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Shah SD, Shukla S, Nandula PS, Vice S, Elgendy M, Gautam S, Hudak ML, Cortez J. Prophylactic early low-dose hydrocortisone and survival without bronchopulmonary dysplasia among extremely preterm infants born at 22-27 weeks' gestation. J Perinatol 2024; 44:947-952. [PMID: 38459373 DOI: 10.1038/s41372-024-01923-5] [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] [Received: 12/17/2023] [Revised: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE To compare survival without BPD among extremely preterm infants (EPI) who received prophylactic early low-dose hydrocortisone (PEH) with those who did not (non-PEH). STUDY DESIGN This single-center retrospective study compared risk-adjusted rates of survival without BPD, BPD, bowel perforation, and late-onset sepsis among infants (22-27 weeks' gestation at birth) who received PEH (n = 82) and who did not (n = 205). RESULTS Infants in the PEH group were of lower gestational age, lower birthweight, and higher day-1 risk of death/BPD. After adjusting for risk of death/BPD, PEH-treated infants demonstrated increased survival without BPD (aOR 2.04, 95%CI 1.1-3.7), and lower BPD rates (aOR 0.46, 95%CI 0.25-0.87). Importantly, bowel perforation or sepsis rate were similar among both groups. CONCLUSION After risk adjustment, PEH-treated infants demonstrated improved survival without BPD and did not increase rates of bowel perforation or sepsis. In our cohort of infants, PEH was safe and effective among the sickest preterm neonates.
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Affiliation(s)
- Sanket D Shah
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Samarth Shukla
- Division of Neonatology, Advent Health, Orlando, FL, USA
| | - P Sireesha Nandula
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Shannon Vice
- Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Marwa Elgendy
- Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Shiva Gautam
- Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
- Department of Biostatistics and Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Mark L Hudak
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Josef Cortez
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA.
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2
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de Medeiros Cavalcante Meneghetti FM, Aragon DC, Calixto C, Ferreira CHF, Vieira EF, Gonçalves-Ferri WA. Personalized lung care: Bronchopulmonary dysplasia risk prediction tool tailored for neonates born in resource-limited settings. Pediatr Pulmonol 2024. [PMID: 38712796 DOI: 10.1002/ppul.27049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 04/17/2024] [Accepted: 04/27/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE Predicting bronchopulmonary dysplasia (BPD) to assess the risk-benefit of therapy is necessary considering the side effects of medications. We developed and validated an instrument for predicting BPD and compared it with an instrument currently used for neonates born in a Brazilian hospital. METHODS This was a retrospective cohort study of patients born between 2016 and 2020 with a gestational age (GA) between 23 and 30 weeks. Predictive equations were elaborated using methods of component variable selection collected on the 14th day of life; 70% of the sample was randomly selected for the construction of risk prediction equations and the remaining 30% for their validation, application, and comparison with the National Institute of Child Health and Human Development (NICHD) instrument. The sensitivity, specificity, and predictive values of the equations were calculated. RESULTS The equation that used variables with p < 5% in Fisher's exact test presented the best results: specificity of 98% and positive predictive value of 93% and could be used for BPD prediction of all small-for-gestational-age (SGA) infants. The NICHD calculator applied to our population had a specificity of 93% and a positive predictive value of 75% and could not be applied to extremely SGA infants. CONCLUSION Our tool can predict the risk of BPD on the 14th day of life, has higher specificity and positive predictive value to our population than the NICHD instrument, and can be suitable for SGA infants. The results must be confirmed by applying it to other populations to validate our tool.
