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Jasani B, Mitra S, Shah PS. Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants. Cochrane Database Syst Rev 2022; 12:CD010061. [PMID: 36519620 DOI: 10.1002/14651858.cd010061.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The different management strategies for patent ductus arteriosus (PDA) in preterm infants are expectant management, surgery, or medical treatment with non-selective cyclo-oxygenase inhibitors. Randomized controlled trials (RCTs) have suggested that paracetamol may be an effective and safe agent for the closure of a PDA. OBJECTIVES To determine the efficacy and safety of paracetamol as monotherapy or as part of combination therapy via any route of administration, compared with placebo, no intervention, or another prostaglandin inhibitor, for prophylaxis or treatment of an echocardiographically-diagnosed PDA in preterm or low birth weight infants. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and three trials registers on 13 October 2021, and one other database on 1 March 2022. We also checked references and contacted study authors to identify additional studies. SELECTION CRITERIA We included RCTs and quasi-RCTs in which paracetamol (single-agent or combination therapy) was compared to no intervention, placebo, or other agents used for closure of PDA, irrespective of dose, duration, and mode of administration in preterm infants. Two independent authors reviewed the search results and made a final selection of potentially eligible articles through discussion. DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of Cochrane Neonatal. We used the GRADE approach to assess the certainty of evidence for the following outcomes: failure of ductal closure after the first course of treatment; all-cause mortality during initial hospital stay; and necrotizing enterocolitis (NEC). MAIN RESULTS For this update, we included 27 studies enrolling 2278 infants. We considered the overall risk of bias in the 27 studies to vary from low to unclear. We identified 24 ongoing studies. Paracetamol versus ibuprofen There was probably little to no difference between paracetamol and ibuprofen for failure of ductal closure after the first course (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.88 to 1.18; 18 studies, 1535 infants; moderate-certainty evidence). There was likely little to no difference between paracetamol and ibuprofen for all-cause mortality during hospital stay (RR 1.09, 95% CI 0.80 to 1.48; 8 studies, 734 infants; moderate-certainty evidence), and for NEC (RR 1.30, 95% CI 0.87 to 1.94; 10 studies, 1015 infants; moderate-certainty evidence). Paracetamol versus indomethacin There was little to no difference between paracetamol and indomethacin for failure of ductal closure after the first course (RR 1.02, 95% CI 0.78 to 1.33; 4 studies, 380 infants; low-certainty evidence). There was little to no difference between paracetamol and indomethacin for all-cause mortality during hospital stay (RR 0.86, 95% CI 0.39 to 1.92; 2 studies, 114 infants; low-certainty evidence). The rate of NEC may be lower in the paracetamol group (3.7%) versus the indomethacin group(9.2%) (RR 0.42, 95% CI 0.19 to 0.96; 4 studies, 384 infants; low-certainty evidence). Prophylactic paracetamol versus placebo/no intervention Prophylactic paracetamol (17%) compared to placebo/no intervention (61%) may reduce failure of ductal closure after one course (RR 0.27, 95% CI 0.18 to 0.42; 3 studies, 240 infants; low-certainty evidence). There was little to no difference between prophylactic paracetamol and placebo/no intervention for all-cause mortality during hospital stay (RR 0.59, 95% CI 0.24 to 1.44; 3 studies, 240 infants; low-certainty evidence). No studies reported on NEC. Early paracetamol treatment versus placebo/no intervention Early paracetamol treatment (28%) compared to placebo/no intervention (79%) may reduce failure of ductal closure after one course when used before 14 days' postnatal age (RR 0.35, 95% CI 0.23 to 0.53; 2 studies, 127 infants; low-certainty evidence). No studies reported on all-cause mortality during hospital stay or NEC. Late paracetamol treatment versus placebo/no intervention There was little to no difference between late paracetamol and placebo for failure of ductal closure after one course of treatment when used at or after 14 days' postnatal age (RR 0.85, 95% CI 0.72 to 1.01; 1 study, 55 infants; low-certainty evidence) or NEC (RR 1.04, 95% CI 0.07 to 15.76; 1 study, 55 infants; low-certainty evidence). No data were reported for all-cause mortality during hospital stay. Paracetamol combined with ibuprofen versus ibuprofen combined with placebo or no intervention There was little to no difference between paracetamol plus ibuprofen compared to ibuprofen plus placebo or no intervention for failure of ductal closure after the first course (RR 0.77, 95% CI 0.43 to 1.36; 2 studies, 111 infants; low-certainty evidence). There was little to no difference between paracetamol plus ibuprofen compared to ibuprofen plus placebo or no intervention for NEC (RR 0.33, 95% CI 0.01 to 7.45; 1 study, 24 infants; low-certainty evidence). No data were reported for all-cause mortality during hospital stay. AUTHORS' CONCLUSIONS: Moderate-certainty evidence suggests that there is probably little or no difference in effectiveness between paracetamol and ibuprofen; low-certainty evidence suggests that there is probably little or no difference in effectiveness between paracetamol and indomethacin; low-certainty evidence suggests that prophylactic paracetamol may be more effective than placebo/no intervention; low-certainty evidence suggests that early paracetamol treatment may be more effective than placebo/no intervention; low-certainty evidence suggests that there is probably little or no difference between late paracetamol treatment and placebo, and probably little or no difference in effectiveness between the combination of paracetamol plus ibuprofen versus ibuprofen alone for the closure of PDA after the first course of treatment. The majority of neonates included in these studies were of moderate preterm gestation. Thus, establishing the efficacy and safety of paracetamol for PDA treatment in extremely low birth weight (ELBW: birth weight < 1000 grams) and extremely low gestational age neonates (ELGANs < 28 weeks' gestation) requires further studies.
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Affiliation(s)
- Bonny Jasani
- Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Souvik Mitra
- Departments of Pediatrics, Community Health & Epidemiology, Dalhousie University & IWK Health Centre, Halifax, 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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Olowoyeye A, Nnamdi-Nwosu O, Manalastas M, Okwundu C. A Network Meta-Analysis of Intravenous Versus Oral Acetaminophen for Patent Ductus Arteriosus. Pediatr Cardiol 2022; 44:748-756. [PMID: 36422654 DOI: 10.1007/s00246-022-03053-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/14/2022] [Indexed: 11/26/2022]
Abstract
The use of acetaminophen to close a PDA in preterm infants is increasing; however, the most effective route of administration is not yet known. This network meta-analysis compares the efficacy of IV versus PO routes of acetaminophen administration on clinical outcomes related to the presence of a PDA in preterm neonates. Medline, Embase, Cochrane Central Register of Controlled Trials, Embase, Web of Science, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform were searched from inception to October 2020. A total 21 randomized controlled trials in neonates less than 37 weeks at birth, comparing oral or intravenously administered acetaminophen to close a PDA based on study criteria were included. Two authors extracted data independently and in duplicate. All outcomes were binary, and a frequentist network meta-analysis was performed. After one or two courses, both PO and IV acetaminophen were efficacious in closing a PDA with oral ranking higher than IV (low confidence). Neither medication was better than no treatment for secondary outcomes of NEC or BPD (moderate and low confidence respectively). We did not test the rectal route of acetaminophen administration and cannot make generalized statements. This study suggests oral acetaminophen increases the odds of being able to close a PDA in preterm neonates when compared to IV acetaminophen.
