Paediatric Respiratory Reviews 16 (2015) 151156

Contents lists available at ScienceDirect

Paediatric Respiratory Reviews

Mini-symposium: Alveolar and Vascular Transition at Birth

Managing Preterm Infants in the First Minutes of Life

Maximo Vento 1,*, Gianluca Lista 2
1
Division of Neonatology; University & Polytechnic Hospital La Fe, Valencia, Spain
2
Division of Neonatology; V Buzzi Childrens Hospital ICP, Milano, Italy

EDUCATIONAL AIMS

The reader will appreciate that:

 Preterm infants postnatal adaptation is a complex process that often requires the intervention of especially trained caregivers.
 The cornerstone of a successful switch from a fetal to an adult type of cardiorespiratory circulation is to provide adequate lung
ventilation. Both alveolar recruitment and achievement of a functional residual capacity are essential for establishing an adequate
gas exchange.
 The use of non invasive ventilation and individual oxygen titration according to oxygen saturation provide the best and less
aggressive means for achieving a successful postnatal adaptation of the preterm infant.

A R T I C L E I N F O S U M M A R Y

Keywords: Premature infants often experience difculties adapting to postnatal life. The most relevant ones are
Prematurity
related to establishing an adult type cardiorespiratory circulation and acquiring hemodynamic stability,
Resuscitation
aerating the lung and attaining a functional residual capacity, performing an adequate gas exchange and
Oxygen
Cord clamping switching to an oxygen enriched metabolism, and keeping an adequate body temperature. In recent
Ventilation years a body of evidence supports a trend towards gentle management in the delivery room aiming to
Delivery room reduce damage especially to the lungs in the so-called rst golden minutes. Herewith, we describe and
Temperature update four of the most relevant interventions performed in the delivery room: delayed cord clamping,
non-invasive ventilation, individualized oxygen supplementation, and maintaining an adequate body
temperature so as to avoid hyperthermia and/or hypothermia.
2015 Elsevier Ltd. All rights reserved.

INTRODUCTION cord clamping for achieving hemodynamic stability, preventing

Experimental and clinical studies performed in recent decades
have shown that interventions performed in the rst minutes after
birth, especially in very preterm infants could cause structural
changes but also trigger inammatory and pro-oxidant cascades
injurious to most organs of the body and that could predispose to
long-term conditions [1]. The 2010 ILCOR guidelines and recent
consensus guidelines have underscored the advantages of delaying
* Corresponding author. Division of Neonatology & Neonatal Research Center,
Health Research Institute & University and Polytechnic Hospital La Fe, Chairman of
the Maternal, Child and Developmental Network Red SAMID, Instituto Carlos III
(Spanish Ministry of Economy & Competitiveness), Bulevar Sur s/n, 46026 Valencia;
Spain Tel.: +34 96 1245688 / 86; fax: +34 96 1245647.
E-mail address: maximo.vento@uv.es (M. Vento).
brain damage, reducing the need of blood transfusions and
improving iron status during the rst year after birth [2,3]. In
addition, non-invasive ventilation has been proposed to avoid or
minimize possible damage to the lungs during postnatal adapta-
tion in preterm babies who frequently need to be ventilated with
positive pressure [2,3]. Of note, the use of individualized oxygen
supplementation titrated according to individual response moni-
tored using by pre-ductal pulse oximetry is a new approach that
tries to avoid damage caused by hyper-and/or-hypoxia [4]. Simi-
larly important is keeping an adequate body temperature which
undoubtedly will inuence mortality and morbidity of very
preterm infants [3].
The aim of present review is to expand on these three newly
evolving approaches meant to improve postnatal transition of very
preterm babies to extra uterine life (Figure 1).

http://dx.doi.org/10.1016/j.prrv.2015.02.004
1526-0542/ 2015 Elsevier Ltd. All rights reserved.
152 M. Vento, G. Lista / Paediatric Respiratory Reviews 16 (2015) 151156

Figure 1. Interventions in preterm delivery after birth.

