OBJECTIVES:The inclusion of neurobiomarkers (NB) into routine clinical practice remains an unresolved challenge. Among the actions recommended by leading international institutions, a key priority is the establishment of reference curves during the perinatal period. The aim of the study was to define urinary reference ranges during the perinatal period for S100B, a well-established biomarker of central nervous system (CNS) development and injury. METHODS:Between May 2015 and January 2020, we conducted a prospective observational study in 2,168 healthy preterm and term newborns. Standard clinical and laboratory parameters were recorded at birth, and urine samples were collected within the first 24 h for S100B measurement. Correlations between S100B levels and perinatal variables (gestational age, birthweight, mode of delivery, sex, and blood gas parameters) were evaluated using multiple regression analysis. RESULTS:S100B concentrations were significantly higher (p<0.05, for all) in preterm than in term infants, even after adjustment for sex and mode of delivery. Multiple regression analysis revealed that S100B levels were gestational age (GA), sex, and mode of delivery dependent (p<0.05 for all). CONCLUSIONS:These findings provide a reference curve for urinary S100B during the perinatal period, supporting its potential as a non-invasive tool for fetal CNS monitoring and facilitating its future integration into routine clinical practice.

Adverse event in the perinatal period constitutes today the wider bulk of investigation. Perinatal asphyxia (PA) and prematurity are the common causes of injury of high risk pregnancies (HR) and can lead to perinatal death or cognitive and neuro-motor impairment in later life. Despite the use of clinical, laboratory, ultrasound and radiological monitoring procedures, for the estimation of the severity of pre-perinatal brain injury and prognosis, there is still a demand for an early and objective diagnostic and prognostic parameter. Former research suggests that several neurobiomarkers could serve as potential both diagnostic and prognostic tools in HR and newborns. Among them, S100B is a well-known biomarker that could be assessed in different biological fluids such as maternal blood. The inclusion in clinical daily practice of a biomarker, measurable in the maternal blood, able to detect at earliest stage fetal/neonatal neurological damage is of utmost importance. Therefore, in the present review we offer an update of the potential usefulness of the measurement in the maternal blood of a well-established marker of perinatal brain development/damage namely S100B.

BACKGROUND AND AIMS:Gestational diabetes (GDM) predisposes women and their offspring to future cardiometabolic disease. Dysregulation of microRNAs (miRNAs) has been linked to environmental influences and complex diseases. MiRNAs (namely miR-27a-3p, -222-3p, -423-3p and -16-5p) and lipoprotein lipase (LPL) are involved in insulin-signaling, glucose and lipid metabolism. Nevertheless, the role of the placental miRNAs in metabolic adaptation in pregnancy remains poorly understood. This cross-sectional study aimed to evaluate the association between placental selected miRNAs expression and clinical parameters of pregnant women and newborns. METHODS AND RESULTS:MiRNAs expression on maternal and fetal side of placenta tissues was analyzed in GDM (n = 25) and normoglycemic (NGT) women (n = 24). Correlations between these miRNAs and placental LPL expression were examined. MiR-27a rs895819 was genotyped. No significant differences in miRNAs expression between GDM and NGT were detected. On the maternal side, placental miR-423-3p expression was negatively associated with total cholesterol (p = 0.037) and triglycerides (TGs) (p = 0.043) at the third trimester. On the fetal side, miR-423-3p was inversely correlated with 2-h OGTT glucose level in GDM (p = 0.029). MiR-222-3p and miR-16-5p expression correlated with HDL-c (p = 0.017 and p = 0.030, respectively). Regarding neonatal outcomes, an association between miR-222-3p on maternal side with birth weight (p = 0.009) and length (p = 0.007) was found. MiR-27a rs895819 TT carriers exhibited higher 2-h OGTT glucose levels compared with other genotypes. In GDM, LPL expression was associated with miR-16-5p (p = 0.014) and TGs (p = 0.036). CONCLUSIONS:These findings suggest that the miRNA expression may reflect metabolic dysregulation during pregnancy and influence cardiometabolic risk in both women and their offspring.