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Affiliation(s)
- Abiola Olowoyeye
- Department of Neonatology, Phoenix Children's Hospital, Phoenix, AZ, USA. .,Department of Child Health, University of Arizona College of Medicine -Phoenix, Phoenix, AZ, USA.
| | | | - Maika Manalastas
- Department of Neonatology, Phoenix Children's Hospital, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine -Phoenix, Phoenix, AZ, USA
| | - Charles Okwundu
- Centre for Evidence-Based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Dani C, Ciarcià M, Miselli F, Luzzati M, Coviello C, Paladini A, Bottoni A, D’Andrea V, Vento G. Platelet Count and Volume and Pharmacological Closure with Paracetamol of Ductus Arteriosus in Preterm Infants. CHILDREN 2022; 9:children9010089. [PMID: 35053714 PMCID: PMC8774717 DOI: 10.3390/children9010089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 11/17/2022]
Abstract
Background: Low platelet count might promote resistance to pharmacological closure with indomethacin and ibuprofen of a hemodynamically significant patent ductus arteriosus (hsPDA). However, no studies have investigated if this occurs with paracetamol. Methods: We retrospectively assessed the correlation between platelet count, mean platelet volume (MPV), and plateletcrit (PCT), as well as the effectiveness of paracetamol in closing hsPDA in infants born at 23+0–31+6 weeks of gestation who were treated with 15 mg/kg/6 h of i.v. paracetamol for 3 days. Results: We studied 79 infants: 37 (47%) Had closure after a course of paracetamol and 42 (53%) did not. Platelet count and PCT did not correlate with paracetamol success or failure in closing hsPDA, while MPV was lower at birth (10.7 ± 1.4 vs. 9.5 ± 1.1; p < 0.001) and prior to starting therapy (11.7 ± 1.9 vs. 11.0 ± 1.6; p = 0.079) in refractory infants. Regression analysis confirmed that the low MVP measured prior to starting the treatment increased the risk of hsPDA paracetamol closure failure (OR 1.664, 95% CI 1.153–2.401). Conclusions: The greater MPV correlated positively with the effectiveness of paracetamol in closing hsPDA, while platelet count and PCT did not influence closure rates. Additional studies are needed to confirm our results.
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Affiliation(s)
- Carlo Dani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, 50134 Florence, Italy
- Division of Neonatology, University of Florence, 50134 Florence, Italy; (M.C.); (F.M.); (M.L.); (C.C.)
- Correspondence: ; Tel.: +39-055-794-8421
| | - Martina Ciarcià
- Division of Neonatology, University of Florence, 50134 Florence, Italy; (M.C.); (F.M.); (M.L.); (C.C.)
| | - Francesca Miselli
- Division of Neonatology, University of Florence, 50134 Florence, Italy; (M.C.); (F.M.); (M.L.); (C.C.)
| | - Michele Luzzati
- Division of Neonatology, University of Florence, 50134 Florence, Italy; (M.C.); (F.M.); (M.L.); (C.C.)
| | - Caterina Coviello
- Division of Neonatology, University of Florence, 50134 Florence, Italy; (M.C.); (F.M.); (M.L.); (C.C.)
| | - Angela Paladini
- Division of Neonatology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of Sacred Heart, 20123 Rome, Italy; (A.P.); (A.B.); (V.D.); (G.V.)
| | - Anthea Bottoni
- Division of Neonatology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of Sacred Heart, 20123 Rome, Italy; (A.P.); (A.B.); (V.D.); (G.V.)
| | - Vito D’Andrea
- Division of Neonatology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of Sacred Heart, 20123 Rome, Italy; (A.P.); (A.B.); (V.D.); (G.V.)
| | - Giovanni Vento
- Division of Neonatology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of Sacred Heart, 20123 Rome, Italy; (A.P.); (A.B.); (V.D.); (G.V.)
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Scerbo D, Cua CL, Rivera BK, Marzec LC, Smith CV, Slaughter JL, Berman DP, Backes CH. Percutaneous Closure of the Patent Ductus Arteriosus in Very-Low-Weight Infants. Neoreviews 2021; 21:e469-e478. [PMID: 32611564 DOI: 10.1542/neo.21-7-e469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In view of the known complications of drug therapy and open surgical ligation, and the potential for prolonged patent ductus arteriosus (PDA) exposure to be harmful, health care practitioners have sought new approaches to achieve definitive ductal closure. Interest in percutaneous (catheter-based) PDA closure has emerged within the neonatal community as a viable treatment option, because it has been fueled by recent procedural and device modifications, as well as mounting feasibility and safety data. Herein, we provide a contemporary review of percutaneous PDA closure among infants at the crux of the medical debate-very-low-weight infants (≤1,500 g), including: 1) characterization of traditional PDA treatments (drug therapy, open surgical ligation) and conservative (nonintervention) management options; 2) a general overview of the major procedural steps of percutaneous ductal closure, including efforts to reduce thrombotic complications and the emergence of a novel US Food and Drug Administration-approved device; 3) a systematic review and meta-analysis to better understand risk profiles of percutaneous PDA closure in this population; and 4) discussion of current gaps in our understanding of optimal PDA care, including the critical need for well-designed, randomized, controlled clinical trials.
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Affiliation(s)
- Danielle Scerbo
- The Ohio University Heritage College of Osteopathic Medicine, Athens, OH.,Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Clifford L Cua
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Brian K Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Laura C Marzec
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Charles V Smith
- Center for Integrated Brain Research, Seattle Children's Hospital, Seattle, WA
| | - Jonathan L Slaughter
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH.,Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH
| | - Darren P Berman
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Carl H Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,The Heart Center, Nationwide Children's Hospital, Columbus, OH.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
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Parkerson S, Philip R, Talati A, Sathanandam S. Management of Patent Ductus Arteriosus in Premature Infants in 2020. Front Pediatr 2021; 8:590578. [PMID: 33643964 PMCID: PMC7904697 DOI: 10.3389/fped.2020.590578] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/22/2020] [Indexed: 12/14/2022] Open
Abstract
The patent ductus arteriosus (PDA) is the most commonly found cardiac condition in neonates. While there have been several studies and thousands of publications on the topic, the decision to treat the PDA is still strongly debated among cardiologists, surgeons, and neonatologists. This is in part due to the shortage of long-term benefits with the interventions studied. Practice variations still exist within sub-specialties and centers. This article briefly summarizes the history, embryology and histology of the PDA. It also succinctly discusses the hemodynamic significance of a PDA which builds the framework to review all the available literature on PDA closure in premature infants, though not a paradigm shift just yet; it introduces transcatheter PDA closure (TCPC) as a possible armament to the clinician for this age-old problem.
