Fiberoptic Endotracheal Intubation Through an Ultra-Thin Bronchoscope with Suction Channel in a Newborn with Difficult Airway

Management of the airway may be difficult in newborns with craniofacial and neck malformations (1). Previous experiences with flexible endoscopic intubation in neonates have shown encouraging results, but a number of limitations, such as no directional control at the tip or lack of an operative channel, were also reported (2,3). We describe a successful intubation by a new 2.5-mm fiberoptic bronchoscope with a 1.2-mm suction channel in a newborn with difficult airway. A 2300-g infant, born at 35 wk of gestation after an urgent cesarean delivery for fetal distress, needed cardiopulmonary resuscitation at birth. Endotracheal intubation was achieved only after several attempts with a 3.0-mm tube inserted nasotracheally. On arrival to our unit, physical examination showed dysmorphic face, micrognathia, and arthrogryposis. A gross air leak around the endotracheal tube (ETT) prevented an adequate ventilation of the patient. We decided to explore the patient’s larynx before exchanging the ETT with a larger one, but micrognathia did not allow proper visualization by conventional laryngoscopy. Thus, we inserted a 3.5-mm ETT using a fiberoptic flexible bronchoscope (Richard Wolf-GmbH, Knittlingen, Germany). This endoscope has a 2.5-mm outer diameter, a 1.2-mm instrument channel, an angle of deflection at the tip of 160° up and 130° down, and a working length of 450 mm. During the procedure, we could remove secretions and provide topical anesthesia via the suction channel of the endoscope. No complications were noted.We believe this new ultra-thin bronchoscope may be useful in newborns and small infants when a difficult intubation is anticipated or, alternatively, when lower airway evaluation, suctioning, bronchoalveolar lavage, or supplemental oxygen delivery during intubation is required

Neonatal screening for glucose-6-phosphate dehydrogenase deficiency fails to detect heterozygote females

We examined glucose-6-phosphate dehydrogenase (G6PD) deficiency in north-eastern Italian Caucasian neonates detected by neonatal screening, in order to measure the incidence of heterozygote females detected by neonatal screening, and to estimate the near-true total incidence. A total of 85,437 Caucasian neonates, born between January 2000 and December 2001, have been enclosed in the study. The total incidence of the disease, measured by fluorescent method, is 0.9‰; the total incidence, calculated by Hardy-Weinberg law, is 4.8‰. The frequency of missed females is 93% of total females expected with G6PD deficiency; most of them are very likely heterozygous females. The sensitivity of the fluorescent method might be not sufficient to detect all females. Since heterozygote females might develop the symptoms of G6PD deficiency later, these results suggest that the G6PD neonatal screening may not be helpful in preventing disease in female

Off to a good start: environmental imprinting in the childbirth period

Our organism and the expression of our genetic inheritance are conditioned by the environment. This is demonstrated by experimental models on animals, but more and more evidence shows similarities also in humans. Evidence now supports that neonatal and maternal health also depends on the interactions between the environment and the DNA itself. Even though the DNA sequence remains the same over the years, some genetic traits of human beings can be affected by the silencing or activation of some nucleotide sequences, for example by DNA methylation. Today, epigenetics is much more important than we used to think in 1942 when Waddington used the word “epigenetics” for the first time. The environment can modify DNA sequence methylation, affecting protein production and the phenotype. Examples of how epigenetics affects childbirth phenomenon are given and mechanisms are discussed. Four biological mechanisms of epigenetics are presented: genomic imprinting and silencing of the paternal set of chromosomes, the unpredictable “on/off” expression patterns of wild type genes, paramutations, and alternative states of protein folding. Some genes are triggered by stress, maternal nutrition, drugs (namely oxytocin, fentanyl), childbirth modalities, labor, environmental behavior, microorganism colonization. Imprinting theory is a good scientific basis, to explain the permanence of some biological effects at a considerable time after birth. Imprinting is an important mechanism of DNA expression, and different types of imprinting are described. The consequences of antibiotic use in the childbirth period are discussed, along with the importance of awareness in the use of antibiotics for maternal prophylaxis. Prenatal antibiotics and cesarean sections do affect neonatal microbiome considerably and, therefore, may be the causes of inflammatory intestinal disorders, asthma, obesity, diabetes. Mode of delivery, labor, breastfeeding, and skin-to-skin practice are strictly related to future neonatal health, and the effects are shown here. One of the most important factors to explain the diseases mentioned above is probably the lack of “bacterial contamination” through the birth canal. However, this mechanism cannot be the only one to act, and, in fact, here we also discuss other mechanisms that contribute to the development of future pathologies. Last but not least, the culture and education of the operators, as well as maternal and providers’ attendance behavior during childbirth,  can change the relative outcomes of children’s long-term health

