Strategies for prevention of neonatal chronic lung disease

Chronic lung disease (CLD) of prematurity remains a substantial problem despite modern perinatal and neonatal care. CLD remains related to gestational age and lung immaturity, although it has become clear that severe initial lung disease is not a prerequisite for CLD to develop. Attempts to prevent CLD to date have not adequately addressed the multifactorial nature of the complex pathophysiology that leads to CLD. Thus, results have been modest at best. Prevention of CLD will require a multifaceted approach with specific interventions and care practices focused on different aspects of the pathway that leads to CLD. This review considers new information related to causation of CLD and the magnitude of the effect of prevention strategies tested to date. This article also advances the hypothesis that CLD is preventable with a global strategy of minimizing inciting events, optimizing management, and specific therapies aimed at intrinsic vulnerabilities.     

Antifungal pharmacotherapy for neonatal candidiasis

Candida is a leading cause of late onset infection (> 3 days of age) in the premature infant. Therefore, decisions about the diagnosis and management of infections caused by Candida are commonplace in the neonatal intensive care unit. Despite this fact, there are few comparative trials about treatment of neonatal Candida infections to guide the practitioner. New antifungals have been developed in the past decade and some clinical experience has been reported that can be used to guide the treatment of infants with serious Candida infections. This article reviews recent pertinent data with regard to dosing guidelines, efficacy, and toxicities of available systemic antifungal agents in the newborn.     

Invasive neonatal candidiasis: an overview

Until the 1980s, recovery of Candida species from normally sterile body sites in high-risk infants was often dismissed as contamination. Such delay in diagnosis often resulted in death, multifocal disease, or significant morbidity, outcomes that still occur today. Problems establishing the diagnosis of invasive candidiasis persist, while the frequency of this infection in increasingly fragile and smaller premature infants appears to be increasing. Standard culture techniques have limited sensitivity and often take several days for recovery of Candida when positive. Heightened suspicion and improved diagnostic tools are needed. Less toxic antifungal agents with better tissue penetration profiles will help. Better understanding of risk factors and pathogenesis may permit more effective strategies for prophylaxis and appropriately targeted empiric antifungal therapy.     

Strategies for ovarian cancer prevention

Women who have documented BRCA1 or BRCA2 mutations have a significantly increased lifetime risk of ovarian and breast malignancies. Many women, however, have a perceived personal risk of ovarian cancer despite a calculated low risk, and some seek ways to reduce the risk for ovarian cancer. Given the low prevalence of ovarian cancer in the general population, no screening test has achieved satisfactory levels of disease prediction. This article discusses the efficacy of available screening modalities and reviews current risk-reduction strategies and their effectiveness for preventing ovarian cancer.     

Liposomal amphotericin B in neonates with invasive candidiasis

Liposomal amphotericin B (L-Amp B), a novel formulation of amphotericin B, is effective for the treatment of invasive fungal infections in children and adults and is associated with less toxicity than the conventional preparation. Data on the use of Liposomal amphotericin B in neonates is scarce. We describe the clinical course of two premature infants who were treated with Liposomal amphotericin B (one infant had candidemia, and the other had candidemia and meningitis), and provide a summary of previously published experience on this topic. Liposomal amphotericin B may be an option for therapy of invasive candidiasis in neonates who are at high risk of nephrotoxicity and other amphotericin-related reactions, but clinical trials are necessary to document its safety and efficacy in this age group.     

Strategies of prevention

Prematurity is one of the most stubborn health problems in our society, no other problem impairs afflicted children more seriously and long lasting. In spite of remarkable progress in the treatment of premature infants, the outcomes are still not satisfying and the prematurity rate is still increasing. Prevention of prematurity therefore seems a public health goal with a high priority in obstetrics. Health promotion should be an important issue of counseling in the gynecological practice, recommending favorable living habits in and before pregnancy. Risk factors have to be identified and adverse influences removed for the primary prevention of premature delivery. Secondary prevention requires screening with predictors for the treatment or avoidance of an imminent premature delivery, while the goal of tertiary prevention is the avoidance of health consequences for mother and newborn from a premature delivery and the prevention of recurrence. Not all risk factors for prematurity are known, so far. The identification and removal of unfavorable factors in the society and the individual are important tasks for the future. Better predictors for screening have to be identified and evaluated for the prevention of a premature delivery in order to make tertiary prevention a rare necessity. The prevention of prematurity remains a persistent challenge to obstetrics.     

Routine phenobarbital for prevention of neonatal hyperbilirubinemia.

