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Kolnik SE, Sahota A, Wood TR, German K, Puia-Dumitrescu M, Mietzsch U, Dighe M, Law JB. Cranial Point-of-Care Ultrasound for Neonatal Providers: A Feasibility Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:1089-1097. [PMID: 38404126 DOI: 10.1002/jum.16437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/08/2024] [Accepted: 02/11/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE Despite strong evidence for its utility in clinical management and diagnosis of intracranial hemorrhage (ICH), the use of neonatal cranial point-of-care ultrasound (POCUS) has not been standardized in neonatal intensive care units (NICUs) in the United States. The primary aim of this study was to evaluate the feasibility of training NICU providers to perform cranial POCUS by tracking the quality of image acquisition following training. METHODS Observational single-center cohort study of cranial POCUS images obtained by trained neonatal practitioners (attendings, fellows, and advanced practice providers) using a protocol developed by a radiologist and neonatologist. Exams were performed on infants born ≤1250 g and/or ≤30 weeks gestation within the first 3 days after birth. A survey to assess attitudes regarding cranial POCUS was given before each of three training sessions. Demographic and clinical data collection were portrayed with descriptive statistics. Metrics of image quality were assessed by a radiologist and sonographer independently. Analysis of trends in quality of POCUS images over time was performed using a multinomial Cochran-Armitage test. RESULTS Eighty-two cranial POCUS scans were performed over a 2-year period. Infant median age at exam was 14 hours (IQR 7-22 hours). Metrics of image quality depicted quarterly demonstrated a significant improvement in depth (P = .01), gain (P = .048), and quality of anatomy images captured (P < .001) over time. Providers perceived increased utility and safety of cranial POCUS over time. CONCLUSION Cranial POCUS image acquisition improved significantly following care team training, which may enable providers to diagnose ICH at the bedside.
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Affiliation(s)
- Sarah E Kolnik
- Department of Pediatrics, Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
| | - Annika Sahota
- Department of Pediatrics, Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
| | - Thomas R Wood
- Department of Pediatrics, Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
- Center on Human Development and Disability, University of Washington, Seattle, Washington, USA
| | - Kendell German
- Department of Pediatrics, Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
- Center on Human Development and Disability, University of Washington, Seattle, Washington, USA
| | - Mihai Puia-Dumitrescu
- Department of Pediatrics, Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
| | - Ulrike Mietzsch
- Department of Pediatrics, Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
| | - Manjiri Dighe
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Janessa B Law
- Department of Pediatrics, Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
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Leon-Martinez D, Bank TC, Lundsberg LS, Culhane J, Silasi M, Son M, Partridge C, Reddy UM, Hoffman MK, Merriam AA. Does Antenatal Progesterone Administration Modify the Risk of Neonatal Intraventricular Hemorrhage? Am J Perinatol 2024; 41:e46-e52. [PMID: 35436803 DOI: 10.1055/a-1827-6712] [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: 11/01/2022]
Abstract
