Short-Term Outcomes of Very Low Birth Weight Infants Born at a Tertiary Care Hospital,Istanbul, Turkey

Objective

To evaluate mortality and short-term outcomes in very low birth weight infants admitted to the tertiary neonatal intensive care unit, Istanbul, Turkey.

Methods

Study data were recorded prospectively from January 1, 2010, to December 31, 2010. The clinical findings in neonates with birth weights <1000g were compared with infants with birth weights of between 1000g and 1499g.

Findings

In the present study, survival rates were 40% and 86.2% for infants weighing <1000g and 1000g to 1499g, respectively. There was no difference between males and females with respect to mortality (P>0.05). The mean (±standard deviation) birth weight was 985.6±150.15 g and mean gestational age was 27.5±2.04 weeks. The antenatal steroid rate was 37.2%, and the Cesarean section rate was 73%. Respiratory distress syndrome was diagnosed in 89% of the infants, with a 69% surfactant administration rate. Severe intracranial hemorrhage (IVH) (grade >II) was 14%. Grade 4 periventricular leukomalacia was 10%. Twelve (24%) infants had evidence of bronchopulmonary dysplasia (BPD). Retinopathy of prematurity (stage >II) was 4%. The correlation between ROP rate and need for ventilation therapy was present (r=0.52). Proven necrotizing enterocolitis (stage >2) was not observed. Patent ductus arteriosus (PDA) was diagnosed in 67% of the neonates. BPD, IVH, and PDA were statistically higher in neonates with a birth weight <1000g.

Conclusion

Survival rate of VLBW infants increased with increasing BW. Sex was not a risk factor for mortality. The need for ventilatory therapy may be an important risk factor for ROP in infants <1500g.     

Heated Humidified High-Flow Nasal Cannula for Prevention of Extubation Failure in Preterm Infants

Objectives

To compare extubation failure rate between the heated humidified high-flow nasal cannula (HHHFNC) and continuous positive airway pressure (CPAP) groups.

Methods

Intubated infants with gestational age (GA) <32 wk, who were ready to extubate, were randomized to receive respiratory support with either CPAP or HHHFNC after extubation. In CPAP group, nasal mask CPAP with preset pressure and fraction of inspired oxygen (FiO₂) equal to positive end-expiratory pressure (PEEP) and FiO₂ of ventilator before extubation was applied. In the HHHFNC group, predefined flow rate according to the protocol was applied. Primary outcome was extubation failure within 72 h after endotracheal tube removal.

Results

Forty-nine infants were enrolled; 24 in the HHHFNC and 25 in the CPAP group. Baseline demographic and respiratory conditions before extubation were similar. There was no difference in infants who met failed extubation criteria between the two groups [8 (33%) in HHHFNC vs. 6 (24%) in CPAP group (p = 0.47)]. However, 6 infants (75%) in HHHFNC and 4 infants (66%) in CPAP group who met failed extubation criteria could be rescued by bilevel CPAP. Therefore, the reintubation rate was comparable [2 infants (8.3%) in HHHFNC vs. 2 infants (8%) in CPAP group]. Morbidities or related complications were not different but infants in the HHHFNC group had significantly less nasal trauma (16.7% vs. 44%; p = 0.03).

Conclusions

In the index study, the extubation failure rate was not statistically different between infants who were on HHHFNC or CPAP support.

     

Time needed to achieve changes in oxygen concentration at the T-Piece resuscitator during respiratory support in preterm infants in the delivery room

OBJECTIVE:

To measure the time needed to achieve changes in fraction of inspired oxygen concentration (FiO₂) from the oxygen blender to the facemask during simulated neonatal resuscitation.

METHOD:

Two oxygen analyzers were placed at each end of the T-Piece. During simulated ventilation, the duration to achieve the set oxygen concentration at the facemask was measured. This was repeated at different gas flow rates (5 L/min, 8 L/min or 10 L/min) and different FiO₂ changes (0.21 to 1.0 to 0.21, with stepwise increases and decreases in 0.05, 0.1 and 0.2 increments).

RESULTS:

A total of 1134 measurements (378 measurements for each flow) were recorded. Overall, the mean (± SD) time required to achieve FiO₂ changes at 5 L/min, 8 L/min and 10 L/min was 36±15 s, 31±14 s and 28±14 s, respectively.

CONCLUSION:

There was a lag time of approximately 30 s to achieve the FiO₂ at the facemask. This delay needs to be considered when making serial adjustments to FiO₂ during neonatal resuscitation.     

