Management Of Persistent Pulmonary Hypertension Research Articles

TO THE ISSUE OF THE DEVELOPMENT AN ALGORITHM FOR A DIFFERENTIATED APPROACH TO THE MANAGEMENT OF PERSISTENT PULMONARY HYPERTENSION IN PREMATURE INFANTS

The management of premature infants with persistent pulmonary hypertension (PPH) remains a major problem in modernneonatology. In recent years, scientifi c studies have identifi ed the role of oxidative stress (OS) in the development and course of PPH. The reserve for reducing mortality and optimizing the management of premature infants with respiratory distress syndrome (RDS) and asphyxia is the development of an algorithm for a diff erentiated approach to the management of PPH in premature infants, taking into account the severity and dynamics of OS, and its implementation into clinical practice.
 Aim of the study. To increase the eff ectiveness of management of premature infants with persistent pulmonary hypertension with asphyxia and respiratory distress syndrome based on the development of an algorithm for a diff erentiated approach to the management of pulmonary hypertension taking into account the levels of oxidative stress as determined by urinary 8-hydroxy-2-deoxyguanosine (8-OHdG).Material and methods. 100 premature infants between 26/1-34/6 weeks of gestation were included in the study: groupI consisted of 50 infants with RDS, group II – 50 newborns with RDS associated with perinatal asphyxia. The presence and severity of PPH was determined in all infants on the fi rst and third to fi fth day of life by echocardiography (EchoCG), and quantitative determination of 8-OHdG level (ng/ml) – in 44 infants on the fi rst day, and in dynamics – on the third to fi fth day of life by enzyme- linked immunosorbent assay (ELISA). For radiographic evaluation of PPH, all infants underwent chest radiography with determination of Moore’s, Schwedel’s and cardiothoracic index (CTI). The research was conducted in compliance with bioethical requirements as part of the planned scientifi c work of the Department (state registration number 0122U000025).Results. It was found that the characteristics of pulmonary hypertension in premature infants with RDS were signifi cantly lower levels of mean pressure in the pulmonary artery (mPAP) on the fi rst and 3-5 days of life than in children with perinatal asphyxia. It was noted that the factors with high diagnostic signifi cance determining the occurrence of persistent pulmonary hypertension are: birth weight <1500 g; presence of perinatal asphyxia; low Apgar score on the 1st (1-3 points) and on the 5th minute of life (<7 points); gestational age <30 weeks; non-appropriateness for gestational age; male sex. Furthermore, it was found that urinary 8-OHdG levels as a biomarker of OS in preterm infants with RDS and perinatal asphyxia correlated with mPAP on the fi rst and third to fi fth days of life, and that urinary 8-OHdG levels had a high diagnostic value for determining the risk of developing severe PPH on the third to fi fth days of life. The diagnostic signifi cance of the data of the comprehensive radiological assessment of PPH – the radiological indices of Moore, Schwedel, CTI for the development of severe PPH was analyzed and the correlations between the indices and mPAP and between the indices and the level of 8-OHdG were established. The Schwedel index showed the highest reliability in all cases.Conclusion. On the basis of scientifi cally established relationships between clinical, laboratory, radiological and genderaspects of premature infants with perinatal pathology and the identifi ed diagnostic and prognostic values of urinary 8-OHdG, an algorithm for a diff erentiated approach to the management of PPH was developed. Determination of the degree of OS and mPAP in premature infants allows us to adjust and individualize the tactics of respiratory support in the management of premature infants, thus improving the quality of medical care of premature infants with RDS and perinatal asphyxia. In prematurely born children in perinatal centers, additional determination of the severity of RDS based on the level of 8-OHdG in urine allows to predict the adverse course of PPH and the development of complications: bronchopulmonary dysplasia, intraventricular hemorrhage III-IV grade, retinopathy II-III grade, hearing impairment, hypoxic- ischemic lesions of the central nervous system II-III grade in prematurely born children.

