Consents or waivers of responsibility? Parents' information in NICU

BACKGROUND

Informing the patient is a base of modern medicine; nonetheless, a great discrepancy exists between hospitals on the way this information should be administered. This is particularly important when the patient are babies: the information should be given to their parents who should approve or disapprove the treatment. Aim of this study is to assess the adequacy of the information administered to the parents of babies admitted into the Neonatal Intensive Care Units.

METHODS

We analyzed the consent forms of center-north Italy NICUs. To this aim, we assessed if the forms had acceptable length and other features; we then asked some volunteers to simulate an information process and to score the forms for their easiness, comprehensibility and explicability to others.

RESULTS

Twenty-one NICUs accepted to participate. Only 7 out of 21 had an adequate information form; the other 14 could be described as "waiver of responsibility" (WOR), because they were too prolix and contained too many hypothetical procedures. The overall level of easiness, comprehensibility and explicability to others was suboptimal, being lower in those forms we defined WOR.

CONCLUSIONS

The results are far to be optimal. More care should be devoted to the process of informing parents at the admission into the NICU: an information overload should be avoided and information should be tailored on the baby's state. Further analysis should be devoted to whether the use of WOR is routine in other countries.

Normal values of creatine kinase and of MB-creatine kinase at birth in healthy babies

BACKGROUND

Today, few studies have been accomplished in order to determine serum creatine kinase (CK) activity in newborns by considering small groups of babies and without taking into account gestational age (GA) differences. Some authors have demonstrated that neonatal CK activity value at birth is higher than the normal range of CK activity considering for adults or older children. The objective of this study is to assess normal values of CK and MB-CK in neonatal blood, according to babies' GA.

METHODS

We retrieved the clinical files of 140 babies admitted into Siena Hospital NICU in a 2-years period, when CK was assessed routinely to all babies at birth. We selected files from 114 newborns and we divided the cohort into group A (non-stressed; N.=41) and group B (stressed; N.=73) on the basis of Apgar Score and signs of neurological lesions. We compared CK and MB-CK values in the two groups according to GA.

RESULTS

Mean CK value of the 41 non-stressed babies' samples: 413 IU/L (232 SD). CK significantly increases with GA. No differences are present in total CK activity between stressed vs. non-stressed babies; but a significant difference appears in these two groups for MB-CK (mean values: 456 vs. 175 IU/L).

CONCLUSIONS

This is the first study that compares CK and MB-CK values at birth according to the GA of the babies. CK values increase with GA, and stressed babies have higher MB-CK values than the non-stressed babies. These reference values are important for clinical practice.

Values of PCT in neonates

BACKGROUND

Procalciton (PCT) is a precursor polypeptide of the hormone calcitonin, produced in C cells of the thyroid. It has been demonstrated that microbial toxins and proinflammatory mediators can cause the release of PCT from tissues and cells in the body. PCT thus has become an important marker in the diagnosis of infection.

METHODS

In this retrospective study we analyzed blood samples performed for clinical purposes from the newborns present in our hospital in the year 2019. We developed a database of 1356 PCT values obtained from 224 infants at risk for neonatal infection; we selected those PCT values obtained within 24 hours from a blood sampling for blood culture.

RESULTS

Babies with positive blood culture had PCT values more elevated than those with negative blood culture (17.061 ng/mL [C.I. 10.8-23.2] vs. 4.6 ng/mL [C.I. 2.6-6.6]). No statistically significant difference was found between babies with negative blood culture born before or after 37 weeks of gestation.

CONCLUSIONS

This paper gives useful data of PCT values in non-infective babies. It is worth to show that the normality values should not be confused with those of older children or adults. Moreover, it shows the reliability of PCT as an infection index.

Neonatal Infant Pain Scale in assessing pain and pain relief for newborn male circumcision

Circumcision-partial or total removal of the penile prepuce-requires cutting nerve-laden, sensitive genital tissue and is therefore liable to be painful. The aim of this review is to evaluate the evidence concerning pain felt by newborns during circumcision and to determine whether current analgesic methods can eliminate such pain. I performed a search in medical databases, selecting the trials published in the last 20 years that assessed pain in neonatal circumcision. Twenty-three trials have been retrieved. To get reliable findings, those trials that used validated pain scales were selected; then it was investigated which trials had comparable data for using the same pain scale. The only pain scale that was used in more than two trials was the modified Neonatal Infant Pain Scale (mNIPS) that ranges 0-6. The results of these trials show that none of the analgesic strategies used obtained the absence of pain. Some differences between circumcision techniques can be noticed, but most assessments exceed the score of 3, chosen as the clinically significant pain.

