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ARTICLES:
Bernt Alm, Laslo Erdes, Per Möllborg, Rolf Pettersson, S. Gunnar Norvenius, Nils Åberg, and Göran Wennergren
Neonatal Antibiotic Treatment Is a Risk Factor for Early Wheezing
Pediatrics 2008; 121: 697-702 [Abstract] [Full text] [PDF]
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[Read P3R] Stairyway to the Perinatal Prevention of Asthma
Dennis T Costakos, MD, Mary Therese Rinzel, Jennifer Walden, Jose M. Yuvienco, Dianne Kreibich   (28 April 2008)

Stairyway to the Perinatal Prevention of Asthma 28 April 2008
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Dennis T Costakos, MD,
Director of Neonatology
Franciscan Skemp-Mayo Health System, LaCrosse WI,
Mary Therese Rinzel, Jennifer Walden, Jose M. Yuvienco, Dianne Kreibich

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Re: Stairyway to the Perinatal Prevention of Asthma

Costakos.Dennis{at}mayo.edu Dennis T Costakos, MD, et al.

In the article by Alm B, et al, Neonatal Antibiotic Treatment Is a Risk Factor for Early Wheezing, the study concludes that neonatal antibiotics for greater than 24 to 48 hours is an independent risk factor for wheezing in both term and preterm infants1. This is an important study because asthma is on the rise in the United States and other countries2. We wonder what is the percent of group B streptococcal (GBS) colonized women in Western Sweden or Sweden? Is the Center for Disease Control recommendation to prevent perinatal GBS disease followed in Western Sweden or Sweden? If the Center for Disease Control protocol is followed2, are any systematic efforts made to administer more than one dose of intrapartum antibiotic greater than 4 hours prior to delivery of the baby if the mother is GBS colonized4? How often are antibiotics given to otherwise well appearing infants born to GBS colonized mothers and greater than 35 weeks in Sweden or Western Sweden?

In the United States it is customary and almost universal to give intrapartum antibiotics to GBS colonized women in an effort to decrease GBS infection in babies3. In this protocol, an infant born of gestational age greater than or equal to 35 weeks, whose mother receives intrapartum antibiotic greater than 4 hours prior to delivery, receives routine care (thus no neonatal antibiotics indicated) if appearing well. In contrast, if the intrapartum antibiotic is given to mom less than 4 hours prior to delivery, a blood culture and complete blood count (CBC) are drawn and a I:T ratio is calculated [bands / (segs+bands+metamyelocytes)]. If the I:T ratio is greater than 0.2 the baby receives antibiotics until the blood culture is negative for 48 hours, even if the baby appears well.

Since 2006 Franciscan Skemp-Mayo Health System in LaCrosse began an umbilical cord blood and infant blood I:T and blood culture program that was modeled after the work published by Dr. Anne Hansen at Harvard and after personal communication (electronic mail 2006) with Dr. Costakos4,5,6. In addition, we mounted an educational campaign and instituted clinical triggers to begin intrapartum antibiotics in accordance with a Yale study7. The result was that compared to the first 5 months of the program in 2006 to the most recent 5 months of the program in 2008, we increased by 25% the number of times mothers got antibiotics greater than 4 hours prior to delivery. This decreased the number of well appearing babies that received antibiotics because of a positive I:T ratio as the only indication for antibiotics. Another benefit of our program has been increased patient and staff satisfaction at Franciscan Skemp-Mayo Health System in LaCrosse. Ideally, antenatal and intrapartum antibiotics do not have the negative effect of being an independent risk factor for wheezing in the baby but this needs to be studied8.

Finally, while maternal smoking in pregnancy was not an independent risk factor in the multivariate analyses in the study by Alm B, et al, we believe that physicians, nurses, and society must help to de-normalize the behavior of tobacco smoking during preconception, pregnancy and postpartum, as other studies have shown fetal and neonatal pulmonary damage associated with maternal tobacco smoking.9,10.

Corresponding Author: Dennis T. Costakos, MD, Franciscan Skemp-Mayo Health System, Department of Neonatology, LaCrosse, WI and Assistant Professor of Pediatrics, Mayo Clinic College of Medicine, Rochester, MN; Mary Therese Rinzel, MSN, RN, CCE, CNS, Department of Family Birthplace, Franciscan Skemp-Mayo Health System, LaCrosse, WI; Jennifer Walden, RNC, MS, NNP, Department of Neonatology, Franciscan Skemp-Mayo Health System, LaCrosse, WI; Jose M. Yuvienco, MD, Department of Neonatology, Franciscan Skemp-Mayo Health System, LaCrosse, WI; Dianne Kreibich, AAS, Department of Neonatology, Franciscan Skemp-Mayo Health System, LaCrosse, WI.

References 1. Alm B, et al. Neonatal Antibiotic Treatment Is a Risk Factor for Early Wheezing. Pediatrics 2008;121:697-702. 2. Moorman JE, et al. National surveillance for asthma—United States, 1980-2004. MMWR Surveill Summ 2007 Oct 19;56(8):1-54. 3. Schrag S, Gorwitz R, Fultz-Butts K, Schuchar A. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep 2002;51:1-22. 4. Hansen A, Forbes P, Buck R. Potential substitution of cord blood for infant blood in neonatal sepsis evaluation. Biol Neonate 2005;88:12-18. 5. Herson VC, Block C, McLaughlin JC, Tetreault J, Eisenfeld LI, Krause PJ. Placental blood sampling: an aid to the diagnosis of neonatal sepsis. J Perinatal 1998;18(2):135-137. 6. Polin JI, Knox I, Baumgart S, Campman E, Mennuti MT, Polin RA. Use of umbilical cord blood culture for detection of neonatal bacteremia. Obstet Gynecol 1981;57(2):233-237. 7. Hamar BD, Illuzzi JL, Funai EF. Clinical Triggers to Initiate Intrapartum Penicillin Therapy for Prevention of Group B Streptococcus Infection. American J of Perinatology 2006;23(8):493-498. 8. Bizzarro MJ, Dembry LM, Saltimore RS, Gallagher PG. Changing Patterns in Neonatal Escherichia coli Sepsis and Ampicillin Resistance in the Era of Intrapartum Antibiotic Prophylaxis. Pediatrics 2008;121;689-696. 9. Fiore M. Wrench in the Killing Machine. In White Coat Wisdom by Stephen J. Busalacchi. 167-169. Apollo’s Voice, LLC Publishing, Middleton, WI. 10. Antonucci R, et al. Intrauterine smoke exposure: a new risk factor for bronchopulmonary dysplasia? J Perinat Med. 32 (2004):272-277.

Conflict of Interest:

None declared