Background:Feeding intolerance (FI) is common in very preterm infants and often leads to unnecessary interruptions in enteral nutrition (EN), delaying full enteral feeding (FEF). The absence of standardized criteria contributes to inconsistent management. We evaluated the impact of a structured protocol-Rapid Assessment of Feeding Intolerance (RAFI)-on FEF achievement in preterm infants. Methods:This single-center, retrospective-prospective superiority cohort study included infants <30 weeks' gestation. Two cohorts were defined: a historical control group (pre-RAFI) and a RAFI group (first implementation phase). The primary outcome was time to FEF (150 mL/kg/day of EN). One-sided statistical tests were used to assess the superiority of RAFI. Stratified analysis was performed for infants with intrauterine growth restriction (IUGR). Results:Sixty infants were included (30 per group). RAFI infants achieved FEF significantly earlier than controls [median 23.0 (IQR 18.0-30.0) vs. 30.0 (24.0-34.5) days; p = 0.041]. Among IUGR infants (n = 14), RAFI group achieved FEF earlier [27.00 (24.00-32.00) vs. 35.00 (34.00-61.00) days; p = 0.036] at earlier post-menstrual age [33.0 (32.5-34.0) vs. 34.0 (34.0-37.5) weeks; p = 0.028] and with a lower weight [1,280 (1,130-1,382) vs. 1,535 (1,325-2,002) g; p = 0.048]. A trend towards a shorter duration of central venous catheter (p = 0.059) and hospital stay (p = 0.064) was observed. Conclusions:RAFI implementation was associated with earlier achievement of FEF, particularly in IUGR infants. These findings suggest that a structured and standardized approach to feeding intolerance assessment may facilitate nutritional advancement in very preterm neonates.

Introduction Improving the quality of life for preterm children is a global health priority, given their vulnerability to neurocognitive impairments and adverse health consequences. Lack of posthospital care further exacerbates these risks, necessitating effective interventions during the neonatal period. This protocol for a pilot study aims to investigate the effects of touch interventions, including physiotherapy and osteopathic manipulative treatment, on brain activity in moderately preterm infants using brain functional MRI (fMRI), computerised EEG and metabolomics.Methods and analysis A 3-arm randomised sham-controlled trial will be conducted with 15 infants per experimental group. The study will include stable preterm infants born between 32.0 and 33.6 weeks of gestational age who do not require any intensive care treatments.The study aims to assess the impact of touch interventions on brain activity and metabolic sequelae. Using fMRI will primarily examine the pre-post changes between groups in blood oxygenation level dependent levels among different brain areas, specifically the anterior insula and the medial prefrontal cortex. Secondarily, we will explore the preterm brain’s neural effects on EEG slow delta wave band. Metabolomics will provide data on the effects among the three groups on metabolic changes associated with touch interventions.Ethics and dissemination Ethical approval has been obtained from the Ethics Committee of the local health agency in Milan (CET 449-2024). Understanding the effects of touch interventions on brain activity in moderately preterm infants, without needs of intensive care, can contribute to improving their clinical outcomes and promoting their growth, development and social behaviour. Findings from this pilot study will pave the way for future research, enabling the development of evidence-based interventions to enhance preterm infants’ well-being and long-term outcomes.Trial registration number NCT05853991.

BACKGROUND:Adrenomedullin (AM) is a potent angiogenic, antioxidant and anti-inflammatory peptide protecting the developing lung from injury due to bronchopulmonary dysplasia (BPD) of the preterm infant. At this stage, no data on the potential effects of chorioamnionitis (CA) occurrence and glucocorticoids (GC) administration on AM in developing lungs are still lacking. OBJECTIVE:to investigate, in a sheep-based model, the positive/side-effects of combined exposure to CA and GC on AM concentrations measured in bronchoalveolar lavage fluid (BALF). METHODS:Time-mated ewes were randomly admitted to one of six treatment groups receiving injection: saline (controls); lipopolysaccharide (L) in intra-amniotic fluid treated alone at 7 or 14 d before delivery or associated with betamethasone (B) intramuscularly; B treated alone (7d) or associated with L (14d). Lambs were surgically delivered at 120 days gestation and euthanized. BALF was used for AM measurement in the studied groups. RESULTS:AM BALF levels significantly (p < 0.05, for all) changed both to B and L exposure in a time-dependent manner. The latter was characterized by AM levels at short term superimposable to controls, whilst significantly (p > 0.05) decreased at long-term. The former showed increased AM at short and decreased at long-term (p < 0.05, for all), respectively. CONCLUSIONS:the present results showing AM BALF changes in a sheep-based model support the AM role in the hemodynamic patterns due to CA and BPD occurrence and open the way to further studies investigating the role of vasoactive agents as trustable markers of lung development/damage.