The role of surfactant and non-invasive mechanical ventilation in early management of respiratory distress syndrome in premature infants

Background

Surfactant replacement therapy has been used for few decades for the treatment of respiratory distress syndrome (RDS) and has significantly improved morbidity and mortality in premature infants. Non-invasive respiratory support has recently emerged as a strategy in the early management of RDS. In this review, we discuss the different strategies of early management of RDS.

Data sources

A literature search of PubMed database was conducted to review the subject. The quality of evidence of key clinical studies was graded according to a modified grading system of the international GRADE group.

Results

Continuous positive airway pressure (CPAP) with selective surfactant is a safe alternative to routine intubation, surfactant and mechanical ventilation in preterm infants with spontaneous breathing, and such an approach has been associated with decreased risk of death and bronchopulmonary dysplasia. There is a risk of pneumothorax when using a high pressure of CPAP (≥8 cm of H₂O), a high partial pressure of carbon dioxide (PCO₂ >75 mm of Hg), and a high fraction of inspired oxygen (FiO₂ >0.6) as a threshold for intubation while on CPAP.

Conclusion

Not all preterm infants need surfactant treatment, and non-invasive respiratory support is a safe and effective approach.     

Respiratory management of extremely low birth weight infants: survey of neonatal specialists

Background

To investigate strategies used for the management of respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD) in extremely low birth weight (ELBW) infants.

Methods

A survey of neonatal specialists working in US academic institutions with fellowship training programs.

Results

Eighty percent (72/89) of the identified academic institutions had at least one physician who responded to the survey. Among respondents, 85% (171/201) agreed or strongly agreed to use continuous positive airway pressure (CPAP) initially for the management of RDS, and the majority agreed or strongly agreed to use a fraction of inspired oxygen (FiO₂) ≥0.4 and a mean airway pressure (MAP) ≥10 cm H₂O as a criteria for surfactant therapy; and 73% (146/200) sometimes or always used caffeine to prevent BPD. Only 25% (50/202) sometimes or almost always used steroids to prevent or treat BPD. Identified indications to use steroids were 3 or more extubation failures or inability to extubate beyond 8 weeks of age.

Conclusions

Variability in treatment strategies of ELBW is common among neonatal specialists. However, the majority of the respondents agreed or strongly agreed to use early CPAP for the management of RDS, consider a FiO₂ ≥0.4 and a MAP ≥10 cm H₂O as criteria for surfactant therapy, and sometimes or almost always used caffeine to prevent BPD. Steroids continue to have a role in the management of BPD in infants who are difficult to extubate.

     

Heliox delivered by high flow nasal cannula improves oxygenation in infants with respiratory syncytial virus acute bronchiolitis

Objective

The objective of this study is to evaluate the hypothesis that use of heliox would result in improvement of gas exchange when used with high flow nasal cannula in infants with RSV acute bronchiolitis.

Early weaning from CPAP to high flow nasal cannula in preterm infants is associated with prolonged oxygen requirement: a randomized controlled trial

Objective

To determine the better approach for weaning preterm infants from nasal continuous positive airway pressure (NCPAP) with or without transitioning to nasal cannula (NC).

Design/methods

This is a randomized, open label, controlled trial. Preterm infants born at ≥ 28 weeks gestation who were clinically stable on NCPAP of 5 cm H₂O with FiO₂ < 0.30 for at least 24 h were randomly assigned to one of 2 groups. The no-NC group were kept on NCPAP until they were on FiO₂ = 0.21 for 24 h, and then were weaned off NCPAP completely without any exposure to NC. If they met failing criteria, NCPAP was re-instituted. The NC-group was weaned off NCPAP when FiO₂ was ≤ 0.30 to NC (2 L/min) followed by gradual weaning from oxygen. Infants who failed NC were supported back with NCPAP for 24 h before making a second attempt of NC.

Results

Sixty neonates were enrolled; 30 in each group. The two groups were similar in birthweight, gestational age, sex, antenatal steroids, mode of delivery, use of surfactant and xanthines, and duration of mechanical ventilation. After randomization, the no-NC group had fewer days on oxygen [median (interquartile range): 5 (1-8) vs 14 (7.5-19.25) days, p < 0.001] and shorter duration of respiratory support [10.5 (4-21) vs 18 (11.5-29) days, p = 0.03]. There were no differences between groups regarding success of weaning from NCPAP.

Conclusions

Weaning preterm infants from NCPAP to NC is associated with increased exposure to oxygen and longer duration of respiratory support.     