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Affiliation(s)
- Sarah Parkerson
- Department of Pediatrics, University of Tennessee, Memphis, TN, United States
| | - Ranjit Philip
- Division of Pediatric Cardiology, University of Tennessee, Memphis, TN, United States
| | - Ajay Talati
- Division of Neonatology, University of Tennessee, Memphis, TN, United States
| | - Shyam Sathanandam
- Division of Pediatric Cardiology, University of Tennessee, Memphis, TN, United States
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Ohlsson A, Shah PS. Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants. Cochrane Database Syst Rev 2020; 1:CD010061. [PMID: 31985831 PMCID: PMC6984659 DOI: 10.1002/14651858.cd010061.pub4] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In preterm newborns, the ductus arteriosus frequently fails to close and the infants require medical or surgical closure of the patent ductus arteriosus (PDA). A PDA can be treated surgically; or medically with one of two prostaglandin inhibitors, indomethacin or ibuprofen. Case reports suggest that paracetamol may be an alternative for the closure of a PDA. An association between prenatal or postnatal exposure to paracetamol and later development of autism or autism spectrum disorder has been reported. OBJECTIVES To determine the effectiveness and safety of intravenous or oral paracetamol compared with placebo or no intervention, intravenous indomethacin, intravenous or oral ibuprofen, or with other cyclo-oxygenase inhibitors for treatment of an echocardiographically diagnosed PDA in preterm or low birth weight infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 10), MEDLINE via PubMed (1966 to 6 November 2017), Embase (1980 to 6 November 2017), and CINAHL (1982 to 6 November 2017). We searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCT) and quasi-randomised trials. SELECTION CRITERIA We included RCTs in which paracetamol was compared to no intervention, placebo or other agents used for closure of PDA irrespective of dose, duration and mode of administration in preterm (≤ 34 weeks' postmenstrual age) infants. We both reviewed the search results and made a final selection of potentially eligible articles by discussion. We included studies of both prophylactic and therapeutic use of paracetamol. DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of evidence for the following outcomes when data were available: failure of ductal closure after the first course of treatment; neurodevelopmental impairment; all-cause mortality during initial hospital stay (death); gastrointestinal bleed or stools positive for occult blood; and serum levels of creatinine after treatment (µmol/L). MAIN RESULTS We included eight studies that reported on 916 infants. One of these studies compared paracetamol to both ibuprofen and indomethacin. Five studies compared treatment of PDA with paracetamol versus ibuprofen and enrolled 559 infants. There was no significant difference between paracetamol and ibuprofen for failure of ductal closure after the first course of drug administration (typical risk ratio (RR) 0.95, 95% confidence interval (CI) 0.75 to 1.21; typical risk difference (RD) -0.02, 95% CI -0.09 to 0.09); I² = 0% for RR and RD; moderate quality of evidence. Four studies (n = 537) reported on gastrointestinal bleed which was lower in the paracetamol group versus the ibuprofen group (typical RR 0.28, 95% CI 0.12 to 0.69; typical RD -0.06, 95% CI -0.09 to -0.02); I² = 0% for RR and RD; number needed to treat for an additional beneficial outcome (NNTB) 17 (95% CI 11 to 50); moderate quality of evidence. The serum levels of creatinine were lower in the paracetamol group compared with the ibuprofen group in four studies (moderate quality of evidence), as were serum bilirubin levels following treatment in two studies (n = 290). Platelet counts and daily urine output were higher in the paracetamol group compared with the ibuprofen group. One study reported on long-term follow-up to 18 to 24 months of age following treatment with paracetamol versus ibuprofen. There were no significant differences in the neurological outcomes at 18 to 24 months (n = 61); (low quality of evidence). Two studies compared prophylactic administration of paracetamol for a PDA with placebo or no intervention in 80 infants. Paracetamol resulted in a lower rate of failure of ductal closure after 4 to 5 days of treatment compared to placebo or no intervention which was of borderline significance for typical RR 0.49 (95% CI 0.24 to 1.00; P = 0.05); but significant for typical RD -0.21 (95% CI -0.41 to -0.02); I² = 0 % for RR and RD; NNTB 5 (95% CI 2 to 50); (low quality of evidence). Two studies (n = 277) compared paracetamol with indomethacin. There was no significant difference in the failure to close a PDA (typical RR 0.96, 95% CI 0.55 to 1.65; I² = 11%; typical RD -0.01, 95% CI -0.09 to 0.08; I² = 17%) (low quality of evidence). Serum creatinine levels were significantly lower in the paracetamol group compared with the indomethacin group and platelet counts and daily urine output were significantly higher in the paracetamol group. AUTHORS' CONCLUSIONS Moderate-quality evidence according to GRADE suggests that paracetamol is as effective as ibuprofen; low-quality evidence suggests paracetamol to be more effective than placebo or no intervention; and low-quality evidence suggests paracetamol as effective as indomethacin in closing a PDA. There was no difference in neurodevelopmental outcome in children exposed to paracetamol compared to ibuprofen; however the quality of evidence is low and comes from only one study. In view of concerns raised regarding neurodevelopmental outcomes following prenatal and postnatal exposure to paracetamol, long-term follow-up to at least 18 to 24 months' postnatal age must be incorporated in any studies of paracetamol in the newborn population. At least 19 ongoing trials have been registered. Such trials are required before any recommendations for the possible routine use of paracetamol in the newborn population can be made.
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Affiliation(s)
- Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and EvaluationTorontoCanada
| | - Prakeshkumar S Shah
- University of Toronto Mount Sinai HospitalDepartment of Paediatrics and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoONCanadaM5G 1XB
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Schindler T, Smyth J, Bolisetty S, Michalowski J, Lui K. Early PARacetamol (EPAR) trial: a study protocol for a randomised controlled trial of early paracetamol to promote closure of the ductus arteriosus in preterm infants. BMJ Open 2019; 9:e031428. [PMID: 31666270 PMCID: PMC6830666 DOI: 10.1136/bmjopen-2019-031428] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The optimal management of patent ductus arteriosus (PDA) remains contentious. The medications used to treat PDA are often non-steroidal anti-inflammatory drugs, which are associated with a number of unwanted adverse effects. Paracetamol is a medication with an excellent safety profile in infants and has been suggested as a safe alternative medication in situations where other medications have failed or are contraindicated. There are limited data on the use of early, intravenous paracetamol in preterm infants. METHODS AND ANALYSIS This trial aims to address whether early treatment with paracetamol will reduce the number of infants requiring intervention for PDA. This is a randomised, double-blind, placebo-controlled trial in preterm infants <29 weeks' gestation. At 6 hours of life, infants with a ductus arteriosus >0.9 mm will be randomised to receive either (1) intravenous paracetamol at a dose of 15 mg/kg initially, followed by every 6 hours at a dose of 7.5 mg/kg for 5 days; or (2) intravenous 5% dextrose every 6 hours for 5 days. The primary outcome is the need for any intervention for management of PDA up to 5 days. Secondary outcomes include closure of the ductus arteriosus at 5 days, size of the ductus arteriosus, ductal reopening, systemic blood flow, mortality and significant morbidities. The target sample size of 100 infants yields >80% power, at the two-sided 5% level significance, to detect a 50% reduction in the need for intervention assuming that approximately 60% of infants in this study would otherwise have required intervention for PDA. ETHICS AND DISSEMINATION A report on the results of the planned analyses will be prepared. The results of the primary analysis of all end points will be presented at medical conferences and submitted for publication in peer-reviewed journals. Separate manuscripts pertaining to the second aim of the study may be written, and these will also be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ACTRN12616001517460.
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Affiliation(s)
- Tim Schindler
- Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - John Smyth
- Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Srinivas Bolisetty
- Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Joanna Michalowski
- Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Kei Lui
- Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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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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9
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Ghaderian M, Armanian AM, Sabri MR, Montaseri M. Low-dose intravenous acetaminophen versus oral ibuprofen for the closure of patent ductus arteriosus in premature neonates. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:13. [PMID: 30988681 PMCID: PMC6421881 DOI: 10.4103/jrms.jrms_631_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 09/11/2018] [Accepted: 11/26/2018] [Indexed: 01/22/2023]
Abstract
Background: Patent ductus arteriosus (PDA) is a common disease in premature neonates, which could occur in up to 50% of the neonates weighting <1000 g. PDA might induce hemodynamic and respiratory disorders and increase mortality and morbidity. This study aimed to compare the effectiveness of oral ibuprofen and a low dose of intravenous acetaminophen in the management of PDA. Materials and Methods: This randomized double-blind clinical trial was conducted on the preterm neonates with an equal gestational age of <34 weeks and weight of >1000 g with symptomatic PDA, who were admitted in Shahid Beheshti and Al-Zahra Hospitals Affiliated to Isfahan University of Medical Sciences, Iran. In total, 40 preterm neonates were examined, 20 of whom received 15 mg/kg/6 h of intravenous acetaminophen for 2 days and 20 infants received 10 mg/kg of intravenous ibuprofen on the 1st day and 5 mg/kg for the next 2 days, and the results include vital signs and echocardiography findings were compared. Results: In the acetaminophen and ibuprofen groups, 16 (80%) and 17 neonates (85%) responded (PDA closure rate) to the treatment, respectively (P = 0.68). Furthermore, acetaminophen and ibuprofen have a similar effect on vital signs. Both drugs did not change in blood pressure, but they reduced the respiratory rate and heart rate after treatment. Conclusion: Low-dose acetaminophen compared to ibuprofen has an equal effectiveness in the closure of PDA.