ALGORITHM OF A DIFFERENTIATED APPROACH TO MANAGEMENT OF PERSISTENT PULMONARY HYPERTENSION IN PREMATURE INFANTS

Introduction. Oxidative stress (OS) is recognized as a contributing factor to the development of persistent pulmonary hypertension (PPH) in premature infants. In the modern scientific literature, there is a lack of unequivocal recommendations for the management of PPH, considering the levels of OS, what determines the need for the development of a differentiated approach for management to infants with pulmonary hypertension.The aim of the study. To increase the efficacy of management of premature infants with persistent pulmonary hypertension with asphyxia and respiratory distress syndrome based on the development of the algorithm of a differentiated approach for management of pulmonary hypertension considering the levels of oxidative stress as determined by the urinary 8-hydroxy-2-deoxyguanosine (8-OHdG).Material and methods. Were analyzed the observations of 96 infants born prematurely at gestational age of 26/1–34/6 weeks: group I consisted of 50 infants with respiratory distress syndrome (RDS), group II - 50 infants with RDS associated with perinatal asphyxia. PPH was determined by echocardiography on the 1st and on the 3rd-5th day of life, and quantitative determination of the urinary 8-OHdG (ng/ml) was performed on 44 neonates on the 1st and in dynamics on the 3rd-5th day of life using enzyme-linked immunosorbent assay (ELISA). For comprehensive radiographic assessment of PPH, all infants received chest X-Ray with determination of Moore's, Schwedel's, and cardiothoracic indexes (CTI).Statistical analysis was performed using Microsoft Excel 2019 software. Under the conditions of normal distribution of quantities, parametric statistical methods were used to calculate the arithmetic mean (M) and the representativeness error of the mean (m). Using Fisher`s exact test (φ) we analyzed the quantitative parameters. Using the heterogeneous sequential Wald procedure, development of diagnostic criteria was performed. The essence of the procedure is to determine both diagnostic (DC), prognostic coefficients (PC) and diagnostic informativeness (I) of the investigated indicators. The minimum informativeness of the feature required for addition to the developed algorithm was considered I ≥ 0.25.The algorithm was developed on the basis of diagnostic coefficients of clinical and anamnestic data of the examined groups of children, echocardiographic criteria for the presence and determination of the degree of PPH, the dynamics of OS levels and their comparison with the indicators of a comprehensive radiological assessment of pulmonary hypertension in prematurely born infants with RDS and perinatal asphyxia in association with RDS in gestational age of 26-34 weeks.Design of a study was discussed and approved at a session of the Ethical commission of the Kharkiv Medical Academy of Postgraduate Education (Prot. № 5 from 18.12.2020). All parents gave an informed consent for examination of their children.The study was carried out in accordance to the plan of the research work of the Department of Neonatology of the Kharkiv Medical Academy of Postgraduate Education "Study of features of the course of oxidative stress diseases in newborns" (January 2022 - December 2024), state registration number 0122U000025.Results. Has been developed an algorithm of a differentiated approach to management of premature infants with RDS and asphyxia with PPH, the essence of which - is to improve and individualize the method of mechanical lung ventilation (MLV) for each individual case.Conclusions. For prematurely born infants at gestational age 26-34 weeks, is important to determine the level of the urinary 8-OHdG on the 1st and 3rd-5th days of life to decide the severity of OS. For management of newborns with PPH, in the case of an increase of the level of 8-OHdG by the 3rd-5th day of life, is recommended to increase the ventilator parameters; in the case of a decrease - diminish the ventilation parameters or extubate an infant.

Persistent Pulmonary Hypertension of the Newborn: The Efficacy Comparison of Vasodilators Sildenafil Plus Bosentan Versus Sildenafil Plus Beraprost at a Tertiary Childcare Health Facility.