Olfactory Stimulation by Vanillin Prevents Apnea in Premature Newborn Infants

Objective

Apnea is one of the most common problems in premature newborns. The present study aimed to determine the effect of olfactory stimulation by vanillin on prevention of apnea in premature newborns.

Methods

In this randomized controlled trial, 36 premature newborns with the postnatal age of 2 days and weight under 2500 grams referred to the hospitals affiliated to Shiraz University of Medical Sciences, were selected through simple random sampling and allocated into control and experimental groups. The experimental group received olfactory stimulation by saturated vanillin solution, while the control group received no interventions. The newborns of both groups were continuously monitored for presence/absence of apnea and number of episodes of apnea as well as arterial blood oxygen saturation and heart rate for 5 days. The data were analyzed by independent Student t-test and repeat measure ANCOVA.

Findings

The presence of apnea revealed to be significantly different between the two groups in the first, second, and fourth day of the study (P<0.05). The number of episodes of apnea during five days was also significantly different between the study groups (t=8.32, P<0.05). Using olfactory stimulation by vanillin caused a 3.1-fold decrease in apnea and the effect size was 0.72. Moreover, the two groups were significantly different regarding the arterial blood oxygen and heart rate during the study period (P<0.05).

Conclusion

This study indicated the beneficial effect of saturated vanillin solution on apnea; therefore, it may be used for prevention and treatment of apnea in premature infants. Further studies are needed to improve evidence-based practice in this regard.     

Evaluation of a practice guideline for the management of respiratory distress syndrome in preterm infants: A quality improvement initiative

BACKGROUND:

The use of mechanical ventilation to treat respiratory distress syndrome in preterm infants has been associated with the development of bronchopulmonary dysplasia. As part of a quality improvement initiative to reduce the incidence of bronchopulmonary dysplasia in preterm infants, a new practice guideline for the management of respiratory distress syndrome was developed and adopted into practice in a neonatal intensive care unit in February 2012.

OBJECTIVE:

To evaluate the effects of implementing the new guideline in regard to the use of mechanical ventilation and surfactant, and the incidence of bronchopulmonary dypslasia.

METHODS:

An historical cohort of very preterm infants (gestational age 26⁰ to 32⁶ weeks) born one year before guideline implementation was compared with a similar cohort of infants born one year following guideline implementation. Data were collected retrospectively from the local neonatal intensive care unit database.

RESULTS:

A total of 272 preterm infants were included in the study: 129 in the preguideline cohort and 143 in the postguideline cohort. Following the implementation of the guideline, the proportion of infants treated with ongoing mechanical ventilation was reduced from 49% to 26% (P<0.001) and there was a trend toward a reduction in bronchopulmonary dysplasia (27% versus 18%; P=0.07). There was no difference in the proportion of infants treated with surfactant (54% versus 50%).

CONCLUSION:

The implementation of the practice guideline helped to minimize the use of ongoing mechanical ventilation in preterm infants.     

Changes in Perinatal Care and Predictors of In-Hospital Mortality for Very Low Birth Weight Preterm Infants

Objective

Mortality of very low birth weight premature infants is of great public health concern. To better guide local intervention program, it is essential that current and reliable statistics be collected to understand the factors associated with mortality of these infants.

Methods

Data of very low birth weight premature infants admitted to a neonatal unit during 2002-2009 was retrospectively collected. Changes in perinatal care between two halves of the study period (2002-2005 and 2006-2009) were identified. Factors associated with in-hospital mortality were found by logistic regression and a predictive score model was established.

Findings

A total of 475 cases were enrolled. In-hospital mortality decreased from 29.8% in 2002-2005 to 28.1% in 2006-2009 (P>0.05). More infants born <28 gestational weeks survived to discharge in the latter epoch (38.1% vs 8.3%, P<0.05). Persistent pulmonary hypertension of newborn, pulmonary hemorrhage, birth weight <000 grams, gestational age <33 weeks, feeding before 3 postnatal days and enteral feeding were found predictors of in-hospital mortality by logistic regression. The discriminating ability of the predictive model was 82.4% and the cutoff point was -0.56.

Conclusion

Survival of very low birth weight premature neonates was not significantly improved in 2006-2009 than 2002-2005. Infants with a score higher than -0.56 were assessed to be at high risk of in-hospital mortality. Multi-center studies of planned follow-up are needed to develop a comprehensive and applicable score system.     