To facilitate to neonatal transition and postnatal adaptation several possible interventions that should be considered: (i) maintaining an adequate body temperature; (ii)
improve hemodynamics stability delaying cord clamping or if resuscitation is needed clamping the cord proximal to the placenta and stripping/milking de cord in direction to
the infant; (iii) if the baby is spontaneously breathing CPAP with mask or nasal prongs can be provided. If the respiratory efforts are not sufcient to achieve an adequate FRC,
intermittent positive pressure ventilation with PEEP should be provided. The use of sustained lung inations is still under debate and should not be a routine of care; (iv) in
babies who are not spontaneously breathing initial PPV + PEEP should be provided, and if not efcient intubation is required; (v) initial FiO2 of 21% to 30% seem appropriate in
most cases. FiO2 should be titrated using an air/oxygen blender according to the response evidenced in evolving heart rate and SpO2.

Allowing placental transfusion immediately after birth
In general there is agreement that delaying clamping of the cord
is of benet to the term and preterm infant. Maintaining blood
supply to the heart (pre-load) while the lung vascular system gets
replenished contributes to keeping an adequate left ventricular
output, thus avoiding reduced blood ow to the CNS, coronary
arteries, kidneys and the rest of the body [5]. Recent experimental
studies in a sheep model of fetal to neonatal transition have clearly
shown that delaying cord clamping after the initiation of positive
pressure ventilation and establishment of a functional residual
capacity favours myocardial stability, carotid ow, and brain
oxygenation, thus prompting a smoother foetal to neonatal
transition [6]. In 2010 ILCOR guidelines stated that for the term
infant after a normal delivery there is evidence of the benecial
effects of delaying the clamping of the cord for at least one minute
but it might be delayed until cessation of cord pulsation. In preterm
infants, for uncomplicated deliveries, cord clamping should be
delayed for a minimum of 30 seconds to 3 minutes after delivery.
However, in extremely preterm infants or preterm infants who are
born moderately to severely depressed there is no evidence as to
whether delaying cord clamping would be of benet instead of
initiating the resuscitation manoeuvers immediately [2]. A recent
systematic review comprising the available information since the
publication of the 2010 ILCOR guidelines indicates that delaying
cord clamping (DCC) up to 3 min in vigorous preterm babies
signicantly reduces hemodynamic instability, improves cerebral
circulation, reduces intraventricular hemorrhage (IVH) all grades,
necrotizing enterocolitis and the need for transfusions, although
peak serum bilirubin was higher in the transfused group. However,
no clear differences were found in the primary outcome of death,
severe IVH or periventricular leukomalacia.
The optimal time to clamp the umbilical cord after delivery is
still controversial. There are several small-randomized controlled
trials (RCTs) that have compared early (20 s) to late (430 s) cord
clamping following preterm birth as well as several prospective
observational studies [7]. Of note, no conclusive data regarding the
benets of DCC in depressed infants and especially in very preterm
infants are yet available. Although experimental studies support a
positive effect on cardiorespiratory circulation, brain perfusion,
and hemodynamic stability with delayed cord clamping, the setup
needed to physically perform resuscitation maneuvers with an
intact cord still constitutes an important impediment in most
delivery rooms. In addition, in asphyxiated newborn infants there
is a vasoconstriction of the placental vessels accompanied by
vasodilatation of the umbilical vessels, thus increasing the
circulating blood volume in the foetus. However, pulmonary
vasoconstriction and reduced myocardial contractility occur,
which may prompt cardiac insufciency and compromise recovery
of the spontaneous circulation [8]. Under these circumstances cord
milking has been suggested as a valid alternative. This manoeuver
consists of clamping the cord near the placenta and stripping
(milking) approximately 20 cm several times (2 to 4) from the
distal (placental) to the proximal (foetal) site of the cord. It can be
performed in few seconds and provides the newly born with a
substantial amount of blood that at least theoretically may
contribute to hemodynamic stabilization. To date only three
clinical trials have been performed in preterm infants, including a
total of 100 babies. Cord milking resulted in increased placental
transfusion and apparently appeared to be as effective as DCC.
 M. Vento, G. Lista / Paediatric Respiratory Reviews 16 (2015) 151156
Authors of these small trials concluded that cord milking may be an
