Based on small studies and not on statistically valid clinical trials, guidelines for neonatal transfusions remain controversial and practices vary greatly. Premature infants and critically ill neonates in the neonatal intensive care unit (NICU) often require blood transfusions and extremely preterm neonates receive at least one red blood cell transfusion during their hospital stay. Transfusions to neonates convey both benefits and risks and consequently it is imperative to establish specific guidelines to improve practice and avoid unnecessary transfusions. Appropriate and lifesaving platelet transfusion in thrombocytopenic bleeding neonates pertains to 2% of all neonates in NICUs. Inversely, 98% of platelet transfusions are given prophylactically, in the absence of bleeding, with the assumption that this reduces the risk of a serious hemorrhage. To date, no evidence base is available for assigning a platelet transfusion trigger to NICU patients. Each NICU should approve specific guidelines that best suit its local clinical practice. Therefore, whatever guidelines are chosen in deciding when to transfuse, what is most important is to adhere strictly to the guidelines adopted, thus limiting unnecessary transfusions that convey no benefits and carry both known and unknown risks.
Even though for certain varieties of neonatal thrombocytopenia, intravenous immunoglobulin or corticosteroids are recommended as treatments, platelet transfusions represent the only specific therapy currently available for most thrombocytopenic neonates in NICUs. The majority of these NICU platelet transfusions, up to 98% in some recent reports, are given to prevent, rather than to treat, bleeding. The trigger limit of platelet count to prophylactically treat non-bleeding patients is generally arbitrary. A complete definition, of the benefits and the risks of prophylactic platelet transfusions in thrombocytopenic neonates is necessary. In fact, there is great variability worldwide in neonatal platelet transfusion practice, due to the lack of concrete evidence to guide transfusion decisions. Evidence-based guidelines do not exist to decide when platelet transfusion should be given. The practice of neonatal platelet transfusions is based almost entirely on expert opinion and reasoning. Consequently, these practices, not supported by definitive data, vary widely. To increase benefits and safety, new widespread changes in platelet transfusion guidelines are necessary. New transfusion paradigms should not be based on reasoning alone, but on important experimental validation. The neonatologists would better accept them and more closely adhere to.
Objective. Emerging evidence indicates a relationship between bronchopulmonary dysplasia (BPD) and chorioamnionitis. Recent data provide evidence of an acute thymic involution in very low birth weight (VLBW) preterm infants and fetuses with histologic chorioamnionitis. We tested the hypothesis that a small thymus detected at birth on the routine chest radiograph is a predictor of BPD in VLBW infants. Methods. A prospective study was conducted on 400 VLBW preterm infants who survived >4 weeks (mean gestational age: 27.5 weeks [range: 24–30]; mean birth weight: 1010 g [range: 450-1450]). Thymic size was measured on routine chest radiographs taken in the first 6 hours after birth and expressed as the ratio between the transverse diameter of the cardiothymic image at the level of the carina and that of the thorax (CT/T). The accuracy of CT/T for identifying infants with BPD was tested using receiver operating characteristic curve analyses and multivariate logistic regression. Results. Fifty-one VLBW infants (12.7%) subsequently developed BPD. A small thymus (CT/T <0.28) was observed in 94.1% of the infants with BPD versus 2.9% of the infants without BPD. A small thymus at birth identified infants with BPD with 94.1% sensitivity and 98.3% specificity (odds ratio: 17.8; 95% confidence interval: 5.7–55.4). Conclusions. A small thymus at birth on the standard chest radiograph can accurately identify VLBW infants who subsequently develop BPD.
