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Hwang-Bo S, Seo YM, Oh MY, Im SA, Youn YA. The prognosis of refractory hypotension and severe intraventricular hemorrhage in very low birth weight infants. Medicine (Baltimore) 2022; 101:e29598. [PMID: 35905281 PMCID: PMC9333540 DOI: 10.1097/md.0000000000029598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The increased survival rate among very low birth weight infants has resulted in a higher risk for developing neuro-complications such as intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), and adverse neurodevelopmental outcomes. PURPOSE We examined refractory hypotension experienced within a week of life in association with severe IVH (grades 3-4) among very low birth weight infants (VLBWIs). METHOD Between Jan 2014 and Dec 2017, the clinical data of 191 VLBWIs were retrospectively chart reviewed. Of a total of 191 VLBWIs, 71.2% (136/191) had IVH, and 28.7% (55/191) had severe IVH. RESULTS The VLBWI with severe IVH group (grade 3-4) presented with a significantly lower gestational age along with higher use of postnatal hydrocortisone for refractory hypotension within a week of life. Resuscitation at delivery, pulmonary hemorrhage, neonatal seizure, and PVL were significantly more frequent in the severe IVH group (P < .05). Higher mortality occurred in the VLBWI with severe IVH group (P < .001). The multivariable logistic regression analysis consistently showed that refractory hypotension within a week of life and neonatal seizures were significantly associated with severe IVH. Those in the severe IVH and refractory hypotension groups had significantly lower composite cognitive, language, motor scores in Bayley Scales of Infant and Toddler Development III scores at corrected 18-24 months. CONCLUSION Refractory hypotension within a week of life and seizures were consistently associated with severe IVH and developmental delay at corrected 18-24 months. VLBWI who experienced refractory hypotension within a week of life may indicate a more vulnerable clinical setting with a higher risk for developmental delay.
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Affiliation(s)
- Seok Hwang-Bo
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yu-Mi Seo
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Moon-Yeon Oh
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soo-Ah Im
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young-Ah Youn
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Josephsen JB, Hemmann BM, Anderson CD, Hemmann BM, Buchanan PM, Williams HL, Lubsch LM, Hillman NH. Presumed adrenal insufficiency in neonates treated with corticosteroids for the prevention of bronchopulmonary dysplasia. J Perinatol 2022; 42:65-71. [PMID: 34725449 DOI: 10.1038/s41372-021-01251-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 10/04/2021] [Accepted: 10/12/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine if extremely preterm (EPT) neonates receiving dexamethasone for the prevention of BPD have a higher incidence of presumed adrenal insufficiency (PAI). STUDY DESIGN Retrospective cohort study of neonates <28 weeks gestation examining PAI after dexamethasone use and PAI after intratracheal budesonide with surfactant administration. RESULT Of 332 neonates, 38% received dexamethasone. The incidence of PAI was higher in neonates who had received dexamethasone (20.8% vs 2.9%, p < 0.001). However, for intubated babies receiving surfactant, dexamethasone was not independently associated with increased PAI after adjusting for gestational age, birthweight, and race (aOR 2.92, 95% CI: 0.79-10.85). Dexamethasone was independently associated with increased PAI in infants previously receiving budesonide/surfactant treatment (aOR 5.38, 95% CI: 1.38-20.90). CONCLUSION The use of dexamethasone alone was not associated with increased PAI, when adjusted for prematurity-related factors. The combination of budesonide with dexamethasone was significantly associated with increased PAI.
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Affiliation(s)
- Justin B Josephsen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA.
