This analysis reports the complications and treatments in the S. Chiara hospital (Trento, Italy) neonatal intensive care unit during 2000–2005. As the only intensive care centre in Trento (an area comprising 6200 km2), and serving the entire population (500000 inhabitants, with 5000 newborns per year), S. Chiara data might be an important source of epidemiological information. Data recorded in S. Chiara were compared with the entire VON database (S. Chiara is part of this network), therefore comparing a small area (2000–2005) with a global group, represented by VON (2004). In this way, it is possible to critically evaluate therapeutic strategies used in S. Chiara, in a global management of a perinatal area.
The two populations had similar rates of congenital anomalies, SGA infants, and multiple births; some intervention strategies were significantly more common in Trento than in VON. For instance, caesarean section, which is a common choice in Italy, especially in recent years [10].
In Trento, the use of prenatal steroids and the use of supplementary surfactant prophylaxis is significantly more common than in VON. The surfactant strategy is based on a multicentre retrospective European study that suggested that prophylactic surfactant administered within 15 minutes of delivery is associated with a significantly greater reduction in RDS than rescue therapy (administration after 15 minutes of life) [11]. Moreover, a head-to-head comparison of surfactant prophylaxis versus rescue therapy confirmed the same finding, suggesting that prophylaxis is associated with a reduction in mortality [12].
The use of prenatal steroids with the greater use of surfactant prophylaxis may be associated with the lower incidence of RDS reported in Trento. Effective management of this condition could reduce the risk of CLD, as suggested by the present analysis and by another study [13]. Surfactant prophylaxis, administered within the first few minutes of birth in the delivery room, may also result in fewer infants requiring assisted ventilation, thus reducing invasive procedures without worsening clinical outcomes [11]. The reduction in frequency of respiratory complications, as CLD, in Trento compared with VON is particularly evident in the two lowest BW groups (501–750 grams and 751–1000 grams), which are characterised by a particularly high risk. In these groups, surfactant prophylaxis was more common, further suggesting that this treatment may be associated with important improvements in clinical outcomes and better management of neonatal respiration, in terms of peak inspiration volume, intermittent positive pressure ventilation and fraction of inhaled oxygen. These results are consistent with the multicentre study by Bevilacqua et al, in which surfactant prophylaxis was associated with a lower incidence of RDS compared with rescue therapy [11]. It is noteworthy that VLBWI receiving surfactant prophylaxis had a lower BW than those treated with rescue therapy [11].
In Trento, the overall rates of PDA, NEC and IVH were lower than in VON, occasionally reaching statistical significance. As observed for respiratory complications, the difference was greatest in the lowest BW groups. Overall, these data are comparable with those reported in the Bevilacqua study [11]. It may be that RDS is less common in Trento area because of several factors: more prenatal steroids; surfactant in delivery room; low amount of infused liquids, thanks to the fact that in Trento the enteral feeding with bank human milk and mother milk is preferred. This management, mainly in the first week of life, gives as a consequence high weight loss (about 20%), less PDA, less RDS and less CLD, but also less indomethacin treatment, less catheters and less antibiotics (with lower risk of complications). In Trento it is usually used only one dose of surfactant (in delivery room or in NICU) with extubation as soon as possible, also in delivery room. It is preferred NCPAP instead of mechanical ventilation when the baby permits it.
Even the lower risk of NEC in Trento compared with VON may be associated with specific therapeutic strategies of the S. Chiara intensive care unit, such as the very early administration of human milk (from the second hour from birth, when possible). In fact, the percentage of discharged infants receiving human milk was significantly higher in Trento than in VON (83% vs. 44%, respectively). Since 1993, the S. Chiara unit has employed the early exclusive enteral feeding (EEEF) protocol that is widely used in Scandinavian countries [14]. This protocol, which is targeted to specific VLBWI conditions, is based on the exclusive administration of human milk, either from the mother or from a donor, to VLBWI weighing 750–1250 grams and with GA > 26 weeks. The EEEF protocol may be suitable for VLBWI undergoing CPAP, but cannot be suggested for those treated with mechanical ventilation or presenting with asphyxia, metabolic acidosis, hypotension, sepsis or persistent hypoglycaemia. During 2000–2005 in S. Chiara, the EEEF protocol was initiated in 51.4% of VLBWI weighing 750–1250 grams and with a GA > 26 weeks. Among these infants, only one out of five (10.3% of the overall population) required further nutritional support, while the majority (41.0% of the total) did not.
Several studies have confirmed the importance of VLBWI feeding with human milk. The high content of oligosaccharides in human milk may improve the development of immune system and prevent onset of NEC [15]. The administration of human milk to VLBWI is recommended by American Academy of Pediatrics and Canadian Pediatrics Society because of its excellent energetic properties and for its important effects on neural, cognitive and psychological development [16, 17]. In particular, feeding with human milk is of great importance in VLBWI weighing less than 1000 grams, because it is associated with significant improvements in survival and clinical outcomes [18]. In Trento, significantly more VLBWI in both the overall population (MH 139.7; p-value 0.00000) and in BW sub-groups were discharged on human milk, compared with VON.
Screening for ROP was about 2.5 times more common in Trento than in VON. This strategy allows more rapid diagnosis of the potential presence of ROP. The frequency of this condition (overall and severe grades) was lower in Trento than in VON. An early diagnosis of ROP is of particular importance to prevent the risk of short- and long-term damage to vision [19].
Mortality was comparable in the two populations, although a trend towards lower mortality in Trento was evident, especially in infants with BW ≤ 750 grams. It is possible that the therapeutic strategies adopted in Trento, such as surfactant prophylaxis and widespread use of human milk, may be associated with a reduction in complications and, as a consequence, with a lower mortality in this high-risk class of VLBWI.
