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Mižíková I, Thébaud B. Perinatal origins of bronchopulmonary dysplasia-deciphering normal and impaired lung development cell by cell. Mol Cell Pediatr 2023; 10:4. [PMID: 37072570 PMCID: PMC10113423 DOI: 10.1186/s40348-023-00158-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/26/2023] [Indexed: 04/20/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a multifactorial disease occurring as a consequence of premature birth, as well as antenatal and postnatal injury to the developing lung. BPD morbidity and severity depend on a complex interplay between prenatal and postnatal inflammation, mechanical ventilation, and oxygen therapy as well as associated prematurity-related complications. These initial hits result in ill-explored aberrant immune and reparative response, activation of pro-fibrotic and anti-angiogenic factors, which further perpetuate the injury. Histologically, the disease presents primarily by impaired lung development and an arrest in lung microvascular maturation. Consequently, BPD leads to respiratory complications beyond the neonatal period and may result in premature aging of the lung. While the numerous prenatal and postnatal stimuli contributing to BPD pathogenesis are relatively well known, the specific cell populations driving the injury, as well as underlying mechanisms are still not well understood. Recently, an effort to gain a more detailed insight into the cellular composition of the developing lung and its progenitor populations has unfold. Here, we provide an overview of the current knowledge regarding perinatal origin of BPD and discuss underlying mechanisms, as well as novel approaches to study the perturbed lung development.
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Affiliation(s)
- I Mižíková
- Experimental Pulmonology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - B Thébaud
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Pediatrics, Children's Hospital of Eastern Ontario (CHEO), CHEO Research Institute, University of Ottawa, Ottawa, ON, Canada
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Mitra S, de Boode WP, Weisz DE, Shah PS. Interventions for patent ductus arteriosus (PDA) in preterm infants: an overview of Cochrane Systematic Reviews. Cochrane Database Syst Rev 2023; 4:CD013588. [PMID: 37039501 PMCID: PMC10091483 DOI: 10.1002/14651858.cd013588.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is associated with significant morbidity and mortality in preterm infants. Several non-pharmacological, pharmacological, and surgical approaches have been explored to prevent or treat a PDA. OBJECTIVES To summarise Cochrane Neonatal evidence on interventions (pharmacological or surgical) for the prevention of PDA and related complications, and interventions for the management of asymptomatic and symptomatic PDA in preterm infants. METHODS We searched the Cochrane Database of Systematic Reviews on 20 October 2022 for ongoing and published Cochrane Reviews on the prevention and treatment of PDA in preterm (< 37 weeks' gestation) or low birthweight (< 2500 g) infants. We included all published Cochrane Reviews assessing the following categories of interventions: pharmacological therapy using prostaglandin inhibitor drugs (indomethacin, ibuprofen, and acetaminophen), adjunctive pharmacological interventions, invasive PDA closure procedures, and non-pharmacological interventions. Two overview authors independently checked the eligibility of the reviews retrieved by the search, and extracted data from the included reviews using a predefined data extraction form. Any disagreements were resolved by discussion with a third overview author. Two overview authors independently assessed the methodological quality of the included reviews using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) tool. We reported the GRADE certainty of evidence as assessed by the respective review authors using summary of findings tables. MAIN RESULTS We included 16 Cochrane Reviews, corresponding to 138 randomised clinical trials (RCT) and 11,856 preterm infants, on the prevention and treatment of PDA in preterm infants. One of the 16 reviews had no included studies, and therefore, did not contribute to the results. Six reviews reported on prophylactic interventions for the prevention of PDA and included pharmacological prophylaxis with prostaglandin inhibitor drugs, prophylactic surgical PDA ligation, and non-pharmacologic interventions (chest shielding during phototherapy and restriction of fluid intake); one review reported on the use of indomethacin for the management of asymptomatic PDA; nine reviews reported on interventions for the management of symptomatic PDA, and included pharmacotherapy with prostaglandin inhibitor drugs in various routes and dosages, surgical PDA ligation, and adjunct therapies (use of furosemide and dopamine in conjunction with indomethacin). The quality of reviews varied. Two reviews were assessed to be high quality, seven reviews were of moderate quality, five of low quality, while two reviews were deemed to be of critically low quality. For prevention of PDA, prophylactic indomethacin reduces severe intraventricular haemorrhage (IVH; relative risk (RR) 0.66, 95% confidence interval (CI) 0.53 to 0.82; 14 RCTs, 2588 infants), and the need for invasive PDA closure (RR 0.51, 95% CI 0.37 to 0.71; 8 RCTs, 1791 infants), but it does not appear to affect the composite outcome of death or moderate/severe neurodevelopmental disability (RR 1.02, 95% CI 0.90 to 1.15; 3 RCTs, 1491 infants). Prophylactic ibuprofen probably marginally reduces severe IVH (RR 0.67, 95% CI 0.45 to 1.00; 7 RCTs, 925 infants; moderate-certainty evidence), and the need for invasive PDA closure (RR 0.46, 95% CI 0.22 to 0.96; 7 RCTs, 925 infants; moderate-certainty evidence). The evidence is very uncertain on the effect of prophylactic acetaminophen on severe IVH (RR 1.09, 95% CI 0.07 to 16.39; 1 RCT, 48 infants). Necrotising enterocolitis (NEC) was lower with both prophylactic surgical ligation (RR 0.25, 95% CI 0.08 to 0.83; 1 RCT, 84 infants), and fluid restriction (RR 0.43, 95% CI 0.21 to 0.87; 4 RCTs, 526 infants). For treatment of asymptomatic PDA, indomethacin appears to reduce the development of symptomatic PDA post-treatment (RR 0.36, 95% CI 0.19 to 0.68; 3 RCTs, 97 infants; quality of source review: critically low). For treatment of symptomatic PDA, all available prostaglandin inhibitor drugs appear to be more effective in closing a PDA than placebo or no treatment (indomethacin: RR 0.30, 95% CI 0.23 to 0.38; 10 RCTs, 654 infants; high-certainty evidence; ibuprofen: RR 0.62, 95% CI 0.44 to 0.86; 2 RCTs, 206 infants; moderate-certainty evidence; early administration of acetaminophen: RR 0.35, 95% CI 0.23 to 0.53; 2 RCTs, 127 infants; low-certainty evidence). Oral ibuprofen appears to be more effective in PDA closure than intravenous (IV) ibuprofen (RR 0.38, 95% CI 0.26 to 0.56; 5 RCTs, 406 infants; moderate-certainty evidence). High-dose ibuprofen appears to be more effective in PDA closure than standard-dose ibuprofen (RR 0.37, 95% CI 0.22 to 0.61; 3 RCTs, 190 infants; moderate-certainty evidence). With respect to adverse outcomes, compared to indomethacin administration, NEC appears to be lower with ibuprofen (any route; RR 0.68, 95% CI 0.49 to 0.94; 18 RCTs, 1292 infants; moderate-certainty evidence), oral ibuprofen (RR 0.41, 95% CI 0.23 to 0.73; 7 RCTs, 249 infants; low-certainty evidence), and with acetaminophen (RR 0.42, 95% CI 0.19 to 0.96; 4 RCTs, 384 infants; low-certainty evidence). However, NEC appears to be increased with a prolonged course of indomethacin versus a shorter course (RR 1.87, 95% CI 1.07 to 3.27; 4 RCTs, 310 infants). AUTHORS' CONCLUSIONS This overview summarised the evidence from 16 Cochrane Reviews of RCTs regarding the effects of interventions for the prevention and treatment of PDA in preterm infants. Prophylactic indomethacin reduces severe IVH, but does not appear to affect the composite outcome of death or moderate/severe neurodevelopmental disability. Prophylactic ibuprofen probably marginally reduces severe IVH (moderate-certainty evidence), while the evidence is very uncertain on the effect of prophylactic acetaminophen on severe IVH. All available prostaglandin inhibitor drugs appear to be effective in symptomatic PDA closure compared to no treatment (high-certainty evidence for indomethacin; moderate-certainty evidence for ibuprofen; low-certainty evidence for early administration of acetaminophen). Oral ibuprofen appears to be more effective in PDA closure than IV ibuprofen (moderate-certainty evidence). High dose ibuprofen appears to be more effective in PDA closure than standard-dose ibuprofen (moderate-certainty evidence). There are currently two ongoing reviews, one on fluid restriction for symptomatic PDA, and the other on invasive management of PDA in preterm infants.
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Affiliation(s)
- Souvik Mitra
- Departments of Pediatrics, Community Health & Epidemiology, Dalhousie University & IWK Health Centre, Halifax, Canada
| | - Willem P de Boode
- Department of Perinatology, Division of Neonatology, Radboud UMC Amalia Children's Hospital, Nijmegen, Netherlands
| | - Dany E Weisz
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Prakeshkumar S Shah
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto Mount Sinai Hospital, Toronto, Canada
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Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Somanath SH, Shaik NB, Pullattayil AK, Weiner GM. Interventions to Prevent Bronchopulmonary Dysplasia in Preterm Neonates: An Umbrella Review of Systematic Reviews and Meta-analyses. JAMA Pediatr 2022; 176:502-516. [PMID: 35226067 DOI: 10.1001/jamapediatrics.2021.6619] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) has multifactorial etiology and long-term adverse consequences. An umbrella review enables the evaluation of multiple proposed interventions for the prevention of BPD. OBJECTIVE To summarize and assess the certainty of evidence of interventions proposed to decrease the risk of BPD from published systematic reviews. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science were searched from inception until November 9, 2020. STUDY SELECTION Meta-analyses of randomized clinical trials comparing interventions in preterm neonates that included BPD as an outcome. DATA EXTRACTION AND SYNTHESIS Data extraction was performed in duplicate. Quality of systematic reviews was evaluated using Assessment of Multiple Systematic Reviews version 2, and certainty of evidence was assessed using Grading of Recommendation, Assessment, Development, and Evaluation. MAIN OUTCOMES AND MEASURES (1) BPD or mortality at 36 weeks' postmenstrual age (PMA) and (2) BPD at 36 weeks' PMA. RESULTS A total of 154 systematic reviews evaluating 251 comparisons were included, of which 110 (71.4%) were high-quality systematic reviews. High certainty of evidence from high-quality systematic reviews indicated that delivery room continuous positive airway pressure compared with intubation with or without routine surfactant (relative risk [RR], 0.80 [95% CI, 0.68-0.94]), early selective surfactant compared with delayed selective surfactant (RR, 0.83 [95% CI, 0.75-0.91]), early inhaled corticosteroids (RR, 0.86 [95% CI, 0.75-0.99]), early systemic hydrocortisone (RR, 0.90 [95% CI, 0.82-0.99]), avoiding endotracheal tube placement with delivery room continuous positive airway pressure and use of less invasive surfactant administration (RR, 0.90 [95% CI, 0.82-0.99]), and volume-targeted compared with pressure-limited ventilation (RR, 0.73 [95% CI, 0.59-0.89]) were associated with decreased risk of BPD or mortality at 36 weeks' PMA. Moderate to high certainty of evidence showed that inhaled nitric oxide, lower saturation targets (85%-89%), and vitamin A supplementation are associated with decreased risk of BPD at 36 weeks' PMA but not the competing outcome of BPD or mortality, indicating they may be associated with increased mortality. CONCLUSIONS AND RELEVANCE A multipronged approach of delivery room continuous positive airway pressure, early selective surfactant administration with less invasive surfactant administration, early hydrocortisone prophylaxis in high-risk neonates, inhaled corticosteroids, and volume-targeted ventilation for preterm neonates requiring invasive ventilation may decrease the combined risk of BPD or mortality at 36 weeks' PMA.