Abstract Background The issue of retreatment with surfactant of infants with respiratory distress syndrome (RDS) has been poorly investigated. Our aim was to identify possible clinical predictors of the need for multiple doses of surfactant in a large cohort of very preterm infants. Methods Data were analyzed from three previous studies on infants born between 25+ 0 and 31+ 6 weeks of gestation with RDS who were treated with surfactant. Results We studied 448 infants. Among them 306 (68%) were treated with a single dose of surfactant and 142 (32%) were treated with multiple doses. Multivariable mixed effects logistic regression analysis showed that the odd of requiring multiple doses of surfactant was significantly lower in patients with higher gestational age (27–28 vs. 25–26 wks: OR 0.46, 95% C.l. 0.26–0.79; ≥29 vs. 25–26 wks: OR 0.34, 95% C.l. 0.13–0.85; overall P = 0.013), while it increased in infants born to mothers with hypertensive disorders of pregnancy (OR 2.53, 95% C.l. 1.49–4.31; P < 0.001) and with hemodynamically significant PDA (OR 2.74, 95% C.l. 1.66–4.53, P < 0.001). Conclusions Gestational age, hypertension in pregnancy, and hemodynamically significant PDA can predict the need for multiple doses of surfactant. Further investigation is needed to evaluate if these sub-groups of preterm infants represent specific phenotypes of RDS who deserve a peculiar surfactant treatment.

The aim of the study is to investigate the effects of olfactory stimuli from breast and formula milk on near-infrared spectroscopy (NIRS) cerebral and splanchnic patterns in late preterm infants. We conducted a multicenter prospective observational pretest-test study in 30 late preterm infants subjected to olfactory stimuli from breast and formula milk. Regional oxygenation status, tissue function in cerebral and splanchnic districts, and cerebral-splanchnic hemodynamic redistribution were recorded at four pre-determined time-points: before sniffing (30 min), during sniffing (30 s), short-term (30 min), and long-term after olfactory stimuli (180 min). After olfactory stimuli from breast and formula milk we found: (i) a significant increase (p < 0.05) in cerebral oxygenation and cerebral-splanchnic hemodynamic redistribution after breast milk stimulus, (ii) a significant increase (p < 0.05) in splanchnic oxygenation and splanchnic-cerebral hemodynamic redistribution after formula milk stimulus. The present results show early changes in NIRS patterns in cerebral and splanchnic districts after breast and formula milk stimuli. Data opens the way to further studies using NIRS as a reliable tool for central nervous system and splanchnic development and response after olfactory stimuli.

To validate the role of Activin A in the early diagnosis and prognosis of preterm newborns at risk for intraventricular hemorrhage and neurological sequelae by means of cerebral ultrasound and magnetic resonance imaging (MRI), currently considered standard of care procedures. We conducted an observational case–control study in 46 preterm newborns, 23 with intraventricular hemorrhage (IVH group) and 23 controls matched for gestational age. Standard clinical, laboratory, cerebral ultrasound monitoring procedures and Activin A urine measurement were performed at four time-points (first void, 24, 48, 96 h) after birth. Cerebral MRI was performed at 40–42 weeks of corrected gestational age. Elevated (P < 0.001, for all) Activin A levels were observed in the IVH group at all monitoring time-point. Activin A correlated (P < 0.05, for all) with intraventricular hemorrhage grade on cerebral ultrasound. At the cut-off of 0.08 pg/mL Activin A at 48-h achieved the best sensitivity, specificity, positive/negative predictive values as early predictor of an abnormal MRI pattern (area under the curve: 0.93). The present data showing a correlation among Activin A, cerebral ultrasound and MRI provide further support to Activin A inclusion in clinical daily management of cases at risk for intraventricular hemorrhage and adverse neurological outcome.