option when DCC is not an option because the newly born baby
requires immediate resuscitation measures. However, there are
still some questions that need to be answered. Hence, how rapid
should the cord be stripped, or how often, or whats the minimum
or maximum length of the cord that should be stripped? In
addition, there is some concern about the rapid perfusion of a
signicant blood volume into the infants circulation that does not
resemble the physiologic ow of DCC [9].
Ventilatory support
Very preterm babies frequently experience difculties initiat-
ing spontaneous effective respiration because of poor respiratory
drive, poor muscle strength, surfactant deciency, and high chest
wall compliance. As a consequence, they need respiratory
assistance to clear lung uid, aerate the lungs, and establish a
consistent functional residual capacity (FRC) to ensure gas
exchange [10]. Failure to perform a uniform and functionally
adequate lung expansion causes the coexistence of areas of
atelectasis and over-distension which characterize respiratory
distress syndrome (RDS) [3]. Preterm babies with RDS often need
intubation and mechanical ventilation in the delivery room. These
aggressive interventions although life-saving may cause trauma to
the lung structure and lead to chronic lung disease [11]
Therefore, there is a search for ventilatory strategies in the
delivery room (DR) capable of helping spontaneously breathing
infants to adequately perform postnatal transition whilst reducing
the risk of lung damage.
Ventilatory strategies that promote airway liquid clearance and
alveolar recruitment
At birth a pressure gradient is required to overcome airow
resistance and move lung uid distally through the airways; then
to advance air to the terminal airspaces where the opening
pressure is necessary to overcome the surface tension and open
the alveoli [12]. This rst lung recruitment manoeuver (LRM) may
be considered the pre-requisite to enable surfactant to reach a
large proportion of alveoli, to begin its action, and to promote
a more uniform lung volume [13]. This LRM is the rst step of a
high lung volume (open lung) strategy that is the key to protect
the neonatal lung during mechanical ventilation [14]. Interestingly,
the optimal technique of lung recruitment immediately after birth
still remains unknown. To prompt lung expansion and establish an
early functional residual capacity [FRC] the use of positive end-
expiratory pressure (PEEP) or continuous positive airway pressure
(CPAP) of at least 4-6 cm H2O has been advocated [1518]. Thus,
resuscitation guidelines underscore the efcacy of PEEP during
resuscitation of preterm infants for the establishment and
maintenance of an early FRC. FRC was achieved both by airway
stabilization and prevention of alveoli collapse during expiration
[2]. However, the use of xed PEEP/CPAP in very preterm infants
in the delivery room has not always been successful in establishing
an adequate FRC. In a recent study, it was shown that a stepwise
PEEP strategy after birth improved gas exchange, lung mechanics,
and end expiratory volume without increasing lung injury in
preterm lambs [19]. Delivery room management with stepwise
increments of PEEP before giving surfactant has been satisfactorily
applied via face mask in non-spontaneously breathing very
preterm infants in order to reach a heart rate >100 beats per
minute [bpm] and an SpO2 >85% within the rst 10 minutes after
birth, increasing the rates of survival and reducing morbidity
[20]. In the study protocol sustained ination (SI) maneuvers were
employed before intubating the babies. In fact SI, dened as the
application of an ination pressure (e.g.: 25 cm H2O) for a period
153
of time signicantly more prolonged that the normal inspiratory
time (e.g.: 15-25 s), is considered an alternative to clear uid-lled
lung and achieve an early FRC [20]. Immediately after birth, when
the initial inations are to be provided, it should be remembered
that the uid lled lung has a prolonged time constant. The rst
breaths of life in healthy term infants are characterized by a
prolonged inspiratory time (4-5 s per breath, according to the
long time constant of the uid-lled lung), prolonged expiratory
phase and high ination pressure (30-35 cmH2O) along the major
airways [21]. During these rst prolonged inations, the delta
pressure moves the air/liquid interface distally towards the
alveoli, thus facilitating direct lung aeration and clearance of
lung liquid from the major airways within seconds after birth, that
will be completed by the interstitial lymphatic and venous
reabsorption (in the hours following the birth). In several minutes,
by the achievement of an early FRC, the healthy term infant is able
to maintain normal values of SpO2 while breathing in room-air
[22].
Therefore to mimic the delta pressure generated by the high