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH) & KMCH Institute of Health Sciences and Research, Coimbatore, India
| | | | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | | | | | - Gary M Weiner
- Department of Pediatrics-Neonatology, University of Michigan, Ann Arbor
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Umapathi KK, Muller B, Sosnowski C, Thavamani A, Murphy J, Awad S, Bokowski JW. A Novel Patent Ductus Arteriosus Severity Score to Predict Clinical Outcomes in Premature Neonates. J Cardiovasc Dev Dis 2022; 9:jcdd9040114. [PMID: 35448090 PMCID: PMC9033137 DOI: 10.3390/jcdd9040114] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/06/2022] [Accepted: 04/10/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Patent Ductus Arteriosus (PDA) in premature neonates has been associated with comorbidities including chronic lung disease (CLD), and death. However, the treatment of PDA remains controversial. There have been several echocardiographic variables previously used to determine the hemodynamic significance of PDA but their utility in early prediction of clinical outcomes is not well studied. Objective: The objective of our study was to evaluate the use of a severity scoring system incorporating markers of systemic under perfusion, pulmonary over perfusion and left ventricular (LV) function in predicting clinical outcomes in premature neonates. Methods: It is a single center prospective observational study involving newborns < 32 weeks’ gestation. An echocardiogram was done within seven days of life to measure variables previously known to predict severity of shunting in PDA including pulmonary perfusion index (PPI). Predictors of CLD/death were identified using multivariate logistic regression. A severity score was derived and its ability to predict clinical outcomes was tested using a receiver operating characteristic curve. Results: We studied 98 infants with a mean (SD) gestation of 28.9 ± 1.91 weeks and birth weight of 1228.06 ± 318.94 g, respectively. We identified five echocardiographic variables along with gestational age that was independently associated with the outcome variable (PPI, LV output, Superior Mesenteric Artery [SMA] Velocity Time Integral [VTI], Peak diastolic flow velocity in Pulmonary Vein [PV Vd], and reversal of flow in diastole in descending aorta [DFR]). The range of severity score was 0 (low risk) to 12 (high risk). A higher score was associated with the primary outcome variable of CLD/death (7.5 [1.2] vs. 3.6 [1.5], p < 0.001). Our severity score had an area under the curve of 0.97 (95% CI 0.93−0.99, p < 0.001) for predicting CLD/death. Conclusion: Our new PDA severity score of 5.5 has a sensitivity and specificity of 94% and 93%, and positive and negative predictive values of 94% and 93%, respectively.
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Affiliation(s)
- Krishna Kishore Umapathi
- Department of Pediatrics, Division of Pediatric Cardiology, Rush University Medical Center, Chicago, IL 60612, USA; (B.M.); (C.S.); (J.M.); (S.A.); (J.W.B.)
- Correspondence: ; Tel.: +312-942-3034; Fax: +312-942-4168
| | - Brieann Muller
- Department of Pediatrics, Division of Pediatric Cardiology, Rush University Medical Center, Chicago, IL 60612, USA; (B.M.); (C.S.); (J.M.); (S.A.); (J.W.B.)
| | - Cyndi Sosnowski
- Department of Pediatrics, Division of Pediatric Cardiology, Rush University Medical Center, Chicago, IL 60612, USA; (B.M.); (C.S.); (J.M.); (S.A.); (J.W.B.)
| | - Aravind Thavamani
- Department of Pediatrics, Division of Pediatric Gastroenterology, UH Rainbow Babies Children’s Hospital, Case Western Reserve University, Cleveland, OH 44106, USA;
| | - Joshua Murphy
- Department of Pediatrics, Division of Pediatric Cardiology, Rush University Medical Center, Chicago, IL 60612, USA; (B.M.); (C.S.); (J.M.); (S.A.); (J.W.B.)
| | - Sawsan Awad
- Department of Pediatrics, Division of Pediatric Cardiology, Rush University Medical Center, Chicago, IL 60612, USA; (B.M.); (C.S.); (J.M.); (S.A.); (J.W.B.)
| | - John W. Bokowski
- Department of Pediatrics, Division of Pediatric Cardiology, Rush University Medical Center, Chicago, IL 60612, USA; (B.M.); (C.S.); (J.M.); (S.A.); (J.W.B.)
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Efficacy and Costs of Three Pharmacotherapies for Patent Ductus Arteriosus Closure in Premature Infants. Paediatr Drugs 2022; 24:93-102. [PMID: 35229248 DOI: 10.1007/s40272-022-00495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND The hemodynamic impact of persistent patent ductus arteriosus (PDA) is associated with neonatal morbidities and mortality in preterm newborns. While there has been considerable debate about optimal management of PDA and its impact on clinical outcomes, there is widespread variation in practice, such as using different pharmacotherapies to achieve closure of hemodynamically significant PDA during the first week of life in very low birth weight infants. AIMS The objective was to estimate the efficacy of acetaminophen, ibuprofen, and indomethacin with regard to ductal closure and to compare the costs of these three commonly used medications to treat PDA in preterm infants. METHODS PubMed, Embase, and Cochrane Registry were searched for trials from the years 2010-2020. We identified 17 randomized clinical trials (RCTs) and 14 case series that enrolled preterm infants < 37 weeks gestational age for inclusion. Pooled estimates of closure rates for acetaminophen (n = 630), ibuprofen (n = 694), and indomethacin (n = 312) were analyzed using the weighted proportion ratio using a Mantel‑Haenszel random effects model. The chi-squared test of proportions was used to determine significance between groups. We accessed cost estimates of pharmacotherapy from the Lexi-Comp average wholesale price database and utilized a decision tree model to appraise cost benefits for the outcome measure of successful PDA closure. RESULTS The pooled proportional point estimates of closure rates from RCTs for acetaminophen, ibuprofen, and indomethacin were 70.1% (95% confidence interval [CI] 60-80), 63.4% (95% CI 52.8-74.1), and 71.5% (95% CI 62.3-80.7), respectively. There was no significant statistical difference in closure rates when RCTs and uncontrolled case series were combined. Pairwise comparisons showed both acetaminophen and indomethacin were each more effective in closing PDA than ibuprofen (acetaminophen vs indomethacin: p = 0.01; ibuprofen vs indomethacin: p = 0.02; acetaminophen vs indomethacin: p = 0.93). Comparing costs for successful closure of PDA, at the average wholesale price of different medications, suggested that treatment with acetaminophen costs significantly less, with a mean of $1487 (95% CI 1300-1737), compared to ibuprofen, with a mean of $2585 (95% CI 2214-3104), and indomethacin, with a mean of $2661 (95% CI 2358-3052), per course of treatment. CONCLUSIONS Our meta-analysis suggests acetaminophen is non-inferior to both indomethacin and ibuprofen, and costs relatively less for successful PDA constriction in premature infants. Further clinical trials are warranted to compare acetaminophen's safety, along with short- and long-term effects, to help resolve the clinical conundrum of the necessity of early treatment in the management of PDA, and the optimal pharmacological course, if indicated.
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Patent ductus arteriosus, tracheal ventilation, and the risk of bronchopulmonary dysplasia. Pediatr Res 2022; 91:652-658. [PMID: 33790415 PMCID: PMC8904244 DOI: 10.1038/s41390-021-01475-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND An increased risk for bronchopulmonary dysplasia (BPD) exists when moderate-to-large patent ductus arteriosus shunts (hsPDA) persist beyond 14 days. GOAL To examine the interaction between prolonged exposures to tracheal ventilation (≥10 days) and hsPDA on the incidence of BPD in infants <28 weeks gestation. STUDY DESIGN Predefined definitions of prolonged ventilation (≥10 days), hsPDA (≥14 days), and BPD (room air challenge test at 36 weeks) were used to analyze deidentified data from the multicenter TRIOCAPI RCT in a secondary analysis of the trial. RESULTS Among 307 infants who survived >14 days, 41 died before 36 weeks. Among survivors, 93/266 had BPD. The association between BPD and hsPDA depended on the length of intubation. In multivariable analyses, prolonged hsPDA shunts were associated with increased BPD (odds ratio (OR) (95% confidence interval (CI)) = 3.00 (1.58-5.71)) when infants required intubation for ≥10 days. In contrast, there was no significant association between hsPDA exposure and BPD when infants were intubated <10 days (OR (95% CI) = 1.49 (0.98-2.26)). A similar relationship between prolonged hsPDA and length of intubation was found for BPD/death (n = 307): infants intubated ≥10 days: OR (95% CI) = 2.41 (1.47-3.95)); infants intubated <10 days: OR (95% CI) = 1.37 (0.86-2.19)). CONCLUSIONS Moderate-to-large PDAs were associated with increased risks of BPD and BPD/death-but only when infants required intubation ≥10 days. IMPACT Infants with a moderate-to-large hsPDA that persist beyond 14 days are only at risk for developing BPD if they also receive prolonged tracheal ventilation for ≥10 days. Infants who receive less ventilatory support (intubation for <10 days) have the same incidence of BPD whether the ductus closes shortly after birth or whether it persists as a moderate-to-large shunt for several weeks. Early PDA closure may be unnecessary in infants who require short durations of intubation since the PDA does not seem to alter the incidence of BPD in infants who require intubation for <10 days.
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El-Khuffash A, Bussmann N, Breatnach CR, Smith A, Tully E, Griffin J, McCallion N, Corcoran JD, Fernandez E, Looi C, Cleary B, Franklin O, McNamara PJ. Early targeted patent ductus arteriosus treatment in premature neonates using a risk based severity score: study protocol for a randomised controlled trial (PDA RCT). HRB Open Res 2021; 3:87. [PMID: 34522836 PMCID: PMC8422343 DOI: 10.12688/hrbopenres.13140.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/25/2022] Open
Abstract
A patent ductus arteriosus (PDA) in preterm infants is associated with increased ventilator dependence and chronic lung disease, necrotizing enterocolitis, intraventricular haemorrhage, and poor neurodevelopmental outcome. Randomised controlled trials of early PDA treatment have not established a drop in the aforementioned morbidities. Those trials did not physiologically categorise PDA severity. Incorporating the specific physiological features of a haemodynamic significant PDA may evolve our understanding of this phenomenon, allowing accurate triaging using echocardiography and targeted treatment. Our group has recently demonstrated that a PDA severity score (PDAsc) derived at 36-48 hours of age can accurately predict the later occurrence of chronic lung disease or death (CLD/Death). Using echocardiography, we assessed PDA characteristics, as well as left ventricular diastolic function and markers of pulmonary overcirculation, and from this formulated a PDAsc. Gestation was also incorporated into the score. We hypothesise that in preterm infants at high risk of developing CLD/Death based on a PDAsc, early treatment with Ibuprofen compared with placebo will result in a reduction in CLD/Death. This is a single centre double-blind two arm randomised controlled trial conducted in the neonatal intensive care unit in the Rotunda Hospital, Dublin. Echocardiogram is carried out in the first 36-48 hours of life to identify preterm infants with a PDAsc ≥ 5.0 and these infants are randomised to Ibuprofen or placebo. Primary outcomes are assessed at 36 weeks post menstrual age. This pilot study’s purpose is to assess the feasibility of performing the trial and to obtain preliminary data to calculate a sample size for a definitive multi-centre trial of early PDA treatment using a PDAsc. We aim to recruit a total of 60 infants with a high risk PDA over three years. Trial Registration: ISRCTN
ISRCTN13281214 (26/07/2016) and the European Union Drug Regulating Authorities Clinical Trials Database
2015-004526-33 (03/12/2015).
