Background: Survival and outcome of extremely preterm (EP) infants have improved due to changes in the management of stabilization at birth and respiratory distress syndrome. Methods: In a retrospective study conducted at an academic perinatal level III center in Romania, we compared the effects of different protocols on the early outcomes of EP infants of two different periods (2008-2012 vs. 2018 vs. 2022). Two subgroups were studied in each period, based on gestational age (GA), 22-25 weeks, and 26-28 weeks, excluding those with significant congenital anomalies or missing data. Results: 270 EP infants were included in the study (121/149), with a mean GA 26.1±1.6/26.7±1.1 weeks. Significant improvements were found during period II regarding initial FiO2 (40% vs. 100%; <0.001), nCPAP (55.7% vs. 19.0%; p<0.001) at birth, early rescue surfactant administration (65.8% vs. 34.7%; p<0.001), need of mechanical ventilation (58.4% vs. 98.3%; p<0.001). Survival rates of EP infants significantly improved from 41.3% to 72.5%, particularly in the 26-28 weeks subgroup (63.8% to 83%). The frequency of severe IVH decreased in period II from 30.6% to 14.1%, while the rates of BPD were lower in period II (23.4% vs. 36.6%; p=0.045), in the 26-28 weeks subgroup. We found improvements but no significant differences in NEC, sepsis, PVL, ROP, or PDA frequencies. Conclusions: Using updated guidelines and protocols is crucial for improving outcomes.

Background: Neonatal transportation of sick newborns is a major predictor of outcome. Prompt identification of the sickest newborns allows immediate corrective intervention and outcome optimization. Multiple severity scores were developed, however an optimal score has not yet been identified. Aim: To identify a rapid, accurate, and easy to perform score predictive for neonatal mortality in outborn neonates. Material and methods: All neonates, irrespective of gestational age, admitted by transfer in our level III regional neonatal unit between 01.01.2015 and 31.12.2021 were included. Infants with congenital critical abnormalities were excluded. Sick neonatal score (SNS) was calculated and compared between survivors and non-survivors. Gestational age (GA), birth weight (BW), gender, Apgar score, place of birth, time between delivery and admission (AT), early onset sepsis were collected from medical records and compared between study groups. Subgroup analysis was performed based on gestational age (preterm versus term infants). A new score was elaborated, including GA, BW, and AT, namely MSNS-AT score, to further improve mortality prediction. The main outcomes were mortality prediction using SNS and MSNS-AT score. Univariable and multivariable analysis, including Cox regression, were performed using SPSS Statistic 22.0. P-value was considered statistically significant if <0.05, 95% confidence intervals, odds ratio and hazard ratios were calculated were appropriate. Results: A total of 418 outborn infants were admitted during study period; 15 infants were excluded due to critical congenital defects. Out of 403 outborn infants, 217 born prematurely (53.8%), 224 males (55.6%), 20 died (4.96%). Compared to the survivors, the non-survivor neonates had significantly lower GA, BW, and SNS score (p<0.05), although only SNS score remained significantly lower in all subgroups (preterm vs term infants). A SNS score ≤8 was associated with mortality both in the whole study group and in subgroups (p<0.001). Time to admission was significantly associated with increased mortality rate in the whole group (p<0.05) and in preterm infants but not in term ones (p>0.05). In univariable and multivariable Cox regression models, MSNS-AT score, with a cut-off optimal value of ≤10 was more precise in predicting mortality compared to SNS (AUC 0.735 vs. 0.775) when applied to the entire group, had a lower accuracy in the term infants (AUC 0.765 vs 0.809) and a better accuracy the preterm infants group (AUC 0.885 vs. 0.810). Conclusions: The MSNS-AT score – calculated by adding GA, BW, and AT to the SNS score - significantly improved mortality prediction at admission in the whole study group as compared to SNS score. The best accuracy prediction of MSNS-AT score was observed in preterm infants suggesting that, besides GA and BW, TA may be decisive for the outcome of outborn preterm infants. Further studies are necessary to confirm the predictive value of MSNS-AT score and to identify variables that can improve its value in term infants without affecting the simplicity, ease, and rapidity of the scoring system.