Diminished lung function, RSV infection, and respiratory morbidity in prematurely born infants

Background

Diminished lung function appears to be a risk factor for respiratory syncytial virus (RSV) infection/bronchiolitis in term born infants.

Aims

To determine if diminished lung function prior to neonatal unit discharge was associated with subsequent symptomatic RSV lower respiratory tract infection (LRTI) and respiratory morbidity in prematurely born infants.

Methods

Of 39 infants in a tertiary neonatal intensive care unit (median gestational age 28 weeks, range 23–31), 20 had bronchopulmonary dysplasia. Lung function (compliance and resistance of the respiratory system (C_rs and R_rs) and functional residual capacity (FRC)) was measured on the neonatal unit at 36 weeks postmenstrual age (PMA). Following neonatal unit discharge, nasopharyngeal aspirates were obtained on every occasion, at home or in hospital, an infant had an LRTI. RSV was identified by immunofluorescence and/or culture.

Results

The 15 infants who suffered a symptomatic RSV LRTI had a higher mean R_rs and suffered more wheeze at follow up than the rest of the cohort. Regression analysis showed that a high R_rs was significantly associated with a symptomatic RSV LRTI; significant factors for cough were a high R_rs and a symptomatic RSV LRTI, and for wheeze were a high R_rs.

Conclusion

Prematurely born infants, who had a symptomatic RSV LRTI and/or respiratory morbidity at follow up, had worse lung function prior to neonatal unit discharge.     

Increasing Low Birth Weight Rates: Deliveries in a Tertiary Hospital in Istanbul

Objective

Prevalence of low birth weight deliveries may vary across different environments. The necessity of determination of regional data prompted this study.

Methods

Information of all deliveries from January 2004 to December 2008 was obtained from delivery registry records retrospectively. Initial data including birth weight, vital status, sex, maternal age and mode of delivery were recorded using medical files. The frequency of low birth weight, very low birth weight, extremely low birth weight and stillbirth deliveries were determined.

Findings

Among 19,533 total births, there were 450 (23.04 per 1000) stillbirths. Low birth weight rate was 10.61%. A significant increase in yearly distribution of low birth weight deliveries was observed (P<0.001). Very low birth weight and extremely low birth weight delivery rates were 3.14% and 1.58% respectively. Among 2073 low birth weight infants, 333 (16.06%) were stillbirths. The stillbirth delivery rate and the birth of a female infant among low birth weight deliveries were significantly higher than infants with birth weight ≥2500g (P<0.001, OR=28.37), (P<0.001) retrospectively. There was no statistical difference between low birth weight and maternal age. The rate of cesarean section among low birth weight infants was 49.4%.

Conclusion

High low birth weight and stillbirth rates, as well as the increase in low birth weight deliveries over the past five years in this study are striking. For reduction of increased low birth weight rates, appropriate intervention methods should be initiated.     

Risk Factors for Hospitalization due to Lower Respiratory Tract Infection in Preterm Infants on Palivizumab Prophylaxis

Objective

To determine the risk factors associated with lower respiratory tract infections (LRTI) related hospitalizations in preterm infants receiving palivizumab throughout the high season for respiratory syncytial virus (RSV) infection.

Methods

Premature infants who were commenced on palivizumab prophylaxis during the RSV season were included in the study following parental consent. Information on demographic, social, prenatal and postnatal clinical characteristics was recorded and risk factors associated with hospitalization were evaluated for each patient.

Findings

While 234 participants (Group 1, 92.8%) did not require hospitalization during the study period, 18 patients (Group 2, 7.2%) were hospitalized at least once for LRTI during the RSV season. The rate of moderate-severe bronchopulmonary dysplasia (BPD) was significantly higher in group 2 compared to group 1 (38.9% vs 16.2%; P=0.016). Of the 18 infants who were hospitalized, 6 (33.3%) tested positive for RSV while the remaining 12 patients (66.7%) were negative for RSV. Odds ratio (OR) analysis of several risk factors revealed the presence of BPD (OR: 3.28; 95%CI: 1.19-9), being from a family with low socioeconomic status (OR: 3.64; 95%CI 1.08-12.3) to be associated with a higher likelihood of LRTI-related hospitalization.

Conclusion

Our data demonstrated that RSV is an important LRTI agent and cause of hospitalization especially in preterm infants with additional risks such as BPD, gestational age of <28 weeks and low socioeconomic status. We suggest that improving care conditions and decreased BPD with prematurity would help in prevention of LRTI hospitalization.     