Nurses and Doctors Heroes? A Risky Myth of the COVID19 Era

Recent newspapers reports have named health professionals as “heroes”. This is surprising, because in the last few decades, doctors and nurses have been taken into account by mass media only to describe cases of misconduct or of violence. This change was due to the coronavirus pandemic scenario that has produced fear in the population and the need for an alleged “savior”. This need for health professionals seen as heroes is also disclosed by the fact that even politicians have abdicated to their role in favor of the healthcare “experts” to whom important decisions on social life during this pandemic have been delegated, even those decisions that fall outside of the specific health field. This commentary is a claim to framing the job of caregivers in its correct role, neither angel nor devil, but allied to the suffering person, that the image of “heroes” risks to overshadow.

The Congress "Yes to Life": A Hand Offered in Dialogue

The Congress "Yes to Life," devoted to the ethical problems in perinatology, has been an important carrefour for the intercultural dialogue on these themes. This paper describes the aim of the Congress and why it was proposed.

New insights into fetal pain

Fetal pain is difficult to assess, because the main feature needed to spot pain, is the subject's capability of declaring it. Nonetheless, much can be affirmed about this issue. In this review we first report the epochs of the development of human nociceptive pathways; then we review since when they are functioning. We also review the latest data about the new topic of analgesia and prenatal surgery and about the scarce effect on fetal pain sentience of the natural sedatives fetuses produce. It appears that pain is a neuroadaptive phenomenon that emerges in the middle of pregnancy, at about 20-22 weeks of gestation, and becomes more and more evident for bystanders and significant for the fetus, throughout the rest of the pregnancy.

Consents or waivers of responsibility? Parents' information in NICU

BACKGROUND

Informing the patient is a base of modern medicine; nonetheless, a great discrepancy exists between hospitals on the way this information should be administered. This is particularly important when the patient are babies: the information should be given to their parents who should approve or disapprove the treatment. Aim of this study is to assess the adequacy of the information administered to the parents of babies admitted into the Neonatal Intensive Care Units.

METHODS

We analyzed the consent forms of center-north Italy NICUs. To this aim, we assessed if the forms had acceptable length and other features; we then asked some volunteers to simulate an information process and to score the forms for their easiness, comprehensibility and explicability to others.

RESULTS

Twenty-one NICUs accepted to participate. Only 7 out of 21 had an adequate information form; the other 14 could be described as "waiver of responsibility " (WOR), because they were too prolix and contained too many hypothetical procedures. The overall level of easiness, comprehensibility and explicability to others was suboptimal, being lower in those forms we defined WOR.

CONCLUSIONS

The results are far to be optimal. More care should be devoted to the process of informing parents at the admission into the NICU: an information overload should be avoided and information should be tailored on the baby's state. Further analysis should be devoted to whether the use of WOR is routine in other countries.

Pain perception in NICU: a pilot questionnaire

PURPOSE

Neonatal pain management has made a great step forward over the last several years. Despite the drafting of International guidelines, an under-treatment of neonatal pain is still reported.

MATERIALS AND METHODS

Medical and paramedical personnel working in five Italian NICUs were asked to complete a questionnaire about pain management. The questionnaire was comprised of three sections: (i) brief explanation of the purpose; (ii) demographic information, including age, profession, religious beliefs, and hospital level; (iii) questionnaire about pain management and prevention.

RESULTS

One-hundred and forty caregivers participated in this study. Non-pharmacological analgesia during heel prick or venipuncture was used by 64% and 60% of them, respectively; topical analgesia was performed in 13% of venipunctures; no analgesia was used in 30% of cases for both heel prick and venipuncture. In the case of lumbar puncture, 35% of participants used topical analgesia, 15% non-pharmacological approach, 10% opioids, and 6% intravenous paracetamol. While 65% of participants gave a score of 4 out of 5 about the importance of pain treatment, 39% of them reported that in their department no pain scales were used.

CONCLUSIONS

Pain treatment in these NICUs is still far to be optimal. This nonetheless reflects a worldwide trend, which requires more attention on pain prevention, assessment, and treatment.

Normal values of creatine kinase and of MB-creatine kinase at birth in healthy babies

BACKGROUND

Today, few studies have been accomplished in order to determine serum creatine kinase (CK) activity in newborns by considering small groups of babies and without taking into account gestational age (GA) differences. Some authors have demonstrated that neonatal CK activity value at birth is higher than the normal range of CK activity considering for adults or older children. The objective of this study is to assess normal values of CK and MB-CK in neonatal blood, according to babies' GA.

METHODS

We retrieved the clinical files of 140 babies admitted into Siena Hospital NICU in a 2-years period, when CK was assessed routinely to all babies at birth. We selected files from 114 newborns and we divided the cohort into group A (non-stressed; n=41) and group B (stressed; n=73) on the basis of Apgar score and signs of neurological lesions. We compared CK and MB-CK values in the two groups according to GA.