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Affiliation(s)
| | - Davi Casale Aragon
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Cristina Calixto
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | | | - Elaine Fukumoto Vieira
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Walusa Assad Gonçalves-Ferri
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, Sao Paulo, Brazil
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3
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Jensen EA, Watterberg KL. Postnatal Corticosteroids To Prevent Bronchopulmonary Dysplasia. Neoreviews 2023; 24:e691-e703. [PMID: 37907402 DOI: 10.1542/neo.24-11-e691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a common, severe chronic respiratory disease that affects very preterm infants. In utero and postnatal exposure to proinflammatory stimuli contribute to the pathophysiology of BPD. Corticosteroids, because of their potent anti-inflammatory properties, may decrease respiratory morbidity and reduce the risk of BPD in very preterm infants. However, these medications can have adverse effects on the developing brain and other organ systems. This review examines current evidence on the risks and benefits of postnatal corticosteroids used to prevent BPD in preterm infants.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Kristi L Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
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Jensen EA, Wiener LE, Rysavy MA, Dysart KC, Gantz MG, Eichenwald EC, Greenberg RG, Harmon HM, Laughon MM, Watterberg KL, Walsh MC, Yoder BA, Lorch SA, DeMauro SB. Assessment of Corticosteroid Therapy and Death or Disability According to Pretreatment Risk of Death or Bronchopulmonary Dysplasia in Extremely Preterm Infants. JAMA Netw Open 2023; 6:e2312277. [PMID: 37155165 PMCID: PMC10167571 DOI: 10.1001/jamanetworkopen.2023.12277] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/24/2023] [Indexed: 05/10/2023] Open
Abstract
Importance Meta-analyses suggest that corticosteroids may be associated with increased survival without cerebral palsy in infants at high risk of bronchopulmonary dysplasia (BPD) but are associated with adverse neurologic outcomes in low-risk infants. Whether this association exists in contemporary practice is uncertain because most randomized clinical trials administered corticosteroids earlier and at higher doses than currently recommended. Objective To evaluate whether the pretreatment risk of death or grade 2 or 3 BPD at 36 weeks' postmenstrual age modified the association between postnatal corticosteroid therapy and death or disability at 2 years' corrected age in extremely preterm infants. Design, Setting, and Participants This cohort study analyzed data on 482 matched pairs of infants from 45 participating US hospitals in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database (GDB). Infants were included in the cohort if they were born at less than 27 weeks' gestation between April 1, 2011, and March 31, 2017; survived the first 7 postnatal days; and had 2-year death or developmental follow-up data collected between January 2013 and December 2019. Corticosteroid-treated infants were propensity score matched with untreated controls. Data were analyzed from September 1, 2019, to November 30, 2022. Exposure Systemic corticosteroid therapy to prevent BPD that was initiated between day 8 and day 42 after birth. Main Outcomes and Measures The primary outcome was death or moderate to severe neurodevelopmental impairment at 2 years' corrected age. The secondary outcome was death or moderate to severe cerebral palsy at 2 years' corrected age. Results A total of 482 matched pairs of infants (mean [SD] gestational age, 24.1 [1.1] weeks]; 270 males [56.0%]) were included from 656 corticosteroid-treated infants and 2796 potential controls. Most treated infants (363 [75.3%]) received dexamethasone. The risk of death or disability associated with corticosteroid therapy was inversely associated with the estimated pretreatment probability of death or grade 2 or 3 BPD. The risk difference for death or neurodevelopmental impairment associated with corticosteroids decreased by 2.7% (95% CI, 1.9%-3.5%) for each 10% increase in the pretreatment risk of death or grade 2 or 3 BPD. This risk transitioned from estimated net harm to benefit when the pretreatment risk of death or grade 2 or 3 BPD exceeded 53% (95% CI, 44%-61%). For death or cerebral palsy, the risk difference decreased by 3.6% (95% CI, 2.9%-4.4%) for each 10% increase in the risk of death or grade 2 or 3 BPD and transitioned from estimated net harm to benefit at a pretreatment risk of 40% (95% CI, 33%-46%). Conclusions and Relevance Results of this study suggested that corticosteroids were associated with a reduced risk of death or disability in infants at moderate to high pretreatment risk of death or grade 2 or 3 BPD but with possible harm in infants at lower risk.
