Recommendations for the prevention of respiratory syncytial virus infections. Standards Committee of the Spanish Society of Neonatology. Board of Directors of the Spanish Society of Neonatology

Premature babies < = 35 weeks gestation, with or without chronic lung disease (CLD), should be considered high risk population for RSV infection and rehospitalization. RSV monoclonal antibodies (palivizumab) have been found useful in decreasing rates of RSV hospitalization in this patients. Guidelines for their administration include: 1. Recommend their use in premature born between 29-32 weeks gestation without CLD and less than 6 months at entry of RSV station. 2. Strongly recommend their use in premature babies < = 28 weeks gestation or affected with CLD in treatment during last 6 months. These patients should be prophylaxed for two RSV seasons. 3. Prophylaxis among premature babies between 32-35 weeks gestation is not recommended on routine bases. Each case has to be individually analyzed considering risk factors.     

Consensus statement on perinatal care

Abstract: While there is general agreement with the framework of the consensus statements, it is at the margins of the ‘grey zone’, particularly at 23 weeks of gestation, that practice in other states appears to differ from practice in New South Wales (NSW)/Australian Capital Territory (ACT). This is evidenced by the lower regional survival in NSW/ACT at 23 weeks compared with other contemporaneous regional Australian cohorts, reflecting the discouragement of active intervention in NSW/ACT at this gestation. At the other end of the ‘grey zone’, surely active intervention, including prenatal transfer to a tertiary obstetric centre, should always be given to an otherwise uncomplicated 25‐week infant? At any of these gestations, where infants survive, the majority are not severely disabled, leading us in this state to support initiation of intensive care to infants of marginal gestations where informed parents wish us to do so. The consensus conference questions and response rates by professional group should be published in full.     

Neonatal clinical outcome after electivecesarean section before the onset of labor at the 37th and 38thweek of gestation

BACKGROUND: Although elective cesarean sections are often performed after the 37th week of gestation without any complicating factor that may influence the timing of delivery,there is a possibility that infants born in the 37th week of gestation,especially early in the 37th week of gestation, do not obtain a satisfactory clinical outcome due to premature birth. METHODS: The authors analyzed the clinical course during the neonatal period in 96 infants born in the 37th (n = 81)and 38th (n = 15) week of gestation by an elective cesarean section. Subjects were retrospectively divided into two groups: infants born in the first half of the 37th week of gestation (37+0-37+3)(n = 48), and infants born from the latter half of the 37th week of gestation (37+4-37+6)through the 38th week of gestation (n = 48).Twin pregnancies, pregnancy with placenta previa, and pregnancy of women who had a diversity of medical complications were excluded from the present study, because of the possibility that these conditions may have affected the infants' status. The incidence of infants who showed clinical symptoms during the neonatal period and who needed medical care was compared between the two groups. RESULTS: Of the 96 subjects, 25 infants(26.0%) had significant clinical symptoms. The incidence of breathing difficulty was significantly higher in the infant group born in the first half of the 37th week of gestation than in the latter group. CONCLUSIONS: An elective cesarean section before the onset of labor early in the 37th week of gestation should not be routinely undertaken.     

Use of plastic bags to prevent hypothermia at birth in preterm infants‐do they work at lower gestations?

Background: Hypothermia at birth is strongly associated with mortality and morbidity in preterm infants. Occlusive wrapping of preterm infants during resuscitation, including polythene bags have been shown to prevent hypothermia.
Objectives: To evaluate the effectiveness of the introduction of polythene bags at resuscitation of infants born below 30 weeks gestation in a large tertiary neonatal centre.
Methods: Retrospective audit of admission temperatures of all infants born below 30 weeks gestation for two years before and two years after the introduction of polythene bags. Hypothermia was defined as admission axillary temperature < 36°C.
Results: A total of 334 eligible infants were born during the study period. Two hundred and fifty-three (75.8%) had admission temperatures recorded. The incidence of hypothermia fell from 25% to 16%(p = 0.098) for the whole group since the introduction of polythene bags. The main reduction in hypothermia was seen in infants born above 28 weeks gestation (19.4% vs. 3.9%, p = 0.017). There was no significant effect in infants born between 28 weeks and 30 weeks (29.3% vs. 24.8%, p = 0.58).
Conclusions Polythene bags are effective in reducing the incidence of hypothermia at admission in infants born below 30 weeks gestation. The benefit in infants born below 28 weeks gestation was only marginal. This is in contrast to previously published studies. This may be related to the comparatively low incidence of hypothermia at the study centre even prior to introduction of polythene bags.     