RESULTS

Mean CK value of the 41 non-stressed babies' samples: 413 IU/L (232 SD). CK significantly increases with GA. No differences are present in total CK activity between stressed vs non-stressed babies; but a significant difference appears in these two groups for MB-CK (mean values: 456 vs 175 IU/L).

CONCLUSIONS

This is the first study that compares CK and MB-CK values at birth according to the GA of the babies. CK values increase with GA, and stressed babies have higher MB-CK values than the non-stressed babies. These reference values are important for clinical practice.

Is fetal analgesia necessary during prenatal surgery?

Fetal pain and fetal anesthesia are still matter of debate: some authors hypothesize that several intrauterine endocrine neuroinhibitors (ENIn) anesthetize the fetus, keeping it in a constant state of sleep, and making pharmacological fetal anesthesia useless for fetal surgery, while others argue fetal pain is possible and shoud be prevented with fetal anesthesy.

AIM

To retrieve evidences about fetal pain, fetal arousability and about the level of sedation induced by the ENIn, in order to assess the necessity of direct fetal anesthesia during prenatal fetal surgery.

METHODS

We performed a careful literature review (1990-2016) on fetal arousability, and on the possibility that ENIn at the average fetal blood levels induce actual anesthesia. We retrieved the papers that fulfilled the research criteria, with particular attention to the second half of pregnancy, the period when most fetal surgery is performed.

RESULTS

Fetuses are awake about 10% of the total time in the last gestational weeks, and they can be aroused by external stimuli. ENIn have not an anesthetic effect at normal fetal values, but only when they areartificialy injected at high doses; their blood levels in the last trimester of average pregnancies are not dissimilar either in the fetus or in the mother.

CONCLUSIONS

During the second half of the pregnancy, external stimuli can awake the fetuses, although they spend most of the time in sleeping state; the presence of ENIn is absolutely not enough to guarantee an effective anesthesia during surgery. Thus, direct fetal analgesia/anesthesia is mandatory, though further studies on its possible drawbacks are necessary.

Analgesia, nil or placebo to babies, in trials that test new analgesic treatments for procedural pain

This review assessed how often neonates in control groups experienced unnecessary pain during clinical trials involving procedural pain. We retrieved 45 studies in the 30 months up to June 2015 and found that in 29 (64%) the control babies received either placebos or no treatment. Placebos were used in 15/25 (60%) studies involving heel pricks and in 6/8 (75%) involving venepuncture.

CONCLUSION

Despite international guidelines, neonates included in control groups during painful procedures do not receive analgesia in the majority of cases. Several historical reasons can explain this, but in the light of present knowledge, this should not continue. Ethical committees are thereof invited since now to not permit clinical trials that do not explicitly rule out pain during treatments and journals are invited to not publish them.

Blue Light and Ultraviolet Radiation Exposure from Infant Phototherapy Equipment

Phototherapy is the use of light for reducing the concentration of bilirubin in the body of infants. Although it has become a mainstay since its introduction in 1958, a better understanding of the efficacy and safety of phototherapy applications seems to be necessary for improved clinical practices and outcomes. This study was initiated to evaluate workers' exposure to Optical Radiation from different types of phototherapy devices in clinical use in Italy. During infant phototherapy the staff monitors babies periodically for around 10 min every hour, and fixation of the phototherapy beam light frequently occurs: almost all operators work within 30 cm of the phototherapy source during monitoring procedures, with most of them commonly working at ≤25 cm from the direct or reflected radiation beam. The results of this study suggest that there is a great variability in the spectral emission of equipments investigated, depending on the types of lamps used and some phototherapy equipment exposes operators to blue light photochemical retinal hazard. Some of the equipment investigated presents relevant spectral emission also in the UVA region. Taking into account that the exposure to UV in childhood has been established as an important contributing factor for melanoma risk in adults and considering the high susceptibility to UV-induced skin damage of the newborn, related to his pigmentary traits, the UV exposure of the infant during phototherapy should be "as low as reasonably achievable," considering that it is unnecessary to the therapy. It is recommended that special safety training be provided for the affected employees: in particular, protective eyewear can be necessary during newborn assistance activities carried out in proximity of some sources. The engineering design of phototherapy equipment can be optimized. Specific requirements for photobiological safety of lamps used in the phototherapy equipment should be defined in the safety product standard for such equipment.

C-reactive protein: a marker of neonatal stress?

AIM

To assess whether blood values of C-reactive protein (CRP) in healthy term newborns, are influenced by stress.

MATERIAL AND METHODS

Since different types of delivery (vaginal delivery [VD], emergency C-section [EMCS] and elective C-section [ELCS]) are notoriously characterized by different levels of stress for the baby, these three groups were used as models of different levels of stress. The mean CRP values of the three groups obtained in the first hours of life were compared.

