Does lactate level in the first 12 hours of life predict mortality in extremely premature infants?

Aims:   To determine if high lactate levels within the first 12 h of life independently or in combination with Clinical Risk Index for Babies (CRIB) II can predict mortality in extremely premature babies.
Study Design:   A retrospective review of medical charts of babies born between 2001 and 2003 with birthweight <1000 g or gestation <28 weeks was performed. Blood gases and highest umbilical lactate levels in first 12 h of life were noted. Area under the curve (AUC) was calculated for lactate, CRIB and CRIB II as a predictor of mortality. The AUC for lactate and CRIB II were combined using discriminant analysis.
Results:   Two hundred nineteen infants were included in the study, 41 (18.7%) of whom died. The AUC for lactate was 0.67 ( P  < 0.001), while AUCs for CRIB and CRIB II score were 0.81 ( P  < 0.001) and 0.82 ( P  < 0.001), respectively. The AUC for the combined measure of lactate and CRIB II was 0.82, similar to CRIB II.
Conclusions:   Lactate predicts mortality in premature infants, but was found to be inferior to CRIB and CRIB II. Adding lactate level to CRIB II score does not improve its predictive ability.     

Warming preterm infants in the delivery room: polyethylene bags,exothermic mattresses or both?

Aims: To compare the admission temperature of infants treated with polyethylene bags alone to infants treated with exothermic mattresses in addition to bags in the delivery room. Methods: We prospectively studied infants born at <31 weeks’ gestation who were placed in bags at birth. Some infants were also placed on mattresses. Admission axillary temperatures were measured in all infants on admission to the neonatal intensive care. We compared the temperatures of infants treated with bags alone to those treated with mattresses and bags. Results: We studied 43 infants: 15 were treated with bags while 28 were treated with a bag and mattress. Mean admission temperature was similar between the groups. Hypothermia and hyperthermia occurred more frequently in infants treated with a bag and mattress, and more infants treated with a bag had admission temperatures 36.5–37.5°C. Conclusion: The use of exothermic mattresses in addition to polyethylene bags, particularly in younger, smaller newborns, may result in more hypothermia and hyperthermia on admission. A randomised controlled trial is necessary to determine which strategy results in more infants having admission temperatures in the normal range.     

Infovac-France survey in pediatric vaccinology: How does it compare with the literature?

BackgroundImmunization is experienced as painful and may be responsible for needle fear and noncompliance. There are rare evidence-based methods to reduce pain and improve comfort during immunization. There are no French immunization guidelines summarizing the good practices, based on recent studies. This study focused on the methods used by physicians and how they compared with those validated by clinical trials.MethodsAn online questionnaire was sent to the practitioners from the Infovac network, and a PubMed bibliographic search was conducted.ResultsAlmost 2000 doctors responded to this survey. Purging the needle was a habit in 77.9% of them and aspiration before injection in 21.1%. Only one-quarter of the responding doctors injected in the deltoid muscle between 15 and 24 months, and some injected in the buttocks at any age. Half of the physicians vaccinated infants in their parent's arms, children were seated with half of the pediatricians and only one-third of the general practitioners (GPs), and teenagers were seated when vaccinated by three-quarters of the doctors. Anesthetic creams were used by 46.6% of the physicians, mostly by pediatricians (61.9%), and for infants. Breastfeeding was suggested by three-quarters of the physicians for infants under 4 months of age, and sugared solutions were used by 55.5% of the pediatricians and 32.3% of the GPs. Half of the doctors used rocking and cuddling for babies under 24 months of age and toys between 11 and 24 months.ConclusionMany methods are available to distract and improve comfort during immunization. Physicians should choose those they prefer, adjusting for the child's age. There should be French guidelines for immunization techniques, based to the latest clinical surveys, to help improve immunization practice.     

Life and death decisions in the extremely preterm infant: What happens in a level III perinatal centre?

OBJECTIVE:

To describe resuscitation decisions and withdrawal of treatment practices in live-born infants at the extremes of prematurity at St Joseph’s Health Care (London, Ontario).

STUDY DESIGN:

A retrospective chart review was conducted on all neonatal deaths between 22 weeks, zero days’ and 25 weeks, six days’ gestational age over an eight-year period. Documentation concerning end-of-life discussions was subjected to thematic review to limit or withhold resuscitation or withdraw treatment.