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Laura Elizabeth Wiener
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Matthew A. Rysavy
- Department of Pediatrics, University of Texas McGovern Medical School, Houston
| | - Kevin C. Dysart
- Neonatal/Perinatal Medicine, Nemours Children’s Hospital, Wilmington, Delaware
| | - Marie G. Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Eric C. Eichenwald
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Rachel G. Greenberg
- Department of Pediatrics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Heidi M. Harmon
- Stead Family Department of Pediatrics, University of Iowa, Iowa City
| | - Matthew M. Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | | | - Scott A. Lorch
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Sara B. DeMauro
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
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5
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Jensen EA, Laughon MM, DeMauro SB, Cotten CM, Do B, Carlo WA, Watterberg KL. Contributions of the NICHD neonatal research network to the diagnosis, prevention, and treatment of bronchopulmonary dysplasia. Semin Perinatol 2022; 46:151638. [PMID: 36085059 PMCID: PMC11075436 DOI: 10.1016/j.semperi.2022.151638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite improvements in the care and outcomes of infants born extremely preterm, bronchopulmonary dysplasia (BPD) remains a common and frustrating complication of prematurity. This review summarizes the BPD-focused research conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN). To improve disease classification and outcome prediction, the NRN developed new data-driven diagnostic criteria for BPD and web-based tools that allow clinicians and investigators to reliably estimate BPD risk in preterm infants. Randomized trials of intramuscular vitamin A and prophylactic nasal continuous positive airway pressure conducted by the NRN have contributed to our current use of these therapies as evidence-based approaches to reduce BPD risk. A recent large, randomized trial of hydrocortisone administered beginning between the 2nd and 4th postnatal weeks provided strong evidence that this therapy promotes successful extubation but does not lower BPD rates. Ongoing studies within the NRN will address important, unanswered questions on the risks and benefits of intratracheal surfactant/corticosteroid combinations and treatment versus expectant management of the patent ductus arteriosus to prevent BPD.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States.
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sara B DeMauro
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Barbara Do
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, United States
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristi L Watterberg
- University of New Mexico Health Sciences Center, Albuquerque, NM, United States
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6
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Using quality improvement to implement consensus guidelines for postnatal steroid treatment of preterm infants with developing bronchopulmonary dysplasia. J Perinatol 2021; 41:891-897. [PMID: 33093625 PMCID: PMC7578580 DOI: 10.1038/s41372-020-00862-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/14/2020] [Accepted: 10/06/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Achieve over 90% adherence to consensus guidelines on use of postnatal steroids (PNS) in preterm infants for bronchopulmonary dysplasia (BPD) within 6 months. METHODS A multidisciplinary team formulated and implemented consensus guidelines using the Plan-Do-Study-Act method of quality improvement. Outcome measure was rate of compliance to guidelines, process measure was age of starting PNS treatment, and balancing measure was rate of repeat steroid courses. RESULTS Retrospective application of guidelines to preceding 10 months showed mean baseline compliance rate of 71% (n = 42). After implementation, compliance escalated to a mean rate of 96% within 6 months. Rate of PNS treatment ≤ 30 days of life increased from 50 to 80%, while rate of repeat PNS was unchanged. CONCLUSIONS Compliance with new guidelines for PNS treatment of BPD was quickly attained using simple quality improvement interventions. Further study is needed to evaluate effects of these guidelines on clinical outcomes.
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7
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Abstract
The premature infant is born into the world unprepared to naturally thrive in a foreign environment. Lung development entails immense growth, structural remodeling and differentiation of specialized cells during the normal term perinatal and postnatal periods. Thus, the premature infant presents with a lung deficient for appropriate respiration. Disruption of lung development seen in bronchopulmonary dysplasia (BPD) and chronic lung disease (CLD) results in not only impaired airway growth but also a deficiency in the accompanying vasculature including the capillary system required for gas exchange. Deficient vascular area can lead to elevated pulmonary vascular resistance and the development of pulmonary hypertension (PH). Unlike PH seen in children and adults with pulmonary arterial hypertension (PAH), treatment with conventional pulmonary vasodilators can be limited in developmental lung disease-associated PH because there are fewer blood vessels to dilate. In this brief review, we highlight some of the knowledge on PH in the premature infant presented at the Proceedings of the 22nd Annual Update on Pediatric and Congenital Cardiovascular Disease.