RESULTS

We retrieved 1012 babies. Median values (3rd-97th ct) were: 0.05 (0.01-0.46), 0.17 (0.02-1.54), 0.30 (0.04-1.77), 0.43 (0.05-1.31), 0.40 (0.04-1.13) at 12, 24, 48, 72 and 96 h, respectively. Mean values in babies born after VD were statistically higher than those born after C-section, and higher CRP values were present in EMCS with respect to ELCS.

CONCLUSION

This study described normal blood CRP values in a wide population of term babies. An influence of the type of delivery on blood CRP is evident, and this may be explained by the different amount of perinatal stress induced by anyone of the three types of delivery we considered.

Abortion and subsequent mental health: Review of the literature

The risk that abortion may be correlated with subsequent mental disorders needs a careful assessment, in order to offer women full information when facing a difficult pregnancy. All research papers published between 1995 and 2011, were examined, to retrieve those assessing any correlation between abortion and subsequent mental problems. A total of 36 studies were retrieved, and six of them were excluded for methodological bias. Depression, anxiety disorders (e.g. post-traumatic stress disorder) and substance abuse disorders were the most studied outcome. Abortion versus childbirth: 13 studies showed a clear risk for at least one of the reported mental problems in the abortion group versus childbirth, five papers showed no difference, in particular if women do not consider their experience of fetal loss to be difficult, or if after a fetal reduction the desired fetus survives. Only one paper reported a worse mental outcome for childbearing. Abortion versus unplanned pregnancies ending with childbirth: four studies found a higher risk in the abortion groups and three, no difference. Abortion versus miscarriage: three studies showed a greater risk of mental disorders due to abortion, four found no difference and two found that short-term anxiety and depression were higher in the miscarriage group, while long-term anxiety and depression were present only in the abortion group. In conclusion, fetal loss seems to expose women to a higher risk for mental disorders than childbirth; some studies show that abortion can be considered a more relevant risk factor than miscarriage; more research is needed in this field.

Analgesia for infants' circumcision

Male circumcision (MC) is one of the oldest and most common operations performed all over the world. It can be performed at different ages, using different surgical techniques, for different religious, cultural and medical reasons.Our aim is to examine and compare the various methods of analgesia and different surgical procedures reported in literature that are applied in infant MC. We performed a PubMed, MEDLINE, EMBASE and Cochrane search in the papers published since 2000: 14 studies met the inclusion criteria, most of them showing that a combined pharmacological and non-pharmacological intervention is the best analgesic option, in particular when the dorsal penile nerve block is combined with other treatments. The Mogen surgical procedure seems to be the less painful surgical intervention, when compared with Gomco clamp or PlastiBell device. Only 3 papers studied groups of at least 20 babies each with the use of validated pain scales. Data show a dramatic decrease of pain with dorsal penile nerve block, plus acetaminophen associated to oral sucrose or topic analgesic cream. However, no procedure has been found to definetively eliminate pain; the gold standard procedure to make MC totally painfree has not yet been established.

Use of fetal analgesia during prenatal surgery

OBJECTIVE

Recent progresses in fetal surgery have raised concern on fetal pain, its long-term consequences and the risks of sudden fetal movements induced by pain. In several studies, surgeons have directly administered opioids to the fetus, while others have considered sufficient the maternally administered analgesics. We performed a review of the literature to assess the state of the art.

METHODS

We performed a PubMed search to retrieve the papers that in the last 10 years reported studies of human fetal surgery and that described whether any fetal analgesia was administered.

RESULTS

We retrieved 34 papers. In three papers, the procedure did not hurt the fetus, being performed on fetal annexes, in two papers, it was performed in the first half of pregnancy, when pain perception is unlikely. In 10 of the 29 remaining papers, fetal surgery was performed using direct fetal analgesia, while in 19, analgesia was administered only to the mother. In most cases, fetal direct analgesia was obtained using i.m. opioids, and muscle relaxant. Rare drawbacks on either fetuses or mothers due to fetal analgesia were reported.

CONCLUSION

Fetal direct analgesia is performed only in a minority of cases and no study gives details about fetal reactions to pain. More research is needed to assess or exclude its possible long-term drawbacks, as well as the actual consequences of pain during surgery.

Assessing burnout among neonatologists

OBJECTIVES

To measure burnout in a cohort of neonatologists and to explore its association with several psychological and biographic factors.

MATERIALS AND METHODS

A total of 110 neonatologists filled in a personal questionnaire composed of four parts: (a) biographic data, (b) personal beliefs, (c) attitudes toward clinical decisions and (d) a validated tool (the Link Burnout Questionnaire [LBQ]) to assess their burnout. The LBQ categorizes burnout into four subscales: psycho-physical exhaustion, relationship deterioration, sense of professional failure and disillusion. Scores of each subscale range from 6 (minimum) to 36 (maximum). Burnout values were matched with the data of the personal questionnaire.