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Affiliation(s)
- Afif El-Khuffash
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Neidin Bussmann
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland
| | | | - Aisling Smith
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland
| | - Elizabeth Tully
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joanna Griffin
- Department of Research & Academic Affairs, Rotunda Hospital, Dublin, Ireland
| | - Naomi McCallion
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John David Corcoran
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Claudia Looi
- Department of Pharmacy, Rotunda Hospital, Dublin, Ireland
| | - Brian Cleary
- Department of Pharmacy, Rotunda Hospital, Dublin, Ireland.,School of Pharmacy, Rotunda Hospital, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Patrick J McNamara
- Division of Neonatology, Stead Family Children's Hospital Stead Family Children's Hospital, Iowa, USA.,Departments of Pediatrics and Cardiology, University of Iowa, Iowa, USA
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Restrictive Threshold for the Management of Patent Ductus Arteriosus in Very Low Birth Weight Neonates. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2130-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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9
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Clyman RI, Kaempf J, Liebowitz M, Erdeve O, Bulbul A, Håkansson S, Lindqvist J, Farooqi A, Katheria A, Sauberan J, Singh J, Nelson K, Wickremasinghe A, Dong L, Hassinger DC, Aucott SW, Hayashi M, Heuchan AM, Carey WA, Derrick M, Fernandez E, Sankar M, Leone T, Perez J, Serize A. Prolonged Tracheal Intubation and the Association Between Patent Ductus Arteriosus and Bronchopulmonary Dysplasia: A Secondary Analysis of the PDA-TOLERATE trial. J Pediatr 2021; 229:283-288.e2. [PMID: 32979387 PMCID: PMC7855529 DOI: 10.1016/j.jpeds.2020.09.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/16/2020] [Accepted: 09/17/2020] [Indexed: 11/24/2022]
Abstract
In the PDA-TOLERATE trial, persistent (even for several weeks) moderate to large patent ductus arteriosus (PDA) was not associated with an increased risk of BPD when the infant required <10 days of intubation. However, in infants requiring intubation for ≥10 days, prolonged PDA exposure (≥11 days) was associated with an increased risk of moderate/severe BPD.
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Affiliation(s)
- Ronald I. Clyman
- Department of Pediatrics, University of California San Francisco,Department of Cardiovascular Research Institute, University of California San Francisco
| | - Joseph Kaempf
- Department of Pediatrics of Providence St. Vincent Medical Center, Portland, OR
| | | | - Omer Erdeve
- Department of Pediatrics of Ankara University School of Medicine Children’s Hospital, Ankara, Turkey
| | - Ali Bulbul
- Department of Pediatrics of Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | | | | | - Aijaz Farooqi
- Department of Pediatrics of Umea University Hospital, Umea, Sweden
| | - Anup Katheria
- Department of Pediatrics of Sharp Mary Birch Hospital, San Diego, CA
| | - Jason Sauberan
- Department of Pediatrics of Sharp Mary Birch Hospital, San Diego, CA
| | - Jaideep Singh
- Department of Pediatrics of University of Chicago, Chicago, IL
| | - Kelly Nelson
- Department of Pediatrics of University of Chicago, Chicago, IL
| | - Andrea Wickremasinghe
- Department of Pediatrics of Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Lawrence Dong
- Department of Pediatrics of Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | | | - Susan W. Aucott
- Department of Pediatrics of Johns Hopkins University, Baltimore, MD
| | - Madoka Hayashi
- Department of Pediatrics of Johns Hopkins University, Baltimore, MD
| | - Anne Marie Heuchan
- Department of Pediatrics of University of Glasgow, Royal Hospital for Sick Children, Glasgow, Scotland, UK
| | | | - Matthew Derrick
- Department of Pediatrics of Northshore University Health System, Evanston, IL
| | - Erika Fernandez
- Department of Pediatrics of University of California San Diego and Rady Children’s Hospital, San Diego, CA
| | - Meera Sankar
- Department of Pediatrics of Good Samaritan Hospital, San Jose, CA
| | - Tina Leone
- Department of Pediatrics of Columbia University Medical Center, New York, NY
| | - Jorge Perez
- Department of Pediatrics of South Miami Hospital/Baptist Health South Florida, Miami, FL
| | - Arturo Serize
- Department of Pediatrics of South Miami Hospital/Baptist Health South Florida, Miami, FL
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10
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Clyman RI, Hills NK. The effect of prolonged tracheal intubation on the association between patent ductus arteriosus and bronchopulmonary dysplasia (grades 2 and 3). J Perinatol 2020; 40:1358-1365. [PMID: 32669644 PMCID: PMC7442702 DOI: 10.1038/s41372-020-0718-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/01/2020] [Accepted: 07/01/2020] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To determine if the need for mechanical ventilation alters the association between prolonged patent ductus arteriosus (PDA) exposure and bronchopulmonary dysplasia (grades 2 and 3) (BPD). STUDY DESIGN Observational study of 407 infants (<28 weeks' gestation) with echocardiograms performed at planned intervals. RESULTS Twelve percent (48/407) of study infants had BPD (grades 2 and 3). In a multivariable regression model, exposure to a moderate-to-large PDA shunt for ≥7 days was associated with an increased risk of BPD (grades 2 and 3) (from 16 to 35%: aRD = 19% (6, 32%), p < 0.005) when infants required ≥10 days of intubation (n = 170). In contrast, there was no significant association between prolonged PDA exposure and BPD when infants required ≤9 days of intubation (aRD = 4%) (-1, 10%) (n = 237). CONCLUSIONS Moderate-to-large PDAs are associated with an increased risk of BPD-but only when infants require intubation ≥10 days.
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Affiliation(s)
- Ronald I. Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA,Department of Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Nancy K. Hills
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA,Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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11
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Sung SI, Lee MH, Ahn SY, Chang YS, Park WS. Effect of Nonintervention vs Oral Ibuprofen in Patent Ductus Arteriosus in Preterm Infants: A Randomized Clinical Trial. JAMA Pediatr 2020; 174:755-763. [PMID: 32539121 PMCID: PMC7296457 DOI: 10.1001/jamapediatrics.2020.1447] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
IMPORTANCE Persistent patent ductus arteriosus (PDA) in preterm infants is associated with increased mortality and respiratory morbidities, including bronchopulmonary dysplasia (BPD). Despite recent increasing use of noninterventional approaches, no study to our knowledge has yet directly compared the nonintervention vs pharmacologic treatment for mediating PDA closure for decreasing mortality and preventing BPD. OBJECTIVE To determine the noninferiority of nonintervention vs oral ibuprofen treatment for PDA in decreasing BPD incidence or death in very preterm infants. DESIGN, SETTING, AND PARTICIPANTS A randomized, double-blind, placebo-controlled, noninferiority clinical trial was conducted on preterm infants (gestational age [GA] 23-30 weeks) with hemodynamically significant PDA (ductal size >1.5 mm plus respiratory support) diagnosed between postnatal days 6 and 14. Participants included 383 infants screened between July 24, 2014, and March 15, 2019. INTERVENTIONS Infants were stratified by GA and randomly assigned (1:1) to receive either oral ibuprofen (initial dose of 10 mg/kg followed by a 5-mg/kg dose after 24 hours and a second 5-mg/kg dose after 48 hours) or placebo. MAIN OUTCOMES AND MEASURES The primary outcome was BPD or death; the secondary outcomes included major morbidities and ductal closure rates. Per-protocol analysis was used. RESULTS Among 383 infants screened for participation, 146 infants were randomly assigned, with 72 in the nonintervention and 70 in the ibuprofen treatment group in the final analyses. The PDA closure rate at 1 week after randomization was significantly higher with ibuprofen (11 [34%]) than nonintervention (2 [7%]) in infants at GA 27 to 30 weeks (P = .007); however, the findings were not significant at GA 23 to 26 weeks (ibuprofen, 3 [8%] vs nonintervention, 1 [2%], P = .34). In addition, the ductal closure rates before hospital discharge (ibuprofen, 62 [89%] vs nonintervention, 59 [82%], P = .27) and device closure (ibuprofen, 2 [3%] vs nonintervention, 4 [6%], P = .40) were not significantly different between the 2 groups. The nonintervention approach was noninferior to ibuprofen treatment in terms of BPD incidence or death (nonintervention, 44%; ibuprofen, 50%; 95% CI, -0.11 to 0.22; noninferiority margin -0.2; P = .51). One infant in the ibuprofen arm received oral ibuprofen backup rescue treatment owing to cardiopulmonary compromise refractory to conservative management, and another infant in the ibuprofen group received surgical ligation; none of the infants in the placebo group received backup treatment. CONCLUSIONS AND RELEVANCE Nonintervention showed noninferiority compared with ibuprofen treatment in closing of hemodynamically significant PDA and reduction of BPD or death. The noninferiority of nonintervention over ibuprofen might be attributable to the low efficacy of oral ibuprofen for closing PDA, especially in infants born at 23 to 26 weeks' gestation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02128191.
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Affiliation(s)
- Se In Sung
- Samsung Medical Center, Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung Hee Lee
- Statistics and Data Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Yoon Ahn
- Samsung Medical Center, Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Sil Chang
- Samsung Medical Center, Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Soon Park
- Samsung Medical Center, Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea
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12
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Mitra S, de Boode WP, Weisz DE, Shah PS. Interventions for patent ductus arteriosus (PDA) in preterm infants: an overview of Cochrane Systematic Reviews. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2020. [DOI: 10.1002/14651858.cd013588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Souvik Mitra
- Departments of Pediatrics, Community Health & Epidemiology; Dalhousie University & IWK Health Centre; Halifax Canada
| | - Willem P de Boode
- Department of Perinatology, Division of Neonatology; Radboud UMC Amalia Children’s Hospital; Nijmegen Netherlands
| | - Dany E Weisz
- Department of Newborn and Developmental Paediatrics; Sunnybrook Health Sciences Centre; Toronto Canada
| | - Prakeshkumar S Shah
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation; University of Toronto Mount Sinai Hospital; Toronto Canada
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13
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Yan H, Ma F, Li Y, Zhou K, Hua Y, Wan C. The optimal timing of surgical ligation of patent ductus arteriosus in preterm or very-low-birth-weight infants: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e19356. [PMID: 32118777 PMCID: PMC7478603 DOI: 10.1097/md.0000000000019356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is a particularly common problem in preterm infants. Although surgical ligation is rarely performed in many contemporary neonatal intensive care units, it remains a necessary treatment option for preterm infants with a large hemodynamically significant PDA under strict clinical criteria, and it can reduce mortality in preterm infants. However, the optimal timing of surgical ligation is still controversial. We conducted this systematic review and meta-analysis to compare the mortality and morbidity of early and late surgical ligation of PDA in preterm or very-low-birth-weight (VLBW) infants. METHODS This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019133686). We searched the databases of PubMed, Embase, the Cochrane Central Register of Controlled Trials, and the World Health Organization International Clinical Trials Registry Platform up to May 2019. RESULTS This review included 6 retrospective studies involving 397 premature or VLBW infants with PDA. Pooled analysis showed that compared with the late ligation group, the early ligation group had a lower fraction of inspired oxygen (FiO2) at 24 hours postoperatively (mean difference [MD] -6.34, 95% confidence interval [CI] -9.45 to -3.22), fewer intubation days (MD -19.69, 95% CI -29.31 to -10.07), earlier date of full oral feeding (MD -22.98, 95% CI -28.63 to -17.34) and heavier body weight at 36 weeks of conceptional age (MD 232.08, 95% CI 57.28 to 406.88). No significant difference in mortality or other complications was found between the early and late groups. CONCLUSION Our meta-analysis implies that compared with late surgical ligation, early ligation might have a better respiratory outcome and nutritional status for PDA in preterm or VLBW infants. There was no difference in mortality or postoperative complications between early and late ligation. A randomized prospective clinical trial with a possible large sample size is urgently needed to reinvestigate this conclusion. PROSPERO REGISTRATION NUMBER CRD42019133686.