Obesity and overweight are common and complex conditions influenced by multiple genetic and environmental factors. Several genetic variants located in the genes involved in clock systems and fat taste perception can affect metabolic health. In particular, the polymorphisms in CLOCK and BMAL1 genes were reported to be significantly related to cardiovascular disease, metabolic syndrome, sleep reduction, and evening preference. Moreover, genetic variants in the CD36 gene have been shown to be involved in lipid metabolism, regulation of fat intake, and body weight regulation. The aim of this study is to evaluate, for the first time, the association between variants in some candidate genes (namely, BMAL1 rs7950226 (G>A), CLOCK rs1801260 (A>G), CLOCK rs4864548 (G>A), CLOCK rs3736544 (G>A), CD36 rs1984112 (A>G), CD36 rs1761667 (G>A)) and overweight/obesity (OB) in pregnant women. A total of 163 normal-weight (NW) and 128 OB participants were included. A significant correlation was observed between A-allele in CLOCK rs4864548 and an increased risk of obesity (OR: 1.97; 95% CI 1.22–3.10, p = 0.005). In addition, we found that subjects carrying the haplotype of rs1801260-A, rs4864548-A, and rs3736544-G are likely to be overweight or obese (OR 1.47, 95% CI 1.03–2.09, p = 0.030), compared with those with other haplotypes. Moreover, a significant relation was observed between third-trimester lipid parameters and genetic variants—namely, CD36 rs1984112, CD36 rs1761667, BMAL1 rs7950226, and CLOCK rs1801260. A multivariate logistic regression model revealed that CLOCK rs4864548 A-allele carriage was a strong risk factor for obesity (OR 2.05, 95% CI 1.07–3.93, p = 0.029); on the other hand, greater adherence to Mediterranean diet (OR 0.80, 95% CI 0.65–0.98, p = 0.038) and higher HDL levels (OR 0.96, 95% CI 0.94–0.99, p = 0.021) were related to a reduced risk of obesity. Interestingly, an association between maternal CLOCK rs4864548 and neonatal birthweight was detected (p = 0.025). These data suggest a potential role of the polymorphisms in clock systems and in fat taste perception in both susceptibility to overweight/obesity and influencing the related metabolic traits in pregnant women.

Objectives Early sepsis detection and diagnosis still constitutes an open issue since the accuracy of standard-of care parameters is biased by a series of perinatal factors including hypoxia. Therefore, we aimed at investigating the effect of fetal chronic hypoxia insult on urine levels of a promising new marker of sepsis, namely presepsin (P-SEP). Methods We conducted a prospective case-control study in 22 cases of early-intrauterine growth restriction (E-IUGR) compared with 22 small-for-gestational-age (SGA) newborns and 66 healthy controls. P-SEP urine samples were collected over the first 72 h from birth. Blood culture and C-reactive protein (CRP) blood levels were measured in E-IUGR and SGA infants. Perinatal standard monitoring parameters and main outcomes were also recorded. Results No significant urinary P-SEP differences (p>0.05, for all) were observed among studied groups. Moreover, no significant correlations (p>0.05, for both) between urinary P-SEP and blood CRP levels in both E-IUGR and SGA groups (R=0.08; R=0.07, respectively) were observed. Conclusions The present results showing the lack of influence of fetal chronic hypoxia on urinary P-SEP levels offer additional data to hypothesize the possible use of urinary P-SEP measurement in neonates in daily clinical practice. Further multicenter prospective data are needed, including infants with early-onset sepsis.