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Affiliation(s)
- Lori A Christ
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer M Sucre
- Mildred Stahlman Division of Neonatology, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - David B Frank
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.,Penn-CHOP Lung Biology Institute and Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA
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8
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Augustine S, Cheng W, Avey MT, Chan ML, Lingappa SMC, Hutton B, Thébaud B. Are all stem cells equal? Systematic review, evidence map, and meta-analyses of preclinical stem cell-based therapies for bronchopulmonary dysplasia. Stem Cells Transl Med 2020; 9:158-168. [PMID: 31746123 PMCID: PMC6988768 DOI: 10.1002/sctm.19-0193] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/10/2019] [Indexed: 12/25/2022] Open
Abstract
Regenerative stem cell-based therapies for bronchopulmonary dysplasia (BPD), the most common preterm birth complication, demonstrate promise in animals. Failure to objectively appraise available preclinical data and identify knowledge gaps could jeopardize clinical translation. We performed a systematic review and network meta-analysis (NMA) of preclinical studies testing cell-based therapies in experimental neonatal lung injury. Fifty-three studies assessing 15 different cell-based therapies were identified: 35 studied the effects of mesenchymal stromal cells (MSCs) almost exclusively in hyperoxic rodent models of BPD. Exploratory NMAs, for select outcomes, suggest that MSCs are the most effective therapy. Although a broad range of promising cell-based therapies has been assessed, few head-to-head comparisons and unclear risk of bias exists. Successful clinical translation of cell-based therapies demands robust preclinical experimental design with appropriately blinded, randomized, and statistically powered studies, based on biological plausibility for a given cell product, in standardized models and endpoints with transparent reporting.
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Affiliation(s)
- Sajit Augustine
- Division of NeonatologyWindsor Regional HospitalWindsorOntarioCanada
- Department of Pediatrics, Schulich Medicine & DentistryWestern UniversityLondonOntarioCanada
| | - Wei Cheng
- Ottawa Hospital Research InstituteOttawaOntarioCanada
| | | | - Monica L. Chan
- Department of NeonatologyChildren's Hospital of Eastern OntarioOttawaOntarioCanada
| | | | - Brian Hutton
- Ottawa Hospital Research InstituteOttawaOntarioCanada
- School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of OttawaOttawaOntarioCanada
| | - Bernard Thébaud
- Ottawa Hospital Research InstituteOttawaOntarioCanada
- Department of NeonatologyChildren's Hospital of Eastern OntarioOttawaOntarioCanada
- Department of PediatricsChildren's Hospital of Eastern Ontario Research Institute, University of OttawaOttawaOntarioCanada
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9
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Randomized Trial of 42-Day Compared with 9-Day Courses of Dexamethasone for the Treatment of Evolving Bronchopulmonary Dysplasia in Extremely Preterm Infants. J Pediatr 2019; 211:20-26.e1. [PMID: 31349916 DOI: 10.1016/j.jpeds.2019.04.047] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/28/2019] [Accepted: 04/24/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare pulmonary and neurodevelopmental outcomes in extremely preterm infants with evolving bronchopulmonary dysplasia treated with either a 42-day course of dexamethasone or 9-day course(s) of dexamethasone. STUDY DESIGN This was a prospective, randomized study in 59 infants ≤27 weeks of gestation born between October 2006 and December 2010, who at day 10-21 of life had ventilatory support with mean airway pressure ≥8 cm H2O and FiO2 ≥60%. Infants received dexamethasone 0.5 mg/k/day × 3 days followed by a slow taper (42-day group, n = 30) or dexamethasone 0.5 mg/k/day followed by a rapid taper (9-day group, n = 29). Infants in the 9-day group received additional 9-day courses if they again required entry support. The primary outcome was intact survival (normal neurologic examination, IQ >70, and functioning in school without supplemental educational support) at 7 years of age. RESULTS The 42-day and 9-day groups were similar for mean gestational age (25 weeks) and all baseline characteristics. Nineteen of 29 infants (66%) in the 9-day group received only 1 course of dexamethasone; therefore, the total steroid dose for the 42-day group (7.56 mg/kg) was significantly greater than that for the 9-day group (4.04 mg/kg), P < .001. Infants in the 42-day group had shorter duration of ventilation (25 vs 37 days), P < .005, received fewer transfusions (2 vs 3.5), P < .01, and reached full enteral feeds earlier (40 vs 46 days), P < .05. Intact survival at school age was significantly increased in the 42-day group (75%) compared with the 9-day group (34%), P < .005. CONCLUSION A 42-day tapering course of dexamethasone in extremely preterm infants at high risk for bronchopulmonary dysplasia decreased hospital morbidities and increased rate of survival without handicap compared with a treatment protocol that attempted to minimize steroid exposure.