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Affiliation(s)
- Mehdi Ghaderian
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Mohammad Armanian
- Department of Pediatrics, Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Reza Sabri
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mojtaba Montaseri
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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10
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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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11
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Karabulut B, Paytoncu S. Efficacy and Safety of Oral Paracetamol vs. Oral Ibuprofen in the Treatment of Symptomatic Patent Ductus Arteriosus in Premature Infants. Paediatr Drugs 2019; 21:113-121. [PMID: 31025304 DOI: 10.1007/s40272-019-00331-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ductus arteriosus (DA) is situated between the aortic arch and the pulmonary artery in fetal circulation, and its closure is one of the most important changes required for the transition to extrauterine life. Prolonged duration of patent DA (PDA) impairs hemodynamics and contributes both to morbidity associated with prematurity and to mortality. Therefore, when best to initiate treatment and what drug to use as first-line treatment to close the ductus is important. OBJECTIVE The aim of this study was to compare the efficacy and side effects of the oral forms of ibuprofen and paracetamol and to contribute to the literature investigating the first drug to be selected in the medical treatment of PDA. METHODS This observational, retrospective cohort study was conducted in infants born at ≤ 28 weeks' gestation and admitted to our Neonatal Intensive Care Unit (Manisa Merkezefendi State Hospital, Manisa, Turkey) between February 2015 and April 2018. Included infants were born at ≤ 28 weeks' gestation, had PDA-related clinical findings and hemodynamically significant PDA on echocardiography, and received oral ibuprofen or oral paracetamol therapy as the closure treatment. RESULTS The most common clinical findings for the diagnosis of PDA were hyperdynamic circulation, tachycardia, and increased oxygen requirement. In total, 43 of the 51 (84.3%) premature infants in the ibuprofen group and 32 of the 36 (88.8%) in the paracetamol group achieved PDA closure after the first treatment cycle. There was no statistically significant difference between the two groups in terms of respiratory morbidity, renal and liver function, intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, retinopathy of prematurity, length of hospital stay, and mortality. CONCLUSIONS Our results indicate that oral paracetamol was as effective as oral ibuprofen in the medical treatment of PDA. In addition, both drugs were considered well-tolerated in terms of effects on kidney, liver, and intestinal functions. Our results demonstrate that oral paracetamol can be used effectively and safely as the first-line treatment of PDA.
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Affiliation(s)
- Birol Karabulut
- Pediatrics, Division of Neonatology, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey.
| | - Sebnem Paytoncu
- Pediatrics, Division of Pediatric Cardiology, Manisa Merkezefendi State Hospital, Manisa, Turkey
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12
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Mitra S, Disher T. Early treatment versus expectant management of hemodynamically significant patent ductus arteriosus for preterm infants. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2019. [DOI: 10.1002/14651858.cd013278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Souvik Mitra
- Dalhousie University & IWK Health Care; Division of Neonatal Perinatal Medicine, Department of Pediatrics; G-2214, 5850/5980 University Avenue Halifax Nova Scotia Canada B3K 6R8
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13
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Xiao Y, Liu H, Hu R, You Q, Zeng M, Jiang X. Efficacy and Safety of Paracetamol for Patent Ductus Arteriosus Closure in Preterm Infants: An Updated Systematic Review and Meta-Analysis. Front Pediatr 2019; 7:568. [PMID: 32133328 PMCID: PMC7039820 DOI: 10.3389/fped.2019.00568] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 12/30/2019] [Indexed: 02/05/2023] Open
Abstract
Background: Indomethacin and ibuprofen, two commonly used prostaglandin inhibitors, are the drugs of choice for patent ductus arteriosus. However, paracetamol is an alternative choice when these drugs are ineffective or contraindicated. This study aimed to confirm paracetamol's efficacy and safety compared with those of other drugs or placebos for patent ductus arteriosus closure in premature infants. Methods: We conducted a literature search using the Cochrane Library, PubMed, CINAHL, and EMBASE databases for randomized controlled trials and quasi-randomized controlled trials. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to direct the process and PICO (P, population; I, intervention/interest; C, comparator; O, outcome) principle to constitute the theme. We combined the research data through qualitative summaries or meta-analyses. Results: The final analyses included 15 trials (N = 1,313). No significant differences were noted between paracetamol and ibuprofen except for shorter mean days needed for patent ductus arteriosus closure, lower risk of gastrointestinal bleeding, and hyperbilirubinemia. No significant difference existed between paracetamol and indomethacin. Oral paracetamol was more effective than placebo in infants weighing 1,501-2,500 g. Conclusions: Our study findings tentatively conclude that paracetamol can induce early patent ductus arteriosus closure without significant side effects but that its efficacy is not superior to that of indomethacin.
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Affiliation(s)
- Yingqi Xiao
- West China School of Nursing/ West China Hospital, Sichuan University, Chengdu, China
| | - Hui Liu
- Key Laboratory of Birth Deficits and Related Diseases of Women and Children, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Rujun Hu
- West China School of Nursing/ West China Hospital, Sichuan University, Chengdu, China
| | - Qiang You
- Department of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Min Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiaolian Jiang
- West China School of Nursing/ West China Hospital, Sichuan University, Chengdu, China
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14
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Jasani B, Weisz DE, McNamara PJ. Evidence-based use of acetaminophen for hemodynamically significant ductus arteriosus in preterm infants. Semin Perinatol 2018; 42:243-252. [PMID: 29958702 DOI: 10.1053/j.semperi.2018.05.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
While cyclooxygenase inhibitors have been the most common medications used to facilitate earlier closure of patent ductus arteriosus in preterm infants, adverse effects and variable efficacy have highlighted a need for alternative options. Acetaminophen facilitates ductal closure via an alternate pathway of prostaglandin inhibition. Despite treatment with high doses, toxicity is uncommon in preterm infants, possibly due to immature hepatic metabolism. Pooled data from randomized clinical trials of early treatment demonstrate that acetaminophen has similar efficacy as cyclooxygenase inhibitors for PDA closure with a favorable side effect profile and without any apparent increase in adverse neonatal outcomes. Acetaminophen may therefore be an ideal first-line agent among moderately and extremely preterm infants, though there is a paucity of data from controlled trials regarding its use in infants at the border of viability (gestation age ≤25 weeks). Evidence from clinical studies of limited quality supports acetaminophen treatment as rescue therapy for infants with persistent PDA after unsuccessful cyclooxygenase inhibitor treatment, including those being considered for surgical ligation.
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Affiliation(s)
- B Jasani
- Division of Neonatology, Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8, Canada; Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - D E Weisz
- Department of Paediatrics, University of Toronto, Toronto, Canada; Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - P J McNamara
- Division of Neonatology, Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8, Canada; Department of Paediatrics, University of Toronto, Toronto, Canada; Department of Physiology, University of Toronto, Toronto, Canada.