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Affiliation(s)
- Hualin Yan
- Department of Medical Ultrasound, West China Hospital, Sichuan University
- West China School of Medicine, Sichuan University
| | - Fan Ma
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yifei Li
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yimin Hua
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chaomin Wan
- West China School of Medicine, Sichuan University
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
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14
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Terrin G, Di Chiara M, Boscarino G, Versacci P, Di Donato V, Giancotti A, Pacelli E, Faccioli F, Onestà E, Corso C, Ticchiarelli A, De Curtis M. Echocardiography-Guided Management of Preterms With Patent Ductus Arteriosus Influences the Outcome: A Cohort Study. Front Pediatr 2020; 8:582735. [PMID: 33409261 PMCID: PMC7779760 DOI: 10.3389/fped.2020.582735] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction: Echocardiography (ECHO) with color flow Doppler is considered as the gold standard to identify a hemodynamic patent ductus arteriosus (hs-PDA). However, the optimal diagnostic and therapeutic management for newborns with hs-PDA is still controversial. We aimed to investigate two clinical strategies: (1) targeted treatment based on ECHO criteria and (2) treatment based on ECHO criteria in addition to clinical signs and symptoms. Materials and Methods: This is a cohort study including all neonates consecutively admitted in the Neonatal Intensive Care Unit of University La Sapienza in Rome, with gestational age <32 weeks or body birth weight <1,500 g and with a diagnosis of hs-PDA as confirmed by ECHO evaluation performed within 72 h of life. We classified the babies in two cohorts: (A) pharmacological treatment immediately after ECHO screening and (B) pharmacological therapy for PDA was administered when the relevance of a hs-PDA was associated with clinical signs of hemodynamic instability. Results: We considered as primary outcome newborns who survived without any morbidities (A: 48.1% vs. B: 22.2%, p = 0.022). In particular, we found that the rate of intraventricular hemorrhage stage ≥2 was increased in cohort B (A: 3.7% vs. B 24.4%, p = 0.020). A multivariate analysis showed that assignment to cohort A independently influences the primary outcome. Conclusions: Adopting an hs-PDA management option based on ECHO-directed therapy regardless of symptoms may reduce the morbidity and improve the survival of very low birth weight infants.
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Affiliation(s)
- Gianluca Terrin
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Maria Di Chiara
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Giovanni Boscarino
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Paolo Versacci
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Violante Di Donato
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Elisabetta Pacelli
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Francesca Faccioli
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Elisa Onestà
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Chiara Corso
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | | | - Mario De Curtis
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
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15
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Clyman RI, Hills NK, Liebowitz M, Johng S. Relationship between Duration of Infant Exposure to a Moderate-to-Large Patent Ductus Arteriosus Shunt and the Risk of Developing Bronchopulmonary Dysplasia or Death Before 36 Weeks. Am J Perinatol 2020; 37:216-223. [PMID: 31600791 PMCID: PMC9940607 DOI: 10.1055/s-0039-1697672] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study was aimed to examine the relationship between duration of infant exposure to a moderate-to-large patent ductus arteriosus (PDA) shunt and the risk of developing bronchopulmonary dysplasia (BPD) or death before 36 weeks (BPD/death). STUDY DESIGN Infants <28 weeks' gestation who survived ≥7 days (n = 423) had echocardiograms performed on day 7 and at planned intervals. RESULTS In multivariable regression models, BPD/death did not appear to be increased until infants had been exposed to a moderate-to-large PDA for at least 7-13 days: OR (95%CI) (referent = closed or small PDA): moderate-to-large PDA exposure for <7 days: 0.38 (range, 0.10-1.46); for 7 to 13 days = 2.12 (range, 1.04-4.32); for ≥14 days = 3.86 (range, 2.15-6.96). Once the threshold of 7 to 13 days had been reached, additional exposure (≥14 days) did not significantly add to the increased incidence of BPD/death: (referent exposure = 7-13 days) exposure for 14 to 27 days = 1.34 (range, 0.52-3.45); for 28 to 48 days = 2.34 (range, 0.88-6.19); for ≥49 days = 1.80 (range. 0.59-5.47). A similar relationship was found for the outcome of BPD-alone. CONCLUSION Infants < 28 weeks' gestation required at least 7 to 13 days of exposure to a moderate-to-large PDA before a significant increase in the incidence of BPD/death was apparent. Once this threshold was reached additional exposure to a moderate-to-large PDA did not significantly add to the increased incidence of BPD/death.
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Affiliation(s)
- Ronald I. Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA,Department of Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Nancy K. Hills
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Melissa Liebowitz
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Sandy Johng
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
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16
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Slaughter JL, Cua CL, Notestine JL, Rivera BK, Marzec L, Hade EM, Maitre NL, Klebanoff MA, Ilgenfritz M, Le VT, Lewandowski DJ, Backes CH. Early prediction of spontaneous Patent Ductus Arteriosus (PDA) closure and PDA-associated outcomes: a prospective cohort investigation. BMC Pediatr 2019; 19:333. [PMID: 31519154 PMCID: PMC6743099 DOI: 10.1186/s12887-019-1708-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patent ductus arteriosus (PDA), the most commonly diagnosed cardiovascular condition in preterm infants, is associated with increased mortality and harmful long-term outcomes (chronic lung disease, neurodevelopmental delay). Although pharmacologic and/or interventional treatments to close PDA likely benefit some infants, widespread routine treatment of all preterm infants with PDA may not improve outcomes. Most PDAs close spontaneously by 44-weeks postmenstrual age; treatment is increasingly controversial, varying markedly between institutions and providers. Because treatment detriments may outweigh benefits, especially in infants destined for early, spontaneous PDA closure, the relevant unanswered clinical question is not whether to treat all preterm infants with PDA, but whom to treat (and when). Clinicians cannot currently predict in the first month which infants are at highest risk for persistent PDA, nor which combination of clinical risk factors, echocardiographic measurements, and biomarkers best predict PDA-associated harm. METHODS Prospective cohort of untreated infants with PDA (n=450) will be used to predict spontaneous ductal closure timing. Clinical measures, serum (brain natriuretic peptide, N-terminal pro-brain natriuretic peptide) and urine (neutrophil gelatinase-associated lipocalin, heart-type fatty acid-binding protein) biomarkers, and echocardiographic variables collected during each of first 4 postnatal weeks will be analyzed to identify those associated with long-term impairment. Myocardial deformation imaging and tissue Doppler imaging, innovative echocardiographic techniques, will facilitate quantitative evaluation of myocardial performance. Aim1 will estimate probability of spontaneous PDA closure and predict timing of ductal closure using echocardiographic, biomarker, and clinical predictors. Aim2 will specify which echocardiographic predictors and biomarkers are associated with mortality and respiratory illness severity at 36-weeks postmenstrual age. Aim3 will identify which echocardiographic predictors and biomarkers are associated with 22 to 26-month neurodevelopmental delay. Models will be validated in a separate cohort of infants (n=225) enrolled subsequent to primary study cohort. DISCUSSION The current study will make significant contributions to scientific knowledge and effective PDA management. Study results will reduce unnecessary and harmful overtreatment of infants with a high probability of early spontaneous PDA closure and facilitate development of outcomes-focused trials to examine effectiveness of PDA closure in "high-risk" infants most likely to receive benefit. TRIAL REGISTRATION ClinicalTrials.gov NCT03782610. Registered 20 December 2018.
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Affiliation(s)
- Jonathan L Slaughter
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Clifford L Cua
- Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA.,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jennifer L Notestine
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Brian K Rivera
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Laura Marzec
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Erinn M Hade
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Nathalie L Maitre
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA
| | - Mark A Klebanoff
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio, USA.,Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Megan Ilgenfritz
- Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA
| | - Vi T Le
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Dennis J Lewandowski
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Carl H Backes
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA. .,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA. .,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA. .,Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio, USA.
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17
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Escobar HA, Meneses-Gaviria G, Revelo-Jurado N, Villa-Rosero JF, Ijají Piamba JE, Burbano-Imbachí A, Cedeño-Burbano AA. Tratamiento farmacológico del conducto arterioso permeable en recién nacidos prematuros. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n2.64146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. Por lo general, el manejo farmacológico del conducto arterioso permeable (CAP) comprende inhibidores no selectivos de la enzima ciclooxigenasa, en especial indometacina e ibuprofeno. En años recientes también se ha sugerido al acetaminofén como alternativa terapéutica.Objetivo. Realizar una revisión narrativa de la literatura acerca del manejo farmacológico del CAP.Materiales y métodos. Se realizó una búsqueda estructurada de la literatura en las bases de datos ProQuest, EBSCO, ScienceDirect, PubMed, LILACS, Embase, Trip Database, SciELO y Cochrane Library con los términos “Ductus Arteriosus, patent AND therapeutics”; “Ductus Arteriosus, patent AND indometacin”; “Ductus Arteriosus, Patent AND ibuprofen”, y “Ductus Arteriosus, patent AND acetaminophen”. La búsqueda se hizo en inglés con sus equivalentes en español.Resultados. Se encontraron 69 artículos con información relevante para llevar a cabo la presente revisión.Conclusiones. En neonatos prematuros, la base del tratamiento farmacológico del CAP continúa siendo los inhibidores no selectivos de la ciclooxigenasa, indometacina e ibuprofeno, ambos con perfiles similares de seguridad y eficacia. La evidencia disponible sugiere que el acetaminofén podría constituir una alternativa útil para el manejo, pero resulta insuficiente para realizar recomendaciones definitivas respecto a la eficacia y seguridad de este medicamento.
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18
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Clyman RI, Liebowitz M, Kaempf J, Erdeve O, Bulbul A, Håkansson S, Lindqvist J, Farooqi A, Katheria A, Sauberan J, Singh J, Nelson K, Wickremasinghe A, Dong L, Hassinger DC, Aucott SW, Hayashi M, Heuchan AM, Carey WA, Derrick M, Fernandez E, Sankar M, Leone T, Perez J, Serize A. PDA-TOLERATE Trial: An Exploratory Randomized Controlled Trial of Treatment of Moderate-to-Large Patent Ductus Arteriosus at 1 Week of Age. J Pediatr 2019; 205:41-48.e6. [PMID: 30340932 PMCID: PMC6502709 DOI: 10.1016/j.jpeds.2018.09.012] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 08/11/2018] [Accepted: 09/06/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare early routine pharmacologic treatment of moderate-to-large patent ductus arteriosus (PDA) at the end of week 1 with a conservative approach that requires prespecified respiratory and hemodynamic criteria before treatment can be given. STUDY DESIGN A total of 202 neonates of <28 weeks of gestation age (mean, 25.8 ± 1.1 weeks) with moderate-to-large PDA shunts were enrolled between age 6 and 14 days (mean, 8.1 ± 2.2 days) into an exploratory randomized controlled trial. RESULTS At enrollment, 49% of the patients were intubated and 48% required nasal ventilation or continuous positive airway pressure. There were no differences between the groups in either our primary outcome of ligation or presence of a PDA at discharge (early routine treatment [ERT], 32%; conservative treatment [CT], 39%) or any of our prespecified secondary outcomes of necrotizing enterocolitis (ERT, 16%; CT, 19%), bronchopulmonary dysplasia (BPD) (ERT, 49%; CT, 53%), BPD/death (ERT, 58%; CT, 57%), death (ERT,19%; CT, 10%), and weekly need for respiratory support. Fewer infants in the ERT group met the rescue criteria (ERT, 31%; CT, 62%). In secondary exploratory analyses, infants receiving ERT had significantly less need for inotropic support (ERT, 13%; CT, 25%). However, among infants who were ≥26 weeks gestational age, those receiving ERT took significantly longer to achieve enteral feeding of 120 mL/kg/day (median: ERT, 14 days [range, 4.5-19 days]; CT, 6 days [range, 3-14 days]), and had significantly higher incidences of late-onset non-coagulase-negative Staphylococcus bacteremia (ERT, 24%; CT,6%) and death (ERT, 16%; CT, 2%). CONCLUSIONS In preterm infants age <28 weeks with moderate-to-large PDAs who were receiving respiratory support after the first week, ERT did not reduce PDA ligations or the presence of a PDA at discharge and did not improve any of the prespecified secondary outcomes, but delayed full feeding and was associated with higher rates of late-onset sepsis and death in infants born at ≥26 weeks of gestation. TRIAL REGISTRATION ClinicalTrials.gov: NCT01958320.