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10
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Neonatal Dexamethasone Treatment Suppresses Hippocampal Estrogen Receptor α Expression in Adolescent Female Rats. Mol Neurobiol 2019; 56:2224-2233. [DOI: 10.1007/s12035-018-1214-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/27/2018] [Indexed: 11/24/2022]
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Usefulness of an Online Risk Estimator for Bronchopulmonary Dysplasia in Predicting Corticosteroid Treatment in Infants Born Preterm. J Pediatr 2018; 197:23-28.e2. [PMID: 29551313 DOI: 10.1016/j.jpeds.2018.01.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/13/2017] [Accepted: 01/24/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess the usefulness of a bronchopulmonary dysplasia (BPD) outcome estimator developed by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) in identifying high-risk preterm infants treated with steroids. STUDY DESIGN This was a single-center retrospective study of infants born ≤30 weeks of gestational age. The NICHD BPD outcome estimator was used to retrospectively calculate BPD risk at various postnatal ages. The best combination of risk estimates for identifying steroid treatment was identified using stepwise model selection. A cut-off value with the best combination of sensitivity and specificity was identified using receiver operating characteristic analysis. RESULTS A total of 165 infants born preterm (mean gestational age 26 ± 1.6 weeks, mean birth weight 837 ± 171 g) were included. Of these, 61 were treated with steroids for BPD and 104 were not. Risk estimates for BPD or death were significantly greater in infants treated with steroids compared with controls. Both combined risk for severe BPD or death and single risk of no BPD were identified as factors with the best predictive power for identifying treatment with steroids, with accurate prediction possible as early as the second week of life. A greater than 37% risk for severe BPD or death or a less than 3% risk of no BPD on day of life 14 had 84%-92% sensitivity and 77%-80% specificity for predicting steroid treatment. CONCLUSION The NICHD BPD outcome estimator can be a useful objective tool for identifying infants at high risk for BPD who may benefit from postnatal steroids.
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Augustine S, Avey MT, Harrison B, Locke T, Ghannad M, Moher D, Thébaud B. Mesenchymal Stromal Cell Therapy in Bronchopulmonary Dysplasia: Systematic Review and Meta-Analysis of Preclinical Studies. Stem Cells Transl Med 2017; 6:2079-2093. [PMID: 29045045 PMCID: PMC5702524 DOI: 10.1002/sctm.17-0126] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 08/25/2017] [Indexed: 01/22/2023] Open
Abstract
Extreme prematurity is the leading cause of death among children under 5 years of age. Currently, there is no treatment for bronchopulmonary dysplasia (BPD), the most common complication of extreme prematurity. Experimental studies in animal models of BPD suggest that mesenchymal stromal cells (MSCs) are lung protective. To date, no systematic review and meta-analysis has evaluated the preclinical evidence of this promising therapy. Our protocol was registered with Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies prior to searching MEDLINE (1946 to June 1, 2015), Embase (1947 to 2015 Week 22), Pubmed, Web of Science, and conference proceedings (1990 to present) for controlled comparative studies of neonatal animal models that received MSCs or cell free MSC-derived conditioned media (MSC-CM). Lung alveolarization was the primary outcome. We used random effects models for data analysis and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. We screened 990 citations; 25 met inclusion criteria. All used hyperoxia-exposed neonatal rodents to model BPD. MSCs significantly improved alveolarization (Standardized mean difference of -1.330, 95% confidence interval [CI -1.724, -0.94, I2 69%]), irrespective of timing of treatment, source, dose, or route of administration. MSCs also significantly ameliorated pulmonary hypertension, lung inflammation, fibrosis, angiogenesis, and apoptosis. Similarly, MSC-CM significantly improved alveolarization, angiogenesis, and pulmonary artery remodeling. MSCs, tested exclusively in hyperoxic rodent models of BPD, show significant therapeutic benefit. Unclear risk of bias and incomplete reporting in the primary studies highlights nonadherence to reporting standards. Overall, safety and efficacy in other species/large animal models may provide useful information for guiding the design of clinical trials. Stem Cells Translational Medicine 2017;6:2079-2093.