The management of prenatally diagnosed sacrococcygeal teratoma

Two of our own and 18 other reported cases with prenatally diagnosed sacrococcygeal teratoma that were delivered by cesarean section are reviewed. Six infants delivered at a gestational age of from 25 to 32 weeks died perinatally. Causes of death were immaturity, intratumoral hemorrhage, and tumor rupture. It is concluded that an attempt should be made to continue pregnancy until 32 weeks' gestation and that after this age infants should be delivered by elective cesarean section as soon as possible. Offprint requests to: H. Ikeda     

Morbidity and mortality of infants born at the threshold of viability: Ten years'' experience in a single neonatal intensive care unit, 1991–2000

BACKGROUND: The purpose of the present paper was to evaluate the mortality and morbidity of infants born at 22-24 weeks gestation. METHODS: A total of 78 infants born at 22-24 weeks gestation, who were admitted between January 1991 through December 2000, were retrospectively studied. RESULTS: Seventy-one of 78 infants were enrolled in the present study. One year survival rates at 22, 23 and 24 weeks were 40.0% (2/5), 61.1% (11/18), and 50.0% (24/48), respectively. Failure of response to surfactant and air leak were associated with death in infants born at 23 weeks gestation. Low Apgar score, intraventricular hemorrhage (> or =III), and sepsis were correlated with death in infants born at 24 weeks gestation. The handicap rates of survivors born at 22, 23, and 24 weeks gestation were 100, 36.4, and 26.1%, respectively. CONCLUSIONS: The present study indicates that infants born at 22 weeks gestation, in whom pulmonary structure is established, that is, a viable lung that can exchange gas with exogenous surfactant, have a chance to survive, but neurological outcome is still poor. Every possible effort should be made to extend gestation beyond 22 weeks.     

Metastasis of soft-tissue myoepithelial carcinoma to clivus

The differential diagnosis for masses involving the clivus is broad. The authors present a case of myoepithelial carcinoma metastatic to the clivus, a lesion that has not been reported to their knowledge. This 14-year-old girl with a history of myoepithelial carcinoma originating in the soft tissues of the left hip and metastatic to the lung presented with left lateral gaze palsy. Imaging demonstrated a 3 × 3-cm osteolytic mass in the clivus. Microscopic transsphenoidal resection with endoscopic assistance was performed. Pathological findings were consistent with the previously diagnosed myoepithelial carcinoma. Within 4 weeks postoperatively and 2 weeks into a chemotherapeutic regimen, the tumor exhibited progression. Radiation therapy was started and growth of the tumor was halted. Myoepithelial carcinoma should be included in the differential diagnosis for clival masses, especially in patients with previously diagnosed myoepithelial carcinoma. The primary management of this tumor should be with chemotherapy and radiation, with surgery serving only for decompression.     

Managing "healthy" late preterm infants

Background:  Late preterm infants are often managed in nursery rooms despite the risks associated with prematurity. The objective of this study was to determine the risks facing late preterm infants admitted to nursery rooms and to establish a management strategy.
Methods:  A total of 210 late preterm infants and 2648 mature infants were assessed. Infants born at 35 and 36 weeks' gestation weighing ≥2000 grams admitted to a nursery room and not requiring medical intervention at birth were of particular interest. The admission rates to the neonatal intensive care unit were evaluated according to the chart review.
Results:  Infants born at 35 and 36 weeks' gestation weighing ≥2000 grams had significantly higher admission rates than term infants at birth (Cochran–Mantel–Haenszel test, P < 0.001; common risk ratio, 4.27; 95% confidence interval, 2.41–7.55) and after birth ( P < 0.001; common risk ratio, 3.57; 95% confidence interval, 2.40–5.33). More than 80% of admissions from the nursery room to the neonatal intensive care unit after birth were due to apnea or hypoglycemia in neonates born at 35 and 36 weeks' gestation. The admission rates due to apnea increased with decreasing gestational age. The admission rates due to hypoglycemia with no cause other than prematurity accounted for 24.3% of admissions for those born at 35 weeks' gestation and 14.1% of admissions for those born at 36 weeks' gestation; hypoglycemia due to other causes accounted for fewer admissions.
Conclusion:  The management strategy for late preterm infants should be individualized, based on apnea and hypoglycemia. The respiratory state of late preterm infants should be monitored for at least 2 days, and they should be screened for hypoglycemia on postnatal day 0.     