OBJECTIVE Progesterone administration has been associated with improved neurological outcomes following traumatic brain injury in adults. However, studies examining the effect of progesterone on the risk of neonatal intraventricular hemorrhage (IVH) are inconsistent. We sought to determine if maternal administration of intramuscular 17-α-hydroxyprogesterone caproate (17-OHPC) is associated with decreased rates of IVH in infants born before 32-weeks gestation. STUDY DESIGN This is a retrospective study of liveborn singleton deliveries between 20- and 32-weeks gestation at two large academic medical centers from January 1, 2012 to August 30, 2020. Data were extracted from hospital electronic medical record data warehouses using standardized definitions and billing and diagnosis codes. We evaluated receipt of 17-OHPC in the antepartum period and diagnosis of IVH (grade I-IV, per Volpe classification) during the neonatal delivery hospitalization encounter. Bivariate and multivariate analyses were performed to examine the association between 17-OHPC and neonatal IVH adjusting for potential confounders. Odds ratio (ORs) and 95% confidence intervals (CIs) were presented. RESULTS Among 749 neonates born between 20- and 32-week gestation, 140 (18.7%) of their mothers had received antenatal 17-OHPC and 148 (19.8%) were diagnosed with IVH after birth. No significant association was observed between maternal 17-OHPC and neonatal IVH in unadjusted (OR 1.14, 95% CI 0.72-1.78) or adjusted analyses (adjusted odds ratio 1.14, 95% CI 0.71-1.84). Independent of exposure to 17-OHPC, as expected, infants born <28-weeks gestation or those with very low birthweight (<1,500 g) were at an increased risk of IVH (OR 2.32, 95% CI 1.55-3.48 and OR 2.19, 95% CI 1.09-4.38, respectively). CONCLUSION Antenatal maternal 17-OHPC administration was not associated with the risk of neonatal IVH. Further research may be warranted to determine whether timing, route of delivery, and duration of progesterone therapy impact rates of neonatal IVH. KEY POINTS · This study aimed to compare the frequency of intraventricular hemorrhage in preterm neonates exposed to antenatal 17-α-hydroxyprogesterone caproate to those not exposed.. · In neonates born at <32-weeks gestation, maternal use of progesterone is not associated with the risk of intraventricular hemorrhage.. · In contrast to preclinical and adult data, this study suggests that progesterone exposure is not associated with the prevention of neonatal brain injury..
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Affiliation(s)
- Daisy Leon-Martinez
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Tracy C Bank
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer Culhane
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Michelle Silasi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Moeun Son
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Caitlin Partridge
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Uma M Reddy
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew K Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
| | - Audrey A Merriam
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
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Clyman RI, Hills NK. Prophylactic indomethacin and the risk of serious pulmonary hemorrhages in preterm infants less than 28 weeks' gestation. J Perinatol 2024:10.1038/s41372-024-01971-x. [PMID: 38658692 DOI: 10.1038/s41372-024-01971-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To determine if prophylactic indomethacin (PINDO) decreases serious pulmonary hemorrhages in infants <28 weeks. STUDY DESIGN Intention-to-treat analysis of 615 consecutively admitted infants during four alternating protocol-driven epochs of PINDO or expectant patent ductus arteriosus (PDA) management. RESULTS 41/615 (6.7%) developed serious pulmonary hemorrhage at 2 (1, 3) days (median (IQR)). In unadjusted and adjusted multivariable models, infants born in a PINDO epoch had significantly lower incidences of pulmonary hemorrhage and pulmonary hemorrhage or death before 7 days. There were less moderate/large PDA during PINDO epochs. The associations between PINDO and pulmonary hemorrhage and pulmonary hemorrhage/death were no longer significant when presence of a PDA was included in the analyses. There was no apparent association between PINDO epochs and the incidence of serious intraventricular hemorrhages. CONCLUSION Even though PINDO no longer appears to affect the incidence of sIVH it still is associated with a lower incidence of pulmonary hemorrhage.
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Affiliation(s)
- Ronald I Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
- Department of Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA.