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Affiliation(s)
- Sajit Augustine
- Division of Neonatology, Department of PediatricsChildren's Hospital of Eastern OntarioOttawaOntarioCanada
| | - Marc T. Avey
- Clinical Epidemiology Program, The Ottawa Hospital Research InstituteOttawaOntarioCanada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Tiffany Locke
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mona Ghannad
- Clinical Epidemiology Program, The Ottawa Hospital Research InstituteOttawaOntarioCanada
| | - David Moher
- Clinical Epidemiology Program, The Ottawa Hospital Research InstituteOttawaOntarioCanada
- School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of OttawaOttawaOntarioCanada
| | - Bernard Thébaud
- Division of Neonatology, Department of PediatricsChildren's Hospital of Eastern OntarioOttawaOntarioCanada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Sinclair Centre for Regenerative MedicineOttawaOntarioCanada
- Children's Hospital of Eastern Ontario Research InstituteOttawaOntarioCanada
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13
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Abstract
All definitions of bronchopulmonary dysplasia (BPD) have limitations and a new definition for the purpose of clinical research, benchmarking, and prognostic prediction is needed. Different inhaled and systemic drugs are currently used to prevent or treat BPD. Despite some positive effects on BPD, more information about the effects of inhaled corticosteroids is required to assess overall efficacy and associated risks. One needs to balance the risks of neurodevelopmental impairment owing to systemic corticosteroids against those of BPD itself. Future studies should, therefore, focus on infants with a very high risk of developing BPD and include pharmacokinetics and long-term developmental outcomes.
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14
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Wright CJ, Polin RA. Noninvasive Support: Does It Really Decrease Bronchopulmonary Dysplasia? Clin Perinatol 2016; 43:783-798. [PMID: 27837759 DOI: 10.1016/j.clp.2016.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Noninvasive support of preterm infants with respiratory distress is an evidenced-based strategy to decrease the incidence of bronchopulmonary dysplasia. Continuous positive airway pressure (CPAP) is the only noninvasive strategy with sufficient evidence to support its use in acute respiratory distress syndrome. It is unclear if one method for delivering CPAP is superior to another. Future research will focus on strategies (eg, sustained lung inflation, and administration of surfactant using a thin plastic catheter) that increase the likelihood of success with CPAP, especially in infants with a gestational age of less than 26 weeks.
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Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Perinatal Research Center, Children's Hospital Colorado, University of Colorado School of Medicine, Mail Stop F441, 13243 East 23rd Avenue, Aurora, CO 80045, USA.
| | - Richard A Polin
- Department of Pediatrics, Morgan Stanley Children's Hospital, 3959 Broadway, New York, NY 10032, USA
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Nakamura T, Yonemoto N, Nakayama M, Hirano S, Aotani H, Kusuda S, Fujimura M, Tamura M. Early inhaled steroid use in extremely low birthweight infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2016; 101:F552-F556. [PMID: 27059072 DOI: 10.1136/archdischild-2015-309943] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 03/16/2016] [Accepted: 03/18/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE We hypothesised that a prophylactic inhaled steroid would prevent the progression of bronchopulmonary dysplasia (BPD) in extremely low birthweight infants (ELBWIs). DESIGN This study was a multicentre, randomised, double-blinded, placebo-controlled trial. SETTING This investigation was conducted in 12 level III neonatal intensive care units (NICUs). PATIENTS A total of 211 ELBWIs requiring ventilator support were enrolled. INTERVENTION Starting within 24 h of birth and continuing until 6 weeks of age or extubation, two doses of 50 μg fluticasone propionate (FP) or placebo were administered every 24 h. MAIN OUTCOME MEASUREMENT The primary outcome measure used to indicate the morbidity of severe BPD incidence was death or oxygen dependence at discharge from the NICU. The secondary measures were neurodevelopmental impairments (NDIs) at 18 months of postmenstrual age and 3 years of age. We performed subgroup analyses based on gestational week (GW) and the presence of chorioamnionitis (CAM). RESULTS Infants were randomised into the FP (n=107) or placebo (n=104) groups. No significant differences were detected between the FP and placebo groups with respect to either the frequency of death or the oxygen dependence at discharge or NDIs. In subgroup analyses, the frequencies of death and oxygen dependence at discharge were significantly decreased in the FP group for infants born at 24-26 GWs and for infants with CAM, regardless of the GW at birth. CONCLUSIONS Inhaled steroids have no effect on the prevention of severe BPD or long-term NDI but might decrease the severity of BPD for ELBWIs with a risk factor. TRIAL REGISTRATION NUMBER UMIN-CTR C000000405.