RESULTS:

Three hundred eighteen infants were delivered between 22 weeks, zero days’ and 25 weeks, six days’ gestational age. Of these, 21% of infants (67 of 318) were stillborn, 38% (121 of 318) were alive on discharge from hospital and 41% (130 of 318) died in the neonatal period. Of the live-born infants who did not survive to discharge, 34% (44 of 130) had no initial attempts at resuscitation. Withdrawal of life-sustaining treatment was the immediate cause of death in 84% of cases (61 of 73) in which the infant survived initial resuscitation. Documented parental rationale for withdrawal of treatment included “preventing pain and suffering”, “not wanting (their baby) to die on a ventilator” and “poor quality of life”. Families in which the mother identified as Catholic were more likely to withhold resuscitation and to withdraw life-sustaining treatment because death was imminent despite ongoing treatment. Non-Catholic families were more likely to withdraw life-sustaining treatment based on prediction of a poor long-term prognosis.

CONCLUSIONS:

Decisions not to initiate resuscitation remain fairly common practice at the extremes of prematurity. The majority of deaths in those who survive initial resuscitative measures are secondary to withdrawal of treatment decisions made in the neonatal intensive care unit.     

Estrogen therapy in Turner syndrome: does the type, dose and mode of delivery matter?

The best type, dose and route of estrogen replacement in hypogonadal females has not been fully elucidated and is the subject of this brief review. When feminizing girls with different forms of hypogonadism micronized 17betaE2 should be considered the first choice as it is the most physiological and can be accurately measured in plasma. Most studies of the metabolic effects of the different routes have also used different types of estrogen making comparisons difficult. However, when using the same estradiol compound, 17betaE2 transdermal results in E2, E1 and bioestrogen concentrations closer to normal as compared to oral and achieves greater suppression of LH/FSH but similar IGF-I and lipid concentrations. Whether this translates into better body composition and metabolic outcomes in girls with hypogonadism is being actively investigated and data will soon be available.     

Review of the role of radiotherapy in craniopharyngiomas: how does patient age influence management decisions?

Craniopharyngioma is a brain tumor that can affect children and adults. Although histologically benign, if untreated it can enlarge and lead to serious morbidity and even death, because of its close proximity to critical structures in the parasellar region, including the pituitary, hypothalamus, optic chiasm, carotid arteries and third ventricle. Surgically, two main approaches are currently pursued: macroscopic complete excision or a primarily conservative approach. Another question is the role of radiotherapy in the postoperative setting. Because the associated morbidities with aggressive surgery or radiotherapy can be particularly pronounced in children, the most appropriate management of craniopharyngiomas in this age group remains controversial.     

Sustained pressure—controlled inflation or intermittent mandatory ventilation in preterm infants in the delivery room? A randomized,controlled trial on initial respiratory support via nasopharyngeal tube

AIM: To prove the hypothesis that sustained pressure-controlled inflation compared to intermittent mandatory ventilation for lung recruitment via nasopharyngeal tube after delivery is more effective in reducing the rate of endotracheal intubation and mechanical ventilation in very preterm infants. METHODS: The study was designed as a randomized, controlled trial. The setting was the delivery room and neonatal intensive care unit of a university hospital in Germany. Subjects were 61 infants (25.0-28.9 wk of gestation) with signs of respiratory distress immediately after birth. The infants were randomized in the delivery room to two different respiratory interventions: either to sustained pressure-controlled inflation (15 s) or to intermittent mandatory ventilation (rate 60 min(-1)). This respiratory support was given by a nasopharyngeal tube. The inflation pressure or peak inspiratory pressure was increased stepwise (20-25-30 cm H2O) according to the response of heart rate and oxygenation. RESULTS: The main outcome measure was treatment failure, i.e., endotracheal intubation and mechanical ventilation according to given intubation criteria. Treatment failure occurred in 61% (95% CI, sustained pressure-controlled inflation: 42-78) and 70% (95% CI, intermittent mandatory ventilation: 51-85) (p = 0.59). The rates of mortality (3/61), severe intraventricular haemorrhage (5/61) and chronic lung disease (10/58) were not different between groups. CONCLUSION: Sufficient spontaneous breathing within the first 48 h of life without endotracheal intubation and mechanical ventilation was achieved in about 30% with both methods of initial respiratory support.     

The Goldilocks principle. Oxygen in the delivery room: When is it too little,too much,and just right?