BackgroundPersistent pulmonary hypertension of the newborn (PPHN) has been known for more than three decades, and lots of advancements have been made regarding its diagnosis and management. However, the exact causes of PPHN and the best treatment strategies remain debatable. This study aimed to compare the effectiveness of sildenafil and bosentan versus sildenafil and beraprost in the management of persistent pulmonary hypertension of the newborn (PPHN).MethodologyThis open-label, non-randomized, quasi-experimental study was conducted at the Department of Pediatric Cardiology and Neonatology, The Children’s Hospital & The Institute of Child Health, Multan, Pakistan, from January 2021 to June 2021. We enrolled a total of 50 newborns (25 in each group) aged <10 days, gestational age above 34 weeks, who presented with respiratory distress and marked hypoxemia (PaO2 < 50 mmHg) as per arterial blood gas (ABG) analysis and confirmed echocardiographic diagnosis of PPHN within 24 hours of admission. A total of 25 cases were given sildenafil and bosentan, while the other 25 cases were given sildenafil and beraprost. Echocardiographic examination was done again after 72 and 120 hours, and the findings were noted. Outcomes were measured in terms of the reduction in tricuspid regurgitation (TR), mortality, and duration of hospital stay.ResultsOf the 50 neonates, 27 (54.0%) were male. Overall, the mean age was calculated to be 3.54 ± 0.7 days. The mean gestational age was 35.0 ± 0.7 weeks. The mode of delivery was cesarean section among 35 (70.0%) neonates. A significantly higher reduction in tricuspid regurgitation after 72 and 120 hours following the initiation of the treatment was observed in the sildenafil plus bosentan group in comparison with the sildenafil plus beraprost group (p < 0.05). No statistically significant difference was observed in terms of the duration of hospitalization between both study groups (p = 0.1776).ConclusionThe combination of sildenafil and bosentan was found to be more effective than sildenafil and beraprost in reducing tricuspid regurgitation after 72 hours, while they have comparable efficacy at 120 hours of treatment in the management of persistent pulmonary hypertension of the newborn.

Guideline on management of Persistent pulmonary hypertension (PPHN) of the newborn using inhaled Nitric Oxide therapy

The Sri Lanka Journal of Perinatal Medicine (SLJPM) was launched in 2019 as the official journal of the Perinatal Society of Sri Lanka. This journal is unique in the fact that it brings together three core specialties of perinatal medicine - obstetrics, neonatology and community medicine. It is an open access peer reviewed journal containing original research articles, expert reviews, current practices and other articles of interest to all involved in perinatal medicine.

B-natriuretic peptide serum levels in neonates with persistent pulmonary hypertension

BackgroundBetter management of persistent pulmonary hypertension of neonates (PPHN) required new markers that can predict the response of patient to treatment and thus influence the medical decision to avoid short-term and long-term adverse effects. Hence, we aimed to evaluate B-natriuretic peptide (BNP) serum levels in neonates with PPHN and to correlate its levels with disease severity and response to treatment.Patients and methodsThe study included 60 neonates (30 PPHN patients and 30 healthy subjects). BNP was assessed, using the ELISA technique, at admission and after 4 days of treatment.ResultsInitial serum BNP levels were significantly higher in patients compared to controls (p < 0.001). Patients with mild severity showed lower BNP levels compared to patients with moderate severity, while patients with moderate severity showed decreased levels in comparison to severe cases (p < 0.001). The group of patients who showed remission after 4 days of treatment had lower pre-treatment and post-treatment BNP levels, compared to patients who showed incomplete remission. Initial levels of BNP showed strong positive correlations with pulmonary artery pressure (PAP) and oxygenation index (OI) before treatment (r = 0.9, p < 0.001 and r = 0.85, p = 0.001), while BNP after treatment showed moderate positive correlations with PAP before treatment (r = 0.6, p = 0.001) and OI before treatment (r = 0.6, p = 0.001). Analysis of the ROC curve revealed an AUC of 0.83with CI = 0.7–0.98 and p = 0.003.ConclusionsBNP may play a role in the pathogenesis of PPHN, and BNP serum level can be used as a marker to detect disease severity and predict response to treatment.