| | - Nancy K Hills
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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Razak A, Johnston E, Stewart A, Clark MAT, Stevens P, Charlton M, Wong F, McDonald C, Hunt RW, Miller S, Malhotra A. Temporal Trends in Severe Brain Injury and Associated Outcomes in Very Preterm Infants. Neonatology 2024:1-10. [PMID: 38471459 DOI: 10.1159/000537801] [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: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Severe brain injury (SBI), including severe intraventricular haemorrhage (sIVH) and cystic periventricular leukomalacia, poses significant challenges for preterm infants, yet recent data and trends are limited. METHODS Analyses were conducted using the Australian and New Zealand Neonatal Network data on preterm infants born <32 weeks' gestation admitted at Monash Children's Hospital, Australia, from January 2014 to April 2021. The occurrence and trends of SBI and sIVH among preterm infants, along with the rates and trends of death and neurodevelopmental impairment (NDI) in SBI infants were assessed. RESULTS Of 1,609 preterm infants, 6.7% had SBI, and 5.6% exhibited sIVH. A total of 37.6% of infants with SBI did not survive to discharge, with 92% of these deaths occurring following redirection of clinical care. Cerebral palsy was diagnosed in 65.2% of SBI survivors, while 86.4% of SBI survivors experienced NDI. No statistically significant differences were observed in the temporal trends of SBI (adjusted OR [95% CI] 1.08 [0.97-1.20]; p = 0.13) or sIVH (adjusted OR [95% CI] 1.09 [0.97-1.21]; p = 0.11). Similarly, there was no statistically significant difference noted in the temporal trend of the composite outcome, which included death or NDI among infants with SBI (adjusted OR [95% CI] 0.90 [0.53-1.53]; p = 0.71). CONCLUSION Neither the rates of SBI nor its associated composite outcome of death or NDI improved over time. A notable proportion of preterm infants with SBI faced redirection of care and subsequent mortality, while most survivors exhibited adverse neurodevelopmental challenges. The development of better therapeutic interventions is imperative to improve outcomes for these vulnerable infants.
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Affiliation(s)
- Abdul Razak
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Emily Johnston
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Alice Stewart
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Marissa A T Clark
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Penelope Stevens
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Margaret Charlton
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Flora Wong
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - C McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Rod W Hunt
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Cerebral Palsy Alliance Research, Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Atul Malhotra
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
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Tamai K, Matsumoto N, Yorifuji T, Takeuchi A, Nakamura M, Nakamura K, Kageyama M. Delivery room intubation and neurodevelopment among extremely preterm infants. Pediatr Res 2024:10.1038/s41390-023-02993-5. [PMID: 38212388 DOI: 10.1038/s41390-023-02993-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/08/2023] [Accepted: 11/18/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND The impact of delivery room intubation (DRI) on neurodevelopment in extremely preterm infants remains unclear. METHODS We retrospectively analyzed data for infants born at 24-27 gestational weeks between 2003 and 2018. The primary outcome was neurodevelopmental impairment (NDI), defined as cerebral palsy or hearing, visual, or cognitive impairment at age 3 years. Secondary outcomes were NDI components and death before and after discharge from the neonatal intensive care unit. We conducted robust Poisson regression analyses, adjusting for perinatal confounders. RESULTS The full cohort included 4397 infants with NDI data, of whom 3703 were intubated in the delivery room and 694 were not intubated in the delivery room. The mean gestational age and birth weight were 26.0 ± 1.1 weeks and 778 ± 184 g for infants with DRI and 26.6 ± 1.0 weeks and 873 ± 184 g for infants without DRI. Compared with infants without DRI, those with DRI had a higher risk for NDI (32.4% vs. 23.3%; adjusted risk ratio 1.18, 95% confidence interval: 1.01-1.37). There were no differences in secondary outcomes between infants with and without DRI. CONCLUSIONS DRI was associated with an increased risk for NDI at age 3 years among extremely preterm infants. IMPACT Few studies have examined the impact of delivery room intubation on neurodevelopment in infants born extremely preterm, and the results have been inconsistent. A total of 4397 infants born at 24-27 gestational weeks who had neurodevelopmental data at age 3 years were included in the present study. The present study found that delivery room intubation was associated with an increased risk for neurodevelopmental impairment at age 3 years among extremely preterm infants.