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15
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Ohlsson A, Shah PS. Paracetamol (acetaminophen) for patent ductus arteriosus in preterm or low birth weight infants. Cochrane Database Syst Rev 2018; 4:CD010061. [PMID: 29624206 PMCID: PMC6494526 DOI: 10.1002/14651858.cd010061.pub3] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND In preterm newborns, the ductus arteriosus frequently fails to close and the infants require medical or surgical closure of the patent ductus arteriosus (PDA). A PDA can be treated surgically; or medically with one of two prostaglandin inhibitors, indomethacin or ibuprofen. Case reports suggest that paracetamol may be an alternative for the closure of a PDA. An association between prenatal or postnatal exposure to paracetamol and later development of autism or autism spectrum disorder has been reported. OBJECTIVES To determine the effectiveness and safety of intravenous or oral paracetamol compared with placebo or no intervention, intravenous indomethacin, intravenous or oral ibuprofen, or with other cyclo-oxygenase inhibitors for treatment of an echocardiographically diagnosed PDA in preterm or low birth weight infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 10), MEDLINE via PubMed (1966 to 6 November 2017), Embase (1980 to 6 November 2017), and CINAHL (1982 to 6 November 2017). We searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCT) and quasi-randomised trials. SELECTION CRITERIA We included RCTs in which paracetamol was compared to no intervention, placebo or other agents used for closure of PDA irrespective of dose, duration and mode of administration in preterm (≤ 34 weeks' postmenstrual age) infants. We both reviewed the search results and made a final selection of potentially eligible articles by discussion. We included studies of both prophylactic and therapeutic use of paracetamol. DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of evidence for the following outcomes when data were available: failure of ductal closure after the first course of treatment; neurodevelopmental impairment; all-cause mortality during initial hospital stay (death); gastrointestinal bleed or stools positive for occult blood; and serum levels of creatinine after treatment (µmol/L). MAIN RESULTS We included eight studies that reported on 916 infants. One of these studies compared paracetamol to both ibuprofen and indomethacin. Five studies compared treatment of PDA with paracetamol versus ibuprofen and enrolled 559 infants. There was no significant difference between paracetamol and ibuprofen for failure of ductal closure after the first course of drug administration (typical risk ratio (RR) 0.95, 95% confidence interval (CI) 0.75 to 1.21; typical risk difference (RD) -0.02, 95% CI -0.09 to 0.09); I² = 0% for RR and RD; moderate quality of evidence. Four studies (n = 537) reported on gastrointestinal bleed which was lower in the paracetamol group versus the ibuprofen group (typical RR 0.28, 95% CI 0.12 to 0.69; typical RD -0.06, 95% CI -0.09 to -0.02); I² = 0% for RR and RD; number needed to treat for an additional beneficial outcome (NNTB) 17 (95% CI 11 to 50); moderate quality of evidence. The serum levels of creatinine were lower in the paracetamol group compared with the ibuprofen group in four studies (moderate quality of evidence), as were serum bilirubin levels following treatment in two studies (n = 290). Platelet counts and daily urine output were higher in the paracetamol group compared with the ibuprofen group. One study reported on long-term follow-up to 18 to 24 months of age following treatment with paracetamol versus ibuprofen. There were no significant differences in the neurological outcomes at 18 to 24 months (n = 61); (low quality of evidence).Two studies compared prophylactic administration of paracetamol for a PDA with placebo or no intervention in 80 infants. Paracetamol resulted in a lower rate of failure of ductal closure after 4 to 5 days of treatment compared to placebo or no intervention which was of borderline significance for typical RR 0.49 (95% CI 0.24 to 1.00; P = 0.05); but significant for typical RD -0.21 (95% CI -0.41 to -0.02); I² = 0 % for RR and RD; NNTB 5 (95% CI 2 to 50); (low quality of evidence).Two studies (n = 277) compared paracetamol with indomethacin. There was no significant difference in the failure to close a PDA (typical RR 0.96, 95% CI 0.55 to 1.65; I² = 11%; typical RD -0.01, 95% CI -0.09 to 0.08; I² = 17%) (low quality of evidence). Serum creatinine levels were significantly lower in the paracetamol group compared with the indomethacin group and platelet counts and daily urine output were significantly higher in the paracetamol group. AUTHORS' CONCLUSIONS Moderate-quality evidence according to GRADE suggests that paracetamol is as effective as ibuprofen; low-quality evidence suggests paracetamol to be more effective than placebo or no intervention; and low-quality evidence suggests paracetamol as effective as indomethacin in closing a PDA. There was no difference in neurodevelopmental outcome in children exposed to paracetamol compared to ibuprofen; however the quality of evidence is low and comes from only one study. In view of concerns raised regarding neurodevelopmental outcomes following prenatal and postnatal exposure to paracetamol, long-term follow-up to at least 18 to 24 months' postnatal age must be incorporated in any studies of paracetamol in the newborn population. At least 19 ongoing trials have been registered. Such trials are required before any recommendations for the possible routine use of paracetamol in the newborn population can be made.
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Affiliation(s)
- Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoCanadaM5G 1X5
| | - Prakeshkumar S Shah
- University of Toronto Mount Sinai HospitalDepartment of Paediatrics and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoCanadaM5G 1XB
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16
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Mitra S, Florez ID, Tamayo ME, Mbuagbaw L, Vanniyasingam T, Veroniki AA, Zea AM, Zhang Y, Sadeghirad B, Thabane L. Association of Placebo, Indomethacin, Ibuprofen, and Acetaminophen With Closure of Hemodynamically Significant Patent Ductus Arteriosus in Preterm Infants: A Systematic Review and Meta-analysis. JAMA 2018; 319:1221-1238. [PMID: 29584842 PMCID: PMC5885871 DOI: 10.1001/jama.2018.1896] [Citation(s) in RCA: 199] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Despite increasing emphasis on conservative management of patent ductus arteriosus (PDA) in preterm infants, different pharmacotherapeutic interventions are used to treat those developing a hemodynamically significant PDA. OBJECTIVES To estimate the relative likelihood of hemodynamically significant PDA closure with common pharmacotherapeutic interventions and to compare adverse event rates. DATA SOURCES AND STUDY SELECTION The databases of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception until August 15, 2015, and updated on December 31, 2017, along with conference proceedings up to December 2017. Randomized clinical trials that enrolled preterm infants with a gestational age younger than 37 weeks treated with intravenous or oral indomethacin, ibuprofen, or acetaminophen vs each other, placebo, or no treatment for a clinically or echocardiographically diagnosed hemodynamically significant PDA. DATA EXTRACTION AND SYNTHESIS Data were independently extracted in pairs by 6 reviewers and synthesized with Bayesian random-effects network meta-analyses. MAIN OUTCOMES AND MEASURES Primary outcome: hemodynamically significant PDA closure; secondary: included surgical closure, mortality, necrotizing enterocolitis, and intraventricular hemorrhage. RESULTS In 68 randomized clinical trials of 4802 infants, 14 different variations of indomethacin, ibuprofen, or acetaminophen were used as treatment modalities. The overall PDA closure rate was 67.4% (2867 of 4256 infants). A high dose of oral ibuprofen was associated with a significantly higher odds of PDA closure vs a standard dose of intravenous ibuprofen (odds ratio [OR], 3.59; 95% credible interval [CrI], 1.64-8.17; absolute risk difference, 199 [95% CrI, 95-258] more per 1000 infants) and a standard dose of intravenous indomethacin (OR, 2.35 [95% CrI, 1.08-5.31]; absolute risk difference, 124 [95% CrI, 14-188] more per 1000 infants). Based on the ranking statistics, a high dose of oral ibuprofen ranked as the best pharmacotherapeutic option for PDA closure (mean surface under the cumulative ranking [SUCRA] curve, 0.89 [SD, 0.12]) and to prevent surgical PDA ligation (mean SUCRA, 0.98 [SD, 0.08]). There was no significant difference in the odds of mortality, necrotizing enterocolitis, or intraventricular hemorrhage with use of placebo or no treatment compared with any of the other treatment modalities. CONCLUSIONS AND RELEVANCE A high dose of oral ibuprofen was associated with a higher likelihood of hemodynamically significant PDA closure vs standard doses of intravenous ibuprofen or intravenous indomethacin; placebo or no treatment did not significantly change the likelihood of mortality, necrotizing enterocolitis, or intraventricular hemorrhage. TRIAL REGISTRATION PROSPERO Identifier: CRD42015015797.
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Affiliation(s)
- Souvik Mitra
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Dalhousie University and IWK Health Center, Halifax, Nova Scotia, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ivan D. Florez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
| | - Maria E. Tamayo
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Thuva Vanniyasingam
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | | | - Adriana M. Zea
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- HIV/STI Surveillance Research Center and WHO Collaborating Center for HIV Surveillance, Kerman University of Medical Sciences, Kerman, Iran
- Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics and Anesthesia, McMaster University, Hamilton, Ontario, Canada
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17
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Matsumura S, Oshima A, Fujinuma S, Tanaka K, Nagano N, Miyake F, Masutani S, Tamura M, Ueda K, Namba F. Low-Dose Intravenous Paracetamol for Patent Ductus Arteriosus in Indomethacin-Resistant or Contraindicated Preterm Infants: Three Cases Reports. AJP Rep 2017; 7:e230-e233. [PMID: 29276647 PMCID: PMC5740229 DOI: 10.1055/s-0037-1615260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 10/26/2017] [Indexed: 11/21/2022] Open
Abstract
Background Although indomethacin (IND) is the standard treatment for hemodynamically significant patent ductus arteriosus (hsPDA) in Japan, it may be associated with renal impairment and gastrointestinal complications. The use of paracetamol for hsPDA closure has recently increased. Unlike IND, paracetamol does not have a peripheral vasoconstrictive effect and can be given to infants with contraindications to IND. Based on limited data available from randomized trials, paracetamol and IND seem to have similar effects. However, there have been no reports of the use of paracetamol for hsPDA in Japan. Cases Our drug administration protocol was approved by the institutional ethics committee after purchasing a clinical trial insurance. In three premature infants in whom IND was contraindicated or ineffective, a 7.5 mg/kg of paracetamol was intravenously administered every 6 hour for 3 days after obtaining parental consents. A temporary hsPDA closure was observed in two of the three infants. However, all three infants eventually needed surgical closure. No side effects, such as hepatic and renal dysfunctions, and adverse events were reported. Conclusion The intravenous administration of paracetamol was safe and feasible in premature infants with hsPDA. Future clinical trials with optimized dose and timing of administration are needed.