Management of Persistent Pulmonary Hypertension in Preterm Infants

Management of Persistent Pulmonary Hypertension in Preterm Infants

The use of supplemental hydrocortisone in the management of persistent pulmonary hypertension of the newborn.

Objective:Characterize association between hydrocortisone receipt and hospital outcomes of infants with persistent pulmonary hypertension of the newborn (PPHN).Study design:Cohort study of infants ≥34 weeks with PPHN who received inhaled nitric oxide at <7 days of age (2010–2016). We generated propensity scores, and performed inverse probability weighted regression to estimate hydrocortisone effect on outcomes: death, chronic lung disease (CLD), oxygen at discharge.Results:Of 2743 infants, 30% received hydrocortisone, which was associated with exposure to mechanical ventilation, sedatives, paralytics, or vasopressors (p<0.001). There was no difference in death, CLD, or oxygen at discharge. In infants with meconium aspiration syndrome, hydrocortisone was associated with decreased oxygen at discharge (odds ratio 0.56; 95% confidence interval 0.21, 0.91).Conclusions:There was no association between hydrocortisone receipt and death, CLD, or oxygen at discharge in our cohort. Prospective studies are needed to evaluate the effectiveness of hydrocortisone in infants with PPHN.

Effects of Inhaled Iloprost for the Management of Persistent Pulmonary Hypertension of the Newborn

The study aimed to evaluate the effects of inhaled iloprost on oxygenation indices in neonates with persistent pulmonary hypertension of the newborn (PPHN). We conducted a retrospective chart review of 30 patients with PPHN from January 2014 to November 2018, who did not respond to inhaled nitric oxide (iNO) alone and received inhaled iloprost. Twenty-two patients met the inclusion criteria and eight patients were excluded from the study (complex cardiac disease and extreme prematurity). Patients were categorized as responders or nonresponders (patients who required extracorporeal membrane oxygenation or died). Oxygenation index, mean airway pressure (MAP), and arterial partial pressure of oxygen (PaO2) were recorded. Among a total of 22 patients who were included in the study, 10 were classified as nonresponders as they required either extracorporeal membrane oxygenation or died. Gestational age and gender did not differ between responders and nonresponders. The median PaO2 was lower (37 vs. 42 mm Hg; p < 0.05) and median MAP was higher (20 vs. 17 cm H2O; p < 0.02) in nonresponders compared with responders just prior to initiating iloprost. Iloprost responders had a significant increase in median PaO2 and decrease in median oxygenation index in the 24 hours after initiating treatment (p < 0.05), with no significant change in required mean airway pressure over that same period. There was no change in vasopressor use or clinically significant worsening of platelets count, liver, and kidney functions after initiating iloprost. Inhaled iloprost is well tolerated and seems to have beneficial effects in improving oxygenation indices in neonates with PPHN who do not respond to iNO. There is a need of well-designed prospective trials to further ascertain the benefits of using inhaled iloprost as an adjunct treatment in neonates with PPHN who do not respond to iNO alone. · Inhaled iloprost seems to have beneficial effects in improving oxygenation indices in PPHN.. · Inhaled iloprost is generally well tolerated in newborns with PPHN.. · There is a need for prospective randomized controlled trials to further ascertain the benefits of using inhaled iloprost..

Management of Persistent Pulmonary Hypertension After Correction of Congenital Heart Defect with Autologous Marrow-Derived Mononuclear Stem Cell Injection into the Pulmonary Artery: A Pilot Study.