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Affiliation(s)
- Kei Tamai
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan.
| | - Naomi Matsumoto
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihito Takeuchi
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
| | - Makoto Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
| | - Kazue Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Misao Kageyama
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
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Ilves N, Metsvaht T, Laugesaar R, Rull K, Lintrop M, Laan M, Loorits D, Kool P, Ilves P. Periventricular hemorrhagic infarction in preterm neonates: Etiology and time of development. J Neonatal Perinatal Med 2024; 17:111-121. [PMID: 38189714 DOI: 10.3233/npm-230033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND To find the obstetrical and delivery associated risk factors of antenatal and postnatal grade III intraventricular hemorrhage (IVH) or periventricular hemorrhagic infarction (PVHI) in preterm neonates. METHODS A retrospective study of obstetric and delivery associated risk factors included neonates (<35 gestational weeks) with severe IVH/PVHI (n = 120) and a prospectively collected control group (n = 50). The children were divided into: (1) antenatal onset group (n = 27) with insult visible on cerebral ultrasonography within the first 12 hours of birth or periventricular cystic changes visible in PVHI within the first 3 days; (2) neonatal onset group (n = 70) with insult diagnosed after initial normal findings or I-II grade IVH, and (3) unknown time-onset group (n = 23) with insult visible at > 12 h of age. RESULTS The mothers of the antenatal onset group had significantly more bacterial infections before delivery compared to the neonatal onset group: 20/27 (74.1%) versus 23/69 (33.3%), (odds ratio (OR) 5.7 [95% confidence interval 2.1-16]; p = 0.0008) or compared to the control group (11/50 (22%); OR 11 [2.8-42]; p = 0.0005). Placental histology revealed chorioamnionitis more often in the antenatal compared to the neonatal onset group (14/21 (66.7%) versus 16/42 (38.1%), respectively; OR 3.7 [1.18-11]; p = 0.025). Neonates with neonatal development of severe IVH/PVHI had significantly more complications during delivery or intensive care. CONCLUSIONS Bacterial infection during pregnancy is an important risk factor for development of antenatal onset severe IVH or PVHI. In neonates born to mothers with severe bacterial infection during pregnancy, cerebral ultrasonography is indicated for early detection of severe IVH or PVHI.
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Affiliation(s)
- N Ilves
- Radiology Clinic of Tartu University Hospital, Tartu, Estonia
- Department of Radiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - T Metsvaht
- Anesthesiology and Intensive Care Clinic of Tartu University Hospital, Tartu, Estonia
- Department of Pediatrics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - R Laugesaar
- Children's Clinic of Tartu University Hospital, Tartu, Estonia
- Department of Pediatrics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - K Rull
- Women's Clinic of Tartu University Hospital, Tartu, Estonia
- Department of Gynecology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - M Lintrop
- Radiology Clinic of Tartu University Hospital, Tartu, Estonia
- Department of Radiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - M Laan
- Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - D Loorits
- Radiology Clinic of Tartu University Hospital, Tartu, Estonia
| | - P Kool
- Department of Radiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - P Ilves
- Radiology Clinic of Tartu University Hospital, Tartu, Estonia
- Department of Radiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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Tamai K, Matsumoto N, Yorifuji T, Takeuchi A, Nakamura M, Nakamura K, Kageyama M. Delivery room intubation and severe intraventricular hemorrhage in extremely preterm infants without low Apgar scores: A Japanese retrospective cohort study. Sci Rep 2023; 13:14990. [PMID: 37696821 PMCID: PMC10495461 DOI: 10.1038/s41598-023-41010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/20/2023] [Indexed: 09/13/2023] Open
Abstract
The purpose of this study was to assess the associations between delivery room intubation (DRI) and severe intraventricular hemorrhage (IVH), as well as other neonatal outcomes, among extremely preterm infants without low Apgar scores using data from a large-scale neonatal registry data in Japan. We analyzed data for infants born at 24-27 gestational weeks between 2003 and 2019 in Japan using robust Poisson regression. Infants with low Apgar scores (≤ 1 at 1 min or ≤ 3 at 5 min) were excluded. The primary outcome was severe IVH. Secondary outcomes were other neonatal morbidities and mortality. The full cohort included 16,081 infants (intubation cohort, 13,367; no intubation cohort, 2714). The rate of DRI increased over time (78.6%, 2003-2008; 83.4%, 2009-2014; 87.8%, 2015-2019), while the rate of severe IVH decreased (7.1%, 2003-2008; 5.7%, 2009-2014; 5.3%, 2015-2019). Infants with DRI had a higher risk of severe IVH than those without DRI (6.8% vs. 2.3%; adjusted risk ratio, 1.86; 95% confidence interval, 1.33-2.58). The results did not change substantially when stratified by gestational age. Despite conflicting changes over time in DRI and severe IVH, DRI was associated with an increased risk of severe IVH among extremely preterm infants in Japan.