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Affiliation(s)
- Ronald I. Clyman
- Department of Pediatrics, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA,Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Melissa Liebowitz
- Department of Pediatrics, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Joseph Kaempf
- Department of Pediatrics, Providence St. Vincent Medical Center, Portland, OR
| | - Omer Erdeve
- Department of Pediatrics, Ankara University School of Medicine Children’s Hospital, Ankara
| | - Ali Bulbul
- Department of Pediatrics, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | | | | | - Aijaz Farooqi
- Department of Pediatrics, Umea University Hospital, Umea, Sweden
| | - Anup Katheria
- Department of Pediatrics, Sharp Mary Birch Hospital, San Diego, CA
| | - Jason Sauberan
- Department of Pediatrics, Sharp Mary Birch Hospital, San Diego, CA
| | - Jaideep Singh
- Department of Pediatrics, University of Chicago, Chicago, IL
| | - Kelly Nelson
- Department of Pediatrics, University of Chicago, Chicago, IL
| | - Andrea Wickremasinghe
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Lawrence Dong
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | | | - Susan W. Aucott
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Madoka Hayashi
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Anne Marie Heuchan
- Department of Pediatrics, University of Glasgow, Royal Hospital for Sick Children, Glasgow, Scotland, United Kingdom
| | | | - Matthew Derrick
- Department of Pediatrics, Northshore University Health System, Evanston, IL
| | - Erika Fernandez
- Department of Pediatrics, University of California San Diego and Rady Children’s Hospital, San Diego
| | - Meera Sankar
- Department of Pediatrics, Good Samaritan Hospital, San Jose, CA
| | - Tina Leone
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Jorge Perez
- Department of Pediatrics, South Miami Hospital/Baptist Health South Florida, Miami, FL
| | - Arturo Serize
- Department of Pediatrics, South Miami Hospital/Baptist Health South Florida, Miami, FL
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Poon WB, Wong KY. Neonatologist-performed point-of-care functional echocardiography in the neonatal intensive care unit. Singapore Med J 2018; 58:230-233. [PMID: 28536728 DOI: 10.11622/smedj.2017036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Functional echocardiography (fECHO) refers to a bedside, limited assessment of the ductus arteriosus, myocardial performance and pulmonary or systemic haemodynamics that is brief in nature and addresses a specific clinical question or management dilemma. This point-of-care ultrasonography is increasingly used internationally and locally among neonatal units to assist with management of neonatal haemodynamic conditions. This article intends to explain the modality, its indications, interpretation and implications for management, and how it impacts long-term outcomes, particularly in chronic lung disease for premature infants born before 32 weeks of gestation. This review will focus on fECHO as a clinical tool to assess the haemodynamics of sick neonates and how it assists in the logical choice for cardiovascular support. Training should be approached as a combined effort between the paediatric cardiology service and neonatology service.
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Affiliation(s)
- Woei Bing Poon
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
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20
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Efficacy of pharmacologic closure of patent ductus arteriosus in small-for-gestational-age extremely preterm infants. Early Hum Dev 2017; 113:10-17. [PMID: 28697406 PMCID: PMC5654678 DOI: 10.1016/j.earlhumdev.2017.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/23/2017] [Accepted: 07/02/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Optimal management of the patent ductus arteriosus (PDA) in preterm infants remains controversial. Therefore, studies identifying infants who are most likely to benefit from PDA treatment are needed. AIM We sought to examine if significant intrauterine growth restriction, defined by birth weight z-score, reduces the efficacy of PDA closure with indomethacin or ibuprofen and thereby increases the need for surgical closure of PDA after pharmacologic treatment. STUDY DESIGN, SUBJECTS, AND OUTCOME MEASURES We studied infants 23-28weeks' gestation born 2006-2013 at NICHD Neonatal Research Network centers. We examined the responses to PDA treatment with indomethacin and/or ibuprofen and whether the PDA was subsequently closed surgically. Logistic regression generated adjusted odds ratios (ORs) for the associations between the z-score groups (<-2, -2 to -0.5, and >-0.5) and PDA surgery following pharmacologic treatment. RESULTS 5606 infants were diagnosed with PDA; 3587 (64.0%) received indomethacin or ibuprofen or both, and 909 (25.3%) underwent PDA surgery. Mothers of infants with PDA non-closure were less likely to have hypertension (19% vs. 28%). Infants with non-closure were more likely to be female (53% vs. 49%), have lower gestational age and birth weight and to develop sepsis (42% vs. 31%). Compared to infants with z-score>-0.5, PDA surgery was increased among infants with z-score -2 to -0.5 (OR=1.23; 95% CI 1.02-1.47) but not among infants with z-score<-2. CONCLUSION Infants with birth weight z-score -2 to -0.5 are more likely than normally grown infants to require PDA surgery following pharmacologic treatment.
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Treatment and Nontreatment of the Patent Ductus Arteriosus: Identifying Their Roles in Neonatal Morbidity. J Pediatr 2017; 189:13-17. [PMID: 28709633 PMCID: PMC5639904 DOI: 10.1016/j.jpeds.2017.06.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 06/22/2017] [Indexed: 11/23/2022]
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Prophylactic Indomethacin Compared with Delayed Conservative Management of the Patent Ductus Arteriosus in Extremely Preterm Infants: Effects on Neonatal Outcomes. J Pediatr 2017; 187:119-126.e1. [PMID: 28396025 PMCID: PMC5533630 DOI: 10.1016/j.jpeds.2017.03.021] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/10/2017] [Accepted: 03/07/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine whether prophylactic indomethacin (PINDO) has more or less morbidity than delayed conservative management of the moderate-to-large patent ductus arteriosus (PDA). STUDY DESIGN We performed a prospective double cohort controlled study of infants delivered at ≤276/7 weeks gestation (n = 397). From January 2005 through April 2011, all infants were treated with PINDO (n = 247). From May 2011 through August 2016, no infant was treated with indomethacin until at least 8 postnatal days (conservative epoch, n = 150). Echocardiograms were performed on day 7 and at planned intervals until the PDA was small or closed. A single neonatologist prospectively collected all data. RESULTS The incidence of moderate-to-large PDA on day 7 and duration of exposure to moderate-to-large PDA were significantly less in the PINDO epoch (incidence = 10%, median = 2 days) than the conservative epoch (incidence = 67%, median = 14 days). Ligation rates were low in both epochs (PINDO = 14%, conservative = 5%). In multivariate analyses, PINDO infants had a significantly lower incidence of bronchopulmonary dysplasia (BPD) (risk ratio = 0.68, CI: 0.46-0.89) and BPD or death (risk ratio= 0.78, CI: 0.62-0.95) than conservative infants. There were no differences between the epochs in death, intraventricular hemorrhage grades 3 and 4, necrotizing enterocolitis, or retinopathy of prematurity receiving treatment. The effects of PINDO on BPD and BPD or death were no longer significant when analyses were adjusted for presence of a moderate-to-large PDA on day 7. The significant effects of PINDO were independent of whether or not a ligation was performed. CONCLUSIONS PINDO decreases BPD and BPD or death compared with delayed conservative PDA management. These effects are mediated by closure of the PDA.
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Poryo M, Khosrawikatoli S, Abdul-Khaliq H, Meyer S. Potential and Limitations of Cochrane Reviews in Pediatric Cardiology: A Systematic Analysis. Pediatr Cardiol 2017; 38:719-733. [PMID: 28239752 DOI: 10.1007/s00246-017-1572-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/19/2017] [Indexed: 11/28/2022]
Abstract
Evidence-based medicine has contributed substantially to the quality of medical care in pediatric and adult cardiology. However, our impression from the bedside is that a substantial number of Cochrane reviews generate inconclusive data that are of limited clinical benefit. We performed a systematic synopsis of Cochrane reviews published between 2001 and 2015 in the field of pediatric cardiology. Main outcome parameters were the number and percentage of conclusive, partly conclusive, and inconclusive reviews as well as their recommendations and their development over three a priori defined intervals. In total, 69 reviews were analyzed. Most of them examined preterm and term neonates (36.2%), whereas 33.3% included also non-pediatric patients. Leading topics were pharmacological issues (71.0%) followed by interventional (10.1%) and operative procedures (2.9%). The majority of reviews were inconclusive (42.9%), while 36.2% were conclusive and 21.7% partly conclusive. Although the number of published reviews increased during the three a priori defined time intervals, reviews with "no specific recommendations" remained stable while "recommendations in favor of an intervention" clearly increased. Main reasons for missing recommendations were insufficient data (n = 41) as well as an insufficient number of trials (n = 22) or poor study quality (n = 19). There is still need for high-quality research, which will likely yield a greater number of Cochrane reviews with conclusive results.
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Affiliation(s)
- Martin Poryo
- Department of Pediatric Cardiology, Saarland University Hospital, Kirrberger Straße, 66421, Homburg/saar, Germany.
| | | | - Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, Saarland University Hospital, Kirrberger Straße, 66421, Homburg/saar, Germany
| | - Sascha Meyer
- Department of Pediatrics and Neonatology, Saarland University Hospital, Homburg/saar, Germany.,Department of Pediatric Neurology, Saarland University Hospital, Homburg/saar, Germany
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Slaughter JL, Reagan PB, Newman TB, Klebanoff MA. Comparative Effectiveness of Nonsteroidal Anti-inflammatory Drug Treatment vs No Treatment for Patent Ductus Arteriosus in Preterm Infants. JAMA Pediatr 2017; 171:e164354. [PMID: 28046188 PMCID: PMC5575787 DOI: 10.1001/jamapediatrics.2016.4354] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
IMPORTANCE Patent ductus arteriosus (PDA) is associated with increased mortality and worsened respiratory outcomes, including bronchopulmonary dysplasia (BPD), in preterm infants. Nonsteroidal anti-inflammatory drugs (NSAIDs) are efficacious in closing PDA, but the effectiveness of NSAID-mediated PDA closure in improving mortality and preventing BPD is unclear. OBJECTIVE To determine the effectiveness of NSAID treatment for PDA in reducing mortality and moderate/severe BPD at 36 weeks postmenstrual age. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 12 018 infants born at 28 gestational weeks or younger discharged between January 2006 and December 2013 from neonatal intensive care units in 25 US children's hospitals included in the Pediatric Health Information System. We performed an instrumental variable analysis that incorporated clinician preference-based, institutional variation in NSAID treatment frequency to determine the effect of NSAID treatment for PDA on mortality and BPD. EXPOSURES Proportion of NSAID-treated infants born at each infant's institution within ±6 months of that infant's birth. MAIN OUTCOMES AND MEASURES The primary composite outcome was death, moderate, or severe BPD at 36 weeks postmenstrual age. RESULTS Of the 6370 male and 5648 female infants in this study, 4995 (42%) were white, 3176 (26%) were African American, 1823 (15%) were Hispanic, and 1555 (13%) were other races/ethnicities. The proportion of NSAID-treated infants at each infant's hospital within ±6 months of that infant's birth was associated with NSAID treatment and not associated with gestation, race/ethnicity, or sex. An infant's chances of receiving NSAID treatment increased by 0.84% (95% CI, 0.8-0.9; P < .001) for every 1% increase in the annual NSAID treatment percentage at a given hospital. An instrumental variable analysis demonstrated no association between NSAID treatment and the odds of mortality or BPD (odds ratio, 0.94; 95% CI, 0.70-1.25; P = .69), mortality (odds ratio, 0.73; 95% CI, 0.43-1.13; P = .18), or BPD (odds ratio, 1.01; 95% CI, 0.73-1.45; P = .94) in survivors. CONCLUSIONS AND RELEVANCE When we incorporated clinician preference-based practice variation as an instrument to minimize the effect of unmeasured confounding, we detected no changes in the odds of mortality or moderate/severe BPD among similar preterm infants born at 28 weeks or younger following NSAID treatment for PDA initiated 2 to 28 days postnatally. Our findings agree with available randomized clinical trial evidence and support a conservative approach to PDA management.