Pulmonary arterial hypertension (PAH) related to left-to-right shunt can progress to Eisenmenger syndrome, a serious and fatal disease that is not yet curable. This pilot study considered stem cell injection as a new treatment modality in persistent pulmonary hypertension after the correction of a congenital heart defect. Three patients with persistent pulmonary hypertension after ventricular septal defect repair were included in this pilot study for a clinical trial. Mononuclear stem cells derived from patients' bone marrow specimens were injected into the right and left pulmonary arteries via cardiac catheterization. The patients were followed over a 6-month period, with six-minute walk test, echocardiography and repeated angiography performed in the sixth month after treatment. The results of the study showed improvement of 40m, 280m and 100m in 6-minute walk distance in patients 1 to 3, respectively. The peak PR gradient decreased 2, 5 and 9mmHg by echocardiography, and mean PA pressure decreased 21, 22 and 9mmHg by catheterization in patients 1 to 3, respectively. Pulmonary artery resistance decreased 4, 4.5 and 1.3 Wood units after 6months of stem cell therapy in the three patients. No short-term complications were detected in this pilot trial, and all patients tolerated the procedure without any complications. Intrapulmonary artery injection of stem cells may have a role in the treatment of persistent PAH secondary to congenital heart disease. This procedure is feasible, with no significant complications, and this study can be considered as a platform for larger studies.

Inhaled nitric oxide as a rescue therapy in a preterm neonate with severe pulmonary hypertension: a case report

BackgroundInhaled nitric oxide (iNO) has been approved for the treatment of persistent pulmonary hypertension of the newborn (PPHN) in term and near-term newborns. Its role in the management of persistent pulmonary hypertension in preterm infants is not clear. Although guidelines do not exist, some studies have shown that iNO could be used as a rescue therapy in preterm neonate with severe pulmonary hypertension.Case presentationWe describe the case of a preterm neonate, born at 30 + 1 weeks of gestation, with hypoxic respiratory failure not responding to maximal conventional therapy. On the third day of life echocardiography showed severe pulmonary hypertension with right to left shunt and therapy with iNO was started. We achieved a rapid improvement in clinical conditions and pulmonary pressure normalized after 42 h of treatment.ConclusionsMoving on a case by case basis, treatment with iNO should be considered as a rescue therapy in preterm newborns with acute hypoxic respiratory failure caused by severe pulmonary hypertension.

The management of persistent pulmonary hypertension of the newborn: A review

The first literary reference to persistent pulmonary hypertension (PH) of the newborn (PPHN) can be found in 1969 by Gersony et al., who described it as persistence of physiologic characteristics of the fetal circulation in the absence of disease. Defined as a failure of normal circulatory transition at birth, or more specifically as failure of the pulmonary vasculature to relax after birth, with continued shunting of non-oxygenated blood into the systemic circulation via fetal channels (ductus arteriosus and foramen ovale), it remains a challenging neonatal emergency to manage. Term and nearterm infants are most commonly affected, but PPHN can occur in premature infants.

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Introduction: Over the last 15 years, there have been changes in the treatment strategies available for the management of persistent pulmonary hypertension of the newborn (PPHN). Methods: Case-based retrospective review of patients admitted to a single tertiary-referral NICU aged 7 days or less between 1998–2012 with a diagnosis of PPHN. Results: 362 patients meeting inclusion criteria were admitted over the study period. Number of patients and baseline patient demographics including: gender, age, gestational age, birth weight, admission diagnosis, paediatric index of mortality (PIM2) score and oxygenation index (OI) at admission have not significantly changed over the last 15 years. Average length of stay remained constant and a decrease in overall mortality rate before discharge was not significant. Rates of referral for ECMO were unchanged but there was a shift over time in the characteristics of those patients that went on to need ECMO support. Almost half (48.1%) of those requiring ECMO support now have a diagnosis of sepsis, in contrast to the earliest period when most (51.7%) had meconium aspiration syndrome. The most common indication for ECMO was previously refractory hypoxaemia, whereas now most (77.7%) of those failing conventional management have more complex air leak or circulatory failure with shock. Those managed with ECMO now have a lower mean OI at admission but higher PIM2 scores. The outcome post ECMO (mean 76.4% survival) has not changed. Conclusions: As strategies for managing meconium aspiration/PPHN have improved, newborns that might previously have been transferred to our institution are now treated in local hospitals and those admitted who might previously have needed ECMO are managed with conventional therapies. Although the number of neonates needing ECMO support has remained constant over the last 15 years, the reasons for failure of conventional management have changed and patients are more likely to have complicating shock/circulatory failure than more straightforward refractory hypoxaemia.