RESULTS

Most neonatologists (60%-65%) were in the "at risk" range for burnout. High burnout was experienced by 30% of the neonatologists. Having no children is associated with low rates of burnout; work experience of less than 5 years, believing that living with a physical disability is unworthy and having recurrent death ideation are associated with high rates of burnout. The attitude to resuscitating a 24-week baby is inversely correlated with the disillusion rate.

CONCLUSION

In our cohort, burnout exceeds the alarm threshold in one-third of cases. Some of the risk factors we examined were correlated with burnout and should be considered in future prevention programs.

Why do we treat the newborn differently?

End-of-life decisions are often taken in neonatology, based on widely accepted guidelines, to avoiding futile therapies. Usually, the criteria upon which these guidelines rely are different from those used for older patients, even when patients require a guardian to decide on their behalf. Main differences are the weight of parental interests and the probabilistic base of the choice. A careful analysis of the literature found three main reasons of this difference: the obsolescence of the guidelines criteria, the difficulty to distinguish between parents' and babies' interests and the neonatologist's responsibility to prolong a life with the prospective of severe disability. In conclusion, the future guidelines for newborn end-of-life decisions should follow at least the same moral criteria used for older patients.

[Which legal consequences for those who provoke pain to infants?]

The advances in perinatal care have led to a significant increase in neonatal survival rate but also to the rise of the number of invasive procedures. Several scientific studies show that newborns are able to feel pain more intensely than adults. Despite this evidence, neonatal pain and the right to an appropriate analgesia are systematically underestimated, ignoring ethical and moral principles of beneficence and non-maleficence. Infants are more susceptible to pain and the prolonged exposure to painful sensations can alter the neural development and the response to pain causing hyperalgesia. Anyone who caused pain without using any analgesic procedure due to negligence or incompetence, should be severely punished. The right to analgesia, fundamental principle, is fully incorporated in the Italian code of Medical deontology (article 3). The doctor who does not use analgesia for newborns' treatment can be indicted by the Italian penal code (art.582 and 583), aggravated by being the victim an infant, who is unable to defend himself. To avoid penal consequences, a careful education and attention are needed: "pediatric analgesia" should become a basic teaching in Universities and in specialization schools; analgesic treatments should be mandatory and annotated in the patient's file even for minor potentially painful procedures.

Exposure to electromagnetic fields from laptop use of "laptop" computers

Portable computers are often used at tight contact with the body and therefore are called "laptop." The authors measured electromagnetic fields (EMFs) laptop computers produce and estimated the induced currents in the body, to assess the safety of laptop computers. The authors evaluated 5 commonly used laptop of different brands. They measured EMF exposure produced and, using validated computerized models, the authors exploited the data of one of the laptop computers (LTCs) to estimate the magnetic flux exposure of the user and of the fetus in the womb, when the laptop is used at close contact with the woman's womb. In the LTCs analyzed, EMF values (range 1.8-6 μT) are within International Commission on Non-Ionizing Radiation (NIR) Protection (ICNIRP) guidelines, but are considerably higher than the values recommended by 2 recent guidelines for computer monitors magnetic field emissions, MPR II (Swedish Board for Technical Accreditation) and TCO (Swedish Confederation of Professional Employees), and those considered risky for tumor development. When close to the body, the laptop induces currents that are within 34.2% to 49.8% ICNIRP recommendations, but not negligible, to the adult's body and to the fetus (in pregnant women). On the contrary, the power supply induces strong intracorporal electric current densities in the fetus and in the adult subject, which are respectively 182-263% and 71-483% higher than ICNIRP 98 basic restriction recommended to prevent adverse health effects. Laptop is paradoxically an improper site for the use of a LTC, which consequently should be renamed to not induce customers towards an improper use.

Increased risk of brain injury in IVF babies

AIM

The aim of this paper was to assess brain injury occurrence among in vitro fertilization (IVF) babies.

METHODS

We examined all babies born in our hospital in the triennium 2004-2006, comparing the presence of brain injuries between IVF babies and the rest of the population.

RESULTS

In IVF group (180 babies), brain injury was present in 4 babies, while in the rest of population (n=3602) it was present in 23 babies (P=0.042, RR: 3.18). IVF babies have a higher risk of being born with a birthweight less than 2 500 grams (P<0.0001; RR: 5.133). When we considered only babies born with a birth weight less than 2 500 grams, the difference of brain injury between the two groups was not significant.

CONCLUSION

In IVF babies, brain injury occurred more frequently than in the rest of population. This is probably due to a higher rate of premature births and low birth weight in IVF population. Anyway, this data should be disclosed to future parents to make an informed decision.