Some studies have suggested that the early sustained lung inflation (SLI) procedure is effective in decreasing the need for mechanical ventilation (MV) and improving respiratory outcome in preterm infants. We planned the present randomized controlled trial to confirm or refute these findings. In this study, 276 infants born at 25+0 to 28+6 weeks' gestation at high risk of respiratory distress syndrome (RDS) will be randomized to receive the SLI maneuver (25 cmH2O for 15 seconds) followed by nasal continuous positive airway pressure (NCPAP) or NCPAP alone in the delivery room. SLI and NCPAP will be delivered using a neonatal mask and a T-piece ventilator. The primary endpoint is the need for MV in the first 72 hours of life. The secondary endpoints include the need and duration of respiratory support (NCPAP, MV and surfactant), and the occurrence of bronchopulmonary dysplasia (BPD). Trial registration number: NCT01440868
Platelets contribute to primary hemostasis, and their function is affected by their number and condition. Platelets arise from the fragmentation of megakaryocytes in the bone marrow and circulate in the blood as disk-shaped non-nucleated particles, with a life span of 7–10 days. Their average diameter is about 1.5 μm, 20% of the diameter of erythrocytes. Once released from the bone marrow, young platelets enter the circulation, where a large proportion pool in the spleen. It has been suggested that this splenic sequestration of young platelets is the result of a longer transit time of large platelets through the splenic cords. The spleen serves as a reservoir for platelets, containing about one-third, which are then able to enter the circulation after exercise or epinephrine administration. In addition to the spleen, the lungs also contain a small pool of platelets, perhaps 10–15% of the total number, and these are also able to enter the circulation after exercise or epinephrine administration (Sola and Christensen 2000).
Background/aims : Epidemiological studies in humans link adult disease to abnormal growth in utero. In addition to general malnutrition of the foetus, preferential blood flow to the brain and heart may furthermore deprive organs such as the liver, spleen and kidneys of oxygen and macroand micronutrients. As a consequence, these organs may not develop normally, which predisposes the individual to the so‐called metabolic syndrome (syndrome X) in later life. The effects of foetal undernutrition on the growth of some abdominal organs were investigated by comparing the volume of the kidneys, spleen and liver in small‐for‐gestational‐age (SGA) newborn infants with that in appropriate‐for‐gestational‐age (AGA) newborn infants. Methods : In 25 randomly selected AGA infants and 25 SGA infants, who were subdivided into three gestational age groups (<30, 30–36 and 37–40 wk) the volumes of the liver, kidneys and spleen were determined by ultrasonography. Organ volumes were estimated using the standard ellipsoid formula (longitudinal × anteroposterior × transverse diameter ×π/6). Liver/kidney, liver/spleen and kidney/spleen volume ratios were also determined. Results : The volumes of the kidneys and liver differed significantly between AGA and SGA infants in all three gestational age groups ( p ≤ 0.0018 and p ≤ 0.029, respectively). The fact that the spleen volume differed only in the 37–40 wk group ( p = 0.0002) may indicate that there is a graded relationship across the whole range of normal birthweight. The correlation between the liver volume and birthweight differed significantly between SGA and AGA infants ( r = 0.56 vs 0.84, p = 0.04). On the other hand, the volume ratios between the three organs were the same in all groups ( p ≥ 0.15). Conclusion : In intrauterine growth retarded infants, foetal growth of the liver and kidneys is more impaired than the body as a whole. Retarded foetal development of these organs may cause metabolic dysfunction, which predisposes to the group of diseases included in the so‐called metabolic syndrome or syndrome X.
Background. Estimating the risk of in-hospital mortality provides essential information in the neonatal intensive care unit (NICU). The clinical risk index for babies (CRIB) is a widely used, risk-adjustment instrument to determine illness severity in infants of gestational age ⩽ 31 wks, or birth weight ⩽ 1,500 g, recently updated and simplified into a five-items scoring system (CRIB-II).Aim. The accuracy values of CRIB and CRIB-II scores in predicting in-hospital mortality were compared in a tertiary level, minimal intubation policy NICU setting.Methods. A total of 147 very low birth weight (VLBW) infants were examined. Both CRIB and CRIB-II scores were calculated for each newborn, and death before hospital discharge was selected as the outcome measure. Comparisons were performed by receiver-operating characteristic (ROC) curve analysis, and the area under the curve (AUC) was used as a measure of predictor accuracy.Results. Mean AUCs for CRIB, CRIB-II, gestational age and birth weight in identifying neonatal mortality in VLBW infants ranged from 0.924 (CRIB) to 0.869 (gestational age). No significant differences were found for the AUCs of CRIB versus CRIB-II, CRIB versus gestational age, CRIB versus birth weight, CRIB-II versus gestational age, or CRIB-II versus birth weight.Conclusions. Our findings show that; 1) CRIB and CRIB-II show similar accuracy values in predicting in-hospital neonatal mortality in VLBW infants; and 2) neither score offers an advantage in predicting mortality, as compared to gestational age or birth weight, thus suggesting that treatment modalities may modify predictive accuracy.