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Affiliation(s)
- Shun Matsumura
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Ayumi Oshima
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Sumie Fujinuma
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Kosuke Tanaka
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Nobuhiko Nagano
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Fuyu Miyake
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Masanori Tamura
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Keiko Ueda
- Clinical Research Support Center, The University of Tokyo Hospital, Bunkyo, Tokyo, Japan
| | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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Al-Lawama M, Alammori I, Abdelghani T, Badran E. Oral paracetamol versus oral ibuprofen for treatment of patent ductus arteriosus. J Int Med Res 2017; 46:811-818. [PMID: 29239259 PMCID: PMC5971505 DOI: 10.1177/0300060517722698] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective This study was performed to investigate the safety and efficacy of oral paracetamol versus oral ibuprofen in the treatment of patent ductus arteriosus (PDA) in premature infants. Methods Premature infants with PDA with a gestational age of ≤32 weeks or birth weight of ≤1500 g were included in this randomized study. Results A total of 120 premature infants fulfilled the inclusion criteria. Of these 120 infants, 34 fulfilled the treatment criteria and 22 were finally randomized. We found no significant difference in the mortality or primary closure rates between the two groups. We also found no significant difference in the short-term neonatal outcomes. Conclusions Either oral paracetamol or oral ibuprofen can be used safely and effectively to treat PDA in premature infants.
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Affiliation(s)
- Manar Al-Lawama
- Pediatric Department, University of Jordan, Jordan University Hospital, Jordan
| | - Iyad Alammori
- Pediatric Department, University of Jordan, Jordan University Hospital, Jordan
| | - Tariq Abdelghani
- Pediatric Department, University of Jordan, Jordan University Hospital, Jordan
| | - Eman Badran
- Pediatric Department, University of Jordan, Jordan University Hospital, Jordan
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19
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Paracetamol in Patent Ductus Arteriosus Treatment: Efficacious and Safe? BIOMED RESEARCH INTERNATIONAL 2017; 2017:1438038. [PMID: 28828381 PMCID: PMC5554551 DOI: 10.1155/2017/1438038] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/22/2017] [Accepted: 06/11/2017] [Indexed: 12/19/2022]
Abstract
In preterm infants, failure or delay in spontaneous closure of Ductus Arteriosus (DA), resulting in the condition of Patent Ductus Arteriosus (PDA), represents a significant issue. A prolonged situation of PDA can be associated with several short- and long-term complications. Despite years of researches and clinical experience on PDA management, unresolved questions about the treatment and heterogeneity of clinical practices in different centers still remain, in particular regarding timing and modality of intervention. Nowadays, the most reasonable strategy seems to be reserving the treatment only to hemodynamically significant PDA. The first-line therapy is medical, and ibuprofen, related to several side effects especially in terms of nephrotoxicity, is the drug of choice. Administration of oral or intravenous paracetamol (acetaminophen) recently gained attention, appearing effective as traditional nonsteroidal anti-inflammatory drugs (NSAIDs) in PDA closure, with lower toxicity. The results of the studies analyzed in this review mostly support paracetamol efficacy in ductal closure, with inconstant low and transient elevation of liver enzymes as reported side effect. However, more studies are needed to confirm if this therapy shows a real safety profile and to evaluate its long-term outcomes, before considering paracetamol as first-choice drug in PDA treatment.
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20
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Mohamed MA, El-Dib M, Alqahtani S, Alyami K, Ibrahim AN, Aly H. Patent ductus arteriosus in premature infants: to treat or not to treat? J Perinatol 2017; 37:652-657. [PMID: 28206995 DOI: 10.1038/jp.2017.4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/08/2016] [Accepted: 12/28/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Closing patent ductus arteriosus (PDA) is a widely accepted approach in the management of very low birth weight (VLBW) infants. Our objective is to test the hypothesis that conservative management (no treatment) of PDA will not affect survival without chronic lung diseases (CLD). STUDY DESIGN This retrospective study utilizes a prospectively collected database to compare two cohorts of VLBW infants. Infants in the first group (2001 to 2009) had their PDA treated with pharmacological and if necessary with surgical ligation. PDA in the second group (2010 to 2014) was not treated with medical or surgical intervention. The primary outcome was survival without oxygen requirement at 36 weeks. Pulmonary and non-pulmonary morbidities were also compared. Logistic regression analyses were performed to control for confounders. RESULTS This study included 643 VLBW infants, of them 415 infants in the Treat group and 228 in the No-Treat group. The rate of survival without CLD did not differ between Treat and No-Treat groups (78.4% vs 83.9%, respectively; adjusted odds ratio (aOR)=1.72, confidence interval (CI): 0.92 to 3.23, P=0.09). Mortality declined in No-Treat group (15.2% vs 10.5%, aOR=0.51, CI: 0.25 to 0.99, P=0.049), but the two groups did not differ in the incidence of CLD among survivors (5.8% vs 5.0%,=P0.47). Pulmonary complications and non-pulmonary morbidities did not differ between groups. CONCLUSIONS Conservative management (no treatment) of PDA may not compromise survival without CLD and is not associated with increased morbidities in VLBW infants. Prospective physiological studies are needed to determine the sector of VLBW infants, if any, who could benefit from PDA treatment.
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Affiliation(s)
- M A Mohamed
- Division of Newborn Services, The George Washington University Hospital, Washington, DC, USA
| | - M El-Dib
- Department of Newborn Services, Brigham and Women's Hospital, Boston, MA, USA
| | - S Alqahtani
- Division of Newborn Services, The George Washington University Hospital, Washington, DC, USA
| | - K Alyami
- Division of Newborn Services, The George Washington University Hospital, Washington, DC, USA
| | - A N Ibrahim
- Division of Newborn Services, The George Washington University Hospital, Washington, DC, USA
| | - H Aly
- Division of Newborn Services, The George Washington University Hospital, Washington, DC, USA
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21
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Chandrasekaran A. A Survey among Neonatologists on the Management of Patent Ductus Arteriosus. Indian J Pediatr 2017; 84:326-327. [PMID: 28000109 DOI: 10.1007/s12098-016-2274-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 12/07/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Aparna Chandrasekaran
- Department of Neonatology, CHILDS Trust Medical Research Foundation and Kanchi Kamakoti CHILDS Trust Hospital, 12 A, Nageswara Rao Road, Nungambakkam, Chennai, Tamil Nadu, 600034, India.
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22
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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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23
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Parker W, Hornik CD, Bilbo S, Holzknecht ZE, Gentry L, Rao R, Lin SS, Herbert MR, Nevison CD. The role of oxidative stress, inflammation and acetaminophen exposure from birth to early childhood in the induction of autism. J Int Med Res 2017; 45:407-438. [PMID: 28415925 PMCID: PMC5536672 DOI: 10.1177/0300060517693423] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The wide range of factors associated with the induction of autism is invariably linked with either inflammation or oxidative stress, and sometimes both. The use of acetaminophen in babies and young children may be much more strongly associated with autism than its use during pregnancy, perhaps because of well-known deficiencies in the metabolic breakdown of pharmaceuticals during early development. Thus, one explanation for the increased prevalence of autism is that increased exposure to acetaminophen, exacerbated by inflammation and oxidative stress, is neurotoxic in babies and small children. This view mandates extreme urgency in probing the long-term effects of acetaminophen use in babies and the possibility that many cases of infantile autism may actually be induced by acetaminophen exposure shortly after birth.