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Affiliation(s)
- Tomohiko Nakamura
- Division of Neonatology, Nagano Children's Hospital, Nagano, Japan.,Division of Neonatology, Department of Pediatrics, Shinshu University School of Medicine, Nagano, Japan
| | - Naohiro Yonemoto
- Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masahiro Nakayama
- Department of Clinical Laboratory Medicine and Anatomic Pathology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Shinya Hirano
- Department of Neonatal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Hirofumi Aotani
- Department of Pediatrics, Kyoto Kizukawa Hospital, Kyoto, Japan
| | - Satoshi Kusuda
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical Center, Tokyo, Japan
| | - Masanori Fujimura
- Department of Neonatal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Masanori Tamura
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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16
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Affiliation(s)
- Anne Monique Nuyt
- Department of Pediatrics, Sainte-Justine University Hospital Research Center, Faculty of Medicine, Université de Montréal, Montreal H3T 1C5, QC, Canada.
| | - Bernard Thébaud
- Department of Pediatrics, Ottawa Hospital Research Institute, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Jensen EA, Foglia EE, Schmidt B. Evidence-Based Pharmacologic Therapies for Prevention of Bronchopulmonary Dysplasia: Application of the Grading of Recommendations Assessment, Development, and Evaluation Methodology. Clin Perinatol 2015; 42:755-79. [PMID: 26593077 DOI: 10.1016/j.clp.2015.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic complication of extreme preterm birth. The authors applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to pharmacologic therapies found to prevent BPD. Caffeine and vitamin A are the only medications shown in high-quality studies to prevent BPD without the risk of clinically important adverse effects. Dexamethasone is effective for the prevention of BPD; but for many infants, the increased risks of hypertrophic cardiomyopathy, gastrointestinal perforation, and cerebral palsy outweigh this benefit. Several medications are currently under investigation for the prevention of BPD, but few are novel agents.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Barbara Schmidt
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania, Philadelphia, PA 19104, USA.
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Neonatal glucocorticoid treatment increased depression-like behaviour in adult rats. Int J Neuropsychopharmacol 2014; 17:1995-2004. [PMID: 24945924 DOI: 10.1017/s1461145714000868] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Synthetic glucocorticoid dexamethasone (DEX) is frequently used as a therapeutic agent to lessen the morbidity of chronic lung disease in premature infants. Previous studies suggested that neonatal DEX treatment altered brain development and cognitive function. It has been recognized that the amygdala is involved in emotional processes and also a critical site of neuronal plasticity for fear conditioning. Little is known about the possible long-term adverse effect of neonatal DEX treatment on amygdala function. The present study was aimed to evaluate the possible effect of neonatal DEX treatment on the synaptic function of amygdala in adult rats. Newborn Wistar rats were subjected to subcutaneous tapering-dose injections of DEX (0.5, 0.3 and 0.1 mg/kg) from post-natal day one to three, PN1-PN3. Animals were then subjected to a forced swimming test (FST) and electrophysiological recording aged eight weeks. The results of the FST showed neonatal DEX treatment increased depression-like behaviour in adulthood. After acute stress evoking, the percentage of time spent free floating is significantly increased in the DEX treated group compared with the control animals. Furthermore, neonatal DEX treatment elevated long-term potentiation (LTP) response and the phosphorylation level of MAPK in the lateral nucleus of amygdala (LA). Intracerebroventricular infusion of the MAPK inhibitor, PD98059, showed significant rescue effects including reduced depression-like behaviour and restoration of LTP to within normal range. In conclusion, our results suggested that MAPK signalling cascade in the LA plays an important role in the adverse effect of neonatal DEX treatment on amygdala function, which may result in adverse consequences in adult age, such as the enhancement of susceptibility for a depressive disorder in later life.
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An update on the impact of postnatal systemic corticosteroids on mortality and cerebral palsy in preterm infants: effect modification by risk of bronchopulmonary dysplasia. J Pediatr 2014; 165:1258-60. [PMID: 25217197 DOI: 10.1016/j.jpeds.2014.07.049] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/01/2014] [Accepted: 07/25/2014] [Indexed: 11/21/2022]
Abstract
Infants at higher risk of bronchopulmonary dysplasia had increased rates of survival free of cerebral palsy after postnatal corticosteroid treatment in a previous metaregression of data from 14 randomized controlled trials. The relationship persists and is stronger in an updated analysis with data from 20 randomized controlled trials.
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