Survival and neonatal morbidity at the limits of viability in the mid 1990s: 22 to 25 weeks

OBJECTIVE: We determined neonatal survival and morbidity rates based on both fetal (stillborn) and neonatal deaths for infants delivered at 22 to 25 weeks' gestation. STUDY DESIGN: Two hundred seventy-eight deliveries at 22 to 25 weeks' completed gestation were analyzed by gestational age groups between January 1993 and December 1997. Logistic regression models were used to identify maternal and neonatal factors associated with survival. RESULTS: The rate of fetal death was 24%; 76% of infants were born alive and 46% survived to discharge. Survival rates including fetal death at 22, 23, 24, and 25 weeks were 1.8%, 34%, 49%, and 76%; and survival rates excluding fetal death were 4.6%, 46%, 59%, and 82%, respectively. Logistic regression analyses showed that higher gestational age (P<.0002), higher birth weight (P<.001), female sex (P<.005), and surfactant (P<.003) were associated with neonatal survival. Cesarean section was associated with decreased survival (P <.006). CONCLUSION: Hospital neonatal survival rates of infants at the limits of viability are significantly lower with the inclusion of fetal deaths. This information should be considered when providing prognostic advice to families when mothers are in labor at 22 to 25 weeks' gestation.     

Calcium-phosphate metabolism in pre-term infants

Physiological and clinical aspects are discussed in this review on calcium-phosphate metabolism in pre-term infants. Calcium accumulation in the bone mass of the foetus is related to the gestational age, and mainly occurs during the last weeks of gestation. Therefore, after birth, hypocalcemia is more frequent in pre-term than term infants. However, clinical symptoms of hypocalcemia, e.g. attacks of apnea, hyperexcitability and hypotonia, are rarely observed. Such symptoms depend upon the serum concentration of ionized calcium and this concentration is influenced by various metabolic factors. During the first two weeks of life phosphate is elevated in comparison to later periods. In spite of sufficient vitamin D supplementation low serum phosphate levels occur due to insufficient supply of phosphate. This correlates with evidence of rickets. An increased alkaline phosphatase activity can be considered an early and sensitive indicator. Pre-term infants develop rickets more frequently than term infants due to calcium-phosphate deficiency. Vitamin D supplementation alone is insufficient and should be combined with phosphate, as had been stated previously.     

Allogeneic hematopoietic stem cell transplantation of patients with FA and high risk features using fludarabine without radiation

Several factors unique to Fanconi anemia (FA) limit the success of allogeneic hematopoietic stem cell transplantation (HSCT) in this population. In this report, we describe a multi‐center pilot study of five consecutive FA patients with high‐risk features for transplant prepared with fludarabine, without radiation. Four patients engrafted quickly, experienced minimal toxicity and are well at 43–65 months post‐transplant. One patient had a C‐mismatched unrelated donor transplant and had unsustained engraftment. This fludarabine based regimen without radiation was safe and effective for four high‐risk patients, suggesting that eliminating radiation should be further studied as an approach to HSCT in children with FA. Pediatr Blood Cancer 2009;52:683–685. © 2009 Wiley‐Liss, Inc.     