Distracting effect of TV watching on children's reactivity

The experiment, aimed to evaluate the distracting effect of television, was carried out on 122 children, divided into three groups. All groups performed the auditory vigilance test (AVT) to assess reaction time (RT) to an auditory stimulus and the number of errors in responding to the stimulus. Children in group 1 performed the AVT while in front of a blank TV set and listening to the soundtrack of a movie (SO test), then watching a black and white cartoon (BW test). Children in group 2 performed the AVT while in front of a blank TV set and listening to the soundtrack of a movie (SO test), then watching a color cartoon (CC test). Group 3 performed SO, BW, and CC tests consecutively. RT and the number and type of errors were measured. In each group, 30 days separated one session from the following. A significant increase of median RTs (more than 10%) and errors (twice and more) was observed both in the case of BW and CC tests with respect to SO test. RT increased throughout all tests. During SO test, errors are mainly "false reactions", but in BW and CC tests, errors are more numerous, and they are mainly "omissions". TV movies have a significant distracting and attention-capturing effect, which increases throughout the vision of the show. No advantage in decreasing this effect is offered by removing color from the movie.

[Influence of prolonged treatment with octreotide on GH, IGF I, insulin, ACTH, cortisol, T3, T4 and TSH secretion in a case of congenital chylothorax]

Congenital chylothorax is a rare condition characterized by the accumulation of lymph fluid in the pleural space that causes respiratory and circulatory dysfunctions, immune deficiencies, hypoalbuminemia, electrolyte imbalance and alterations of the coagulation. Mortality rates are elevated and can rise to 50%. Therapy consists in conservative treatment based on thoracic drainage combined with total parenteral nutrition or use of low-fat high-protein diet supplemented with medium chain triglycerides. In case of failure surgical intervention may be considered. During the last years some authors have experienced the use of octreotide with doubtful results. In no case the drug impact on insulin, GH and cortisol secretion in neonatal age has been investigated and only in one case the effect on thyroid hormones has been assessed. We report the case of a 36-week baby with congenital chylothorax treated with octreotide for 42 days. The drug was well tolerated but hormonal level measurements showed a deep depression of insulin secretion unaccompanied by alterations of glucose levels. Levels of GH and TSH showed only a transitory decrease. ACTH and cortisol remained normal. At 5 months, the measurements of hormonal levels did not show significant alterations. It is not possible to determine if such a drug played an essential role in the solution of the pleural effusion, but it is important to emphasize that a prolonged treatment with octreotide has not caused, in our case, persistent hormonal alterations.

[Survival rates in a single neonatal intensive care unit (period 2002-2007). Neuro-developmental outcome and survival for infants born at 23-25 weeks of gestation]

AIM

The aim of this study was to evaluate survival rates in a single Neonatal Intensive Care Unit (NICU) (period 2002-2007), with a special focus on the survival data and outcome at one-year of corrected age for infants born at 23-25 weeks of gestation.

METHODS

All infants who had evidence of heart activity at birth were actively resuscitated, regardless of birth weight or gestational age. Survival rate was calculated as a function of the following variables: birth weight and gestational category; gender in infants of birth weight < or = 1000 g ; appropriate (AGA) or small (SGA) weight for gestational age; inborn or outborn. Twenty-eight newborns (23-25 weeks of gestation) completed follow-up at one-year of corrected age.

RESULTS

During the examined period, no infants died in the delivery room; 833 newborns were admitted to the NICU. Overall survival rates were as following: <500 g (37%), 501-750 g (59%), 751-1,000 g (82%), 1,001-1,250 g (96%), 1251-1,500 g (97%), 1,501-2,000 g (100%), 2,001-2,500 g (98%), >2,500 g (99%); 23-25 weeks of gestation (50%); 26-27 weeks (77%), 28-32 weeks (90%); males < or = 1,000 g (68%), females < or = 1,000 g (68%); AGA < or = 1,000 g (63%), SGA < or = 1,000 g (79%), AGA < or =28 weeks (63%), SGA < or = 28 weeks (67%); inborn (54%), outborn (25%). A fraction of 64% (infants of 23-25 weeks of gestation) did not show handicap at one-year of corrected age, while 25% presented severe, 7% moderate, and 4% mild handicaps.

CONCLUSION

High rate of survival without handicap at one-year of corrected age at extremely low gestational age and the chance of improvements in neonatal care for newborn < or = 24 weeks, indicate the appropriateness for our strategy of resuscitating all newborns with evidence of heart activity in the delivery room.

Effects of lutein on oxidative stress in the term newborn: a pilot study

BACKGROUND

Oxidative stress (OS) plays a crucial role in pathological conditions during the early neonatal period. The newborns are susceptible to oxidative damage due to high metabolic rate and low levels of antioxidant enzymes. Lutein has been found to have protective functions in adult humans as antioxidant.

AIM

To evaluate the effects of lutein on OS in newborns. We tested the hypothesis that lutein would act both by increasing antioxidant capacity and inhibiting OS.

