5±0.5 and 37±0.2 years, respectively. Results : Our results indicate that these parents present an increased state anxiety level upon hospital discharge of their oxygen-dependent premature infants, which decreases as the improvement of respiratory status and the cessation of oxygen-dependency become evident [mean±S.D. related to age ( T ) maternal values 47.1±7.0, 41.8±5.6, 39.1±4.7, respectively; mean±S.D. related to age ( T ) paternal values 42.2±8.5, 41.1±8.1, 40.5±8.2, respectively]. When assessed separately by parental gender, in the maternal group, state anxiety decreased significantly (ANOVA, p Conclusions : These data indicate that although neonatologists generally define the discharge of prematures with chronic lung disease based upon the acquired stabilization of vital parameters, in the oxygen-dependent group, they should also pay special attention to the emotional support of the parents who we have identified as being at increased risk for pre-discharge anxiety.

Peripartal maternal apprehension and anxiety are associated with abnormal labour, dystocia and higher rates of fetal and maternal morbidity. Since colostral beta-endorphin (beta-EP) concentrations are twofold higher than circulating levels, we hypothesised that substantial maternal emotional distress in puerperium might induce consistent changes in colostral beta endorphin galactopoiesis. To test this hypothesis, we assessed the effects of postpartum maternal anxiety (State-Trait Anxiety Inventory-Y form, Spielberger CD, Palo Alto, CA, USA, 1983) on colostral milk beta-EP levels (beta-endorphin 125I RIA, INCSTAR Corporation-Stillwater, Minnesota, USA) in a population of healthy lactating mothers, on the fourth postpartum discharge day, 14 after at term vaginal delivery, 14 after premature (> or = 34

OBJECTIVE : Studies in animals indicate that stress and anxiety can depress lactation, but there is much less information available concerning humans. We aimed to determine whether maternal anxiety in puerperium, potentially exacerbated by the primiparity inexperience, has a negative impact on breast-feeding outcomes. SUBJECTS AND METHODS : The state-trait anxiety inventory Y form (Spielberger, 1983) was administered to a total of 204 mothers, 101 primiparae, and 103 pluriparae on the third to fourth day postpartum. RESULTS : We found that primiparae had state anxiety (T) scores significantly higher than pluriparae (44.57 +/- 5.85 vs 43.28 +/- 7.10, P = 0.03). Increased state anxiety levels impaired breast-feeding success. In addition, in the logistic regression analysis model used to assess factors predictive of breast-feeding longer than 3 months, maternal state anxiety was the most significant risk factor (odds ratio 0.99; 0.88-0.98, P < 0.01). CONCLUSIONS : In the puerperium, anxiety, potentially exacerbated by primiparae inexperience, is associated with impaired lactation. Alleviating maternal anxiety could be beneficial for stimulating breast-feeding in more vulnerable women.

Background Diagnostic tools of birth asphyxia provide only an uncertain prediction of neurological outcome. Aims To assess whether TOI and ΔCBV, combined with a set of biochemical and neurophysiological variables, have any diagnostic and prognostic value in birth depression or asphyxia. Study design Case control study at the nursery and NICU of the Padova University Children's Hospital. Subjects 22 term neonates with an Apgar score ≤ 6 at 5′, a 1-h umbilical artery pH value ≤ 7.25 with an increased base deficit and a gestational age ≥ 36 weeks; 15 healthy term infants with an Apgar score ≥ 9 at 5′. Outcome measures Troponin I and NIRS measurements (TOI and ΔCBV) were assessed in both groups. Blood gases, neurological evaluation, US, NIRS, EEG and SEP were evaluated in the infants with depression or asphyxia. Results Troponin I was higher in the study group than in controls ( p = 0.04), showing a correlation with base excess values. In the depressed/asphyxiated neonates with an abnormal outcome at 1 year, TOI rose to 80.1% vs 66.4% in controls ( p = 0.04) and 74.7% in infants with a normal 1-year outcome. A multiple regression model showed a significant multiple correlation coefficient, R = 0.79, p Conclusions Troponin I is a useful short-term index of birth asphyxia or perinatal depression. An increased TOI suggests a risk of abnormal neurological outcome at 1 year. Among the cotside variables, BE and evoked potential abnormalities were the best predictors of abnormal outcome in this study.