The success rate and complications of awake caudal epidural bupivacaine alone or in combination with intravenous midazolam and ketamine in pre-term infants

Background:

The aim of the present study is to compare the success rate and complications of caudal epidural bupivacaine alone or in combination with intravenous (IV) midazolam and ketamine in awake infants undergoing lower abdominal surgery.

Materials and Methods:

In this double-blind, clinical trial study, 90 infants (aged below 3 months and weight below 5 kg) with American Society of Anaesthesiologists I-II, were divided into three groups of each 30: Group 1 received bupivacaine 0.25%, 1 mL/kg for caudal epidural block; Groups 2 and 3 received caudal block with same dose bupivacaine along with IV pre-treatment with midazolam 0.1 mg/kg or IV midazolam 0.1 mg/kg and ketamine 0.3 mg/kg, respectively.

Results:

The success rates in Groups 2 and 3 were 93.3% and 93.1%, respectively, compared with a caudal block with bupivacaine alone 80%; P = 0.015). There was no significant difference among the three groups in terms of mean systolic and diastolic blood pressures and mean heart rate at intervals of 0, 20, 40 and 60 min (P < 0.05). There were no significant differences in the pain scores >3 on the Neonatal Infant Pain Scale at three intervals (30, 60 and 120 min) after surgery among the three groups. The complications such as apnoea or desaturation were not found in any of the studied groups.

Conclusions:

Adding IV ketamine and/or midazolam to bupivacaine caudal epidural block in the conscious infants can positively affect block success rate.Key words: Awake caudal epidural block, bupivacaine, children, ketamine, midazolam     

Surfactant treatment for acute respiratory distress syndrome

OBJECTIVE—To determine prospectively the efficacy of surfactant in acute respiratory distress syndrome.STUDY DESIGN—Twenty patients, 1 month to 16 years of age, diagnosed with an acute pulmonary disease with severe hypoxaemia (PaO₂/FiO₂ < 100) (13 with systemic or pulmonary disease and seven with cardiac disease) were treated with one to six doses of 50-200 mg/kg of porcine surfactant administered directly into the trachea. The surfactant was considered to be effective when the PaO₂/FiO₂ improved by > 20%.RESULTS—After initial surfactant administration the PaO₂/FiO₂ increased significantly in patients with systemic or pulmonary disease from 68 to 111, and the oxygenation index (OI) diminished significantly from 36.9 to 27.1. The PaO₂/FiO₂ and OI did not improve in children with cardiac disease. The improvement of the patients who survived was greater than that of those who died.CONCLUSIONS—Surfactant moderately improves oxygenation in some children with severe acute respiratory distress syndrome secondary to pulmonary or systemic disease.     

Comparison of Epinephrine to Salbutamol in Acute Bronchiolitis

Objective

An appropriate treatment of acute viral bronchiolitis can reduce the symptoms, hospitalization duration and exorbitant costs which is imposed on the families and insurance organizations. This study was conducted to determine the efficacy of epinephrine in comparison with salbutamol in the treatment of the disease.

Methods

Forty infants aged one month to 2 years with acute bronchiolitis in Amin and Al-Zahra hospitals, during 2008, were enrolled in this study. The participants were randomized in two treatment groups to receive epinephrine 0.1 ml/kg or salbutamol 0.15 mg/kg. Three doses of each medication were prescribed at intervals of 20 minutes and continued every 10 minutes after the third dose. The patients in both groups were monitored and rated by RDAI, number of the hospitalized days in the hospital, level of oxygen saturation and vital signs.

Findings

Mean hospitalization duration was 3.3±1.1 and 3±0.9 in the patients receiving salbutamol and epinephrine, respectively (P=0.03). There was a significant difference in assessing RDAI index between the two groups (P=0.03). There were no differences in SPO2, PR, or RR variables in the studied intervals in both groups (P>0.05).

Conclusion

Regarding the effect of epinephrine on reduction of hospitalization duration and the RDAI index in patients with acute bronchiolitis, it seems that using epinephrine instead of salbutamol could be more effective in the management of the disease.     