Intra-arterial blood pressure reference ranges, death and morbidity in very low birthweight infants during the first seven days of life

OBJECTIVES: We aimed to: (1) assess the association of average, low, high and variable mean blood pressure (mbp) on death and the common morbidities of very low birthweight infants, and in doing so, (2) to derive representative reference ranges for mbp in very low birthweight infants. STUDY DESIGN: This five year retrospective study assessed 1 min computer recordings of intra-arterial mbp in 232 very low birthweight infants over the first 7 days of life in a tertiary NICU. Four measures of mbp were assessed: average, variability, maximum (per time period), and percentage of time with a mean blood pressure less than the infant's gestation. Correlation was made with death and the development of intraventricular haemorrhage (IVH), periventricular leukomalacia (PVL) and retinopathy of prematurity (ROP). RESULTS: The mbp increased with increasing birthweight and postnatal age (though with a slight decrease on days 6 and 7). Birthweight, gestation and colloid support (adjusted for birthweight and gestation) were the only factors significantly associated with mbp. IVH was predominantly associated with a low and variable mbp on the day IVH was noted or the day before. PVL and ROP were not associated with blood pressure. CONCLUSIONS: These reference ranges include more infants and data than previously published and relate mbp in this cohort to morbidity and mortality. They could assist clinicians in judging appropriate mbp for birthweight.     

Relationship between length of gestation,birth weigth and certain other factors

Summary A prospective study of 9000 single live born babies with known gestation was conducted during the period January 1967 to June 1970 with a view to find out incidence of prematurity, relationship between gestation and birth weight and other anthropometric measurements. Feeding and respiratory problems along with mortality rate was studied for accurate appraisal of the newborns. The incidence of prematurity on the basis of 2000 G. and below was 11.27% as compared to 48.16% when based on the international standard of 2500 G. Prematurity in the gestational age group of 37 weeks or less was only 10.9% which was further reduced to 9.07% when gestation below 37 weeks and weight below 2500 G. were combined. Majority of the babies below 2500 G. (81.17%) had gestation period more than 37 weeks. In the same weight group all the anthropometric measurements were higher in babies with longer gestation. A higher mortality was observed amongst the same group of babies with low birth weight and shorter gestation. Prognosis improved with increase in weight and in the length of gestation. Physiological response was more mature in the babies with longer gestation in the same weight group. On the basis of the above observations the authors suggest that for correct and accurate appraisal of the newborn, gestation, birth weight with other anthropometric measurements, functional maturity, different clinical problems peculiar to newborns and mortality should be studied in combination and where this is not possible, babies below 2000 G. with gestation less than 37 weeks should be labelled ‘Premature Low Birth Weight Infants’ and babies between 2000–2500 G. with gestation more than 37 weeks be labelled ‘Full Term Low Birth Weight Infants’. This study was partially supported by a grant-in-aid by the Indian Council of Medical Research, New Delhi-16.     

Multiple intestinal atresias and encephalomalacia in the survivor after in-utero death of a monozygous co-twin

A twin infant who survived the death of his monochorionic co-twin in utero and was born with multiple jejunoileal atresias and severe cerebral damage is reported. The pathogenesis of these defects is discussed in the light of previously reported similar cases. The incidence of severe brain damage in twins born alive after the intrauterine death of a monochorionic co-twin is high, suggesting brain destruction by embolization of thromboplastin-rich material from the dead fetus via placental vascular anastomoses. A similar mechanism could be evoked in the present case to account for the intestinal atresias, which likely occurred after the 22nd gestational week, i.e. after the normal permeabilization of the embryonic gut. In the light of this observation and similar ones made by others, it is clear that surgical management of congenital defects during the neonatal period should be influenced by the knowledge of in-utero death of a monochorionic co-twin during the second half of gestation.     

Pneumoperitoneum in a newborn without intestinal perforation (author's transl)]

This is the report of the rare complication of an isolated pneumoperitoneum in a premature infant of 28 weeks gestation with artificial ventilation due to severe RDS. This rare occurrence in immature babies with artificial ventilation should be considered in the differential diagnosis of abdominal emergencies in this age group. Etiology as well as therapeutic consequences will be discussed.     

