Showing papers in "Archives of Disease in Childhood-fetal and Neonatal Edition in 2015"
TL;DR: The increasing number of multidrug-resistant Gram-negative micro-organisms in neonatal intensive care units (NICU) worldwide is a serious concern, which requires thorough and efficient surveillance strategies and appropriate treatment regimens.
Abstract: The incidence of neonatal late-onset sepsis (LOS) is inversely related to the degree of maturity and varies geographically from 0.61% to 14.2% among hospitalised newborns. Epidemiological data on very low birth weight infants shows that the predominant pathogens of neonatal LOS are coagulase-negative staphylococci, followed by Gram-negative bacilli and fungi. Due to the difficulties in a prompt diagnosis of LOS and LOS-associated high risk of mortality and long-term neurodevelopmental sequelae, empirical antibiotic treatment is initiated on suspicion of LOS. However, empirical therapy is often inappropriately used with unnecessary broad-spectrum antibiotics and a prolonged duration of treatment. The increasing number of multidrug-resistant Gram-negative micro-organisms in neonatal intensive care units (NICU) worldwide is a serious concern, which requires thorough and efficient surveillance strategies and appropriate treatment regimens. Immunological strategies for preventing neonatal LOS are not supported by current evidence, and approaches, such as a strict hygiene protocol and the minimisation of invasive procedures in NICUs represent the cornerstone to reduce the burden of neonatal LOS.
330 citations
Newcastle University1, University of Southampton2, Ulster University3, University Hospital of Lausanne4, University of Barcelona5, University of Zagreb6, University of Ferrara7, University of Strasbourg8, University of Leicester9, Medical University of Graz10, French Institute of Health and Medical Research11, University of Bergen12, Poznan University of Medical Sciences13, Instituto Nacional de Saúde Dr. Ricardo Jorge14, University of Mainz15, Otto-von-Guericke University Magdeburg16, University of Oxford17, University of New South Wales18
TL;DR: This large population-based study found an increase in total CDH prevalence over time and significant variation in total and isolated CDHPrevalence between registers and according to geographical location.
Abstract: Introduction Published prevalence rates of congenital diaphragmatic hernia (CDH) vary. This study aims to describe the epidemiology of CDH using data from highquality, population-based registers belonging to the European Surveillance of Congenital Anomalies (EUROCAT). Methods Cases of CDH delivered between 1980 and 2009 notified to 31 EUROCAT registers formed the population-based case series. Prevalence over time was estimated using multilevel Poisson regression, and heterogeneity between registers was evaluated from the random component of the intercept. Results There were 3373 CDH cases reported among 12 155 491 registered births. Of 3131 singleton cases, 353 (10.4%) were associated with a chromosomal anomaly, genetic syndrome or microdeletion, 784 (28.2%) were associated with other major structural anomalies. The male to female ratio of CDH cases overall was 1:0.69. Total prevalence was 2.3 (95% CI 2.2 to 2.4) per 10 000 births and 1.6 (95% CI 1.6 to 1.7) for isolated CDH cases. There was a small but significant increase (relative risk (per year)=1.01, 95% credible interval 1.00–1.01; p=0.030) in the prevalence of total CDH over time but there was no significant increase for isolated cases (ie, CDH cases that did not occur with any other congenital anomaly). There was significant variation in total and isolated CDH prevalence between registers. The proportion of cases that survived to 1 week was 69.3% (1392 cases) for total CDH cases and 72.7% (1107) for isolated cases. Conclusions This large population-based study found an increase in total CDH prevalence over time. CDH prevalence also varied significantly according to geographical location. No significant association was found with maternal age.
213 citations
TL;DR: Compared with term-born peers, LMPT infants are at double the risk for neurodevelopmental disability at 2 years of age, with the majority of impairments observed in the cognitive domain.
Abstract: Objective There is a paucity of data relating to neurodevelopmental outcomes in infants born late and moderately preterm (LMPT; 32 +0 –36 +6 weeks). This paper present the results of a prospective, populationbased study of 2-year outcomes following LMPT birth. Design 1130 LMPT and 1255 term-born children were recruited at birth. At 2 years corrected age, parents completed a questionnaire to assess neurosensory (vision, hearing, motor) impairments and the Parent Report of Children’s Abilities-Revised to identify cognitive impairment. Relative risks for adverse outcomes were adjusted for sex, socio-economic status and small for gestational age, and weighted to account for oversampling of term-born multiples. Risk factors for cognitive impairment were explored using multivariable analyses. Results Parents of 638 (57%) LMPT infants and 765 (62%) controls completed questionnaires. Among LMPT infants, 1.6% had neurosensory impairment compared with 0.3% of controls (RR 4.89, 95% CI 1.07 to 22.25). Cognitive impairments were the most common adverse outcome: LMPT 6.3%; controls 2.4% (RR 2.09, 95% CI 1.19 to 3.64). LMPT infants were at twice the risk for neurodevelopmental disability (RR 2.19, 95% CI 1.27 to 3.75). Independent risk factors for cognitive impairment in LMPT infants were male sex, socioeconomic disadvantage, non-white ethnicity, preeclampsia and not receiving breast milk at discharge. Conclusions Compared with term-born peers, LMPT infants are at double the risk for neurodevelopmental disability at 2 years of age, with the majority of impairments observed in the cognitive domain. Male sex, socio-economic disadvantage and preeclampsia are independent predictors of low cognitive scores following LMPT birth.
200 citations
TL;DR: Remote ischaemic postconditioning whereby endogenous brain tolerance can be activated through hypoxia/reperfusion stimuli started immediately after the index hypoxic-ischaemic insult is discussed.