Objectives: The measurement of blood pH and gas analytes (BPGA), soon after birth, constitutes the first-line standard of care procedure in high-risk newborns. However, no data is available in capillary blood on perinatal bias such as gestational age (GA), weight at birth (BW), delivery mode, and gender. The aims of the present study were to investigate whether in a cohort of healthy preterm (PT) and term (T) infants BPGA were GA, BW, delivery mode and gender dependent, thus affecting BPGA reliability as diagnostic test. Methods: We performed a prospective case-control study in 560 healthy infants (PT: n=115, T: n=445). BPGA was measured within 24-h from birth. Perinatal characteristics, outcomes, and clinical examination were also recorded. Results: PT infants showed higher (p<0.001) carbon dioxide partial pressure (pCO(2)), fraction of fetal hemoglobin (HbF), base excess (BE), bicarbonate (HCO3), and lower lactate (Lac) levels. When corrected for delivery mode, higher (p<0.001) HbF, BE, HCO3, and lower Lac levels were found. Similarly, higher (p<0.05, for all) pCO(2), HbF, BE, HCO(3 )and lower Lac levels were found between female and male PT and T infants. Repeated multiple logistic regression analysis showed that BPGA was GA, BW, delivery mode and gender dependent. Conclusions: The present results showing that BPGA can be affected by a series of perinatal outcomes open the way to further investigations providing longitudinal BPGA reference curves in the transitional phase, thus empowering BPGA role as a reliable diagnostic and therapeutic strategies efficacy marker.

Objectives: Seizures (SZ) are one of the main complications occurring in infants undergoing therapeutic hypothermia (TH) due to perinatal asphyxia (PA) and hypoxic ischemic encephalopathy (HIE). Phenobarbital (PB) is the first-line therapeutic strategy, although data on its potential side-effects need elucidation. We investigated whether: i) PB administration in PA-HIE TH-treated infants affects S100B urine levels, and ii) S100B could be a reliable early predictor of SZ. Methods: We performed a prospective case-control study in 88 PA-HIE TH infants, complicated (n=44) or not (n=44) by SZ requiring PB treatment. S100B urine levels were measured at 11 predetermined monitoring time-points from first void up to 96-h from birth. Standard-of-care monitoring parameters were also recorded. Results: S100B significantly increased in the first 24-h independently from HIE severity in the cases who later developed SZ and requested PB treatment. ROC curve analysis showed that S100B, as SZ predictor, at a cut-off of 2.78 mu g/L achieved a sensitivity/specificity of 63 and 84 %, positive/negative predictive values of 83 and 64 %. Conclusions: The present results offer additional support to the usefulness of S100B as a trustable diagnostic tool in the clinical daily monitoring of therapeutic and pharmacological procedures in infants complicated by PA-HIE.

Objectives: Thermostability is one of the pre-requisites for the reliability of analytes in clinical practice and biomedical research. Although presepsin represents a promising new biomarker for the early diagnosis of sepsis in newborns, data on its stability under different storage conditions are lacking. We aimed to investigate presepsin thermostability in blood, urine and saliva samples after thawing at 4 predetermined monitoring time-points in a cohort of preterm and term infants.Methods: We conducted an observational study, where each case served as its own control, in 24 preterm and term infants. Blood, urine and saliva samples were stored at -80 C-degrees for 18 months, and presepsin measured in different biological fluids at thawing (T0), 24 (T1), 48 (T2) and at 72 (T3) hours after thawing.Results: No significant differences (p>0.05, for all) in presepsin levels were observed at T0-T3 in the different biological fluids. Furthermore, no differences at T0-T3 were observed in presepsin levels between blood and saliva fluids, whilst urine levels were significantly higher (p<0.05, for all) than blood and saliva at T0-T3.Conclusions: Results on presepsin pre-analytical thermo-stability in different biological fluids after long-term refrigeration support the reliability of this biomarker in the diagnosis and monitoring of perinatal sepsis.