and prolonged ination pressure of the newly born infant, a SI has
been suggested for infants at high risk of respiratory failure. The
application of a SI maneuver (prolonged ination for 5 s) during
resuscitation procedures was demonstrated to be efcacious in a
population of asphyxiated term infants in relation to lung volume
changes [23]. A rapid increase in heart rate and oxygen saturation
reected the efcacy of the resuscitation maneuvers. [24,25]
Clinical observations of the rst breath during neonatal
resuscitation of preterm infants show that an initial inating
pressure around 20-25 cmH2O is generally effective in improving
heart rate and chest expansion [2]. Nevertheless, the premature
infant is often unable to generate such high inating pressures
within the rst inspiratory excursions and is, therefore, incapable
of achieving a homogeneous and generalized alveolar recruitment.
As a consequence, many preterm infants need respiratory support
and/or oxygen supplementation [26,27]. Intriguingly, SI manoeu-
vers have not to markedly improved all the respiratory outcomes
in clinical practice. Hence, the application after birth of SI
manoeuvers consisting of a peak pressure of 20-25 cmH2O for
10-20 seconds using a nasopharyngeal tube or an adequately sized
mask and a Neo-puff (Fisher & Paykel Healthcare Ltd, Auckland,
New Zealand) device, followed by the application of an adequate
PEEP (e.g.: 5 cmH2O) were shown to be effective in the
achievement of FRC and in improving short-term respiratory
outcomes [reduction of tracheal intubation in DR and the need of
mechanical ventilation (MV)] in preterm infants < 29 weeks
gestation at risk for respiratory distress syndrome [28]. Recently, a
study was launched which focused on the effect upon heart rate,
SpO2 and cerebral tissue oxygenation of applying SI to a small
group of preterm infants of 28 weeks gestation immediately
after birth to enhance lung recruitment and consisted of three
sustained inations of 20, 25 and 30 cm H2O each of 15 sec
duration followed by nasal CPAP. The majority of these infants
needed more than one SI (with the application of growing
pressures) because of persistent hypoxia or bradycardia. Sustained
ination did not negatively affect heart rate, arterial saturation
or cerebral tissue oxygen saturation and a rapid increase in the
infants heart rate and an increase in cerebral tissue oxygen
saturation were observed [29]. The results of these small clinical
trials seem to indicate that, under certain clinical conditions, SI
could contribute to enhance alveolar recruitment and help to
stabilize preterm infants in the DR without intubation. However,
there are still many unanswered questions that need to be
evaluated including appropriate setting of SI (duration and peak
pressure), selection of patients (rescue or prophylactic proce-
dure?), individually tailored setting of respiratory parameters used
to manage the preterm infants, effects upon cerebral circulation,
154 M. Vento, G. Lista / Paediatric Respiratory Reviews 16 (2015) 151156
management of a brisk increase in SpO2, and short and long-term
outcomes of respiratory conditions.
Oxygen supplementation
Oxygen in foetal life
Foetal life elapses in an environment, which is relatively
hypoxic compared to the extra uterine world. The arterial partial
pressure of oxygen (paO2) in utero is  25-30 mmHg (3.0-3.5 kPa)
while in the rst minutes after birth it will increase to 80-
90 mmHg (10.5-12.0 kPa) [30]. Of note, oxygen delivery to tissue
does not substantially differ in the foetus from the newborn. The
reasons are: (i) the presence of foetal hemoglobin with a greater
afnity for oxygen facilitates foetal oxygen uptake from the
intervillous spaces from the placenta and increases oxygen
saturation for a given paO2; (ii) extremely high foetal cardiac
output as compared with adults (250-300 mL/kg/min); (iii)
shunting from venous return coming from the placenta to organs
with high oxygen needs ex-utero [31]. The intervillous partial
pressure of oxygen is of 60 mmHg at 24-30 weeks gestation and
of 45-48 mmHg at term. These values correspond to an SpO2 of
50%-60% in the foetus [32]. Interestingly, oxygen supplementation
to the mother will cause a signicant increase of foetal paO2 and
oxidative stress. In addition, conditions of the mother causing
foetal hypoxaemia, such as preeclampsia or insulin dependent
diabetes, also cause oxidative stress to the foetus, and provoke
postnatal maladaptation [32].
Use of the pulse oximeter in the delivery room
Pulse oximetry is now widely employed in the DR to objectively
evaluate newborn postnatal arterial oxygen saturation instead
of color, which has been traditionally employed but is subject to
great individual variability [33]. Oxygen saturation (SpO2) reects
the percentage of oxy-hemoglobin present in the arterial blood.
The pulse oximeter transforms, by means of specic algorithms,