Abstract: Intrapartum-related events are the third leading cause of childhood mortality worldwide and result in one million neurodisabled survivors each year. Infants exposed to a perinatal insult typically present with neonatal encephalopathy (NE). The contribution of pure hypoxia-ischaemia (HI) to NE has been debated; over the last decade, the sensitising effect of inflammation in the aetiology of NE and neurodisability is recognised. Therapeutic hypothermia is standard care for NE in high-income countries; however, its benefit in encephalopathic babies with sepsis or in those born following chorioamnionitis is unclear. It is now recognised that the phases of brain injury extend into a tertiary phase, which lasts for weeks to years after the initial insult and opens up new possibilities for therapy.There has been a recent focus on understanding endogenous neuroprotection and how to boost it or to supplement its effectors therapeutically once damage to the brain has occurred as in NE. In this review, we focus on strategies that can augment the body's own endogenous neuroprotection. We discuss in particular remote ischaemic postconditioning whereby endogenous brain tolerance can be activated through hypoxia/reperfusion stimuli started immediately after the index hypoxic-ischaemic insult. Therapeutic hypothermia, melatonin, erythropoietin and cannabinoids are examples of ways we can supplement the endogenous response to HI to obtain its full neuroprotective potential. Achieving the correct balance of interventions at the correct time in relation to the nature and stage of injury will be a significant challenge in the next decade.
167 citations
TL;DR: A gradient of increasing risk with decreasing gestation was evident, and although 60% of late preterm infants were never admitted to a NNU, 83% required medical input on postnatal wards, clinical management differed significantly between services.
Abstract: Objective To describe neonatal outcomes and explore variation in delivery of care for infants born late (34–36 weeks) and moderately (32–33 weeks) preterm (LMPT). Design/setting Prospective population-based study comprising births in four major maternity centres, one midwifery-led unit and at home between September 2009 and December 2010. Data were obtained from maternal and neonatal records. Participants All LMPT infants were eligible. A random sample of term-born infants (≥37 weeks) acted as controls. Outcome measures Neonatal unit (NNU) admission, respiratory and nutritional support, neonatal morbidities, investigations, length of stay and postnatal ward care were measured. Differences between centres were explored. Results 1146 (83%) LMPT and 1258 (79% of eligible) term-born infants were recruited. LMPT infants were significantly more likely to receive resuscitation at birth (17.5% vs 7.4%), respiratory (11.8% vs 0.9%) and nutritional support (3.5% vs 0.3%) and were less likely to be fed breast milk (64.2% vs 72.2%) than term infants. For all interventions and morbidities, a gradient of increasing risk with decreasing gestation was evident. Although 60% of late preterm infants were never admitted to a NNU, 83% required medical input on postnatal wards. Clinical management differed significantly between services. Conclusions LMPT infants place high demands on specialist neonatal services. A substantial amount of previously unreported specialist input is provided in postnatal wards, beyond normal newborn care. Appropriate expertise and planning of early care are essential if such infants are managed away from specialised neonatal settings. Further research is required to clarify optimal and cost-effective postnatal management for LMPT babies.
106 citations
TL;DR: If the infant commences breathing, aerates its lungs and increases pulmonary blood flow before the umbilical cord is clamped, then pulmonary venous return can immediately take over the supply of left ventricular preload upon cord clamping, and there is no intervening period of reduced preload and cardiac output and the large swings in arterial pressures and flows are reduced leading to a more stable circulatory transition.
Abstract: Umbilical cord clamping at birth has a major impact on an infant's cardiovascular system that varies in significance depending upon whether the infant has commenced breathing. As umbilical venous return is a major source of preload for the left ventricle during fetal life, recent experimental evidence has shown that clamping the umbilical cord severely limits cardiac venous return in the absence of pulmonary ventilation. As a result, cardiac output greatly reduces and remains low until breathing commences. Once the infant begins breathing, aeration of the lung triggers a large increase in pulmonary blood flow, which replaces umbilical venous return as the source of preload for the left ventricle. As a result, cardiac output markedly increases, as indicated by an increase in heart rate immediately after birth. Thus, infants born apnoeic and hypoxic and have their cords immediately clamped, are likely to have a restricted cardiac output combined with hypoxia. As increased cardiac output is a major physiological defence mechanism that counteracts the effects of hypoxaemia, limiting the increase in cardiac output exposes the infant to ischaemia along with hypoxia. However, if the infant commences breathing, aerates its lungs and increases pulmonary blood flow before the umbilical cord is clamped, then pulmonary venous return can immediately take over the supply of left ventricular preload upon cord clamping. As a result, there is no intervening period of reduced preload and cardiac output and the large swings in arterial pressures and flows are reduced leading to a more stable circulatory transition.
98 citations
TL;DR: It is questioned whether exposure to the risks of therapeutic interventions targeted for ductal closure is warranted since a PDA closes spontaneously in at least 73% of infants born before 28 weeks.
Abstract: Objective The persistence of the patent ductus arteriosus (PDA) is frequently encountered in very preterm infants. Neither preventive nor curative treatments of PDA have been shown to improve the outcome of these infants. Since no consensus on optimal treatment of PDA is established, we evaluated the rate of spontaneous PDA closure in infants born before 28 weeks of gestation.
Patients and methods We studied a retrospective cohort of 103 infants (gestational age 24–27 weeks) admitted to our neonatal intensive care unit from 1 June 2008 to 31 July 2010. Maternal and neonatal characteristics were collected. The PDA was defined by the persistence of ductal patency after 72 h and was followed up by regular echocardiography.