To investigate the effects of caffeine loading/maintenance administration on near-infrared spectroscopy cerebral, kidney and splanchnic patterns in preterm infants. We conducted a multicentre case–control prospective study in 40 preterm infants (gestational age 29 ± 2 weeks) where each case acted as its own control. A caffeine loading dose of 20 mg/kg and a maintenance dose of 5 mg/kg after 24 h were administered intravenously. Near infrared spectroscopy monitoring parameters were monitored 30 min before, 30 min during and 180 min after caffeine therapy administration. A significant increase ( p  < 0.05) in splanchnic regional oxygenation and tissue function and a decrease ( p  < 0.05) in cerebral tissue function after loading dose was shown. A preferential hemodynamic redistribution from cerebral to splanchnic bloodstream was also observed. After caffeine maintenance dose regional oxygenation did not change in the monitored districts, while tissue function increased in kidney and splanchnic bloodstream. Different caffeine administration modalities affect cerebral/systemic oxygenation status, tissue function and hemodynamic pattern in preterm infants. Future studies correlating near infrared spectroscopy parameters and caffeine therapy are needed to determine the short/long-term effect of caffeine in preterm infants.

Asphyxiated newborns often require both therapeutic hypothermia (TH) and mechanical ventilation (MV) and the complex interrelationship between these two therapeutic interventions is very interesting, which could not only have several synergistic positive effects but also some risks. Perinatal asphyxia is the leading cause of neonatal hypoxic-ischemic encephalopathy (HIE) and TH is the only approved neuroprotective treatment to limit brain injury, improving the mortality rate and long-term neurological outcomes. HIE is often associated with severe respiratory failure, requiring MV, due to different lung diseases or an impairment of the respiratory drive. The respiratory support management of asphyxiated newborns is very difficult, considering (a) various pathophysiological contexts, (b) the strong impact of TH on gas metabolism and (c) on lung mechanics, and (d) complex TH-MV interactions. Therefore, it is necessary to evaluate the real indications of MV for cooled newborns, considering the risks of respiratory overassistance (hypocapnia/hyperoxia), as well as the adequate monitoring systems. To date, specific randomized studies about the optimal respiratory approach for cooled newborns are lacking, and strategies for MV support vary from center to center. Moreover, there are many open questions about the real effects of cooling on lung mechanics and on surfactant, most appropriate method of blood gas analysis, and clear indications for pharmacological sedation. The aim of this review is to propose a reasoned approach for respiratory management of cooled newborns, considering the pathophysiological context, multiple actions of TH, and consequences of TH-MV matched action and its related risks.

Breast milk is the natural source of nutrition for infants, but while it supports their health, it can also be a potential source of toxic inorganic particulate matter, and this applies to both breast milk and industrially produced milk. The aim of the present study was to evaluate the presence of nanoparticles in both breast milk and formula milk samples. We collected and analyzed, via a new electron scanning microscopic procedure, 19 samples of breast milk from Italian women and 19 formula milk samples produced by different companies. Organic–inorganic agglomerates were detected in 58% of formula and in 63% of breast milk samples, respectively. In addition, a significantly (p < 0.05) greater size of nanoparticles was observed in formula milk samples. The results, showing the presence of inorganic nanosized particles in breast and artificial milk, may lead to future studies aimed at investigating possible nanosized contamination of milk and identifying early prevention strategies for women and animals involved in the food chain.

Background: In utero exposure to maternal hyperglycemia and obesity can trigger detrimental effects in the newborn through epigenetic programming. We aimed to assess the DNA methylation levels in the promoters of MC4R and LPL genes from maternal blood, placenta, and buccal swab samples collected in children born to mothers with and without obesity and Gestational Diabetes Mellitus (GDM). Methods: A total of 101 Caucasian mother–infant pairs were included in this study. Sociodemographic characteristics, clinical parameters, physical activity, and adherence to the Mediterranean diet were evaluated in the third trimester of pregnancy. Clinical parameters of the newborns were recorded at birth. Results: A negative relationship between MC4R DNA methylation on the fetal side of the GDM placenta and birth weight (r = −0.630, p = 0.011) of newborns was found. MC4R DNA methylation level was lower in newborns of GDM women (CpG1: 2.8% ± 3.0%, CpG2: 3.8% ± 3.3%) as compared to those of mothers without GDM (CpG1: 6.9% ± 6.2%, CpG2: 6.8% ± 5.6%; p < 0.001 and p = 0.0033, respectively), and it was negatively correlated with weight (r = −0.229; p = 0.035), head circumference (r = −0.236; p = 0.030), and length (r = −0.240; p = 0.027) at birth. LPL DNA methylation was higher on the fetal side of the placenta in obese patients as compared to normal-weight patients (66.0% ± 14.4% vs. 55.7% ± 15.2%, p = 0.037), and it was associated with maternal total cholesterol (r = 0.770, p = 0.015) and LDL-c (r = 0.783, p = 0.012). Conclusions: These results support the role of maternal MC4R and LPL methylation in fetal programming and in the future metabolic health of children.