A European multicenter randomized controlled trial of single dose surfactant therapy for idiopathic respiratory distress syndrome

We performed a multicenter prospective randomized controlled trial to determine the efficacy and safety of the surfactant preparation, Survanta (Abbott Laboratories, Chicago, USA), for 750–1750 g infants with idiopathic respiratory distress syndrome, (IRDS) receiving assisted ventilation with 40% or more oxygen. One hundred and six eligible infants from the eight participating centers were randomly assigned between March 1986 and June 1987 to receive either surfactant (100 mg phospholipid/kg, 4 ml/kg) or air (4 ml/kg) administered into the trachea within 8 h of brith (median time of treatment 6.2 h, range 3.2–9.1 h). The study was stopped before enrollment was completed at the request of the United States Food and Drug Administration when significant differences were observed in incidence of periventricular-intraventricular hemorrhage (PIH), between the surfactant treated and control infants. Surfactant treated infants had larger average increases in the arterial-alveolar oxygen ratio, (a/A ratio) (P<0.0001), and larger average decreases in FiO₂ (P<0.0001) and mean airway pressure, (MAP) (P<0.017) than controls over the 48 h following treatment. The magnitude of the differences between the surfactant and control groups were 0.19 (SE=0.03) for a/A ratio, –0.28 (SE=0.04) for FiO₂ and –1.7 cm H₂O (SE=0.70) for MAP. The clinical status on days 7 and 28 after treatment was classified using four predefined ordered categories: (1) no respiratory support; (2) supplemental O₂ with or without continuous positive airway pressure (CPAP); (3) intermittent mandatory ventilation; and (4) death. There were no statistically significant differences in the status categories on days 7 or 28 between surfactant and control infants. There were no significant differences between the groups with respect to the incidence of patent ductus arteriosus, bronchopulmonary dysplasia, necrotizing entero-colitis, air leaks or death. There was a statistically significant difference between treated and control infants in the frequency and severity of periventricular-intraventricular hemorrhage (PIH) (Cochran-Mantel-Haenszel ²adj=6.36,P=0.01). Hemorrhages occurred in 59.6% of surfactant treated infants and 26.9% of controls. Severe hemorrhages (grades 3 or 4) occurred in 38.5% of surfactant treated infants and 15.4% of controls ( ²adj=4.01,P=0.045). We conclude that the intratracheal administration of Survanta prior to 8 h of age to infants with IRDS receiving assisted ventilation with 40% or more oxygen results in a reduction in the severity of respiratory distress during the 48 h after therapy. Because of the difference in incidence of PIH between surfactant and control infants in this study, we recommend that future clinical trials of surfactant include more frequent prospective serial ultrasound evaluations for diagnosis of hemorrhage.     

High prevalence of vitamin D deficiency in newborn infants of high-risk mothers

Objective

To determine the prevalence of vitamin D deficiency in newborn infants of mothers at risk of vitamin D deficiency because of dark skin or the wearing of concealing clothes (such as a veil) compared with a group presumed not to be at risk. A second aim was to correlate these newborn infants'' vitamin D concentrations with biochemical parameters of vitamin D metabolism and bone turnover at birth.

Design

A prospective study conducted between April 2004 and February 2006 including women delivering during this period and their newborn infants.

Setting

The outpatient clinic of the obstetrics department, Sint Franciscus Gasthuis, Rotterdam, the Netherlands.

Patients

Eighty seven newborn infants of healthy mothers with either dark skin and/or concealing clothing (risk group) or light skin (control group).

Results

We found a significant difference in the prevalence of vitamin D deficiency (25‐hydroxyvitamin D₃ <25 nmol/l) between newborn infants of mothers at risk and those of mothers in the control group (63.3% vs 15.8%; p<0.001). Mean alkaline phosphatase concentrations were significantly higher in the at risk group.

Conclusions

Newborn infants of mothers with dark skin or wearing concealing clothes are at great risk of vitamin D deficiency at birth. The clinical implications are unknown. Further research is necessary to determine the long‐term consequences of maternal and neonatal vitamin D deficiency so that guidelines on vitamin D supplementation during pregnancy can be issued.     

Nephrotic Syndrome Following H1N1 Influenza in a 3-Year-Old Boy

Background

The pandemic influenza A/H1N1, spread through the world in 2009, producing a serious epidemic in Italy. Complications are generally limited to patients at the extremes of age (<6 months or >65 years) and those with comorbid medical illness. The most frequent complications of influenza involve the respiratory system.

Case Presentation

A 3-year-old boy with a recent history of upper respiratory tract infection developed a nephrotic syndrome. Together with prednisone, furosemide and albumin bolus, a therapy with oseltamivir was started since the nasopharyngeal swab resulted positive for influenza A/H1N1. Clinical conditions and laboratory findings progressively improved during hospitalization, becoming normal during a 2 month follow up.

Conclusion

The possibility of a renal involvement after influenza A/H1N1 infection should be considered.