Background : The aim of this study was to investigate the effects of patent ductus arteriosus (PDA) ligature on cerebral oxygen saturation, cerebral blood volume (CBV) and cerebral blood fl ow velocity by means of near- infrared spectroscopy (NIRS) and transcranial Doppler simultaneous examinations. Methods : This is an observational study considering 16 babies of gestational age 24 - 34 weeks diagnosed with PDA who underwent surgical ligation. The cerebral oxygen saturation, CBV and blood gases values were obtained 35 min before ligation, so also around the 14th and 27th min after the clip's insertion. Results : Cerebral oxygen saturation, measured as tissue oxygenation index (TOI), decreased signifi cantly after PDA ligation from a basal value of 61.1 (3.8) before surgery to 56.6 (3.3) and 55.8 (2.6)%, for the 14th and 27th min, respectively ( P < 0.04). CBV before and after clipping was unvaried. A negative correlation was found between pH and CBV after ligation ( R = 0.52, P = 0.03), whilst a positive correlation was found between CBV and P aCO2 ( R = 0.62, P = 0.009). pH increased at the 27th min post-ligation. Conclusions : NIRS is a tool for obtaining information on cerebral oxygen saturation and CBV changes during surgical PDA ligation at the bedside. A fall in TOI suggests an increased oxygen extraction during PDA surgery. The lack of increase in CBV or in diastolic fl ow velocity show that the PDA before the clipping did not limit cerebral blood fl ow, the drop in TOI suggests increased oxygen consumption over the clip and the need for accurate monitoring of oxygen utilization after the surgical treatment.

We compared neonatal helmet continuous positive airway pressure (CPAP) and the conventional nasal Infant Flow driver (IFD) CPAP in the noninvasive assessment of absolute cerebral blood flow (CBF) and relative cerebral blood volume changes (DeltaCBV) by near-infrared spectroscopy.A randomized crossover study in a tertiary referral NICU.Assessment of CBF and DeltaCBV in 17 very low birth weight infants with respiratory distress (median age 5 days) treated with two CPAP devices at a continuous distending pressure of 4 mbar.Neonates were studied for two consecutive 60-min periods with helmet CPAP and with IFD CPAP. Basal chromophore traces enabled DeltaCBV changes to be calculated. CBF was calculated in milliliters per 100 grams per minute from the saturation rise integral and rate of rise O(2)Hb-HHb. Median (range) CBF with helmet CPAP was 27.37 (9.47-48.20) vs. IFD CBF 34.74 (13.59-60.10)(p=0.049) and DeltaCBV 0.15 (0.09-0.28) with IFD and 0.13 (0.07-0.27) with helmet CPAP (NS). Using helmet and IFD CPAP, the neonates showed no difference in mean physiological parameters (transcutaneous carbon dioxide and oxygen tension, pulse oximetry saturation, heart rate, breathing rate, mean arterial blood pressure, desaturation rate, axillary temperature).Assessing CBF and DeltaCBV measured by near-infrared spectroscopy with two CPAP devices revealed no differences in relative blood volume, but CBF was lower with helmet CPAP. Greater active vasoconstriction and/or passive capillary and/or venous vessel compression seem the most likely reason, due to a positive pressure around the head, neck, and shoulders by comparison with the airway pressure.

In critically ill neonates, peripheral perfusion and oxygenation assessment may provide indirect information on the circulatory failure of vital organs during circulatory shock. The development of pulse oximetry has recently made it possible to calculate the perfusion index (PI), obtained from the ratio between the pulsatile and nonpulsatile signals of absorbed light. The main goals of this study were: (1) to study foot PI; and (2) to evaluate the relationship between foot PI, obtained continuously by pulse oximetry, and a number of variables, i.e. blood flow (BF), oxygen delivery (DO(2)), oxygen consumption (VO(2)), and fractional oxygen extraction (FOE), measured indirectly by near-infrared spectroscopy (NIRS) on the calf in 43 healthy term neonates (weight 3474.6 +/- 466.9 g; gestational age 39.1 +/- 1.4 weeks).Calf BF, DO(2) and VO(2) were assessed by NIRS on short-lived venous and arterial occlusion maneuvers. PI was measured on the contralateral foot.Foot PI was 1.26 +/- 0.39. There was a positive correlation between foot PI and both calf BF (r = 0.32, p = 0.03) and DO(2) (r = 0.32, p = 0.03), but no correlation was found between foot PI and calf FOE and between foot PI and VO(2).In the neonatal intensive care unit, continuously measuring foot PI by pulse oximetry seems clinically more feasible for peripheral perfusion monitoring than spot measurements of the calf BF and/or VO(2) by indirect NIRS.