Nasal high-frequency oscillatory ventilation (nHFOV) has emerged as an effective initial and rescue noninvasive respiratory support mode for preterm infants with respiratory distress syndrome (RDS). Multiple noninvasive respiratory support modes are currently available in Romania, but little is known about nHFOV use in Romanian neonatal intensive care units (NICUs). We aimed to identify the usage extent and clinical application of nHFOV in Romania. A structured web-based questionnaire was designed to find the rate of nHFOV use and knowledge of this new method of noninvasive respiratory support in Romanian level III NICUs. The questionnaire was addressed to the leaders of all level III Romanian NICUs. Using multiple-choice, open-ended, and yes/no questions, we collected information on the NICU’s size, noninvasive respiratory support modes used, nHFOV use, indications, settings, nasal interfaces, secondary effects, and equipment used. Descriptive statistics and comparisons were performed using IBM SPSS Statistics 26.0. A total of 21/23 (91.3%) leaders from level III NICUs (median [IQR] number of beds of 10 [10-17.5]) responded to the survey. The most frequently used noninvasive ventilation modes were CPAP mode on mechanical ventilators (76.2%), followed by NIPPV (76.2%), heated, humidified high flow nasal cannula (HHHFNC) (61.9%), and nHFOV (11/21 units; 52.4%); 5/11 units reported frequent nHFOV use (in 2 or more newborns/month) in both term and preterm infants. The main indications reported for nHFOV use were CPAP failure (90.9%), hypercapnia (81.8%), and bronchopulmonary dysplasia (72.7%). 10/11 units reported setting a mean airway pressure (MAP) equal to the CPAP level plus 1-2 cmH₂O on rescue nHFOV after CPAP failure. Both dedicated equipment (45.5%) and hybrid ventilators (63.6%) were used for nHFOV delivery, with face/nasal masks and short binasal prongs being the most commonly used nasal interfaces (90.9% and 72.7%, respectively). Air leaks at the interface level (90.9%), thick secretions (81.8%), and airway obstruction (63.6%) were the most frequently mentioned adverse effects of nHFOV; none of the units mentioned pneumothorax as an adverse effect. Only 3 of the NICUs had a written protocol for nHFOV use. Initial, minimum, and maximum amplitude and initial and minimum MAP settings used were significantly higher with hybrid ventilators as compared to dedicated equipment (p<0.05). Most units not yet using nHFOV cited lack of equipment, experience, training, or insufficient information and evidence for the clinical use and outcome of nHFOV use in neonates as the main reasons for not implementing this noninvasive respiratory mode. Our survey showed that nHFOV is already used in more than half of the Romanian level III NICUs to support term and preterm infants with respiratory distress despite a lack of consensus regarding indications and settings during nHFOV. A need for training for nHFOV use was identified, and efforts are needed at the national level to develop courses and training sessions, including using simulation workshops, to offer more information on optimal nHFOV use in clinical practice.

Background and Objectives: The purpose of this study was to investigate whether early surfactant administration affects the status of ductus arteriosus (DA) in preterm infants ≤32 weeks of gestational age (GA) within 24 hours of birth. Materials and Methods: It is a prospective study conducted from March 15, 2022, to November 15, 2023, in a tertiary academic center. In-born infants ≤ 32 weeks of gestation (n = 88) were enrolled. The study group was further divided into surfactant (n=44) and non-surfactant (n=44) subgroups. Results: 76% of the preterm infants who received surfactant therapy (RRR = 0.839) recorded an increase in Kindler Score at 24 hours of life (1-RR = 1-0.24 = 76%). Surfactant administration was significantly associated with decreased pre-ductal diastolic pressure (29.9 mmHg vs. 34.8 mmHg, p=0.0231), post-ductal diastolic pressure (28.7 mmHg vs. 32.2 mmHg, p=0.0178) pre-ductal MAP (41.6 mmHg vs. 46.5 mmHg, p=0.0210) post-ductal MAP (41.0 mmHg vs. 45.3 mmHg, p=0.0336). There were no significant changes in ductus arteriosus parameters at 24 hours of life. Conclusions: Early surfactant administration does not affect the status of ductus arteriosus in preterm infants ≤32 weeks of gestational age at 24 hours of life.

Candida spp. is rarely found in the etiology of neonatal early-onset sepsis (EOS). However, candidemia is associated with increased mortality and morbidity, as in late-onset sepsis. Congenital candidiasis may present as mucocutaneous infection or, more rarely, as a systemic infection in term and preterm infants. Material and methods: Case reports of two cases of congenital systemic candidiasis (CSC) produced by Candida albicans and a review of the data in the literature. Results: Both neonates were male, born vaginally, with risk factors for congenital candidiasis. One of the infants was born at term and presented with an almost generalized maculopapular rash at birth; C. albicans grew in the blood culture sampled at 36 hours; parenteral fluconazole was started immediately, and no complications were noted. The other infant was born preterm, at 28 weeks of gestation, and presented signs of respiratory distress on the 4th day of life after initial successful treatment of the respiratory distress syndrome with surfactant and non-invasive respiratory support. C. albicans was present in the neonatal blood and gastric aspirate cultures, and in the maternal vaginal cultures (all sampled at birth); parenteral fluconazole therapy was administered for 30 days as investigations revealed both liver and renal involvement and the infant development bronchopulmonary dysplasia. Conclusion: As data in the literature suggests, despite occurring at any gestational age, CSC may present various clinical pictures, the rash may mimic many other neonatal conditions, and the systemic dissemination cannot be distinguished from bacterial EOS. Careful anamnesis and a high index of suspicion are important for the prompt recognition and treatment of CSC, optimizing the short- and long-term outcomes.