In a parallel study conducted over a 1-year period, involivng 460 private prenatal patients, the effect of routine prenatal phenobarbital for the prevention of neonatal jaundice was evaluated. The incidence of significant jaundice (bilirubin levels greater than or equal to 10 mg/100 ml) occurred in 4.1% of the 221 test patients compared to 16.3% of the 239 control patients. No significant complications resulted from the drug therapy, and the newborn infants demonstrated no adverse effects attributable to the phenobarbital. Mothers who were given prophylactic phenobarbital took their infants home earlier, less often brought infants back to the hospital for photo-therapy, and spent fewer dollars for their total medical care than their control conterparts. Routine phenobarbital prophylaxis was found to be a safe, effective, and economic method of preventing hyperbilirubinemia in the newborn.     

Colonization and epithelial adhesion in the pathogenesis of neonatal candidiasis

Candida species are important nosocomial pathogens in the newborn population, particularly among the premature very-low-birth-weight infants in neonatal intensive care units. Candida colonization of the neonatal skin and gastrointestinal tract is an important first step in the pathogenesis of invasive disease. C albicans is the most commonly isolated species in colonized or infected infants. Over the past decade the incidence of both colonization and infection with other Candida species, particularly C parapsilosis, has risen dramatically. Colonization of the infant occurs early in life and is affected by a variety of common practices in neonatal intensive care. Microbial factors also augment colonization, including the ability of Candida to adhere to human epithelium. A better understanding of the complex interactions between host risk factors and virulence traits of colonizing yeast may allow the risk of systemic spread to be reduced in the population of premature infants.     

Strategies for prevention of RSV nosocomial infection.

OBJECTIVE: To review the literature on respiratory syncytial virus (RSV) as a cause of nosocomial infections (NI) on neonatal intensive care units (NICUs) and pediatric wards, and the effectiveness of various containment strategies. STUDY DESIGN: We conducted a literature review to define characteristics of RSV NI, and to evaluate the relative effectiveness of various infection containment programs, including the use of palivizumab on the reported incidence of RSV NI on NICUs and pediatric wards. RESULT: Highly variable rates of RSV NI have not significantly changed since RSV was first identified. The evaluation of the effectiveness of containment strategies has relied on before/after study designs. Focus on rapid patient diagnosis, compliance of acceptable handwashing techniques and cohorting of patients and staff appears to form the backbone of most prevention and containment programs. When these or other measures have failed, the administration of palivizumab has been useful in halting the spread of RSV NI in children. CONCLUSION: RSV NI continues to be prevalent in the NICU despite adoption of infection control programs. Preventive measures should be employed to lower the risk of RSV NI and, if identified, appropriate containment strategies should be rapidly implemented.     

Neonatal invasive candidiasis: a prospective multicenter study of 118 cases

A prospective multicenter study was conducted to assess the epidemiology of neonatal invasive candidiasis in Spain. In a total of 20,565 admissions to the 27 participating neonatal units over an 18-month period, systemic candidiasis was diagnosed in 118 (0.57%) neonates. Candida species were isolated from the blood in 79 infants, from the urine in 33, and from the cerebrospinal fluid in 4; in 2 cases, histologic evidence of deep tissue candidiasis was found at autopsy. Very-low-birth-weight (VLBW) infants (< or = 1500 g) showed a significantly higher incidence of systemic candidiasis (4.8%) than infants weighing > 1500 g (0.2%) ( p < 0.001). Candida albicans was the most frequent species (52.5%) followed by C. parapsilosis (23.7%), and C. tropicalis (7.6%). Only seven infants were treated with amphotericin B (initial dose 0.18 +/- 0.3 mg/kg, maximal daily dose 1.7 +/- 0.9 mg/kg) but treatment was stopped in three of them (43%) due to nephrotoxicity. Liposomal amphotericin B was given to 81 neonates and amphotericin B lipid complex to 29. There were no differences in mortality rate and in the incidence of adverse effects in relation to treatment with liposomal amphotericin B or amphotericin B lipid complex. The mortality rate was 10.2% and all deaths occurred in the VLBW cohort with candidemia.     