Oxygen has been used to stabilize newborn infants for more than a century. Over the last two decades, a paradigm shift towards using less oxygen has occurred but without firm evidence of benefit. Using lower levels of oxygen has also added new conundrums to clinical care. Can oxygen delivery to sick newborn babies meet the Goldilocks principle, of being “just right”? This review discusses the history of oxygen use in the delivery room and the impetus to change from the long-established practice of using pure oxygen to using lower oxygen concentrations. The review also highlights knowledge gaps, particularly for oxygen exposure and monitoring, as well as the sequelae of oxygen administration, including short- and long-term outcomes.     

Sudden infant death syndrome in South Australia 1968–97. Part 3: Is bed sharing safe for infants?

OBJECTIVE: To examine the risk of death for bed-sharing infants. METHODOLOGY: All unexpected infant deaths occurring in South Australia between 1970 and 1997, occurring after the infant was put to rest and diagnosed by after death scene investigation and autopsy as sudden death infant syndrome, accidental death, or 'undetermined' were studied. RESULTS: Accidents were the most likely cause of death for 5% of infants who died in designated infant containers (cots, cradles, etc), 24% of those who were sharing a bed or couch, and 72% of those who were placed alone on a bed or couch. CONCLUSIONS: While bed sharing showed an increased risk of dying accidentally, when compared with infants sleeping in designated infant containers, the risk of accidental death in this study was even greater for infants left alone on adult beds or couches.     

Prospective follow-up of a cohort of preterm infants < 33 WG receiving ketamine for tracheal intubation in the delivery room: Neurological outcome at 1 and 2 years

Objective

Although ketamine analgesia is effective in reducing pain and facilitating the tracheal intubation of newborns in the delivery room, no data on the neurological effects of this treatment are available. This study compared the neurodevelopmental outcomes at 2 years of age in a cohort of preterm newborns having received ketamine prior to tracheal intubation at birth (the ketamine group) and in a control group.

Bone measurements of infants in the first 3 months of life by quantitative ultrasound: the influence of gestational age, season, and postnatal age

Background: There are a few quantitative ultrasound (QUS) studies of bone status for Chinese children. Objective: To evaluate the clinical application and to investigate the bone status of neonates and young infants with QUS. Materials and methods: An ultrasound bone sonometer was used to measure the bone speed of sound (SOS) of the tibia in 542 neonates within 3 months of birth. Results: At birth, no significant difference of SOS was found between boys and girls, but there was a significant difference of SOS between premature infants and full-term infants. The SOS in neonates born during spring and summer was significantly lower than those born during autumn and winter. There were significant correlations between SOS and gestational age, and between bone SOS and birth weight in appropriate for gestational age (AGA) infants. Multiple regression analysis found that gestational age and infant birth season were two important factors influencing SOS. During the first 3 months, there was no significant difference in SOS between sexes. The SOS of infants showed an inverse correlation with postnatal age, and the decrease of bone SOS with age in premature infants was more marked than in full-term infants. Conclusions: QUS is suitable for evaluating bone status in infants with high precision. The study offers some basic data for neonates and young infants.     

Umbilical vein catheterization through Wharton's jelly: A possibility for a fast and safe way to deliver treatments in the delivery room?

Fast and safe venous access can be a critical issue in the delivery room during neonatal cardiopulmonary resuscitation or before endotracheal intubation. Here, we describe a new method to inject drugs using the umbilical vein, directly punctured through Wharton's jelly, performed in ten newborns between November 2016 and May 2018. The umbilical vein was identified and punctured easily and a reflux was obtained in all patients. The treatments were efficient in all but two patients, which was imputable to the method in one patient. We describe a new route for administration of drugs that has been successfully used in neonates.     

How young patients with cancer perceive the COVID‐19 (coronavirus) epidemic in Milan,Italy: Is there room for other fears?

The rapid spread of coronavirus disease 2019 epidemic in Italy, in particular in the Milan focal point, required drastic measures and led to panic in the population. While in our center we did not change our approach to the treatment of our young patients with cancer, we developed a qualitative survey to assess their perception of the risk and level of stress. The survey showed that a relatively large proportion of young patients felt personally at risk of severe complications. We believe that we need to adequately inform our patients, focusing on hygienic measures and personal protection and prompt reporting of any suspicious symptoms.