the degree of light absorption of oxygenated and deoxygenated
haemoglobin at different infrared light spectra, compared to
reference values of adult volunteers, and displays it as a
percentage. This is the reason why no saturation values below
60%-70% are reliable. Pulse oximetry in the delivery room should
be put at maximum sensitivity with averaging measurements
every 2 seconds in order to detect minimal changes in a rapidly
evolving clinical situation. The sensor is preferably put on the right
hand or wrist to evaluate oxygenation of pre-ductal blood
perfusing the central nervous system. Importantly, the sensor
should be protected from intense light to avoid false readings. To
achieve a rapid and reliable reading the oximeter should be turned
on, then the sensor should be applied rst to the baby and
thereafter to the oximeter cable. In this way reliable readings can
be mostly achieved with 60-90 seconds after birth. The presence of
foetal hemoglobin, which represents almost 100% of the hemoglo-
bin present in very preterm infants, may slightly alter the reading
but lacks clinical relevance [3436]. Pulse oximeters also display
heart rate with great accuracy. This is extremely useful when
evaluating the response to resuscitation since heart rate is
probably the most practical clinical parameter reecting a good
or bad response [37]. For all the above-mentioned reasons, pulse
oximetry together with an air/oxygen blender and a well-trained
and sufcient human team round the clock altogether have
optimised the resuscitation of term but especially very preterm
infants [38].
Postnatal oxygen saturation
Immediately after birth the newly born infant has to aerate the
lungs and establish a functional residual capacity to initiate an
effective gas exchange. In order to do so liquid lling the airspaces
has to be removed. The rst inspiratory efforts cause an elevation
of the negative intra-thoracic pressure that highly contributes to
the passage of lung uid to the interstitium. In addition, blockage
of the active chloride mediated secretion and efcient Na+/K+
ATPase dependent pumps in type II alveolar cells both contribute
to virtually clearing the uid from the airways. Components of the
lung uid are cleared directly into the vasculature or via lymphatic
from the lung interstitium over many hours. Processes that
interfere with this mechanism such as prematurity, operative
delivery and/or excessive sedation will delay airway uid
clearance and the establishment of effective gas exchange.
Simultaneously, with the onset of labour, surfactant is secreted
into the foetal lung uid in large quantities. Surfactant deposition
favouring alveolar distension upon expiration is essential for the
establishment of a functional residual capacity (FRC) [10]. Preterm
infants have delayed maturation of both, the Na+/K+ ATPase
dependent pumps and surfactant metabolism, have a compliant
chest wall and muscular weakness, or do not spontaneously
initiate respiratory efforts [poor respiratory drive]. Altogether
these factors will predispose preterm infants to respiratory
insufciency and the need for positive pressure ventilation and
oxygen supplementation. In this scenario, the achievement of a
stable pre-ductal SpO2 is substantially delayed even in healthy
well-adapted preterm infants [10,37]. Recently, a group of
researchers developed a SpO2 reference range for the rst ten
minutes after birth for term and preterm infants who did not
receive any medical intervention in the delivery room. Three
databases were merged, two from the Royal Womens Hospital
(Melbourne; Australia) and another from the University &
Polytechnic Hospital La Fe (Valencia; Spain). Caregivers put a
pre-ductal pulse oximeter (right hand or wrist) immediately after
birth on all recruited babies and stored the data during the rst ten
minutes of postnatal adaptation. Pulse oximeters were adjusted to
measure SpO2 every 2 seconds with maximum sensitivity. A total
of 468 infants and 61650 data points were studied. Centile charts
were elaborated for term, late preterm and very preterm infants.
These charts can be used to monitor SpO2 after birth and intervene
when titrating FiO2 individually according to the infants response
[4]. Interestingly, term infants needed a mean of approximately
4-5 minutes to reach SpO2 of 90%; however, preterm infants
needed 6-7 minutes to reach the same SpO2. Moreover, very
preterm infants of <32 weeks needed almost 9-10 minutes to
reach a similar SpO2 [4]. In addition, heart rate was simultaneously
recorded and independently of the time needed to achieve SpO2
heart rate was above 100 beats per min indicating that cardiac
oxygenation was adequate [39]. At present, Dawsons nomogram
is the best available reference for titrating FiO2 in newly born
preterm infants in the delivery room. It is important to note that