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Affiliation(s)
- William Parker
- 1 Departments of Surgery, Duke University Medical Center, Durham, NC USA
| | - Chi Dang Hornik
- 2 Departments of Pediatrics, Duke University Medical Center, Durham, NC USA
| | - Staci Bilbo
- 3 Departments of Pediatrics, Harvard Medical School, Charlestown, MA, USA
| | - Zoie E Holzknecht
- 1 Departments of Surgery, Duke University Medical Center, Durham, NC USA
| | - Lauren Gentry
- 1 Departments of Surgery, Duke University Medical Center, Durham, NC USA
| | - Rasika Rao
- 1 Departments of Surgery, Duke University Medical Center, Durham, NC USA
| | - Shu S Lin
- 1 Departments of Surgery, Duke University Medical Center, Durham, NC USA
| | - Martha R Herbert
- 4 Departments of Neurology, Harvard Medical School, Charlestown, MA, USA
| | - Cynthia D Nevison
- 5 Institute for Arctic and Alpine Research, University of Colorado, Boulder, Boulder, CO, USA
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Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GHA, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update. Neonatology 2017; 111:107-125. [PMID: 27649091 DOI: 10.1159/000448985] [Citation(s) in RCA: 321] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/08/2016] [Indexed: 02/04/2023]
Abstract
Advances in the management of respiratory distress syndrome (RDS) ensure that clinicians must continue to revise current practice. We report the third update of the European Guidelines for the Management of RDS by a European panel of expert neonatologists including input from an expert perinatal obstetrician based on available literature up to the beginning of 2016. Optimizing the outcome for babies with RDS includes consideration of when to use antenatal steroids, and good obstetric practice includes methods of predicting the risk of preterm delivery and also consideration of whether transfer to a perinatal centre is necessary and safe. Methods for optimal delivery room management have become more evidence based, and protocols for lung protection, including initiation of continuous positive airway pressure and titration of oxygen, should be implemented from soon after birth. Surfactant replacement therapy is a crucial part of the management of RDS, and newer protocols for surfactant administration are aimed at avoiding exposure to mechanical ventilation, and there is more evidence of differences among various surfactants in clinical use. Newer methods of maintaining babies on non-invasive respiratory support have been developed and offer potential for greater comfort and less chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease although minimizing the time spent on mechanical ventilation using caffeine and if necessary postnatal steroids are also important considerations. Protocols for optimizing the general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.
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Affiliation(s)
- David G Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
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25
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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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Kumar A, Sundaram V, Yadav R, Oleti TP, Murki S, Krishna A, Sundaram M, Saini SS, Dutta S. Oral paracetamol versus oral ibuprofen for closure of haemodynamically significant patent ductus arteriosus in preterm neonates (<32 weeks): a blinded, randomised, active-controlled, non-inferiority trial. BMJ Paediatr Open 2017; 1:e000143. [PMID: 29637155 PMCID: PMC5862198 DOI: 10.1136/bmjpo-2017-000143] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/10/2017] [Accepted: 07/10/2017] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Haemodynamically significant patent ductus arteriosus (hsPDA) is a common cause of mortality and morbidity in preterm infants. Existing medical therapies with ibuprofen or indomethacin have multiple adverse effects. Hence, an alternative drug like paracetamol given through oral route with less side effects need to be tested in an appropriate study design with least risk of bias to arrive at a conclusion. METHODS AND ANALYSIS Multisite, randomised, active-controlled, non-inferiority design. The primary objective is to study the efficacy of oral paracetamol for closure of hsPDA in comparison to oral ibuprofen in preterm neonates of <32 weeks' gestation. Randomisation web-based and allocation concealment would be done; the treating team, investigators, outcome assessors and laboratory personnel would be blinded from the intervention. Echocardiography images would be coded for independent review. Closure of PDA by the end of last dose of study drug or earlier would be the study endpoint. A sample size of 196 neonates would be enrolled with a non-inferiority margin of 15%. Both intention-to-treat and per-protocol analysis will be done to assess the effect of contamination and protocol violations in the primary outcome. ETHICS AND DISSEMINATION The trial would follow international code of ethics for clinical trial. The trial protocol was approved by the Institute Ethics Committee of all three centres. All serious adverse events would be reported in detail to the Institute Ethics Committee. A written informed consent would be obtained from one of the parents. No plan has been made for dissemination. TRIAL REGISTRATION NUMBER CTRI/2014/08/004805.
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Affiliation(s)
- Ashutosh Kumar
- Division of Neonatology, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Venkataseshan Sundaram
- Division of Neonatology, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rahul Yadav
- Department of Neonatology, Fernandez Hospital, Bogulkunta, Hyderabad, Telangana, India
| | - Tejo Pratap Oleti
- Department of Neonatology, Fernandez Hospital, Bogulkunta, Hyderabad, Telangana, India
| | - Srinivas Murki
- Department of Neonatology, Fernandez Hospital, Bogulkunta, Hyderabad, Telangana, India
| | - Arun Krishna
- Department of Neonatology, Institute of Child Health, Egmore, Chennai, Tamil Nadu, India
| | | | - Shiv Sajan Saini
- Division of Neonatology, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mitra S, Florez ID, Tamayo ME, Aune D, Mbuagbaw L, Veroniki AA, Thabane L. Effectiveness and safety of treatments used for the management of patent ductus arteriosus (PDA) in preterm infants: a protocol for a systematic review and network meta-analysis. BMJ Open 2016; 6:e011271. [PMID: 27456327 PMCID: PMC4964163 DOI: 10.1136/bmjopen-2016-011271] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Management of patent ductus arteriosus (PDA) in preterm infants is one of the most controversial topics in neonatal medicine. The availability of different pharmacotherapeutic options often poses a practical challenge to the practising neonatologist as to which one to choose as a therapeutic option. Our objectives are to determine the relative merits of the available pharmacotherapeutic options for the management of PDA. METHODS AND ANALYSIS We will conduct a systematic review of all randomised controlled trials evaluating the use of intravenous or oral: indomethacin, ibuprofen and acetaminophen for the treatment of PDA in preterm infants. The primary outcome is failure of closure of the PDA. Secondary outcomes are neonatal mortality, need for surgical closure, duration of ventilator support, chronic lung disease, intraventricular haemorrhage, periventricular leukomalacia, necrotising enterocolitis, gastrointestinal bleeding, time to full enteral feeds and oliguria. We will search Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) as well as grey literature resources. Two reviewers will independently screen titles and abstracts, review full texts, extract information, and assess the risk of bias (ROB) and the confidence in the estimate (with Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach). Subgroup analysis according to gestational age, birth weight, different doses of interventions, time of administration of the first dose of the intervention, and echocardiographic definition of haemodynamically significant PDA and ROB are planned. We will perform a Bayesian network meta-analysis to combine the pooled direct and indirect treatment effect estimates for each outcome, if adequate data are available. ETHICS AND DISSEMINATION The results will help to reduce the uncertainty about the safety and effectiveness of the interventions, will identify knowledge gaps or will encourage further research for other therapeutic options. Therefore, its results will be disseminated through peer-reviewed publications and conference presentations. On the basis of the nature of its design, no ethics approval is necessary for this study. TRIAL REGISTRATION NUMBER CRD42015015797.