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Affiliation(s)
- Kei Tamai
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan.
| | - Naomi Matsumoto
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihito Takeuchi
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
| | - Makoto Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
| | - Kazue Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Misao Kageyama
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
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Kolnik SE, Upadhyay K, Wood TR, Juul SE, Valentine GC. Reducing Severe Intraventricular Hemorrhage in Preterm Infants With Improved Care Bundle Adherence. Pediatrics 2023; 152:e2021056104. [PMID: 37609772 DOI: 10.1542/peds.2021-056104] [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] [Accepted: 05/26/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intraventricular hemorrhage prevention bundles (IVHPBs) can decrease the incidence of intraventricular hemorrhage (IVH) in premature infants. Our center had a high rate of severe (grade III/IV) IVH (9.8%), and poor adherence (24%) to an IVHPB in neonates born ≤1250 g or ≤30 gestational weeks. Improvement initiatives were planned to decrease the incidence of severe IVH by 30% over 2 years. METHODS A multidisciplinary team undertook interventions including in-service training, prompt initiation of IVHPB, revision of guidelines, and process standardization. Baseline data were collected from May 2016 to June 2018, with interventions occurring from July 2018 to May 2020. Adherence to the IVHPB was the primary process measure, and incidence of severe IVH the primary outcome measure. Control charts were used to analyze the effect of interventions on outcome. Balancing measures included use of breast milk at discharge, use of mechanical ventilation after initial resuscitation, and bronchopulmonary dysplasia. RESULTS A total of 240 infants were assessed preintervention, and 185 during interventions. Adherence to the IVHPB improved from 24% to 88%. During this period, the incidence of severe IVH decreased from 9.8% to 2.4%, a 76% reduction from baseline. A higher adherence score was associated with reduced odds of IVH (odds ratio 0.30; 95% confidence interval 0.10-0.90, P = .03). CONCLUSIONS Interventions focused on enhancing adherence to an IVHPB were associated with a reduced rate of severe IVH in high-risk neonates, highlighting the importance of assessing adherence to clinical guidelines.
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Affiliation(s)
- Sarah E Kolnik
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Kirtikumar Upadhyay
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Thomas R Wood
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington
- Center on Human Development and Disability, University of Washington, Seattle, Washington
| | - Sandra E Juul
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington
- Center on Human Development and Disability, University of Washington, Seattle, Washington
| | - Gregory C Valentine
- Division of Neonatology, University of Washington/Seattle Children's Hospital, Seattle, Washington
- Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, Texas
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Giesinger RE, Rios DR, Chatmethakul T, Bischoff AR, Sandgren JA, Cunningham A, Beauchene M, Stanford AH, Klein JM, Ten Eyck P, McNamara PJ. Impact of Early Hemodynamic Screening on Extremely Preterm Outcomes in a High-Performance Center. Am J Respir Crit Care Med 2023; 208:290-300. [PMID: 37209133 PMCID: PMC10395724 DOI: 10.1164/rccm.202212-2291oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/18/2023] [Indexed: 05/22/2023] Open
Abstract