Results Twelve infants died within the first 72 h and were excluded from the analysis. Among 91 infants analysed, 8 (9%) closed their ductus arteriosus before 72 h and the ductus could not be determined patent in 13. Of the 70 infants with a PDA still persistent, one underwent surgical ligation and echocardiography showed spontaneous closure in 51 (73%) of them. In the remaining 18 infants, the date of PDA closure could not be determined either because of their death (n=11) or due to discharge (n=7). Overall, a spontaneous closure of the ductus arteriosus was observed in 59 of the 91 infants.
Conclusions We have to question whether exposure to the risks of therapeutic interventions targeted for ductal closure is warranted since a PDA closes spontaneously in at least 73% of infants born before 28 weeks.
92 citations
TL;DR: Hypotension during the first 24 h of life is associated with adverse outcomes in VLBW infants and underlines the need for randomised controlled trials on the use of vasoactive drugs in this vulnerable patient cohort.
Abstract: Objective To evaluate lowest mean arterial blood pressure during the first 24 h of life (minMAP 24 ) in verylow-birthweight (VLBW) infants and to identify associations between hypotension and short-term outcome. Design Retrospective cohort analysis of the minMAP 24 of 4907 VLBW infants with a gestational age <32 weeks in correlation with clinical data. Hypotension was defined as minMAP 24 being lower than the median value of all patients of the same gestational age. Results MinMAP 24 values correlated with gestational age. Median minMAP 24 values of VLBW infants ≤29 weeks’ gestation were 1–2 mm Hg lower than gestational age in completed weeks. Hypotensive infants had a higher rate of intraventricular haemorrhage (IVH, 20.3% vs 15.9%, p<0.001), bronchopulmonary dysplasia (BPD, 19.2% vs 15.1%, p<0.001) and death (5.2% vs 3.0%, p<0.001). Multivariate logistic regression analyses, including potential confounders, confirmed these data. MinMAP 24 was an independent risk factor for IVH (OR 0.97/mm Hg, 95% CI 0.96 to 0.99, p=0.003), BPD (OR 0.96/mm Hg, 95% CI 0.94 to 0.98, p<0.001) and mortality (OR 0.94/mm Hg, 95% CI 0.90 to 0.98, p=0.003). Conclusions Hypotension during the first 24 h of life is associated with adverse outcomes in VLBW infants. This underlines the need for randomised controlled trials on the use of vasoactive drugs in this vulnerable patient cohort.
85 citations
TL;DR: Compared with IPPV, preterm infants initially treated with SI at birth required less mechanical ventilation with no improvement in the rate of BPD and/or death, and should be restricted to randomised trials until future studies demonstrate the efficacy and safety of this lung aeration manoeuvre.
Abstract: Context Sustained inflation (SI) has been advocated as an alternative to intermittent positive pressure ventilation (IPPV) during the resuscitation of neonates at birth, to facilitate the early development of an effective functional residual capacity, reduce atelectotrauma and improve oxygenation after the birth of preterm infants. Objective The primary aim was to review the available literature on the use of SI compared with IPPV at birth in preterm infants for major neonatal outcomes, including bronchopulmonary dysplasia (BPD) and death. Data source MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials, until 6 October 2014. Study selection Randomised clinical trials comparing the effects of SI with IPPV at birth in preterm infants for neonatal outcomes. Data extraction and synthesis Descriptive and quantitative information was extracted; data were pooled using a random effects model. Heterogeneity was assessed using the Q statistic and I 2 . Results Pooled analysis showed significant reduction in the need for mechanical ventilation within 72 h after birth (relative risk (RR) 0.87 (0.77 to 0.97), absolute risk reduction (ARR) −0.10 (−0.17 to −0.03), number needed to treat 10) in preterm infants treated with an initial SI compared with IPPV. However, significantly more infants treated with SI received treatment for patent ductus arteriosus (RR 1.27 (1.05 to 1.54), ARR 0.10 (0.03 to 0.16), number needed to harm 10). There were no differences in BPD, death at the latest follow-up and the combined outcome of death or BPD among survivors between the groups. Conclusions Compared with IPPV, preterm infants initially treated with SI at birth required less mechanical ventilation with no improvement in the rate of BPD and/or death. The use of SI should be restricted to randomised trials until future studies demonstrate the efficacy and safety of this lung aeration manoeuvre.
84 citations
TL;DR: Flow-SNIPPV seems more effective than NIPPV and NCPAP in reducing the incidence of desaturations, bradycardias and central apnoea episodes in preterm infants.
Abstract: Background Apnoea, desaturations and bradycardias are common problems in preterm infants which can be treated with nasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV). It is unclear whether synchronised NIPPV (SNIPPV) would be even more effective. Objective To assess the effects of flow-SNIPPV, NIPPV and NCPAP on the rate of desaturations and bradycardias in preterm infants and, secondarily, to evaluate their influence on pattern of breathing and gas exchange. Patients and methods Nineteen infants (mean gestational age at study 30 weeks, 9 boys) with apnoeic spells were enrolled in a randomised controlled trial with a cross-over design. They received flow-SNIPPV, NIPPV and NCPAP for 4 h each. All modes were provided by a nasal conventional ventilator able to provide synchronisation by a pneumotachograph. The primary outcome was the event rate of desaturations (≤80% arterial oxygen saturation) and bradycardias (≤80 bpm) per hour, obtained from cardiorespiratory recordings. The incidence of central apnoeas (≥10 s) as well as baseline heart rate, FiO 2 , SpO 2 , transcutaneous blood gases and respiratory rate were also evaluated. Results The median event rate per hour during flow-SNIPPV, NIPPV and NCPAP was 2.9, 6.1 and 5.9, respectively (p Conclusions Flow-SNIPPV seems more effective than NIPPV and NCPAP in reducing the incidence of desaturations, bradycardias and central apnoea episodes in preterm infants.