METHODS

This was a randomized, double-blind, placebo-controlled, single-center study. 20 healthy term newborns were assigned to receive lutein or placebo (lutein and control group, respectively) at 12 and 36 h after birth. Total hydroperoxides (TH), as marker of OS, and biological antioxidant potential (BAP), as marker of antioxidant power, were detected on cord blood and at 48 h of life in all babies.

RESULTS

TH significantly increased from birth to 48 h in the control group (p = 0.02), but not in the lutein group. In the lutein group, BAP significantly increased after 48 h (p = 0.02), showing a strengthening of antioxidant activity due to lutein. At 48 h of life, compared with those in the control group, neonates assigned to receive lutein had significantly lower TH levels (p = 0.04) and higher BAP levels (p = 0.028).

CONCLUSIONS

Lutein administration in newborns increases the levels of BAP decreasing TH. The enhancement of antioxidant activity in plasma clearly results in protecting newborn from perinatal OS. These preliminary results, adding a new contribution in antioxidant strategies, strongly require to be confirmed by RCT.

Biomarkers of oxidative stress in babies at high risk for retinopathy of prematurity

Oxygen-induced oxidative stress (OS) has damaging effects in the perinatal period. For now there is a lake of evidence that OS occurs in babies with retinopathy of prematurity (ROP) We tests the hypothesis that a strict oxygen policy may minimize postnatal OS reducing severity of ROP. Multicenter prospective cohort study (72 newborns), using a common clinical management protocol with a strict control of oxygen administration. Assessment of biochemical markers of OS in blood samples at birth and on days 7, 14, and 21. Sixteen babies (22.2 per cent) developed ROP stage 1-2. No severe form of ROP was observed. Birth weight and O2 administration in delivery room were the factors significantly associated with the development of ROP stage 1-2. Prematurity and O2 administration in delivery room are the main factors coming into play in the course of ROP. Because room air is richer in oxygen than intrauterine environment, higher OS can be minimized, as well as incidence and severity of ROP, using standardized management with a restricted oxygen breathing policy.

Flaws in the assessment of the best interests of the newborn

We examined the literature on ethical decisions regarding neonates, to assess whether personal beliefs and prejudices influence end-of-life decisions taken by caregivers. Studies show that religion and familiarity with disability influence caregivers' decisions, whereas the influx of already being a parent, age, sex and professional experience is controverse. Caregivers' attitudes towards end-of-life decisions are also affected by personal concerns about litigation, prejudices and their view of disability. The concept of 'poor quality of life' is widely used as a reference in end-of-life decisions, but this can be interpreted differently, leaving room for a wide range of personal viewpoints. In most cases, parents' opinions are considered important and are sometimes the main determinant in decision making. However, it is unclear whether parents' decisions are based on their own wishes or on the best interests of the newborn.

CONCLUSION

In neonatal end-of-life decisions, patients may not receive cures based only on their best interests.

Electromagnetic fields produced by incubators influence heart rate variability in newborns

BACKGROUND

Incubators are largely used to preserve preterm and sick babies from postnatal stressors, but their motors produce high electromagnetic fields (EMFs). Newborns are chronically exposed to these EMFs, but no studies about their effects on the fragile developing neonatal structure exist.

AIM

To verify whether the exposure to incubator motor electric power may alter autonomous nervous system activity in newborns.

MATERIAL AND METHODS

Heart rate variability (HRV) of 43 newborns in incubators was studied. The study group comprised 27 newborns whose HRV was studied throughout three 5-minute periods: with incubator motor on, off, and on again, respectively. Mean HRV values obtained during each period were compared. The control group comprised 16 newborns with constantly unrecordable EMF and exposed to changes in background noise, similar to those provoked by the incubator motor.

RESULTS

Mean (SD) total power and the high-frequency (HF) component of HRV increased significantly (from 87.1 (76.2) ms2 to 183.6 (168.5) ms2) and the mean low-frequency (LF)/HF ratio decreased significantly (from 2.0 (0.5) to 1.5 (0.6)) when the incubator motor was turned off. Basal values (HF = 107.1 (118.1) ms2 and LF/HF = 1.9 (0.6)) were restored when incubators were turned on again. The LF spectral component of HRV showed a statistically significant change only in the second phase of the experiment. Changes in background noise did not provoke any significant change in HRV.

CONCLUSION

EMFs produced by incubators influence newborns' HRV, showing an influence on their autonomous nervous system. More research is needed to assess possible long-term consequences, since premature newborns may be exposed to these high EMFs for months.

Inter-observer reliability of two pain scales for newborns

AIM

To assess inter-observer reliability of two of the most widely used pain scales for newborns.

BACKGROUND

More than 30 scales exist to assess neonatal pain, but they are rarely used because they are too complicated or unreliable.