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Affiliation(s)
- Jonathan L Slaughter
- The Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH 43205,Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205
| | - Patricia B Reagan
- The Department of Economics, The Ohio State University, Columbus, OH 43210,Center for Human Resource Research, The Ohio State University, Columbus, OH 43210
| | - Thomas B Newman
- Department of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Mark A Klebanoff
- The Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH 43205,Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205
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Liebowitz M, Koo J, Wickremasinghe A, Allen IE, Clyman RI. Effects of Prophylactic Indomethacin on Vasopressor-Dependent Hypotension in Extremely Preterm Infants. J Pediatr 2017; 182:21-27.e2. [PMID: 27915200 PMCID: PMC5328836 DOI: 10.1016/j.jpeds.2016.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/13/2016] [Accepted: 11/02/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether a moderate-to-large patent ductus arteriosus (PDA) is responsible for vasopressor-dependent hypotension, occurring at the end of the first postnatal week. STUDY DESIGN We performed a retrospective, double cohort controlled study of infants delivered at ≤27+6 weeks' gestation (n = 313). From January 2004 through April 2011, all infants were treated with prophylactic indomethacin ([PINDO] epoch). From May 2011 through December 2015, no infant was treated with indomethacin until at least 8 postnatal days (conservative epoch). Echocardiograms were performed on postnatal days 6 or 7. Hypotension was managed by a predefined protocol. The primary outcome was the incidence of dopamine-dependent hypotension, defined as having received at least 6 µg/kg/min dopamine for at least 24 hours during postnatal days 4-7. RESULTS As expected, the incidence of moderate-to-large PDA at the end of the first week differed significantly between epochs (PINDO = 8%; conservative = 64%). In multivariate analyses, infants in the PINDO epoch had a significantly lower incidence of vasopressor-dependent hypotension (11%) than infants in the conservative epoch (21%; OR = 0.40, 95% CI 0.20-0.82). Infants in the PINDO epoch also required less mean airway pressure, had a lower respiratory severity score, and lower mode of ventilation score than infants in the conservative epoch during postnatal days 4-7. The effects of PINDO on both the incidence of vasopressor-dependent hypotension and the need for respiratory support were no longer significant when analyses were adjusted for "presence or absence of a moderate-to-large PDA." CONCLUSION PINDO decreases vasopressor-dependent hypotension and the need for respiratory support at the end of the first postnatal week. These effects are mediated by closure of the PDA.
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Affiliation(s)
- Melissa Liebowitz
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Jane Koo
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Andrea Wickremasinghe
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Isabel Elaine Allen
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Ronald I Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA; Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA.
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26
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Consider pharmacological treatment to close patent ductus arteriosus in preterm infants when the condition is haematologically significant. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-016-0329-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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27
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Trends and variation in management and outcomes of very low-birth-weight infants with patent ductus arteriosus. Pediatr Res 2016; 80:785-792. [PMID: 27509008 DOI: 10.1038/pr.2016.166] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/23/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND We examined recent trends and interhospital variation in use of indomethacin, ibuprofen, and surgical ligation for patent ductus arteriosus (PDA) in very-low-birth-weight (VLBW) infants. METHODS Included in this retrospective study of the Pediatric Hospital Information System database were 13,853 VLBW infants from 19 US children's hospitals, admitted at age < 3 d between 1 January 2005 and 31 December 2014. PDA management and in-hospital outcomes were examined for trends and variation. RESULTS PDA was diagnosed in 5,719 (42%) VLBW infants. Cyclooxygenase inhibitors and/or ligation were used in 74% of infants with PDA overall, however studied hospitals varied greatly in PDA management. Odds of any cyclooxygenase inhibitor or surgical treatment for PDA decreased 11% per year during the study period. This was temporally associated with improved survival but also with increasing bronchopulmonary dysplasia, periventricular leukomalacia, retinopathy of prematurity, and acute renal failure in unadjusted analyses. There was no detectable correlation between hospital-specific changes in PDA management and hospital-specific changes in outcomes of preterm birth during the study period. CONCLUSION Use of cyclooxygenase inhibitors and ligation for PDA in VLBW infants decreased over a 10-y period at the studied hospitals. Further evidence is needed to assess the impact of this change in PDA management.
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28
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Slaughter JL, Reagan PB, Bapat RV, Newman TB, Klebanoff MA. Nonsteroidal anti-inflammatory administration and patent ductus arteriosus ligation, a survey of practice preferences at US children's hospitals. Eur J Pediatr 2016; 175:775-83. [PMID: 26879388 PMCID: PMC5056586 DOI: 10.1007/s00431-016-2705-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 11/23/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
UNLABELLED We surveyed neonatal leadership at 46 US children's hospitals via web-based survey to identify local preferences and concerns regarding indomethacin prophylaxis, nonsteroidal anti-inflammatory drug (NSAID) treatment, and patent ductus arteriosus (PDA) ligation. We received a 100 % survey response (N = 46). Practice guidelines for prophylactic indomethacin were reported at 28 % of NICUs, for NSAID treatment of PDA at 39 % and for surgical ligation at 27 %. Respondents noted intra-institutional practice variation for indomethacin prophylaxis (33 %), NSAID treatment (70 %), and PDA ligation (73 %). The majority of institutions did not prescribe indomethacin prophylaxis (72 %). For PDA treatment, indomethacin was preferred over ibuprofen (80 %). We validated our survey results via comparison with billing data as documented in the Pediatric Health Information System (PHIS) database, finding that survey responses directly correlated with local billing data (p < 0.0001). At institutions that did not typically administer NSAIDs for PDA closure or surgical PDA ligation, a lack of evidence for their effectiveness in improving long-term outcomes and the risk of treatment-associated adverse effects were the most often cited reasons. CONCLUSION No consensus exists among providers at US children's hospitals regarding prophylactic indomethacin, NSAID treatment, or PDA ligation. Lack of evidence and safety concerns play a prominent role. WHAT IS KNOWN • NSAIDs and surgical PDA ligation are efficacious in preventing intraventricular hemorrhage (IVH) and closing PDA in preterm infants, but have not been shown to improve long-term respiratory, neurodevelopmental, or mortality outcomes. What is New: • Practice preferences for indomethacin prophylaxis, NSAID, and surgical PDA treatment vary both among and within institutions. Lack of treatment effectiveness and the risk of adverse effects are major concerns.
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Affiliation(s)
- Jonathan L Slaughter
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA. .,Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH, USA.
| | - Patricia B Reagan
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Department of Economics and Center for Human Resource Research, Ohio State University Columbus, OH, USA
| | - Roopali V Bapat
- Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH, USA
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Mark A Klebanoff
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children’s Hospital, Columbus, OH, USA
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Sivanandan S, Agarwal R. Pharmacological Closure of Patent Ductus Arteriosus: Selecting the Agent and Route of Administration. Paediatr Drugs 2016; 18:123-38. [PMID: 26951240 DOI: 10.1007/s40272-016-0165-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Opinions are divided regarding the management of a persistently patent ductus arteriosus (PDA). Some of the adverse effects associated with a large hemodynamically significant duct, including prolonged ventilation, pulmonary hemorrhage, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), and mortality, indicate that active management of infants with large ductal shunts may sometimes be necessary. Indomethacin and ibuprofen are the two US FDA-approved cyclooxygenase (COX) inhibitors used for the closure of a ductus in preterm babies. Both these drugs are effective in 70-80% of extremely low birthweight infants. Treatment with COX inhibitors may be associated with renal impairment, gastrointestinal hemorrhage, NEC, and spontaneous intestinal perforation when given concurrently with steroids, as well as changes in cerebrovascular auto-regulation. Ibuprofen appears to be a better choice for PDA closure, with a better side effect profile and efficacy that equals that of indomethacin. However, long-term outcome studies of ibuprofen are lacking, and prophylactic ibuprofen is ineffective in decreasing severe IVH. The choice of one drug over the other also depends on local availability of both drugs and the intravenous or enteral preparation. The oral preparation of ibuprofen appears as effective as the intravenous preparation. The use of paracetamol to close a hemodynamically significant PDA has increased in recent years. Paracetamol also decreases prostacyclin synthesis; however, unlike COX inhibitors, it does not have a peripheral vaso-constrictive effect and can be given to infants with contraindications to non-steroidal anti-inflammatory drugs. It appears to have similar efficacy based on limited data available from randomized trials. Until more data are available on efficacy, safety, and long-term outcomes, it cannot be recommended as the first choice.
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Affiliation(s)
- Sindhu Sivanandan
- Division of Neonatology, Department of Pediatrics (Newborn Health Knowledge Center (NHKC), ICMR Center for Advanced Research in Newborn Health and WHO Collaborating Centre for Newborn Training and Research, New Private Ward-1st Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Ramesh Agarwal
- Division of Neonatology, Department of Pediatrics (Newborn Health Knowledge Center (NHKC), ICMR Center for Advanced Research in Newborn Health and WHO Collaborating Centre for Newborn Training and Research, New Private Ward-1st Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Lee JA, Kim MJ, Oh S, Choi BM. Current Status of Therapeutic Strategies for Patent Ductus Arteriosus in Very-Low-Birth-Weight Infants in Korea. J Korean Med Sci 2015; 30 Suppl 1:S59-66. [PMID: 26566359 PMCID: PMC4641065 DOI: 10.3346/jkms.2015.30.s1.s59] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 09/25/2015] [Indexed: 11/25/2022] Open
Abstract
This study aimed to investigate current therapeutic strategies for patent ductus arteriosus (PDA) in very-low-birth-weight (VLBW) infants in Korea. A total of 2,254 VLBW infants among 2,386 from Korean Neonatal Network cohort born from January 2013 to June 2014 were included. No PDA was seen for 1,206 infants (53.5%) and the infants diagnosed or treated for PDA were 1,048 infants (46.5%). The proportion of infants with PDA was decreased according to the increase in gestational age (GA) and birthweight. Infants with PDA were divided into groups according to the therapeutic strategies of PDA: prophylactic treatment (PT, n = 69, 3.1%), pre-symptomatic treatment (PST, n = 212, 9.4%), symptomatic treatment (ST, n = 596, 26.4%), and conservative treatment (CT, n = 171, 7.6%). ST was the most preferred treatment modality for preterm PDA and the proportion of the patients was decreased in the order of PST, CT, and PT. Although ST was still the most favored treatment in GA < 24 weeks group, CT was more preferred than PST or ST when compared with GA ≥ 32 weeks group [CT vs. PST, OR 5.3, 95% CI 1.56-18.18; CT vs. ST, OR 2.9, 95% CI 1.03-8.13]. A total of 877 infants (38.9%) received pharmacological or surgical treatment about PDA, and 35.5% (801 infants) received pharmacological treatment, mostly with ibuprofen. Seventy-six infants (3.4%) received primary ligation and 8.9% (201 infants) received secondary ligation. Diverse treatment strategies are currently used for preterm PDA in Korea. Further analyses of neonatal outcomes according to the treatment strategies are necessary to obtain a standardized treatment guideline for preterm PDA.
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Affiliation(s)
- Jin A Lee
- Department of Pediatrics, Seoul National University Boramae Hospital, Seoul, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Myo-Jing Kim
- Department of Pediatrics, Dong-A University College of Medicine, Busan, Korea
| | - Sohee Oh
- Department of Biostatistics, Seoul National University Boramae Hospital, Seoul, Korea
| | - Byung Min Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
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Current controversies in the management of patent ductus arteriosus in preterm infants. Indian Pediatr 2015; 51:289-94. [PMID: 24825266 DOI: 10.1007/s13312-014-0403-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Patent ductus arteriosus is very commonly seen in very low birth weight (VLBW) infants, affecting about one-third. The present review tries to identify the group of VLBW infants who need active intervention in day-to-day practice and to determine the mode of intervention, based on current published literatures. METHODS We searched the Cochrane library, MEDLINE, EMBASE and CINAHL databases, and reference that of identified trials. RESULTS AND CONCLUSIONS Preterm infants with a birth weight of <800g are at risk of significant morbidity and mortality from PDA; it would be reasonable to treat them when symptomatic or if requiring positive pressure ventilator support. Those weighing >800g are unlikely to need treatment unless they are ventilator-dependent or show evidence of congestive heart failure.