76 citations
TL;DR: There was a lack of consensus on the time frame for definition of extubation failure (EF), the majority proposing a period between 24 and 72 h; 43% believed that EF is an independent risk factor for increased mortality and morbidity.
Abstract: Objective To determine periextubation practices in extremely preterm infants ( Design A survey consisting of 13 questions related to weaning from mechanical ventilation, assessment of extubation readiness and postextubation respiratory support was developed and sent to clinical directors of level III NICUs in Australia, Canada, Ireland, New Zealand and USA. A descriptive analysis of the results was performed. Results 112/162 (69%) units responded; 36% reported having a guideline (31%) or written protocol (5%) for ventilator weaning. Extubation readiness was assessed based on ventilatory settings (98%), blood gases (92%) and the presence of clinical stability (86%). Only 54% ensured that infants received caffeine ≤24 h prior to extubation. 16% of units systematically extubated infants on the premise that they passed a Spontaneous Breathing Test with a duration ranging from 3 min (25%) to more than 10 min (35%). Nasal continuous positive airway pressure was the most common type of respiratory support used (84%) followed by nasal intermittent positive pressure ventilation (55%) and high-flow nasal cannula (33%). Reintubation was mainly based on clinical judgement of the responsible physician (88%). There was a lack of consensus on the time frame for definition of extubation failure (EF), the majority proposing a period between 24 and 72 h; 43% believed that EF is an independent risk factor for increased mortality and morbidity. Conclusions Periextubation practices vary considerably; decisions are frequently physician dependent and not evidence based. The definition of EF is variable and well-defined criteria for reintubation are rarely used. High-quality trials are required to inform guidelines and standardise periextubation practices.
TL;DR: VP/VLBW birth poses an important risk for a global withdrawn personality, as indicated by being less socially engaged, low in taking risks, poor in communication (autistic features), and easily worried (neuroticism).
Abstract: Objectives To examine very preterm (gestational age at birth Design The Bavarian Longitudinal Study is a geographically defined prospective cohort study of neonatal at-risk children born in 1985/1986 in Germany. A total of 200 VP/VLBW and 197 controls completed main outcome measures including broad autism phenotype, personality traits (eg, introversion, neuroticism), and risk taking at 26 years of age. Results When compared with term controls, VP/VLBW adults scored significantly higher in autistic features, introversion and neuroticism but not in conscientiousness and closeness scales. They also reported lower risk taking. Profile analysis showed higher introversion, autistic features and neuroticism and lower risk taking as unique features of VP/VLBW adults (F within-group =0.81, ns; F between-group =49.56, p 2 =12.49, df=7, ns; comparative fit index=0.98). VP/VLBW birth significantly predicted the profile factor (β=0.33, p Conclusions VP/VLBW birth poses an important risk for a global withdrawn personality, as indicated by being less socially engaged (introversion), low in taking risks, poor in communication (autistic features) and easily worried (neuroticism). This profile might help to explain the social difficulties VP/VLBW individuals experience in adult roles, such as in peer/partner relationships and career.
TL;DR: The BTAT provides an objective, clear and simple measure of the severity of a tongue-tie, to inform selection of infants for frenotomy and to monitor the effect of the procedure.
Abstract: Aim To produce a simple tool with good transferability to provide a consistent assessment of tongue appearance and function in infants with tongue-tie. Methods The Bristol Tongue Assessment Tool (BTAT) was developed based on clinical practice and with reference to the Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF). This paper documents 224 tongue assessments using the BTAT. There were 126 tongue assessments recorded using the BTAT and ATLFF tools to facilitate comparisons between them. Paired BTAT assessments were obtained from eight midwives who were using the new assessment tool. Results There was acceptable internal reliability for the four-item BTAT (Cronbach9s α=0.708) and the eight midwives who used it showed good correlation in the consistency of its use (ICC=0.760). The BTAT showed a strong and significant correlation (0.89) with the ATLFF, indicating that the simpler BTAT could be used in place of the more detailed assessment tool to score the extent of a tongue-tie. Midwives found it quick and easy to use and felt that it would be easy to teach to others. Conclusions The BTAT provides an objective, clear and simple measure of the severity of a tongue-tie, to inform selection of infants for frenotomy and to monitor the effect of the procedure.
TL;DR: The effects of prematurity and ROP are presented as regional and global estimates of acute-phase ROP and the consequent mild/moderate and severe visual impairment and the impact on visual functions is considered.
Abstract: The preterm baby may develop ophthalmic sequelae which can be due to prematurity per se, due to retinopathy of prematurity (ROP) or due to neurological damage. Focusing on the former two, we discuss how in high-income countries the risk of sight-threatening ROP is largely confined to babies <1000 g birth weight (BW), whereas in low-income or middle-income countries babies exceeding 2500 g BW can be blinded. The effects of prematurity and ROP are presented as regional and global estimates of acute-phase ROP and the consequent mild/moderate and severe visual impairment. We discuss sequelae and how they affect the eye and its shape, strabismus and finally consider their impact on visual functions, including visual acuity, the visual field, colour vision and contrast sensitivity.
TL;DR: This review focuses on how these biomarkers can be used in real-life clinical settings for daily surveillance, bedside point-of-care testing, early diagnosis and predicting the severity and prognosis of neonatal sepsis/NEC.