Antenatal phenobarbital for the prevention of neonatal intracerebral hemorrhage

Forty-six pregnant women less than 35 weeks of gestation were enrolled in a prospective randomized controlled study evaluating the effects of antenatal phenobarbital on neonatal intracerebral hemorrhage. The women were randomly assigned to control (n = 22) or treatment (n = 24) groups; the treatment group received 500 mg of phenobarbital intravenously. The time interval between the dose of phenobarbital and delivery was 5.5 +/- 4.8 hours (mean +/- SD). The infants in the control group (n = 23) and those in the phenobarbital-treated group (n = 25) were comparable regarding birth weight, gestational age, and other obstetric and neonatal risk factors associated with intracerebral hemorrhage. The incidence of intracerebral hemorrhage was 56.5% (13 of 23 infants) in the control group and 32% (eight of 25 infants) in the phenobarbital-treated group (p = 0.08). Moderate or severe hemorrhage was diagnosed in six of 13 control infants and in none of the phenobarbital-treated infants (p less than 0.01). The mortality rate was significantly lower in the phenobarbital-treated group (two of 25 infants) than in the control group (eight of 23 infants; p less than 0.05). Our study suggests that antenatal phenobarbital administration results in a decrease in mortality and in the severity of intracerebral hemorrhage in the preterm neonate.     

Strategies for prevention of mother-to-child transmission of HIV.

Over 90 per cent of paediatric HIV infections are maternally acquired, most of these in sub-Saharan Africa. Mortality trends underscore the humanitarian and ethical obligation for urgent global action to protect children from HIV. With the adoption of anti-retroviral therapy in pregnancy, mother-to-child transmission rates have declined to 4-6 per cent in the USA and other industrialised countries. In low-resource settings, where most of the children are continuously being exposed to HIV, the cost of anti-retroviral therapy is prohibitive. Very few developing countries apart from Botswana, Thailand and Brazil have national policies for integration of preventive anti-retroviral therapy in antenatal clinics. This paper reviews anti-retroviral and non-anti-retroviral interventions for prevention of mother-to-child transmission of HIV. To support the health of mothers as well, it supports the implementation of a comprehensive package of care in pregnancy and post-partum, such as access to antenatal and delivery services; anti-retroviral preventive therapy; malaria treatment; family planning; multivitamin, iron and folate supplementation; counselling on feeding options; post-natal care for the child and post-partum care for the mother, and calls for a strategy for advocacy, programme communication and community mobilisation.     

Complications of laparoscopy. Strategies for prevention and cure

With a detailed knowledge of pelvic anatomy, familiarity with the many laparoscopic instruments, and attention to the details of good technique, many of the complications of laparoscopy described in this article can be avoided. The information presented complements that in the other articles in this issue and briefly summarizes many salient lessons already published in other excellent texts. The focus is on the most common laparoscopic complications, namely, those associated with insufflation and trocar insertion, such as vascular injury and bowel perforation. Other complications that may arise during adhesiolysis, removal of and bleeding from an ectopic pregnancy, and specimen removal from the abdomen are also discussed.     

Strategies for prevention of varicella pneumonia: a cost-effectiveness analysis

Objective: The objective of this study was to compare the cost-effectiveness of 3 strategies of serologic enzyme-linked immunosorbent assay (ELISA) testing and post-exposure varicella zoster immune globulin (VZIG) prophylaxis for the prevention of maternal varicella pneumonia during pregnancy in patients with negative or uncertain histories of varicella infection.Methods: A decision tree was constructed to compare the following strategies: 1) routine serologic testing for varicella immunity followed by targeted post-exposure VZIG prophylaxis, 2) post-exposure serologic testing followed by targeted VZIG prophylaxis, and 3) untargeted post-exposure VZIG administration. The probabilities for the model were obtained from the medical literature and supplemented by expert opinion. The costs were obtained by a review of inpatient hospitalizations for varicella pneumonia. All costs were converted to 1995 dollars.Results: Routine serologic testing followed by targeted post-exposure VZIG prophylaxis was the most costly strategy ($37.22/person), with no demonstrable increase in benefit compared with the other 2 strategies. The disutility of this strategy compared with the others was stable across a wide range of values for the probabilities and costs utilized in the sensitivity analysis. We were unable to differentiate between the cost-effectiveness of the other 2 strategies.Conclusions: Routine serologic testing for varicella immunity in patients with negative or uncertain histories of varicella infection should not be performed. The remaining options of screening and prophylaxis appear to be reasonable alternatives for dealing with varicella exposures.     

Early-onset neonatal group B streptococcal infection: 2002 guidelines for prevention

In 1996, the Centers for Disease Control and Prevention (CDC) and relevant professional organizations jointly released guidelines for prevention of early-onset neonatal group B streptococcal infections. The guidelines recommended that all obstetric providers and institutions providing intrapartum services follow one of two strategies. This year, on the basis of multistate surveillance data collected since prevention strategies were initiated, the CDC has released revised prevention recommendations. This article reviews the new guidelines and discusses clinical implications for practice in a variety of settings.