The use of ECMO for persistent pulmonary hypertension of the newborn: A decade of experience

PurposeDespite improvements in the management of persistent pulmonary hypertension of the newborn (PPHN), a number of infants with inadequate gas exchange are treated with extracorporeal membrane oxygenation (ECMO). The objectives of this study were to use the Extracorporeal Life Support Organization Registry to review the outcomes of neonates with PPHN receiving ECMO, and to identify pre-ECMO variables that may be associated with increased mortality. Materials and methodsThe study is a retrospective analysis of all patients with PPHN supported with ECMO and reported to the Extracorporeal Life Support Organization registry from 2000 to 2010. Prematurity was defined as <37 wk gestation. Univariate analysis was performed using Student's t-test or Fisher's exact test. Variables found to be statistically significant underwent multivariate analysis by logistic regression. Kaplan-Meier survival curves were generated to analyze the relationship between duration of ECMO support and patient survival. ResultsA total of 1569 neonates with PPHN received ECMO support during the study period, at an average age of 3.1 d of life and for a duration of 6.9 d. Survival among neonates with PPHN receiving ECMO support was 81%, and those receiving support for 7, 10, 14, and 21 d survived at rates of 88%, 78%, 55%, and 25%, respectively. By logistic regression, prematurity (P < 0.01), pre-ECMO pH ≤7.2 (P = 0.02), pre-ECMO SaO2 ≤65% (P = 0.01), and duration of ECMO ≥7 d (P < 0.001) were independent predictors of death in this group. An average of 2.2 complications occurred per patient, with cardiovascular, mechanical, and renal complications being the most common. ConclusionsNeonates with PPHN have high survival rates with ECMO support. Prematurity, acidosis, and profound hypoxemia are independently associated with increased mortality. Furthermore, prolonged ECMO support (>7 d) is associated with a higher risk of mortality in this cohort than in patients supported for <1 wk.

Variation in the Management of Persistent Pulmonary Hypertension of the Newborn: A Survey of Physicians in Canada, Australia, and New Zealand

Despite advances in management of persistent pulmonary hypertension of the newborn (PPHN), the risk of mortality and adverse neurological sequelae remains high. Characterizing variation in practices is a crucial step toward improved patient outcome. Evaluate intensive care practices in Canada and the Australia-New Zealand region (AUS-NZ). A prospective cross-sectional online survey of neonatologists was conducted. A 35-item questionnaire was developed, validated, and piloted to collect information on diagnosis, inhaled nitric oxide (iNO) practices, alternative vasodilators or cardiotropes, and echocardiography. Variation among survey respondents as well as intergroup comparison was performed. Data were collected from 217 respondents. Echocardiography and arterial blood gas were the most common diagnostic tests to assess the severity of PPHN. iNO administration is more frequently scrutinized in Canada (36% versus 10% [AUS-NZ], p < 0.001). Canadian physicians reported higher use of intravenous milrinone (p < 0.001), vasopressin (p = 0.02), and inhaled prostacyclin (p = 0.02), but lower use of sildenafil (p = 0.01) for refractory pulmonary hypertension. A greater proportion of neonatologists in AUS-NZ were trained to perform echocardiography (p < 0.001) to optimize treatment decisions. Wide variation exists in the management of PPHN. There is a need to provide more guidance regarding principles of management in PPHN, while recognizing the dynamic nature of cardiopulmonary physiology in individual patients.