Abstract: Biomarkers have been used to differentiate systemic neonatal infection and necrotising enterocolitis (NEC) from other non-infective neonatal conditions that share similar clinical features. With increasing understanding in biochemical characteristics of different categories of biomarkers, a specific mediator or a panel of mediators have been used in different aspects of clinical management in neonatal sepsis/NEC. This review focuses on how these biomarkers can be used in real-life clinical settings for daily surveillance, bedside point-of-care testing, early diagnosis and predicting the severity and prognosis of neonatal sepsis/NEC. In addition, with recent development of 'multi-omic' approaches and rapid advancement in knowledge of bioinformatics, more novel biomarkers and unique signatures of mediators would be discovered for diagnosis of specific diseases and organ injuries.
TL;DR: In this article, the authors compared non-invasive ventilation neurally adjusted ventilatory assist (NIV-NAVA) and NIV-PS in preterm infants on patient-ventilator synchrony.
Abstract: Objective To compare non-invasive ventilation neurally adjusted ventilatory assist (NIV-NAVA) and non-invasive pressure support (NIV-PS) in preterm infants on patient–ventilator synchrony. Design A randomised phase II crossover trial. Setting Neonatal intensive care units of two tertiary university hospitals in Korea. Patients Preterm infants born Intervention NIV-NAVA and NIV-PS were applied in random order after ventilator weaning. Data were recorded for sequential 5 min periods after 10 min applications of each mode. Main outcome measures The electrical activity of the diaphragm (Edi), ventilator flow and pressure curves were compared to examine the trigger delay (primary outcome) and other parameters of patient–ventilator interaction (secondary outcomes) for each period. Results Fifteen infants completed the protocol. Trigger delay (35.2±8.3 vs 294.6±101.9 ms, p 2 O, p=0.003) were also lower during NIV-NAVA. The main asynchrony events during NIV-PS were ineffective efforts and autotriggering. All types of asynchronies except double triggering were reduced with NIV-NAVA. Asynchrony index was significantly lower during NIV-NAVA compared with NIV-PS (p Conclusions NAVA improved patient–ventilator synchrony and diaphragmatic unloading in preterm infants during non-invasive nasal ventilation even in the presence of large air leaks. Trial registration number Registered with http://www.clinicaltrials.gov (NCT01877720).
TL;DR: Diagnostic dilemmas are discussed in this review, and suggestions offered for practical management while awaiting a more rapidly available ‘gold standard’ test.
Abstract: Early onset neonatal sepsis is persistently associated with poor outcomes, and incites clinical practice based on the fear of missing a treatable infection in a timely fashion. Unnecessary exposure to antibiotics is also hazardous. Diagnostic dilemmas are discussed in this review, and suggestions offered for practical management while awaiting a more rapidly available 'gold standard' test; in an ideal world, this test would be 100% sensitive and 100% specific for the presence of organisms.
TL;DR: The neonates of the IVH group showed significantly lower crSO2 values during the immediate transition, although there was no difference concerning SpO2 and HR.
Abstract: Objectives To investigate the occurrence of peri/ intraventricular haemorrhage (P/IVH) in preterm infants and its potential association with cerebral regional oxygen saturation (crSO2) during the immediate transition. Methods In this two-centre prospective observational cohort study, crSO2 was measured with near-infrared spectroscopy in preterm infants (<32 weeks of gestational age) during the immediate neonatal transition (15 min). In addition, arterial oxygen saturation (SpO2) and heart rate (HR) were monitored with pulse oximetry. Cranial ultrasound scans were performed on day 4, day 7 and day 14 after birth and before discharge. Neonates with IVH of any grade (IVH group) were matched to the neonates without IVH (Non-IVH group) on gestational age (±1 week) and birth weight (±100 g). The duration and magnitude of deviation from the 10th centile in crSO2 during immediate transition was analysed and expressed in %minutes. Results IVH was found in 12 of the included neonates, who were matched to 12 neonates without IVH. There was no difference in SpO2 and HR between these two groups. The duration and magnitude of centiles-deviation of crSO2 was significantly pronounced in the IVH group compared with the Non-IVH group (1870%min vs 456%min). Conclusions The neonates of the IVH group showed significantly lower crSO2 values during the immediate transition, although there was no difference concerning SpO2 and HR. The additional monitoring of crSO2 during the immediate transition could reveal neonates with higher risk of developing an IVH later in the course.
TL;DR: Repeat CRP led to further investigations, increased LPs and longer durations of treatment and stay, which impacted on workload and cost, and influenced parental experience in the first few days of life.
Abstract: Background In August 2012, new national guidance (National Institute of Health and Care Excellence (NICE) CG149) for management of early onset sepsis (EOS) was introduced in the UK. The guidance outlined a consistent approach for septic screens in newborn infants based on risk factors, and suggested biochemical and clinical parameters to guide management. In particular, it advised a second C-reactive protein level (CRP) 18–24 h into treatment to help determine length of antibiotic course, need for lumbar puncture (LP), and suggested review of blood culture at 36 h. Objective We evaluated impact of this guidance in our neonatal unit. Methods We compared two time periods, before and following the guidance. We evaluated length of stay, second CRP 18–24 h into treatment, percentage of babies having LP and duration of antibiotics. Results Before NICE guidance, 38.1% of screened babies stayed 5 days, which increased to 27.7% following NICE recommendations. Repeat CRP measurements increased from 45% to 97%. In 58% of these babies, repeat CRPs influenced management and hospital stay. An increase in LPs performed from 14% to 23% was noted. There were no positive blood cultures or LP results. Conclusions We envisaged shorter hospital stays with new NICE standards, particularly, with the aim of 36 h blood culture reporting. However, repeat CRP led to further investigations, increased LPs and longer durations of treatment and stay. This, in turn, impacted on workload and cost, and influenced parental experience in the first few days of life.