This report presents the long-term (36 months) neurologic outcome in 12 neonates and 9 children who survived after extracorporeal membrane oxygenation and attempts to identify its prognostic indicators through a prospective study in the pediatric intensive care unit of a university hospital. Outcome assessment, neurodevelopmental tests, electroencephalogram, auditory evoked potentials, visual evoked potentials, and somatosensory evoked potentials, cerebral sonography, or cerebral tomography were evaluated at the end of bypass and at 6, 12, 24, and 36 months after extracorporeal membrane oxygenation. "Before extracorporeal membrane oxygenation" variables (oxygenation index, pH, oxygen arterial partial pressure) and "during extracorporeal membrane oxygenation" variables (pH, oxygen arterial partial pressure, duration of bypass, clotting activated time, electroencephalogram) were also analyzed. A negative neurologic outcome (Glasgow Outcome Score different from "good recovery" or neurodevelopmental score less than 70) 12 months after extracorporeal membrane oxygenation was documented in 8.3% of neonates and in 30% of children who survived. There was no further change in subsequent evaluations (24 and 36 months follow-up). The most abnormal electroencephalogram during extracorporeal membrane oxygenation, the first electroencephalogram, neuroimaging score, and somatosensory evoked potentials after extracorporeal membrane oxygenation treatment were associated with negative neurologic outcome. The study documented that neonates and children treated with extracorporeal membrane oxygenation require long-term follow-up; electroencephalogram, neuroimaging score, and somatosensory evoked potentials have prognostic value for abnormal neurologic outcome.

The study aimed to assess how well the severity of clinical conditions in extremely low birth weight infants in the first 12 h of life, as measured by the CRIB (clinical risk index for babies), relates to hospital outcome and subsequent disability at 18 months of age. The CRIB was confirmed as a valid index of initial neonatal risk, even in extremely low birth weight infants, predicting hospital outcome (death or major brain lesions) more accurately than birth weight or gestational age. However, an adjustment of the CRIB score for gestational age might enhance its positive predictive value in relation to short-term developmental outcome in this particular population.

To the Editor. We read with great interest “Lactation Counseling for Mothers of Very Low Birth Weight Infants: Effect on Maternal Anxiety and Infant Intake of Human Milk” by Sisk et al.1 Their objective was to examine whether mothers of very low birth weight infants who initially planned to formula feed were different in terms of their levels of anxiety and maternal stress compared with mothers who had planned to breastfeed their infants. The study showed that counseling mothers …

428 Role of Cerebral Blood Volume, Tissue Oxygenation Index, Troponin I and Neuro-Physiological Variables in Birth Asphyxia, Related to Outcome.

Aim: To evaluate whether clamping time could affect peripheral and heart hemodynamics, in a group of healthy term newborns. Subjects and Methods: We evaluated 9 early cord clamping (ECC) (30 seconds) in comparison with 10 late cord clamping neonates (LCC) (4 minutes) at the mean age of 68.7 hrs. The following variables were evaluated: hematocrit (Ht %), hemoglobin (Hb g/dL), total bilirubin (TB mg/dL), heart left diastolic ventricular diameter LDV(D) (cm) by a sonographer (HDI 3000 CV); calf blood flow (mL/100g/min), calf Hb flow (micromoles/100 mL/min), calf O2 delivery (DO2), O2 consumption (VO2) (micromoles/100 mL/min), using near-infrared spectroscopy (NIRS, NIRO 300 oximeter). Perfusion index (PI) were obtained using a Masimo SET radical pulse oximeter with a sensor placed on the foot contralateral. Data are presented as mean (SD). Mann Whitney test was used to compare the two groups values. A p value less than 0.05 was considered significant. Results: Ht 55.5 (4.8) vs 64.5 (5.3) (p 0.004) in ECC and LCC groups respectively, Hb 15.2 (1.2) vs 17.9 (1.4) (p 0.002), TB 8.2 (3.6) vs 7.3 (2.8) (ns), calf Hb flow 2.1 (1.4) vs 1.9 (0.9) (ns), calf BF 0.7 (0.4) vs 0.7 (0.3) (ns), calf DO2 10.1 (1.3) vs 11.2 (1.1) (ns), calf VO2 calculated by arterial occlusion 0.4 (0.1) vs 0.3 (0.1) (ns), LDV(D) 1.5 (0.08) vs 1.7 (0.1) (p 0.01), and foot PI 1.08 (0.3) vs 1.1 (0.3) (ns). Conclusion: Our study shows that LCC group has an increased placental transfusion, that was expressed by higher hematocrit and hemoglobin, in comparison with ECC group; so a bigger left ventricle diameter at the diastole. There was no evidence of changing in both calf Hb flow and blood flow, as well as in oxygen tissue metabolic demand and foot PI. The increased blood volume seems not to increase the jaundice risk.