Rationale: Increasing survival of extremely preterm infants with a stable rate of severe intraventricular hemorrhage represents a growing health risk for neonates. Objectives: To evaluate the role of early hemodynamic screening (HS) on the risk of death or severe intraventricular hemorrhage. Methods: All eligible patients 22-26+6 weeks' gestation born and/or admitted <24 hours postnatal age were included. As compared with standard neonatal care for control subjects (January 2010-December 2017), patients admitted in the second epoch (October 2018-April 2022) were exposed to HS using targeted neonatal echocardiography at 12-18 hours. Measurements and Main Results: A primary composite outcome of death or severe intraventricular hemorrhage was decided a priori using a 10% reduction in baseline rate to calculate sample size. A total of 423 control subjects and 191 screening patients were recruited with a mean gestation and birth weight of 24.7 ± 1.5 weeks and 699 ± 191 g, respectively. Infants born at 22-23 weeks represented 41% (n = 78) of the HS epoch versus 32% (n = 137) of the control subjects (P = 0.004). An increase in perinatal optimization (e.g., antepartum steroids) but with a decline in maternal health (e.g., increased obesity) was seen in the HS versus control epoch. A reduction in the primary outcome and each of severe intraventricular hemorrhage, death, death in the first postnatal week, necrotizing enterocolitis, and severe bronchopulmonary dysplasia was seen in the screening era. After adjustment for perinatal confounders and time, screening was independently associated with survival free of severe intraventricular hemorrhage (OR 2.09, 95% CI [1.19, 3.66]). Conclusions: Early HS and physiology-guided care may be an avenue to further improve neonatal outcomes; further evaluation is warranted.
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Affiliation(s)
| | | | - Trassanee Chatmethakul
- Department of Pediatrics
- Department of Pediatrics, University of Oklahoma, Oklahoma City, Oklahoma
| | | | | | | | | | | | | | | | - Patrick J. McNamara
- Department of Pediatrics
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa; and
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Ilves N, Pajusalu S, Kahre T, Laugesaar R, Šamarina U, Loorits D, Kool P, Ilves P. High Prevalence of Collagenopathies in Preterm- and Term-Born Children With Periventricular Venous Hemorrhagic Infarction. J Child Neurol 2023; 38:373-388. [PMID: 37427422 PMCID: PMC10467006 DOI: 10.1177/08830738231186233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/12/2023] [Accepted: 06/16/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate genetic risk factors in term-born children with antenatal periventricular hemorrhagic infarction (PVHI), presumed antenatal periventricular venous infarction and periventricular hemorrhagic infarction in preterm neonates. METHODS Genetic analysis and magnetic resonance imaging were performed in 85 children: term-born children (≥36 gestational weeks) with antenatal periventricular hemorrhagic infarction (n = 6) or presumed antenatal (n = 40) periventricular venous infarction and preterm children (<36 gestational weeks) with periventricular hemorrhagic infarction (n = 39). Genetic testing was performed using exome or large gene panel (n = 6700 genes) sequencing. RESULTS Pathogenic variants associated with stroke were found in 11 of 85 (12.9%) children with periventricular hemorrhagic infarction/periventricular venous infarction. Among the pathogenic variants, COL4A1/A2 and COL5A1 variants were found in 7 of 11 (63%) children. Additionally, 2 children had pathogenic variants associated with coagulopathy, whereas 2 other children had other variants associated with stroke. Children with collagenopathies had significantly more often bilateral multifocal stroke with severe white matter loss and diffuse hyperintensities in the white matter, moderate to severe hydrocephalus, moderate to severe decrease in size of the ipsilesional basal ganglia and thalamus compared to children with periventricular hemorrhagic infarction/periventricular venous infarction without genetic changes in the studied genes (P ≤ .01). Severe motor deficit and epilepsy developed more often in children with collagenopathies compared to children without genetic variants (P = .0013, odds ratio [OR] = 233, 95% confidence interval [CI]: 2.8-531; and P = .025, OR = 7.3, 95% CI: 1.3-41, respectively). CONCLUSIONS Children with periventricular hemorrhagic infarction/periventricular venous infarction have high prevalence of pathogenic variants in collagene genes (COL4A1/A2 and COL5A1). Genetic testing should be considered for all children with periventricular hemorrhagic infarction/periventricular venous infarction; COL4A1/A2 and COL5A1/A2 genes should be investigated first.