| | - Brianna M Hemmann
- Cincinnati Children's Hospital Medical Center, Department of Pharmacy, Cincinnati, OH, USA
| | - Connie D Anderson
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Brett M Hemmann
- The Christ Hospital Health Network, Department of Pharmacy, Cincinnati, OH, USA
| | - Paula M Buchanan
- Department of Health and Clinical Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Howard L Williams
- SSM Health Cardinal Glennon Children's Hospital, Department of Pharmacy, St. Louis, MO, USA
| | - Lisa M Lubsch
- SSM Health Cardinal Glennon Children's Hospital, Department of Pharmacy, St. Louis, MO, USA.,Southern Illinois University Edwardsville School of Pharmacy, Department of Pharmacy Practice, Edwardsville, IL, USA
| | - Noah H Hillman
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
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Prelipcean I, Wynn JL, Thompson L, Burchfield DJ, James-Woodley L, Chase PB, Barnes CP, Bernier A. Absence of relationship between serum cortisol and critical illness in premature infants. Arch Dis Child Fetal Neonatal Ed 2021; 106:408-412. [PMID: 33541918 PMCID: PMC8852370 DOI: 10.1136/archdischild-2020-319970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 12/05/2020] [Accepted: 12/10/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Inadequate cortisol production in response to critical illness in extremely preterm infants may exacerbate poor outcomes. Despite commonly measuring cortisol concentration and administering hydrocortisone for presumed adrenal insufficiency, the relationship between serum cortisol concentration and illness severity remains unclear in this unique population. OBJECTIVE To determine the relationship between cortisol concentrations and illness severity as measured by the Score for Neonatal Acute Physiology II, neonatal Sequential Organ Failure Assessment and Vasoactive-Inotropic Score in premature infants. DESIGN/METHODS This retrospective, single-center cohort study included preterm infants born <30 weeks gestational age admitted to a level IV neonatal intensive care unit (NICU) between June 2011 and July 2018, who had a serum cortisol obtained for clinical indications before 36 weeks PMA. Demographic data were collected on infants and mothers. Nine clinical variables were identified a priori that could potentially modify cortisol concentration including critical illness. Univariate and multivariable analyses determined the relationship between cortisol concentration and each of these variables. RESULTS A total of 224 preterm infants with pretreatment serum cortisol concentration met criteria for inclusion. The median (IQR) gestational age at birth was 25 weeks (24, 26) and at cortisol measurement was 26 weeks (25, 28). The median cortisol was 13.3 ug/dL. Non-survivors had the highest values. Cortisol concentration did not correlate with any of the selected illness severity scores. CONCLUSIONS Cortisol concentrations in extremely preterm infants did not correlate with illness severity regardless of gestational age. Further studies are needed to identify clinically useful mediators of adrenal dysfunction and to guide clinical management.
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Affiliation(s)
- Irina Prelipcean
- Pediatrics, University of Rochester, Rochester, New York, USA .,Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville, Florida,Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Lindsay Thompson
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | | | | | - Philip B. Chase
- Clinical and Translational Science - Informatics and Technology, University of Florida
| | - Christopher P. Barnes
- Clinical and Translational Science - Informatics and Technology, University of Florida
| | - Angelina Bernier
- Department of Pediatrics, University of Florida, Gainesville, Florida
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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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Onland W, Cools F, Kroon A, Rademaker K, Merkus MP, Dijk PH, van Straaten HL, Te Pas AB, Mohns T, Bruneel E, van Heijst AF, Kramer BW, Debeer A, Zonnenberg I, Marechal Y, Blom H, Plaskie K, Offringa M, van Kaam AH. Effect of Hydrocortisone Therapy Initiated 7 to 14 Days After Birth on Mortality or Bronchopulmonary Dysplasia Among Very Preterm Infants Receiving Mechanical Ventilation: A Randomized Clinical Trial. JAMA 2019; 321:354-363. [PMID: 30694322 PMCID: PMC6439762 DOI: 10.1001/jama.2018.21443] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Dexamethasone initiated after the first week of life reduces the rate of death or bronchopulmonary dysplasia (BPD) but may cause long-term adverse effects in very preterm infants. Hydrocortisone is increasingly used as an alternative, but evidence supporting its efficacy and safety is lacking. OBJECTIVE To assess the effect of hydrocortisone initiated between 7 and 14 days after birth on death or BPD in very preterm infants. DESIGN, SETTING, AND PARTICIPANTS Double-blind, placebo-controlled randomized trial conducted in 19 neonatal intensive care units in the Netherlands and Belgium from November 15, 2011, to December 23, 2016, among preterm infants with a gestational age of less than 30 weeks and/or birth weight of less than 1250 g who were ventilator dependent between 7 and 14 days of life, with follow-up to hospital discharge ending December 12, 2017. INTERVENTIONS Infants were randomly assigned to receive a 22-day course of systemic hydrocortisone (cumulative dose, 72.5 mg/kg) (n = 182) or placebo (n = 190). MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death or BPD assessed at 36 weeks' postmenstrual age. Twenty-nine secondary outcomes were analyzed up to hospital discharge, including death and BPD at 36 weeks' postmenstrual age. RESULTS Among 372 patients randomized (mean gestational age, 26 weeks; 55% male), 371 completed the trial; parents withdrew consent for 1 child treated with hydrocortisone. Death or BPD occurred in 128 of 181 infants (70.7%) randomized to hydrocortisone and in 140 of 190 infants (73.7%) randomized to placebo (adjusted risk difference, -3.6% [95% CI, -12.7% to 5.4%]; adjusted odds ratio, 0.87 [95% CI, 0.54-1.38]; P = .54). Of 29 secondary outcomes, 8 showed significant differences, including death at 36 weeks' postmenstrual age (15.5% with hydrocortisone vs 23.7% with placebo; risk difference, -8.2% [95% CI, -16.2% to -0.1%]; odds ratio, 0.59 [95% CI, 0.35-0.995]; P = .048). Twenty-one outcomes showed nonsignificant differences, including BPD (55.2% with hydrocortisone vs 50.0% with placebo; risk difference, 5.2% [95% CI, -4.9% to 15.2%]; odds ratio, 1.24 [95% CI, 0.82-1.86]; P = .31). Hyperglycemia requiring insulin therapy was the only adverse effect reported more often in the hydrocortisone group (18.2%) than in the placebo group (7.9%). CONCLUSIONS AND RELEVANCE Among mechanically ventilated very preterm infants, administration of hydrocortisone between 7 and 14 days after birth, compared with placebo, did not improve the composite outcome of death or BPD at 36 weeks' postmenstrual age. These findings do not support the use of hydrocortisone for this indication. TRIAL REGISTRATION Netherlands National Trial Register Identifier: NTR2768.