Influence of antenatal steroids and sex on maturation of the epidermal barrier in the preterm infant

BACKGROUND: The epidermal barrier is well developed in term infants but defective in the immature infant with important clinical consequences. The development of the barrier shares similarities with production of pulmonary surfactant. Studies in the rat have shown that barrier maturation is accelerated by antenatal steroids, both structurally and functionally. Females have a more mature barrier than males at the same gestational age. These factors have not been studied in the human. AIM: To examine the influence of antenatal steroids and sex on maturation of the epidermal barrier in the preterm infant. SUBJECTS: A total of 137 infants born before 34 weeks gestation, 80 boys and 57 girls, were studied: 87 had been exposed to antenatal steroids, and 50 had not; 99 were studied prospectively, and 38 had been studied previously. METHOD: Barrier function was measured as transepidermal water loss from abdominal skin by evaporimetry. Measurements were made within the first 48 hours and corrected to a standard relative humidity of 50% (TEWL(50)). RESULTS: The relation between TEWL(50) and gestation was exponential with very high levels in the most immature infants. No influence of antenatal steroids or sex could be shown. When infants who were optimally exposed to antenatal steroids were considered alone, no effect could be shown. CONCLUSION: Epidermal maturation in the preterm infant does not appear to be influenced by antenatal steroids or sex, suggesting that the mechanism of maturation differs from that of the rat.     

Radiation biology for pediatric radiologists

The biological effects of radiation result primarily from damage to DNA. There are three effects of concern to the radiologist that determine the need for radiation protection and the dose principle of ALARA (As Low As Reasonably Achievable). (1) Heritable effects. These were thought to be most important in the 1950s, but concern has declined in recent years. The current ICRP risk estimate is very small at 0.2%/Sv. (2) Effects on the developing embryo and fetus include weight retardation, congenital anomalies, microcephaly and mental retardation. During the sensitive period of 8 to 15 weeks of gestation, the risk estimate for mental retardation is very high at 40%/Sv, but because it is a deterministic effect, there is likely to be a threshold of about 200 mSv. (3) Carcinogenesis is considered to be the most important consequence of low doses of radiation, with a risk of fatal cancer of about 5%/Sv, and is therefore of most concern in radiology. Our knowledge of radiation carcinogenesis comes principally from the 60-year study of the A-bomb survivors. The use of radiation for diagnostic purposes has increased dramatically in recent years. The annual collective population dose has increased by 750% since 1980 to 930,000 person Sv. One of the principal reasons is the burgeoning use of CT scans. In 2006, more than 60 million CT scans were performed in the U.S., with about 6 million of them in children. As a rule of thumb, an abdominal CT scan in a 1-year-old child results in a life-time mortality risk of about one in a thousand. While the risk to the individual is small and acceptable when the scan is clinically justified, even a small risk when multiplied by an increasingly large number is likely to produce a significant public health concern. It is for this reason that every effort should be made to reduce the doses associated with procedures such as CT scans, particularly in children, in the spirit of ALARA.     

Non-viable delivery at 20-23 weeks gestation: observations and signs of life after birth

OBJECTIVE: To describe the outcome of labour, signs of life at birth, and duration of survival after delivery at 20-23 weeks gestation. DESIGN: An observational study using data from the Confidential Enquiry into Stillbirths and Deaths in Infancy 1995-2000. SETTING: All deliveries to mothers resident in Trent Health Region. PATIENTS: 1306 babies delivered at 20-23 weeks gestation. RESULTS: Termination of pregnancy accounted for 33% of deliveries at 20-23 weeks; these were excluded from further analysis. Spontaneous delivery occurred at a frequency of 2.5/1000 deliveries; 30% died before the onset of labour, 27% died during labour, and 35% showed signs of life at birth. Of the latter, 8% were not registered as statutory live births. Of the live born infants, the largest group (39%) had a heart beat but no other signs of life. There was no trend for infants of lower gestation to show fewer signs of life. Duration of survival varied widely (median 60 minutes at 20-22 weeks), and this did not increase with gestation until 23 weeks (median six hours), probably because of selective treatment. Survival curves are presented for each gestation group. At 23 weeks, 4.5% survived to 1 year of age; all were > 500 g birth weight. Below 23 weeks gestation, none survived, and 94% had died within 4 hours of age. CONCLUSIONS: This information on surviving labour, signs of life at birth, duration of survival, and birth weight at 20-23 weeks gestation should help decision making in the management of pre-viable delivery.     