The Use of ECMO for Persistent Pulmonary Hypertension of the Newborn: A Decade of Experience

Introduction: Despite improvements in the management of persistent pulmonary hypertension of the newborn (PPHN), a number of infants with inadequate gas exchange may benefit from treatment with extracorporeal membrane oxygenation (ECMO). The objectives of this study were to utilize the Extracorporeal Life Support Organization (ELSO) Registry to review the outcomes of neonates with PPHN receiving ECMO and to identify pre-ECMO variables that may be associated with mortality. Methods: The study is a retrospective analysis of all PPHN ECMO patients reported to the ELSO registry from 2000 to 2010.

Is sildenafil an effective therapy in the management of persistent pulmonary hypertension?

Persistent pulmonary hypertension of the newborn (PPHN) is a life-threatening neonatal pathology resulting from poor hemodynamic and respiratory transition to extra uterine life. Inhaled nitric oxide (iNO) is a current, commonly used treatment of PPHN. However, iNO is not available therapy in many developing countries and around 50% of infants with PPHN do not respond to iNO therapy. Sildenafil is a phosphodiesterase inhibitor type 5 (PDE5) that has been shown to selectively reduce pulmonary vascular resistance in both animal models and adult humans. Recent studies have found that in PPHN, administration of Sildenafil was associated with a significant increase in the oxygenation and a reduction in mortality with no clinically important side effects.

Effect of Bicarbonate on Neonatal Serum Ionized Magnesium In Vivo

Sodium bicarbonate is used to treat metabolic acidosis or to induce metabolic alkalosis in sick neonates. The aim of this study was to quantify the decrease in serum concentration of ionized magnesium ([Mg(2+)]) when sodium bicarbonate is administered in vivo. We administered 1 mEq/kg body weight sodium bicarbonate 4.2% for correction of metabolic acidosis (n = 11) for management of persistent pulmonary hypertension (n = 3). After sodium bicarbonate treatment, serum pH increased by an average of 0.046 (P < 0.001), serum [Mg(2+)] decreased by an average of 0.07 mmol/L (P < 0.01), and serum [Ca(2+)] decreased by an average of 0.06 mmol/L (P = 0.04). There was a significant correlation between baseline [Mg(2+)] and baseline [Ca(2+)] (R(2) = 0.328, P = 0.032). Sodium bicarbonate therapy in infants causes a significant decrease in [Mg(2+)] and serum [Ca(2+)]. We suggest that infusion of sodium bicarbonate be effected while monitoring serum [Mg(2+)] and serum [Ca(2+)].

The n-3 polyunsaturated fatty acids: Another option in the management of persistent pulmonary hypertension of the newborn?*

University of Medicine and Pharmacy “Carol Davila”, Institute for Mother and Child Care “Alfred Rusescu”, Bucharest, Romania The author has not disclosed any potential conflicts of interest.

Do we need to use nitric oxide in preterm babies in developing countries?

Neonatal care in developing nations is advancing rapidly. There is an increasing tendency to include nitric oxide in the therapeutic armamentarium. But the opinion regarding its use remains divided among neonatologists even in the western world. Nitric oxide has an established role in the management of persistent pulmonary hypertension in term neonates. However, the use of nitric oxide in preterm neonates has been controversial and the Cochrane review updated in 2001 did not give conclusive answers. There have been adequately powered multi-centre trials recently on the issue, planned to resolve the controversy. The present communication highlights the salient features and conclusions drawn from these trials.

Variation in the Management of Persistent Pulmonary Hypertension of Newborn (Pphn): a Survey of Neonatologists in Canada, Australia and New Zealand (Anzac)

Variation in the Management of Persistent Pulmonary Hypertension of Newborn (Pphn): a Survey of Neonatologists in Canada, Australia and New Zealand (Anzac)