METHOD

We scored pain level in two groups of babies during a heelprick. The first group of 20 premature babies (mean gestational age: 34.2+/-1.2 weeks) was studied using the PIPP scale, and the second group of 20 term babies (mean gestational age: 39.5+/-0.9 weeks) with the NIPS scale. We compared the pain scores assigned by the nurse who took the blood sample (nurse A) and those assigned by another who was present during heelprick (nurse B) with those assigned by a nurse who later watched the video clip of the procedure (nurse C). We chose the latter as "objective" score, because in this case the scorer could watch the recorded event several times, timing and scoring it thoroughly.

FINDING

NIPS: 8/20 scores were different between nurse A and nurse C, but only in one case was this difference greater than 2 (Cohen's K=0.60). In the case of nurse B, there were 12/20 differences with respect to the score assigned by nurse C but only one baby was assigned a score that differed by more than 2 (Cohen's K=0.30). PIPP: 16/20 scores were different between nurse A and nurse C; in 9 cases this difference was more than 2 (Cohen's K=0.10). In the case of nurse B, differences with respect to the score assigned by nurse C occurred in 17/20 cases and for six babies the difference in score was more than 2 (Cohen's K=0.16).

CONCLUSION

Our results indicate a higher inter-observer reliability of NIPS than PIPP, though NIPS did not have a very high inter-observer agreement score. Caregivers who use them to assess pain in real time at the cribside should be aware of the limits we have highlighted in this study.

Oxidative kidney damage in preterm newborns during perinatal period

BACKGROUND

Oxidative stress has recently been found to play a key role in post-ischemic kidney damage. We tested the hypothesis that oxidative kidney damage due to perinatal hypoxia in preterm newborns is associated with an increased production of oxidative free radicals in plasma.

METHODS

Blood and urine samples were obtained at birth and on days 7 and 14, from 55 preterm newborns, without any known congenital abnormalities. Total hydroperoxides (TH) and advanced oxidation protein products (AOPP) as indices of oxidative stress, xanthine (Xa) and hypoxanthine (Hx) as indices of hypoxia, alpha1-microglobulin and N-acetyl-beta-D-glucosaminidase (NAG) as indices of kidney damage were assayed.

RESULTS

Statistically significant correlations (p<0.05) were found between biochemical markers of hypoxia, oxidative stress and proximal tubules damage at days 7 and 14.

CONCLUSIONS

Perinatal oxidative stress is associated with a variable degree of kidney damage detectable at birth and continuing up to 14 days.

Is prenatal bonding enhanced by prenatal education courses?

AIM

Prenatal education courses (PEC) are a way of allaying anxiety in pregnancy. PEC consist of a series of five 1-hour lessons in the first and second trimesters of pregnancy. Conducted by nurses or midwives, the course syllabus includes the basics of fetal physiology and development, singing sessions, dance sessions, massage-through-the-womb sessions. Here we investigated whether they can enhance feto-maternal bonding.

METHODS

We studied 77 pregnant women (mean age: 31.5+/-4.1 years), 36 of whom attended PEC. We used the Prenatal Attachment Inventory (PAI), a validated 21-item questionnaire, to score prenatal bonding and compared the scores of the two groups. Three months after delivery, we asked the mothers to fill in another questionnaire to assess infant and maternal well-being.

RESULTS

The PEC group showed a higher PAI score than the control group (65.5+/-6.9 vs. 59.9+/-6.1; P<0.05). Babies born to the PEC group had a higher frequency of unexplained crying.

CONCLUSION

PEC positively influenced prenatal attachment. More studies are needed to assess whether this may be useful for the development of the mother-infant relationship.

Sensorial Saturation for Neonatal Analgesia

AIM

Sensorial saturation (SS) is a procedure in which touch, massage, taste, voice, smell, and sight compete with pain, producing almost complete analgesia during heel prick in neonates. SS is an apparently complex maneuvre, but when correctly explained it is easily learnt. In the present paper, we studied its feasibility, assessing whether a long training is really needed to achieve good results.

MATERIALS AND METHODS

We enrolled 66 consecutive babies and divided them randomly into 3 groups which received the following forms of analgesia: glucose plus sucking (A), SS performed by nurses (B), SS performed by mothers (C). We did not use perfume on the caregivers' hands, so that babies could smell the natural scent of the hands. We assessed pain level by the ABC scale.

RESULTS

Median scores of groups A, B, and C were: 1 (0 to 6), 0 (0 to 4), and 0 (0 to 6), respectively. Mean scores were: 0.6, 0.6, and 1.7 and standard errors were 0.38, 0.22, and 0.32, respectively. Scores of groups B and C were significantly lower than that of A (P=0.03 and 0.006, respectively). No significant difference was found between values of scores of groups B and C.

CONCLUSIONS

Even without the use of perfume on the hands, SS was effective as an analgesic maneuvre. It made no difference whether SS was performed by mothers who applied it for the first time or experienced nurses. SS is rapid to learn and any caregiver (mother, pediatrician or nurse) can effectively use it.