Pediatric Obesity: Looking into Treatment

Prevalence of pediatric obesity continues to rise worldwide. Increasing the number of health care practitioners as well as pediatricians with expertise in obesity treatment is necessary. Because many obese patients suffer obesity-associated cardiovascular, metabolic and other health complications that could increase the severity of obesity, it is fundamental not only to identify the child prone to obesity as early as possible, but to recognize, treat and monitor obesity-related diseases during adolescence. This short review outlines the treatment of pediatric obesity that may have applications in the primary care setting. It examines current information on eating behavior, sedentary behavior, and details studies of multidisciplinary, behavior-based, obesity treatment programs. We also report the less common and more aggressive forms of treatment, such as medication and bariatric surgery. We emphasize that health care providers have the potential to improve outcomes by performing early identification, helping families create the best possible home environment, and by providing structured guidance to obese children and their families

A premature twin affected with FHLH

[No abstract available

Development of the Italian Clinical Practice Guidelines on Bariatric and Metabolic Surgery: Design and Methodological Aspects

Unlabelled: Development of the Italian clinical practice guidelines on bariatric and metabolic surgery, as well as design and methodological aspects. Background: Obesity and its complications are a growing problem in many countries. Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) developed the first Italian guidelines for the treatment of obesity. Methods: The creation of SICOB Guidelines is based on an extended work made by a panel of 24 members and a coordinator. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide the aims, reference population, and target health professionals. Clinical questions have been created using the PICO (Patient, Intervention, Comparison, Outcome) conceptual framework. The definition of questions used the two-step web-based Delphi method, made by repeated rounds of questionnaires and a consensus opinion from the panel. Results: The panel proposed 37 questions. A consensus was immediately reached for 33 (89.2%), with 31 approved, two rejected and three which did not reach an immediate consensus. The further discussion allowed a consensus with one approved and two rejected. Conclusions: The areas covered by the clinical questions included indications of metabolic/bariatric surgery, types of surgery, and surgical management. The choice of a surgical or a non-surgical approach has been debated for the determination of the therapeutic strategy and the correct indications

Development of the Italian Clinical Practice Guidelines on Bariatric and Metabolic Surgery: Design and Methodological Aspects

Development of the Italian clinical practice guidelines on bariatric and metabolic surgery, as well as design and methodological aspects. Background: Obesity and its complications are a growing problem in many countries. Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell’Obesità e delle Malattie Metaboliche—SICOB) developed the first Italian guidelines for the treatment of obesity. Methods: The creation of SICOB Guidelines is based on an extended work made by a panel of 24 members and a coordinator. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide the aims, reference population, and target health professionals. Clinical questions have been created using the PICO (Patient, Intervention, Comparison, Outcome) conceptual framework. The definition of questions used the two-step web-based Delphi method, made by repeated rounds of questionnaires and a consensus opinion from the panel. Results: The panel proposed 37 questions. A consensus was immediately reached for 33 (89.2%), with 31 approved, two rejected and three which did not reach an immediate consensus. The further discussion allowed a consensus with one approved and two rejected. Conclusions: The areas covered by the clinical questions included indications of metabolic/bariatric surgery, types of surgery, and surgical management. The choice of a surgical or a non-surgical approach has been debated for the determination of the therapeutic strategy and the correct indications