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Affiliation(s)
- Wes Onland
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Andre Kroon
- Department of Neonatology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Karin Rademaker
- Department of Neonatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maruschka P. Merkus
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter H. Dijk
- Department of Neonatology, University Medical Center Groningen, Beatrix Children’s Hospital, University of Groningen, Groningen, the Netherlands
| | | | - Arjan B. Te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Thilo Mohns
- Department of Neonatology, Maxima Medical Center, Veldhoven, the Netherlands
| | - Els Bruneel
- Department of Neonatology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Arno F. van Heijst
- Department of Neonatology, Radboud University Medical Center–Amalia Children’s Hospital, Nijmegen, the Netherlands
| | - Boris W. Kramer
- Department of Neonatology, Medical University Center Maastricht, Maastricht, the Netherlands
| | - Anne Debeer
- Department of Neonatology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Inge Zonnenberg
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universteit Amsterdam, Amsterdam, the Netherlands
| | - Yoann Marechal
- Department of Neonatology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Henry Blom
- Department of Neonatology, Universitair Ziekenhuis Antwerpen, Antwerp, Belgium
| | - Katleen Plaskie
- Department of Neonatology, St Augustinus Ziekenhuis, Antwerp, Belgium
| | - Martin Offringa
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Division of Neonatology and Child Health Evaluative Sciences, the Hospital for Sick Children Research Institute, University of Toronto, Canada
| | - Anton H. van Kaam
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universteit Amsterdam, Amsterdam, the Netherlands
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Abstract
Antenatal steroid treatment to enhance fetal lung maturity and surfactant treatment to prevent or treat respiratory distress syndrome have been major advances in perinatal medicine in the past 40 years contributing to improved outcomes for preterm infants. Use of postnatal steroids to prevent or treat chronic lung disease in preterm infants has been less successful and associated with adverse neurodevelopmental outcomes. Although early (in the first week of life) postnatal steroid treatment facilitates earlier extubation and reduces the risk of chronic lung disease, it is associated with adverse effects, such as hyperglycemia, hypertension, gastrointestinal bleeding and perforation, hypertrophic cardiomyopathy, growth failure, and cerebral palsy, and cannot be recommended. Early treatment with hydrocortisone may also improve survival without chronic lung disease, but concerns remain about possible adverse effects such as gastrointestinal perforation and sepsis, particularly in very preterm infants. Early inhaled budesonide also reduces the incidence of chronic lung disease but there are concerns that this may occur at the expense of increased risk of death. More studies of early low-dose steroids with adequate long-term follow-up are needed before they can be recommended for the prevention of chronic lung disease. Late (after the first week of life) postnatal steroids may have a better benefit-to-harm ratio than early steroids. A Cochrane Review shows that late steroid treatment reduces chronic lung disease, the combination of death and chronic lung disease at both 28 days and 36 weeks' corrected age, and the need for later rescue dexamethasone. Adverse effects include hyperglycemia, hypertension, hypertrophic cardiomyopathy, and severe retinopathy of prematurity but without an increase in blindness. Long-term neurodevelopmental effects are not significantly increased by late postnatal steroid treatment. Current recommendations are that postnatal steroid treatment should be reserved for preterm infants who are ventilator-dependent after the first 7-14 days of life and any course should be low dose and of short duration to facilitate endotracheal extubation. Budesonide/surfactant mixtures show some promise as a means of reducing chronic lung disease in preterm infants with severe respiratory distress syndrome, but further larger studies with long-term follow-up are needed before this treatment can be recommended as a routine intervention.
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