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Affiliation(s)
- Souvik Mitra
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ivan D Florez
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
| | - Maria E Tamayo
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
| | - Dagfinn Aune
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK
| | - Lawrence Mbuagbaw
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Areti-Angeliki Veroniki
- Knowledge Translation program, Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics and Anesthesia, McMaster University, Hamilton, Ontario, Canada
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Valerio E, Valente MR, Salvadori S, Frigo AC, Baraldi E, Lago P. Intravenous paracetamol for PDA closure in the preterm: a single-center experience. Eur J Pediatr 2016; 175:953-66. [PMID: 27146832 DOI: 10.1007/s00431-016-2731-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 04/23/2016] [Accepted: 04/28/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED Increasing recent evidence favors paracetamol use for patent ductus arteriosus (PDA) closure in preterms. Our study aims were (1) to assess efficacy and safety of intravenous (i.v.) paracetamol for PDA closure in a 23-32-week preterm population, as "first-line" (when traditional ibuprofen treatment was contraindicated) or "rescue" treatment (after ibuprofen failed), and (2) to identify predictors of PDA closure. The cumulative efficacy of consecutive cycles of i.v. paracetamol on PDA closure was confirmed after both "first-line" and "rescue" treatment, the overall PDA closure rates being, respectively, 56.7 and 61.1 % (p = 0.7624) after two cycles and 63.3 and 77.8 % (p = 0.2959) after three cycles. No toxicity was apparent after either "first-line" or "rescue" i.v. paracetamol treatment. On multivariate analysis, gestational age (GA) emerged as an independent predictor of PDA closure in the "first-line" i.v. paracetamol treatment group, while clinical risk index for babies (CRIB) score (a patient risk index based on birth weight, GA at birth, sex, patient's temperature on admission, and maximum base excess in first 12 h of life) was an independent predictor of PDA closure failure in the "rescue" group. CONCLUSION I.V. paracetamol proved effective in our study population. Randomized control trials (RCTs) are warranted to further investigate the efficacy and safety of i.v. paracetamol for PDA closure in preterms. WHAT IS KNOWN • Oral paracetamol has been judged as effective as oral ibuprofen for PDA closure in the preterm. • To date, only a handful of non-randomized studies exist to support the effectiveness of i.v. paracetamol in PDA closure. What is New: • Our observations confirm the clinical efficacy of i.v. paracetamol for PDA closure in a very low birth weight (VLBW)/extremely low birth weight (ELBW) preterm population. • Gestational age and CRIB score emerge as independent predictors of PDA closure.
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Affiliation(s)
- Enrico Valerio
- Neonatal Intensive Care Unit, Department of Woman and Child's Health, University of Padua, Medical School, Via Giustiniani, 3, 35128, Padova, Italy.
| | - Marta Rossella Valente
- Neonatal Intensive Care Unit, Department of Woman and Child's Health, University of Padua, Medical School, Via Giustiniani, 3, 35128, Padova, Italy
| | - Sabrina Salvadori
- Neonatal Intensive Care Unit, Department of Woman and Child's Health, University of Padua, Medical School, Via Giustiniani, 3, 35128, Padova, Italy
| | - Anna Chiara Frigo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Medical School, Padova, Italy
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Woman and Child's Health, University of Padua, Medical School, Via Giustiniani, 3, 35128, Padova, Italy
| | - Paola Lago
- Neonatal Intensive Care Unit, Department of Woman and Child's Health, University of Padua, Medical School, Via Giustiniani, 3, 35128, Padova, Italy
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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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Oncel MY, Erdeve O. Oral medications regarding their safety and efficacy in the management of patent ductus arteriosus. World J Clin Pediatr 2016; 5:75-81. [PMID: 26862505 PMCID: PMC4737696 DOI: 10.5409/wjcp.v5.i1.75] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 11/22/2015] [Accepted: 01/07/2016] [Indexed: 02/05/2023] Open
Abstract
Patent ductus arteriosus (PDA) is a common clinical condition in preterm infants which is inversely related to birth weight and gestational age. Cyclooxygenase inhibitors such as indomethacin and ibuprofen which block the prostaglandin conversion from arachidonic acid are the most commonly used drugs for ductal closure. This review focuses on the safety and efficacy oral medications in the management of PDA in preterm infants. Ibuprofen seems to be the first choice due to its higher safety profile, as it is associated with fewer gastrointestinal and renal side effects when compared to indomethacin. PDA closure rates are better with oral than with intravenous ibuprofen probably due to the pharmacokinetic of the drug. However, these medications were reported to be associated with several adverse including transient renal failure, gastrointestinal bleeding and perforation, hyperbilirubinemia and platelet dysfunction. Paracetamol seems be an alternative to PDA therapy with lower adverse events and side effects.
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Cook SF, Roberts JK, Samiee-Zafarghandy S, Stockmann C, King AD, Deutsch N, Williams EF, Allegaert K, Wilkins DG, Sherwin CMT, van den Anker JN. Population Pharmacokinetics of Intravenous Paracetamol (Acetaminophen) in Preterm and Term Neonates: Model Development and External Evaluation. Clin Pharmacokinet 2016; 55:107-19. [PMID: 26201306 PMCID: PMC5564323 DOI: 10.1007/s40262-015-0301-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims of this study were to develop a population pharmacokinetic model for intravenous paracetamol in preterm and term neonates and to assess the generalizability of the model by testing its predictive performance in an external dataset. METHODS Nonlinear mixed-effects models were constructed from paracetamol concentration-time data in NONMEM 7.2. Potential covariates included body weight, gestational age, postnatal age, postmenstrual age, sex, race, total bilirubin, and estimated glomerular filtration rate. An external dataset was used to test the predictive performance of the model through calculation of bias, precision, and normalized prediction distribution errors. RESULTS The model-building dataset included 260 observations from 35 neonates with a mean gestational age of 33.6 weeks [standard deviation (SD) 6.6]. Data were well-described by a one-compartment model with first-order elimination. Weight predicted paracetamol clearance and volume of distribution, which were estimated as 0.348 L/h (5.5 % relative standard error; 30.8 % coefficient of variation) and 2.46 L (3.5 % relative standard error; 14.3 % coefficient of variation), respectively, at the mean subject weight of 2.30 kg. An external evaluation was performed on an independent dataset that included 436 observations from 60 neonates with a mean gestational age of 35.6 weeks (SD 4.3). The median prediction error was 10.1 % [95 % confidence interval (CI) 6.1-14.3] and the median absolute prediction error was 25.3 % (95 % CI 23.1-28.1). CONCLUSIONS Weight predicted intravenous paracetamol pharmacokinetics in neonates ranging from extreme preterm to full-term gestational status. External evaluation suggested that these findings should be generalizable to other similar patient populations.
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Affiliation(s)
- Sarah F Cook
- Center for Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
| | - Jessica K Roberts
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Samira Samiee-Zafarghandy
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Chris Stockmann
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
| | - Amber D King
- Center for Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
| | - Nina Deutsch
- Division of Anesthesiology, Sedation, and Perioperative Medicine, Children's National Health System, Washington, DC, USA
| | - Elaine F Williams
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Karel Allegaert
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Diana G Wilkins
- Center for Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT, USA
- Division of Medical Laboratory Sciences, Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Departments of Pediatrics, Integrative Systems Biology, Pharmacology and Physiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland
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Bourgoin L, Cipierre C, Hauet Q, Basset H, Gournay V, Rozé JC, Flamant C, Gascoin G. Neurodevelopmental Outcome at 2 Years of Age according to Patent Ductus Arteriosus Management in Very Preterm Infants. Neonatology 2016; 109:139-46. [PMID: 26726863 DOI: 10.1159/000442278] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 11/09/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is a condition frequently found in very preterm infants, and its treatment remains a subject of debate. Furthermore, there are only a few studies available that have examined the impact of these treatments on the neurological outcome of the patient. OBJECTIVE To evaluate the neurodevelopmental outcome of PDA treatment on preterm infants born between 24+0 and 28+6 weeks of gestation. METHODS We conducted an observational multicentric cohort study (LIFT Cohort). We compared three groups of patients according to their PDA treatment strategy: medical treatment with ibuprofen, surgical ligation, and no treatment. The neurodevelopmental outcome was assessed with a physical examination and cognitive function evaluation at 2 years of age. A propensity score was used to reduce bias in the analysis. RESULTS Between 2003 and 2011, 857 infants (91.3%) were evaluated at 2 years of corrected age and included in the analysis: 248 received ibuprofen treatment (29%), 104 had PDA surgical ligation (12%), and 505 did not receive any PDA treatment (59%). Surgical ligation of PDA was significantly associated with neurodevelopmental impairment at 2 years of age (adjusted odds ratio = 2.2; 95% confidence interval: 1.4-3.4). CONCLUSION We found an association between PDA surgical ligation and a nonoptimal neurodevelopmental outcome at 2 years of age for preterm infants born before 29 weeks of gestation. These results suggest that if surgical ligation is unavoidable, particular attention should be given to the patient's neurodevelopmental follow-up.
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Affiliation(s)
- Laura Bourgoin
- Department of Neonatal Medicine, University Hospital of Angers, Angers, France
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