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Gudmundsdottir A, Johansson S, Håkansson S, Norman M, Källen K, Bonamy AK. Timing of pharmacological treatment for patent ductus arteriosus and risk of secondary surgery, death or bronchopulmonary dysplasia: a population-based cohort study of extremely preterm infants. Neonatology 2015; 107:87-92. [PMID: 25412681 DOI: 10.1159/000367887] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 08/26/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND The optimal timing of pharmacological treatment for patent ductus arteriosus (PDA) in extremely preterm infants is unknown. OBJECTIVE To investigate whether timing of pharmacological PDA treatment is associated with a risk of secondary PDA surgery or death before 3 months of age, or bronchopulmonary dysplasia (BPD) in extremely preterm infants. METHODS In this population-based cohort of infants born before 27 gestational weeks in Sweden in 2004-2007, 290/585 infants (50%) received pharmacological PDA treatment. Cox proportional hazards regression estimated the hazard ratio (HR, with 95% confidence interval, CI) of secondary PDA surgery or death as a composite outcome in relation to postnatal age at the start of pharmacological treatment: early (0-2 days); intermediate (3-6 days); late (≥7 days). Furthermore, the odds ratio (OR, with 95% CI) of BPD was estimated in relation to postnatal age at PDA treatment by conditional logistic regression. RESULTS The median postnatal age at the start of pharmacological PDA treatment was 4 days. 102 infants had secondary PDA surgery. Timing of PDA treatment was not associated with risk of PDA surgery or death; adjusted HRs were 0.89 (95% CI 0.57-1.39) after an intermediate start and 1.10 (95% CI 0.53-2.28) after a late start, compared to an early start of treatment. Compared to the early start of PDA treatment, the intermediate start was not associated with any risk of BPD, while late PDA treatment was associated with a lower BPD risk; adjusted ORs were 0.83 (95% CI 0.42-1.64) and 0.28 (95% CI 0.13-0.61), respectively. CONCLUSION Timing of pharmacological PDA treatment after extremely preterm birth is not associated with the risk of secondary PDA surgery or death. Moreover, expectant PDA management is not associated with an increased risk of BPD.
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Affiliation(s)
- Anna Gudmundsdottir
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Jannatdoust A, Samadi M, Yeganehdoust S, Heydarzadeh M, Alikhah H, Piri R, Naghavi-Behzad M. Effects of intravenous indomethacin on reduction of symptomatic patent ductus arteriosus cases and decreasing the need for prolonged mechanical ventilation. J Cardiovasc Thorac Res 2014; 6:257-9. [PMID: 25610559 PMCID: PMC4291606 DOI: 10.15171/jcvtr.2014.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 12/11/2014] [Indexed: 11/29/2022] Open
Abstract
Introduction: We decided to investigate the effects of injecting Indomethacin on reducing complications of Patent Ductus Arteriosus (PDA) and the need for prolonged mechanical ventilation.
Methods: During this randomized clinical trial, 70 premature infants with matched gestational age and birth weight were divided into case and control groups. In the study group, intravenous indomethacin started from the first 2-12 hours of birth. All patients were followed by echocardiography at the fourth day and skull ultrasound in the second week.
Results: Symptomatic PDA rate was significantly higher in the control group (25.7% vs. 0%; P≤0.001). Incidence of grade 1-3 intraventricular hemorrhage was higher in the control group and the ratio of needed time for respiratory support in the control group to the case group was approximately 2.1.
Conclusion: Intravenous Indomethacin reduced the number of PDA cases and incidence of grade 2 and 3 intraventricular hemorrhage, without any short term side effects.
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Affiliation(s)
- Abdollah Jannatdoust
- Children Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahmoud Samadi
- Children Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Mohammad Heydarzadeh
- Children Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Alikhah
- Children Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Piri
- Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran ; Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Naghavi-Behzad
- Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran ; Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Patent ductus arteriosus in preterm infants: do we have the right answers? BIOMED RESEARCH INTERNATIONAL 2013; 2013:676192. [PMID: 24455715 PMCID: PMC3885207 DOI: 10.1155/2013/676192] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 09/13/2013] [Accepted: 10/04/2013] [Indexed: 12/20/2022]
Abstract
Patent ductus arteriosus (PDA) is a common clinical condition in preterm infants. Preterm newborns with PDA are at greater risk for several morbidities, including higher rates of bronchopulmonary dysplasia (BPD), decreased perfusion of vital organs, and mortality. Therefore, cyclooxygenase (COX) inhibitors and surgical interventions for ligation of PDA are widely used. However, these interventions were reported to be associated with side effects. In the absence of clear restricted rules for application of these interventions, different strategies are adopted by neonatologists. Three different approaches have been investigated including prophylactic treatment shortly after birth irrespective of the state of PDA, presymptomatic treatment using echocardiography at variable postnatal ages to select infants for treatment prior to the duct becoming clinically significant, and symptomatic treatment once PDA becomes clinically apparent or hemodynamically significant. Future appropriately designed randomized controlled trials (RCTs) to refine selection of patients for medical and surgical treatments should be conducted. Waiting for new evidence, it seems wise to employ available clinical and echocardiographic parameters of a hemodynamically significant (HS) PDA to select patients who are candidates for medical treatment. Surgical ligation of PDA could be used as a back-up tool for those patients who failed medical treatment and continued to have hemodynamic compromise.
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DeMauro SB, Cohen MS, Ratcliffe SJ, Abbasi S, Schmidt B. Serial echocardiography in very preterm infants: a pilot randomized trial. Acta Paediatr 2013; 102:1048-53. [PMID: 23952100 DOI: 10.1111/apa.12389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 08/08/2013] [Accepted: 08/09/2013] [Indexed: 11/28/2022]
Abstract
AIM To determine whether routine echocardiography increases diagnosis and treatment for patent ductus arteriosus (PDA) and whether randomized nondisclosure is a feasible strategy for studying PDA management. METHODS Two-centre, pilot randomized, controlled trial. 88 infants with birth weights ≤1250 grams and gestational ages ≤30 weeks were randomized to disclosure or nondisclosure of serial echocardiogram findings. Echocardiograms were performed at 3-5 and 7-10 days of life. The primary outcome was time to regain birth weight. RESULTS 100% of echocardiograms in the disclosure group were disclosed; 16% (echocardiogram #1) and 29% (echocardiogram #2) were disclosed in the nondisclosure group. There was a statistically nonsignificant decrease in drug therapy for PDA in the nondisclosure group (adjusted odds ratio [AOR] 0.56, 95% confidence interval [CI] 0.24-1.34). There was no difference in time to regain birth weight or in other important neonatal outcomes. However, infants in the nondisclosure group were more likely to demonstrate appropriate weight loss and then regain birth weight within 7-14 days (AOR 2.64, 95% CI 1.08-6.44). CONCLUSION Randomized nondisclosure of echocardiograms is a feasible strategy for evaluation of approaches to PDA management in very preterm infants. Avoidance of routine echocardiography may reduce drug therapy for PDA without adverse clinical effects.
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Affiliation(s)
- Sara B DeMauro
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Clinical pharmacology of indomethacin in preterm infants: implications in patent ductus arteriosus closure. Paediatr Drugs 2013; 15:363-76. [PMID: 23754139 DOI: 10.1007/s40272-013-0031-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Indomethacin is a non-steroidal anti-inflammatory drug that is a potent inhibitor of prostaglandin E(2) synthesis. After birth, the ductus arteriosus closes spontaneously within 2-4 days in term infants. The major factor closing the ductus arteriosus is the tension of oxygen, which increases significantly after birth. Prostaglandin E(2) has the opposite effect to that of oxygen; it relaxes smooth muscle and tends to inhibit the closure of the ductus arteriosus. In preterm infants with respiratory distress syndrome, the ductus arteriosus fails to close (patent ductus arteriosus [PDA]) because the concentration of prostaglandin E2 is relatively high. PDA occurs in more than 70 % of neonates weighing less than 1,500 g at birth. The aim of this article was to review the published data on the clinical pharmacology of indomethacin in preterm infants in order to provide a critical analysis of the literature and a useful tool for physicians. The bibliographic search was performed electronically using the PubMed and EMBASE databases as search engines and February 2012 was the cutoff point. A remarkable interindividual variability was observed for the half-life (t(½)), clearance (CL), and volume of distribution (V(d)) of indomethacin. Prophylactic indomethacin consists of a continuous infusion of low levels of indomethacin and may be useful in preterm infants. Extremely preterm infants are less likely to respond to indomethacin. Infants with a postnatal age of 2 months do not respond to treatment with indomethacin. Indomethacin has several adverse effects, the most common of which is renal failure. An increase in serum creatinine of ≥0.5 % mg/dL after indomethacin was observed in about 10-15 % of the patients and creatinine returns to a normal level about 1 week after cessation of therapy. Indomethacin should be administered intravenously by syringe pump for at least 30 min to minimize adverse effects on cerebral, gastrointestinal, and renal blood flow velocities. A prolonged course of indomethacin appears to reduce the risk of severe intracranial hemorrhage and renal impairment in patients with PDA. In conclusion, indomethacin is a useful drug to treat PDA.
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Abstract
A persistent left-to-right shunt through a patent ductus arteriosus (PDA) increases the rate of hydrostatic fluid filtration into the lung's interstitium, impairs pulmonary mechanics, and prolongs the need for mechanical ventilation. In preclinical trials, pharmacologic PDA closure leads to improved alveolarization and minimizes the impaired postnatal alveolar development that is the pathologic hallmark of the "new bronchopulmonary dysplasia (BPD)". Although early pharmacologic closure of the PDA decreases the incidence of pulmonary hemorrhage, intraventricular hemorrhage, and the need for PDA ligation, there is little evidence from controlled, clinical trials to support or refute a causal role for the PDA in the development of BPD. However, evidence from epidemiologic, preclinical, and randomized controlled clinical trials demonstrate that early ductus ligation is an independent risk factor for the development of BPD and may directly contribute to the neonatal morbidities it is trying to prevent.
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Affiliation(s)
- Ronald I Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
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38
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Abstract
Although significant advances in respiratory care have been made in neonatal medicine, bronchopulmonary dysplasia (BPD) remains the most common serious pulmonary morbidity in premature infants. The development of BPD is the result of the complex interactions between multiple perinatal and postnatal factors. Early identification of infants at the most risk of developing BPD through the use of estimators and models may allow a targeted approach at reducing BPD in the future.
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Affiliation(s)
- Andrea Trembath
- Rainbow Babies & Children's Hospital, 11000 Euclid Avenue, RBC Suite 3100, Cleveland, OH 44106, USA.
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Abstract
Debate about the importance of the preterm patent ductus arteriosus (PDA) remains unresolved. Ultrasound studies of PDA have suggested that the haemodynamic impact may be much earlier after birth than previously thought, but we still do not know when to treat a PDA. Studies that have tested symptomatic or pre-symptomatic treatment are mainly historical and have not tested the effect of no treatment. Prophylactic treatment is the best studied regimen, but improvements in some short-term outcomes do not translate to any difference in longer term outcomes. Neonatologists have been reluctant to engage in trials that test treatment against not treating at all or very rarely. Targeting treatment on the basis of the early post-natal constrictive response of the duct is currently being tested as a possible strategy.
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Affiliation(s)
- Nick Evans
- Department of Newborn Care, Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia.