What physicians think about the need for informed consent for communicating the risk of cancer from low-dose radiation

Background  The National Institute of Environmental Health Sciences, a subsidiary of the Food and Drug Administration, has declared that X-ray radiation at low doses is a human carcinogen. Objective  The purpose of our study was to determine if informed consent should be obtained for communicating the risk of radiation-induced cancer from radiation-based imaging. Materials and methods  Institutional review board approval was obtained for the prospective survey of 456 physicians affiliated with three tertiary hospitals by means of a written questionnaire. Physicians were asked to state their subspecialty, number of years in practice, frequency of referral for CT scanning, level of awareness about the risk of radiation-induced cancer associated with CT, knowledge of whether such information is provided to patients undergoing CT, and opinions about the need for obtaining informed consent as well as who should provide information about the radiation-induced cancer risk to patients. Physicians were also asked to specify their preference among different formats of informed consent for communicating the potential risk of radiation-induced cancer. Statistical analyses were performed using the chi-squared test. Results  Most physicians stated that informed consent should be obtained from patients undergoing radiation-based imaging (71.3%, 325/456) and the radiology department should provide information about the risk of radiation-induced cancer to these patients (54.6%, 249/456). The informed consent format that most physicians agreed with included modifications to the National Institute of Environmental Health Services report on cancer risk from low-dose radiation (20.2%, 92/456) or included information on the risk of cancer from background radiation compared to that from low-dose radiation (39.5%, 180/456). Conclusion  Most physicians do not know if patients are informed about cancer risk from radiation-based imaging in their institutions. However, they believe that informed consent for communicating the risk of radiation-induced cancer should be obtained from patients undergoing radiation-based imaging. A commentary on this article is available at doi:     

Retinopathy of prematurity in infants < 32 weeks' gestation at birth in New South Wales in 1993 and 1994

OBJECTIVE: To study the incidence and severity of retinopathy of prematurity (ROP) in infants < 32 weeks' gestation. DESIGN: Review of the records maintained in the New South Wales Neonatal Intensive Care Unit Study (NICUS) database on infants admitted to the neonatal intensive care units (NICU) in NSW from 1 January 1993 to 31 December 1994. RESULTS: In the more premature infants, 23-26 weeks' gestation, 65% developed ROP (102 of 157 examined for ROP). Forty-four infants (28%) developed severe ROP (Stage >/= 3 ROP), 19 infants (12.1%) required cryo/laser therapy and one infant (0.6%) in this group had a retinal detachment. One hundred and fifty-seven of 159 surviving infants (98.7%) were examined for ROP. In the infants 27-28 weeks' gestation, 38.3% developed ROP (103 of 269 examined for ROP). Fifteen infants (5.6%) developed severe ROP, seven infants (2. 6%) required cryo/laser therapy for threshold ROP and three infants (1.1%) in this group had a retinal detachment. Two hundred and sixty-nine of 299 surviving infants (90%) were examined for ROP. In the infants 29-31 weeks' gestation, 10.8% developed ROP (48 of 443 examined for ROP). Six infants (1.4%) developed severe ROP, one infant (0.2%) required cryo/laser therapy for threshold ROP and no infant in this group had a retinal detachment. However, only 443 of 681 surviving infants (65.1%) in this group were examined for ROP. Of the four infants with detached retinas, one was a 25 week gestation infant weighing 840 g, two were 27 weeks' gestation weighing 960 and 980 g and one infant was a 28 week gestation infant weighing 620 g. No infant developed Stage 5 ROP. CONCLUSION: In the more mature infants 29-31 weeks' gestation, the rate of ROP is low, although severe ROP still occurs. However, only 65.1% of these infants were examined for ROP and we should be diligent in screening for ROP in the sicker infants in this group. The incidence of severe ROP as well as the rate of cryo/laser therapy in premature infants 23-26 weeks' in NSW has not changed since the increases seen in the early 1990s. Retinal detachment also occurs in the infants 27-28 weeks' gestation and it is important that all these infants are screened for ROP.