Dawsons nomogram was made retrieving SpO2 in preterm babies
spontaneously breathing air. However, a substantial number of
preterm infants and especially those who are below 28 weeks
gestation receive continuous positive pressure (CPAP) ventilation
for stabilization in the rst minutes after birth. In a recent study,
it was shown that preterm babies breathing air, but supported
with CPAP, achieve higher SpO2 signicantly earlier than reected
in Dawsons nomogram, and therefore caregivers in the DR
should be aware of a rapid increase of SpO2 and avoid
hyperoxaemia [40].
Titrating oxygen in preterm infants in the rst minutes after birth
The initial steps once the baby is born are to achieve
stabilization from a cardio-respiratory and thermal perspective
following the ILCOR 2010 guidelines. This includes delayed cord
clamping, keeping a neutral temperature, applying pulse oximetry
on the right hand or wrist and non-invasive ventilation if the baby
needs it [2]. Independently of the respiratory support needed, the
 M. Vento, G. Lista / Paediatric Respiratory Reviews 16 (2015) 151156
resuscitation team should be taking note carefully of the evolution
of heart rate and SpO2. SpO2 should be individually titrated
adjusting the FiO2 according to the infants response. The blender
should be adjusted every 10-15 seconds aiming to keep the
infants SpO2 within the intended range. In this regard, the AAP in
the 2010 recommendations suggested that the SpO2 should be
60%-65% at 1 min, 65%-70% at 2 min, 70%-75% at 3 min, 75%-80% at
4 min, 80%-85% at 5 min and 85%-90% at 10 min [41]. The Dawson
nomogram offers the possibility of adjusting SpO2 within specic
centiles. To avoid hypo-or-hyperoxaemia the infant should be
ideally kept within a safety range of SpO2 between P10-25 and
P50-75 centiles. Of note, it should be underscored that there is no
proven evidence for establishing a denitive SpO2 safety range
during the period of stabilization of very preterm infants [42].
Keeping preterm babies warm
Thermoregulation after birth is highly dependent on the ability
of the newborn infant to enhance heat production through the
activation of thermogenesis using brown adipose tissue [43].
Unfortunately, preterm infants lack adequate brown adipose tissue
deposition and are, therefore, not capable of achieving normal
body temperature homeostasis with an unequivocal tendency
towards hypothermia once they leave maternal milieu [44]. In the
DR, maintenance of an adequate body temperature (target range of
36 8C to 38 8C) is one of the most important supportive therapies
during fetal-neonatal transition especially for preterm infants.
Both hypothermia and hyperthermia should be avoided during
stabilization and upon admission to the neonatal intensive care
unit. Of note, hypothermia at birth has been associated with an
increased morbidity and mortality during hospital stay in preterm
infants and/or very low birth (VLBW) infants. Therefore, specic
interventions designed to prevent hypothermia are needed
[45]. Hence, the delivery suite should maintained a temperature of
at least 26 8C when the birth of a very preterm infant (<28 weeks
gestation) is expected. Moreover, all babies below 28 weeks
gestation or <1500 g should be wrapped in polyethylene or
polyurethane bags up to their necks at birth without previous drying
to reduce heat loss and keep an adequate humidity. Nevertheless,
when exothermic mattresses and radiant heaters are used, servo-
control of the babies temperature should be mandatory especially
after the rst ten minutes after birth have elapsed and the risk of
hyperthermia substantially increases [2,3]. For extremely preterm
infants, polyethylene caps seem to be comparable with polyethylene
occlusive skin wrapping to prevent heat loss after delivery [46].
Of note, careful monitoring of central and peripheral temperature
is needed because effective temperature control under a radiant
infant warmer (set in manual control) signicantly varies among
commercially available devices, suggesting that neonates can be
easily put at risk of hypo- or hyperthermia [47]. Metabolic and
haemodynamic changes due to hyperthermia (e.g. neonates born to
febrile mothers) are at risk of adverse neurological outcomes [48],
respiratory depression and increased mortality [49]
Therefore, every hospital delivering high risk neonates,
especially extremely low birth weight infants, should have
established protocols controlling room temperature, systematic
use of plastic bags and/or caps, monitoring of temperature during
resuscitation [preferably skin and central (rectal)] and during
transport to the NICU trying to avoid hyper-and/or- hypothermia
during the rst golden minutes after birth [2,3,4446].
DECLARATION OF CONFLICTS
None of the authors declares having conicts of interest with
the content of this manuscript
155
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