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40
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Clyman RI, Couto J, Murphy GM. Patent ductus arteriosus: are current neonatal treatment options better or worse than no treatment at all? Semin Perinatol 2012; 36:123-9. [PMID: 22414883 PMCID: PMC3305915 DOI: 10.1053/j.semperi.2011.09.022] [Citation(s) in RCA: 178] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Although a moderate-sized patent ductus arteriosus (PDA) needs to be closed by the time a child is 1-2 years old, there is great uncertainty about whether it needs to be closed during the neonatal period. Although 95% of neonatologists believe that a moderate-sized PDA should be closed if it persists in infants (born before 28 weeks) who still require mechanical ventilation, the number of neonatologists who treat a PDA when it occurs in infants who do not require mechanical ventilation varies widely. Both the high likelihood of spontaneous ductus closure and the absence of randomized controlled trials, specifically addressing the risks and benefits of neonatal ductus closure, add to the current uncertainty. New information suggests that early pharmacologic treatment has several important short-term benefits for the preterm newborn. By contrast, ductus ligation, while eliminating the detrimental effects of a PDA on lung development, may create its own set of morbidities that counteract many of the benefits derived from ductus closure.
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MESH Headings
- Cardiovascular Agents/therapeutic use
- Ductus Arteriosus, Patent/drug therapy
- Ductus Arteriosus, Patent/physiopathology
- Ductus Arteriosus, Patent/surgery
- Ductus Arteriosus, Patent/therapy
- Female
- Humans
- Indomethacin/therapeutic use
- Infant, Newborn
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/physiopathology
- Infant, Premature, Diseases/surgery
- Ligation
- Male
- Pregnancy
- Respiration, Artificial
- Unnecessary Procedures
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Affiliation(s)
- Ronald I Clyman
- Department of Pediatrics, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA.
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41
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Abstract
Although ongoing patency of the ductus arteriosus is common in small extremely preterm infants, consensus is lacking regarding its clinical significance and treatment strategies. Literature regarding likelihood of spontaneous closure, impact on neonatal morbidity and long-term outcomes, and adverse effects of intervention has led to uncertainty as to the best course of action. Enhancing the determination of hemodynamic significance and refining patient selection for therapeutic intervention will streamline the decision-making process. Targeted neonatal echocardiography performed by the clinician has gained popularity worldwide, and preliminary data show that it has the potential to optimize patient outcomes. We review the arguments for and against medical and surgical therapy, explore how targeted neonatal echocardiography used in conjunction with biomarkers may refine the treatment approach, and consider future directions in the field.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Medical Centre, Clayton, Victoria, Australia
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Zonnenberg I, de Waal K. The definition of a haemodynamic significant duct in randomized controlled trials: a systematic literature review. Acta Paediatr 2012; 101:247-51. [PMID: 21913976 DOI: 10.1111/j.1651-2227.2011.02468.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM A patent ductus arteriosus (PDA) is associated with morbidity in preterm infants. Treatment is prescribed for a haemodynamically significant duct (HSDA), but its definition varies. We systematically reviewed the clinical and ultrasound criteria used for the definition of an HSDA. METHODS PubMed and the Cochrane library were searched for randomized trials evaluating ductal treatment. The included studies were explored, and we categorized clinical and ultrasound criteria used to define an HSDA. RESULTS Sixty-seven trials were included in our review. Forty-two were placebo-controlled trials, and 25 were comparative trials. The diagnosis of the PDA was made by clinical examination, followed by ultrasound in most trials. Most trials used clinical and ultrasound criteria to define an HSDA, but there was a wide variety in criteria and cut-offs used. Of the clinical criteria, a murmur or hyperdynamic circulation was most used, and of the ultrasound criteria, the left-atrium-to-aorta ratio (LA/Ao ratio) was most used. CONCLUSION We found a wide variety in the definition of an HSDA. This finding implies that comparison of studies is difficult. International consensus should be reached on the definition of an HSDA, which will make future studies more comparable.
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MESH Headings
- Ductus Arteriosus, Patent/diagnosis
- Ductus Arteriosus, Patent/diagnostic imaging
- Ductus Arteriosus, Patent/physiopathology
- Hemodynamics
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/diagnostic imaging
- Infant, Premature, Diseases/physiopathology
- Randomized Controlled Trials as Topic
- Ultrasonography, Doppler
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Affiliation(s)
- Inge Zonnenberg
- Department of Neonatology, VU Medical Centre, Amsterdam, The Netherlands
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43
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Patent ductus arteriosus in infants <29 weeks gestation — outcomes and factors affecting closure. Indian Pediatr 2012; 49:615-20. [DOI: 10.1007/s13312-012-0132-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 10/19/2011] [Indexed: 11/27/2022]
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Mosalli R, Alfaleh K, Paes B. Role of prophylactic surgical ligation of patent ductus arteriosus in extremely low birth weight infants: Systematic review and implications for clinical practice. Ann Pediatr Cardiol 2011; 2:120-6. [PMID: 20808624 PMCID: PMC2922659 DOI: 10.4103/0974-2069.58313] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objectives: To investigate the effectiveness and safety of prophylactic surgical ligation of patent ductus arteriosus (PDA) on mortality and morbidity of preterm infants weighing less than 1000 g at birth. Materials and Methods: The study conducted a systematic search of available database from 1996-2008. Retrieved articles were assessed for eligibility and data was abstracted independently by two reviewers. Decisions to include studies for review and the methodological quality of included studies were asssessed in duplicate based on predetermined criteria. No language restrictions were applied. Results: Only one eligible study that enrolled 84 extremely low birth weight infants was identified. Prophylactic surgical ligation of PDA resulted in a statistically significant reduction of severe stage II or III necrotizing enterocolitis, [RR 0.25, 95% CI (0.08, 0.83), P value 0.02, number needed to treat 5]. The study, however, found no statistically significant difference in mortality, intraventricular hemorrhage, bronchopulmonary dysplasia, and retinopathy of prematurity. Conclusions: Current evidence does not support the use of prophylactic surgical ligation of PDA in the management of the preterm infants.
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Affiliation(s)
- Rafat Mosalli
- Departments of Pediatrics, Omm Al-Qura University, Mecca
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46
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Abstract
Treatment of persistent patency of the ductus arteriosus in preterm infants remains heterogeneous and controversial. Routine early treatment to induce ductal closure is not beneficial, but the potential criteria for, timing of, methods for and benefits of later ductal closure have not been determined. Management strategies for infants awaiting spontaneous closure or meeting criteria for treatment may be based on pathophysiological considerations but require evaluation in clinical trials. Better diagnostic tools allowing the identification of infants who might benefit from ductal closure, supplemented by data from clinical trials confirming realization of that potential, are urgently needed.
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47
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Fowlie PW, Davis PG, McGuire W. Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants. Cochrane Database Syst Rev 2010; 2010:CD000174. [PMID: 20614421 PMCID: PMC7045285 DOI: 10.1002/14651858.cd000174.pub2] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Persistent patent ductus arteriosus (PDA) is associated with mortality and morbidity in preterm infants. Prostaglandin synthetase inhibitors such as indomethacin promote PDA closure but also have potential side effects. The effect of the prophylactic use of indomethacin, where infants who may not have gone on to develop a symptomatic PDA would be exposed to indomethacin, warrants particular scrutiny. OBJECTIVES To determine the effect of prophylactic indomethacin on mortality and morbidity in preterm infants. SEARCH STRATEGY The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2010), MEDLINE, EMBASE and CINAHL (until April 2010), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that compared prophylactic indomethacin versus placebo or no drug in preterm infants. DATA COLLECTION AND ANALYSIS The standard methods of the Cochrane Neonatal Review Group were used, with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS Nineteen eligible trials in which 2872 infants participated were identified. Most participants were very low birth weight, but the largest single trial restricted participation to extremely low birth weight infants (N = 1202). The trials were generally of good quality.The incidence of symptomatic PDA [typical relative risk (RR) 0.44, 95% confidence interval (CI) 0.38 to 0.50] and PDA surgical ligation (typical RR 0.51, 95% CI 0.37,0.71) was significantly lower in treated infants. Prophylactic indomethacin also significantly reduced the incidence of severe intraventricular haemorrhage (typical RR 0.66, 95% CI 0.53 to 0.82). Meta-analyses found no evidence of an effect on mortality (typical RR 0.96, 95% CI 0.81 to 1.12) or on a composite of death or severe neurodevelopmental disability assessed at 18 to 36 months old (typical RR 1.02, 95% CI 0.90, 1.15). AUTHORS' CONCLUSIONS Prophylactic indomethacin has short-term benefits for preterm infants including a reduction in the incidence of symptomatic PDA, PDA surgical ligation, and severe intraventricular haemorrhage. However, there is no evidence of effect on mortality or neurodevelopment.
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Affiliation(s)
- Peter W Fowlie
- Ninewells Hospital and Medical SchoolWomen & Child HealthDundeeScotlandUKDD1 9SY
| | - Peter G Davis
- The Royal Women's HospitalDepartment of Newborn Research20 Flemington RdParkvilleVictoriaAustralia3052
| | - William McGuire
- Hull York Medical SchoolCentre for Reviews and DisseminationUniversity of YorkYorkY010 5DDUK
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48
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Benitz WE. Treatment of persistent patent ductus arteriosus in preterm infants: time to accept the null hypothesis? J Perinatol 2010; 30:241-52. [PMID: 20182439 DOI: 10.1038/jp.2010.3] [Citation(s) in RCA: 240] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Medical and surgical interventions are widely used to close a persistently patent ductus arteriosus in preterm infants. Objective evidence to support these practices is lacking, causing some to question their usage. Emerging evidence suggests that treatments that close the patent ductus may be detrimental. This review examines the history of and evidence underlying these treatments. Neither individual trials, pooled data from groups of randomized-controlled trials, nor critical examination of the immediate consequences of treatment provide evidence that medical or surgical closure of the ductus is beneficial in preterm infants. These conclusions are supported by sufficient evidence. Neither continued routine use of these treatments nor additional clinical trials using similar designs seems to be justified. A definitive trial, comparing current standard management with novel strategies not primarily intended to achieve ductal closure, may be necessary to resolve doubts regarding the quality or conduct of prior studies.
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Affiliation(s)
- W E Benitz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304-1510, USA.
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49
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Abstract
Considerable effort has been devoted to the development of strategies to reduce the incidence of bronchopulmonary dysplasia (BPD), including use of medications, nutritional therapies, and respiratory care practices. Unfortunately, most of these strategies have not been successful. To date, the only two treatments developed specifically to prevent BPD whose efficacy is supported by evidence from randomized, controlled trials are the parenteral administration of vitamin A and corticosteroids. Two other therapies, the use of caffeine for the treatment of apnea of prematurity and aggressive phototherapy for the treatment of hyperbilirubinemia, were evaluated for the improvement of other outcomes and found to reduce BPD. Cohort studies suggest that the use of continuous positive airway pressure as a strategy for avoiding mechanical ventilation might also be beneficial. Other therapies reduce lung injury in animal models but do not appear to reduce BPD in humans. The benefits of the efficacious therapies have been modest, with an absolute risk reduction in the 7-11% range. Further preventive strategies are needed to reduce the burden of this disease. However, each will need to be tested in randomized, controlled trials, and the expectations of new therapies should be modest reductions of the incidence of the disease.
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Affiliation(s)
- Matthew M. Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, NC, CB# 7596, 4 Floor, UNC Hospitals, Chapel Hill, NC 27599-7596, Phone: (919) 966-5063, Fax: (919) 966-3034
| | - P. Brian Smith
- Duke University, Durham, NC, PO Box 17969, Durham, NC 27715, Phone: (919) 668-8951, Fax: (919) 668-7058
| | - Carl Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC, CB# 7596, 4 Floor, UNC Hospitals, Chapel Hill, NC 27599-7596, Phone: (919) 966-5063, Fax: (919) 966-3034
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50
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Marcoux MO, Denizot S, Dassieu G, Picaud JC, Cristini C, Arnaud C, Montjaux N, Bonnet S, Rozé JC, Danan C, Bloom MC, Casper C. Niveaux de preuves versus pratiques cliniques : l’exemple de l’extrême prématurité. Arch Pediatr 2009; 16 Suppl 1:S49-55. [DOI: 10.1016/s0929-693x(09)75301-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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