TL;DR: Recent studies investigating cerebral oxygenation targeted treatment, and defining optimal blood pressure based on an assessment of cerebrovascular reactivity, suggest ways in which near-infrared spectroscopy technology may yet be clinically useful.
Abstract: Near-infrared spectroscopy (NIRS) has been used to study cerebral haemodynamics and oxygenation in the preterm infant for many years, but its use as a clinical tool has remained elusive. This has partly been due to the challenges of providing a continuous quantitative measurement that is valid and reliable, as well as demonstrating that interventions based on NIRS measurements improve clinical outcome. Recent studies investigating cerebral oxygenation targeted treatment, and defining optimal blood pressure based on an assessment of cerebrovascular reactivity, suggest ways in which this technology may yet be clinically useful.
TL;DR: Describing cause-specific neonatal mortality in rural areas of Malawi, Bangladesh, Nepal and rural and urban India using verbal autopsy (VA) data shows population-based VA methods can fill information gaps on the burden and causes of neonatal deaths in resource-poor and data-poor settings.
Abstract: Objective Understanding the causes of death is key to tackling the burden of three million annual neonatal deaths. Resource-poor settings lack effective vital registration systems for births, deaths and causes of death. We set out to describe cause-specific neonatal mortality in rural areas of Malawi, Bangladesh, Nepal and rural and urban India using verbal autopsy (VA) data. Design We prospectively recorded births, neonatal deaths and stillbirths in seven population surveillance sites. VAs were carried out to ascertain cause of death. We applied descriptive epidemiological techniques and the InterVA method to characterise the burden, timing and causes of neonatal mortality at each site. Results Analysis included 3772 neonatal deaths and 3256 stillbirths. Between 63% and 82% of neonatal deaths occurred in the first week of life, and males were more likely to die than females. Prematurity, birth asphyxia and infections accounted for most neonatal deaths, but important subnational and regional differences were observed. More than one-third of deaths in urban India were attributed to asphyxia, making it the leading cause of death in this setting. Conclusions Population-based VA methods can fill information gaps on the burden and causes of neonatal mortality in resource-poor and data-poor settings. Local data should be used to inform and monitor the implementation of interventions to improve newborn health. High rates of home births demand a particular focus on community interventions to improve hygienic delivery and essential newborn care.
TL;DR: Although poor, the outcome for infants with an Apgar of 0 at 10 min of life has improved substantially in recent years and may be related to treatment with hypothermia, enhanced resuscitation techniques and/or other supportive management.
Abstract: Objective Asystole at birth and extending through 10 min is rare, with current international recommendations stating it may be appropriate to consider discontinuation of resuscitation in this clinical scenario. These recommendations are based on small case series of both term and preterm infants, where death or abnormal outcome was nearly universal. Study objective was to determine recent outcome of infants with an Apgar score of 0 at 10 min despite cardiopulmonary resuscitation, treated with therapeutic hypothermia or standard treatment, in randomised cooling studies. Design Outcome studies of infants with an Apgar of 0 at 10 min subsequently resuscitated and treated with hypothermia or standard treatment were reviewed and combined with local outcome data of infants treated with hypothermia. Results Four recent studies (n=81) and local data (n=9) yielded a total of 90 infants with an Apgar of 0 at 10 min, with 56 treated with hypothermia and 34 controls. Primary outcome of death or abnormal neurodevelopmental outcome (18–24 months) occurred in 73% cooled and 79.5% normothermic infants (p=0.61). Implications Although poor, the outcome for infants with an Apgar of 0 at 10 min of life has improved substantially in recent years. This may be related to treatment with hypothermia, enhanced resuscitation techniques and/or other supportive management. Current recommendations to consider discontinuation of resuscitation without a detectable heart rate at 10 min should consider these findings.
TL;DR: Infants treated with octreotide or somatostatin had similar outcomes compared with those not treated, and CCT seems to have a favourable prognosis if not associated with genetic disorders.
Abstract: Background Congenital chylothorax (CCT) is a rare disease of unknown aetiology. Treatment approaches vary; none has been evaluated prospectively. Objective To prospectively determine incidence, treatment and outcome of infants with CCT born in Germany in 2012. Design CCT was defined as non-traumatic chylous pleural effusion within 28 days after birth. As part of the Surveillance Unit for Rare Pediatric Conditions in Germany (Erhebungseinheit fur seltene padiatrische Erkrankungen in Deutschland), all paediatric departments (n=432) received monthly reporting cards to notify the study centre of CCT cases, which were analysed based on anonymised questionnaires and discharge summaries. Data are shown as median (range) or n/N. Results Of 37 cases reported, 28 met inclusion criteria. Questionnaires and/or discharge summaries were available for 27/28. Assuming complete reporting, the incidence of CCT was 1:24 000. Nine infants suffered from proven or suspected syndromal anomalies, most frequently Noonan syndrome (5/9). Postnatally, 23 required mechanical ventilation, 3 continuous positive airway pressure; only 1 had no respiratory support. 17 infants were treated with inotropes/vasopressors, 25 required pleural drainage for 11 (1–36) days. In 13 infants, enteral feeds were withheld initially; 25 received medium-chain triglyceride diet at some time, 9 were treated with octreotide or somatostatin. 18 infants survived without, 6 with sequelae attributable to the underlying disorder; 3 infants died (median age at death 37 (2–144) days). Duration of hospital stay in survivors was 51 (20–127) days. Infants treated with octreotide or somatostatin had similar outcomes compared with those not treated. Conclusions Based on this small observational study, CCT seems to have a favourable prognosis if not associated with genetic disorders.