Surfactant is a well-established therapy for preterm neonates affected by respiratory distress syndrome (RDS). The goals of different methods of surfactant administration are to reduce the duration of mechanical ventilation and the severity of bronchopulmonary dysplasia (BPD); however, the optimal administration method remains unknown. This study compares the effectiveness of the INtubate-RECruit-SURfactant-Extubate (IN-REC-SUR-E) technique with the less-invasive surfactant administration (LISA) technique, in increasing BPD-free survival of preterm infants. This is an international unblinded multicenter randomized controlled study in which preterm infants will be randomized into two groups to receive IN-REC-SUR-E or LISA surfactant administration. In this study, 382 infants born at 24+0–27+6 weeks’ gestation, not intubated in the delivery room and failing nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV) during the first 24 h of life, will be randomized 1:1 to receive IN-REC-SUR-E or LISA surfactant administration. The primary outcome is a composite outcome of death or BPD at 36 weeks’ postmenstrual age. The secondary outcomes are BPD at 36 weeks’ postmenstrual age; death; pulse oximetry/fraction of inspired oxygen; severe intraventricular hemorrhage; pneumothorax; duration of respiratory support and oxygen therapy; pulmonary hemorrhage; patent ductus arteriosus undergoing treatment; percentage of infants receiving more doses of surfactant; periventricular leukomalacia, severe retinopathy of prematurity, necrotizing enterocolitis, sepsis; total in-hospital stay; systemic postnatal steroids; neurodevelopmental outcomes; and respiratory function testing at 24 months of age. Randomization will be centrally provided using both stratification and permuted blocks with random block sizes and block order. Stratification factors will include center and gestational age (24+0 to 25+6 weeks or 26+0 to 27+6 weeks). Analyses will be conducted in both intention-to-treat and per-protocol populations, utilizing a log-binomial regression model that corrects for stratification factors to estimate the adjusted relative risk (RR). This trial is designed to provide robust data on the best method of surfactant administration in spontaneously breathing preterm infants born at 24+0–27+6 weeks’ gestation affected by RDS and failing nCPAP or NIPPV during the first 24 h of life, comparing IN-REC-SUR-E to LISA technique, in increasing BPD-free survival at 36 weeks’ postmenstrual age of life. ClinicalTrials.gov NCT05711966. Registered on February 3, 2023.

Breast milk (BM) is a unique food due to its nutritional composition and anti-inflammatory characteristics. Evidence has emerged on the role of Presepsin (PSEP) as a reliable marker of early sepsis diagnosis. In the present study, we aimed to investigate the measurability of PSEP in BM according to different maturation stages (colostrum, C; transition, Tr; and mature milks, Mt) and corrected for delivery mode and gender. We conducted a multicenter prospective case–control study in women who had delivered 22 term (T) and 22 preterm (PT) infants. A total of 44 human milk samples were collected and stored at −80 °C. BM PSEP (pg/mL) levels were measured by using a rapid chemiluminescent enzyme immunoassay. PSEP was detected in all samples analyzed. Higher (p < 0.05) BM PSEP concentrations were observed in the PT compared to the T infants. According to the grade of maturation, higher (p < 0.05) levels of PSEP in C compared to Tr and Mt milks were observed in the whole study population. The BM subtypes’ degrees of maturation were delivery mode and gender dependent. We found that PSEP at high concentrations supports its antimicrobial action both in PT and T infants. These results open the door to further studies investigating the role of PSEP.