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Affiliation(s)
- Norman Ilves
- Radiology Clinic of Tartu University Hospital; Department of Radiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Sander Pajusalu
- Department of Laboratory Genetics, Genetics and Personalized Medicine Clinic, Tartu University Hospital, Tartu, Estonia
- Department of Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Tiina Kahre
- Department of Laboratory Genetics, Genetics and Personalized Medicine Clinic, Tartu University Hospital, Tartu, Estonia
- Department of Genetics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Rael Laugesaar
- Children's Clinic of Tartu University Hospital; Department of Pediatrics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Ustina Šamarina
- Genetics and Personalized Medicine Clinic of Tartu University Hospital, Tartu, Estonia
| | - Dagmar Loorits
- Department of Radiology, Radiology Clinic of Tartu University Hospital, Tartu, Estonia
| | - Pille Kool
- Department of Radiology, Radiology Clinic of Tartu University Hospital, Tartu, Estonia
| | - Pilvi Ilves
- Radiology Clinic of Tartu University Hospital; Department of Radiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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11
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Razak A, Patel W, Durrani NUR, Pullattayil AK. Interventions to Reduce Severe Brain Injury Risk in Preterm Neonates: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e237473. [PMID: 37052920 PMCID: PMC10102877 DOI: 10.1001/jamanetworkopen.2023.7473] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/23/2023] [Indexed: 04/14/2023] Open
Abstract
Importance Interventions to reduce severe brain injury risk are the prime focus in neonatal clinical trials. Objective To evaluate multiple perinatal interventions across clinical settings for reducing the risk of severe intraventricular hemorrhage (sIVH) and cystic periventricular leukomalacia (cPVL) in preterm neonates. Data Sources MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception until September 8, 2022, using prespecified search terms and no language restrictions. Study Selection Randomized clinical trials (RCTs) that evaluated perinatal interventions, chosen a priori, and reported 1 or more outcomes (sIVH, cPVL, and severe brain injury) were included. Data Extraction and Synthesis Two co-authors independently extracted the data, assessed the quality of the trials, and evaluated the certainty of the evidence using the Cochrane GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Fixed-effects pairwise meta-analysis was used for data synthesis. Main Outcomes and Measures The 3 prespecified outcomes were sIVH, cPVL, and severe brain injury. Results A total of 221 RCTs that assessed 44 perinatal interventions (6 antenatal, 6 delivery room, and 32 neonatal) were included. Meta-analysis showed with moderate certainty that antenatal corticosteroids were associated with small reduction in sIVH risk (risk ratio [RR], 0.54 [95% CI, 0.35-0.82]; absolute risk difference [ARD], -1% [95% CI, -2% to 0%]; number needed to treat [NNT], 80 [95% CI, 48-232]), whereas indomethacin prophylaxis was associated with moderate reduction in sIVH risk (RR, 0.64 [95% CI, 0.52-0.79]; ARD, -5% [95% CI, -8% to -3%]; NNT, 20 [95% CI, 13-39]). Similarly, the meta-analysis showed with low certainty that volume-targeted ventilation was associated with large reduction in risk of sIVH (RR, 0.51 [95% CI, 0.36-0.72]; ARD, -9% [95% CI, -13% to -5%]; NNT, 11 [95% CI, 7-23]). Additionally, early erythropoiesis-stimulating agents (RR, 0.68 [95% CI, 0.57-0.83]; ARD, -3% [95% CI, -4% to -1%]; NNT, 34 [95% CI, 22-67]) and prophylactic ethamsylate (RR, 0.68 [95% CI, 0.48-0.97]; ARD, -4% [95% CI, -7% to 0%]; NNT, 26 [95% CI, 13-372]) were associated with moderate reduction in sIVH risk (low certainty). The meta-analysis also showed with low certainty that compared with delayed cord clamping, umbilical cord milking was associated with a moderate increase in sIVH risk (RR, 1.82 [95% CI, 1.03-3.21]; ARD, 3% [95% CI, 0%-6%]; NNT, -30 [95% CI, -368 to -16]). Conclusions and Relevance Results of this study suggest that a few interventions, including antenatal corticosteroids and indomethacin prophylaxis, were associated with reduction in sIVH risk (moderate certainty), and volume-targeted ventilation, early erythropoiesis-stimulating agents, and prophylactic ethamsylate were associated with reduction in sIVH risk (low certainty) in preterm neonates. However, clinicians should carefully consider all of the critical factors that may affect applicability in these interventions, including certainty of the evidence, before applying them to clinical practice.