TL;DR: A cost analysis of targeted screening and subsequent treatment for cCMV-related sensorineural hearing loss in an, otherwise, asymptomatic infant from the perspective of the UK National Health Service shows an estimate of cost per case that compares favourably with other screening programmes.
Abstract: Background Congenital cytomegalovirus (cCMV) is an important cause of childhood deafness, which is modifiable if diagnosed within the first month of life. Targeted screening of infants who do not pass their newborn hearing screening tests in England is a feasible approach to identify and treat cases to improve hearing outcome. Aims To conduct a cost analysis of targeted screening and subsequent treatment for cCMV-related sensorineural hearing loss (SNHL) in an, otherwise, asymptomatic infant, from the perspective of the UK National Health Service (NHS). Methods Using data from the newborn hearing screening programme (NHSP) in England and a recent study of targeted screening for cCMV using salivary swabs within the NHSP, we estimate the cost (in UK pounds (£)) to the NHS. The cost of screening (time, swabs and PCR), assessing, treating and following up cases is calculated. The cost per case of preventing hearing deterioration secondary to cCMV with targeted screening is calculated. Results The cost of identifying, assessing and treating a case of cCMV-related SNHL through targeted cCMV screening is estimated to be £6683. The cost of improving hearing outcome for an infant with cCMV-related SNHL through targeted screening and treatment is estimated at £14 202. Conclusions The costs of targeted screening for cCMV using salivary swabs integrated within NHSP resulted in an estimate of cost per case that compares favourably with other screening programmes. This could be used in future studies to estimate the full economic value in terms of incremental costs and incremental health benefits.
TL;DR: Higher PaCO2 was an independent predictor of sIVH/death, BPD/death and NDI/ death and further trials are needed to evaluate optimal PaCO1 targets for high-risk infants.
Abstract: Objective To determine the association of arterial partial pressure of carbon dioxide PaCO 2 with severe intraventricular haemorrhage (sIVH), bronchopulmonary dysplasia (BPD), and neurodevelopmental impairment (NDI) at 18–22 months in premature infants. Design Secondary exploratory data analysis of Surfactant, Positive Pressure, and Oxygenation Randomised Trial (SUPPORT). Setting Multiple referral neonatal intensive care units. Patients 1316 infants 24 0/7 to 27 6/7 weeks gestation randomised to different oxygenation (SpO 2 target 85–89% vs 91–95%) and ventilation strategies. Main outcome measures Blood gases from postnatal day 0 to day14 were analysed. Five PaCO 2 variables were defined: minimum (Min), maximum (Max), SD, average (time-weighted), and a four level categorical variable (hypercapnic (highest quartile of Max PaCO 2 ), hypocapnic (lowest quartile of Min PaCO 2 ), fluctuators (hypercapnia and hypocapnia), and normocapnic (middle two quartiles of Max and Min PaCO 2 )). PaCO 2 variables were compared for infants with and without sIVH, BPD and NDI (±death). Multivariable logistic regression models were developed for adjusted results. Results sIVH, BPD and NDI (±death) were associated with hypercapnic infants and fluctuators. Association of Max PaCO 2 and outcomes persisted after adjustment (per 10 mm Hg increase: sIVH/death: OR 1.27 (1.13 to 1.41); BPD/death: OR 1.27 (1.12 to 1.44); NDI/death: OR 1.23 (1.10 to 1.38), death: OR 1.27 (1.12 to 1.44), all p 2 category and SpO 2 treatment group for sIVH/death, NDI/death or death. Max PaCO 2 was positively correlated with maximum FiO 2 (r s 0.55, p s 0.61, p Conclusions Higher PaCO 2 was an independent predictor of sIVH/death, BPD/death and NDI/death. Further trials are needed to evaluate optimal PaCO 2 targets for high-risk infants.
TL;DR: Evidence on optimal IH treatment in preterms is lacking despite their high incidence, and topical treatment without systemic side effects like cryotherapy is an attractive alternative at an early growth stage.
Abstract: Infantile haemangioma (IH) are vascular tumours with a unique growth dynamic, mostly absent at birth, growth in the first months followed by involution over several years, often resulting in residual skin changes. Immune-histologically, IH cells are exclusively glucose transporter protein-1 positive.The incidence of IH is increasing with decreasing gestational age, from 1–4% in term infants to 23% in those of
TL;DR: Following the update of the JRC guidelines on neonatal resuscitation, an increased use of CPAP via face mask was observed, which was associated with a higher prevalence of pulmonary air leak in early-term neonates in the authors' centre.
Abstract: Objective The Japan Resuscitation Council (JRC) Guidelines 2010 for neonatal resuscitation introduced continuous positive airway pressure (CPAP) in delivery room. The present study evaluated the effect of CPAP for pulmonary air leak at term birth. Design, setting and patients This retrospective single-centre study used the data of term neonates who were born without major congenital anomalies at our centre between 2008 and 2009, and between 2011 and 2012. Interventions Resuscitation according to the JRC Guidelines 2010. Main outcome measures We examined the association between the JRC Guidelines 2010, CPAP by face mask and pulmonary air leak. Results A total of 5038 infants were analysed. The frequency of CPAP by face mask increased after the update of the JRC Guidelines in 2010 (1.7% vs 11.1%; p<0.001). Pulmonary air leak increased at early term (37 weeks: 1.0% vs 3.5%, p=0.02; 38 weeks: 0.7% vs 2.2%, p=0.02). While adjusting for confounders, the JRC Guidelines 2010 was associated with pulmonary air leak in early-term neonates (37 weeks: adjusted OR (aOR) 4.37; 95% CI 1.40 to 17.45; 38 weeks: aOR 2.80; 95% CI 1.04 to 8.91), but this association disappeared while adjusting for face mask CPAP additionally (37 weeks: aOR 1.90; 95% CI 0.47 to 8.71; 38 weeks: aOR 1.66; 95% CI 0.54 to 5.77). Conclusions Following the update of the JRC guidelines on neonatal resuscitation, we observed an increased use of CPAP via face mask, which was associated with a higher prevalence of pulmonary air leak in early-term neonates in our centre.
TL;DR: The IDF approach was associated with significant reduction in time to full feeds and discharge, an effect that was most pronounced in infants >28 weeks GA, and the downstream benefits included provider and parent satisfaction.
Abstract: Background Many neonatal units are adopting developmentally appropriate feeding practices such as cue-based or infant-driven feeding (IDF). There have been limited studies examining the clinical benefit of this approach. Methods A quality improvement initiative was undertaken to introduce an IDF protocol for premature infants 6/7 and 32–33 6/7 weeks gestation. A questionnaire assessed provider9s acceptance of the plan. Results The PMA at full nipple feeds and at discharge was significantly lower in the IDF than PDF group. Infants 6/7 weeks GA reached full nipple feeds 11 days sooner and were discharged 9 days earlier in the IDF versus PDF group. Babies 32–33 6/7 weeks GA reached full nipple feeds 3 days sooner and were discharged 3 days earlier in the IDF versus PDF group. Providers viewed the implementation of the plan favourably. Conclusions The IDF approach was associated with significant reduction in time to full feeds and discharge, an effect that was most pronounced in infants >28 weeks GA. The downstream benefits included provider and parent satisfaction.
TL;DR: The results of this study might support developing a nursing research strategy for the nursing section of the European Society of Paediatric and Neonatal Intensive Care and promote more European researcher collaboratives for neonatal nursing research.
Abstract: Objective This study aimed to identify and prioritise neonatal intensive care nursing research topics across Europe using an e-Delphi technique. Design An e-Delphi technique with three questionnaire rounds was performed. Qualitative responses of round one were analysed by content analysis and research statements were generated to be ranged on importance on a scale of 1–6 (not important to most important). Setting Neonatal intensive care units (NICUs) in 17 European countries. Population NICU clinical nurses, managers, educators and researchers (n=75). Intervention None. Main outcome measures A list of 43 research statements in eight domains. Results The six highest ranking statements (≥5.0 mean score) were related to prevention and reduction of pain (mean 5.49; SD 1.07), medication errors (mean 5.20; SD 1.13), end-of-life care (mean 5.05; SD 1.18), needs of parents and family (mean 5.04; SD 1.23), implementing evidence into nursing practice (mean 5.02; SD 1.03), and pain assessment (mean 5.02; SD 1.11). The research domains were prioritised and ranked: (1) pain and stress; (2) family centred care; (3) clinical nursing care practices; (4) quality and safety; (5) ethics; (6) respiratory and ventilation; (7) infection and inflammation; and (8) professional issues in neonatal intensive care nursing. Conclusions The results of this study might support developing a nursing research strategy for the nursing section of the European Society of Paediatric and Neonatal Intensive Care. In addition, this may promote more European researcher collaboratives for neonatal nursing research.
TL;DR: Maternal treatment with allopurinol during fetal hypoxia did not significantly lower neuronal damage markers in cord blood, but post hoc analysis revealed a potential beneficial treatment effect in girls.
Abstract: Objective To determine whether maternal allopurinol treatment during suspected fetal hypoxia would reduce the release of biomarkers associated with neonatal brain damage. Design A randomised double-blind placebo controlled multicentre trial. Patients We studied women in labour at term with clinical indices of fetal hypoxia, prompting immediate delivery. Setting Delivery rooms of 11 Dutch hospitals. Intervention When immediate delivery was foreseen based on suspected fetal hypoxia, women were allocated to receive allopurinol 500 mg intravenous (ALLO) or placebo intravenous (CONT). Main outcome measures Primary endpoint was the difference in cord S100s, a tissue-specific biomarker for brain damage. Results 222 women were randomised to receive allopurinol (ALLO, n=111) or placebo (CONT, n=111). Cord S100s was not significantly different between the two groups: 44.5 pg/mL (IQR 20.2–71.4) in the ALLO group versus 54.9 pg/mL (IQR 26.8–94.7) in the CONT group (difference in median −7.69 (95% CI −24.9 to 9.52)). Post hoc subgroup analysis showed a potential treatment effect of allopurinol on the proportion of infants with a cord S100s value above the 75th percentile in girls (ALLO n=5 (12%) vs CONT n=10 (31%); risk ratio (RR) 0.37 (95% CI 0.14 to 0.99)) but not in boys (ALLO n=18 (32%) vs CONT n=15 (25%); RR 1.4 (95% CI 0.84 to 2.3)). Also, cord neuroketal levels were significantly lower in girls treated with allopurinol as compared with placebo treated girls: 18.0 pg/mL (95% CI 12.1 to 26.9) in the ALLO group versus 32.2 pg/mL (95% CI 22.7 to 45.7) in the CONT group (geometric mean difference −16.4 (95% CI −24.6 to −1.64)). Conclusions Maternal treatment with allopurinol during fetal hypoxia did not significantly lower neuronal damage markers in cord blood. Post hoc analysis revealed a potential beneficial treatment effect in girls. Trial registration number NCT00189007, Dutch Trial Register NTR1383.