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Affiliation(s)
- Abdul Razak
- Department of Pediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, Victoria, Australia
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Waseemoddin Patel
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
| | - Naveed Ur Rehman Durrani
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
- Department of Pediatrics, Weill Cornell Medicine–Qatar, Doha, Qatar
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12
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Levy-Mendelovich S, Cohen O, Klang E, Kenet G. 50 Years of Pediatric Hemostasis: Knowledge, Diagnosis, and Treatment. Semin Thromb Hemost 2023; 49:217-224. [PMID: 36174607 DOI: 10.1055/s-0042-1756704] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Studies from the past 50 years have contributed to the expanding knowledge regarding developmental hemostasis. This is a dynamic process that begins in the fetal phase and is characterized by physiological variations in platelet counts and function, and concentrations of most coagulation factors and the native coagulation inhibitors in early life, as compared with adulthood. The developmental hemostasis studies since the 1980 to 1990s established the laboratory reference values for coagulation factors. It was only a decade or two later, that thromboelastography (TEG) or (rotational thromboelastometry [ROTEM]) as well as thrombin generation studies, provided special pediatric reference values along with the ability to evaluate clot formation and lysis. In addition, global whole blood-based clotting assays provided point of care guidance for proper transfusion support to children hospitalized in intensive care units or undergoing surgery. Although uncommon, thrombosis in children and neonates is gaining increasing recognition, typically as a secondary complication in sick children. Bleeding in children, and particularly intracerebral hemorrhage in newborns, still represent a therapeutic challenge. Notably, our review will outline the advancements in understanding developmental hemostasis and its manifestations, with respect to the pathophysiology of thrombosis and bleeding complications in young children. The changes of transfusion policy and approach to thrombophilia testing during the last decade will be mentioned. Subsequently, a brief summary of the data on anticoagulant treatments in pediatric patients will be presented. Finally, we will point out the 10 most cited articles in the field of pediatric and neonatal hemostasis.
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Affiliation(s)
- Sarina Levy-Mendelovich
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omri Cohen
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Klang
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
| | - Gili Kenet
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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13
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Zheng Z, Shen W, Tang LX, Zhang R, Cheng R, Wang SN, Chen DM, Chen C, Lin XZ. High-proportion breast milk feeding is associated with a reduction in the incidence of IVH in very preterm infants. Front Neurol 2023; 13:993985. [PMID: 36742049 PMCID: PMC9889932 DOI: 10.3389/fneur.2022.993985] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/19/2022] [Indexed: 01/19/2023] Open
Abstract
Objective To investigate the protective effect of high-proportion breast milk feeding (>50%) on intraventricular hemorrhage (IVH) in very preterm infants (VPIs). Methods This was a retrospective secondary analysis of a prospective multi-center study, which included 604 VPIs from six hospitals in eastern China between September 2019 and December 2020. The 604 VPIs were divided into two groups according to whether IVH occurred. High-proportion breast milk feeding was defined as breast milk accounting for 51-100% of the total feeding amount both within 7 days and throughout the hospitalization. The IVH grades and the rate of high-proportion breast milk feeding were analyzed. Furthermore, to explore the relationship between high-proportion breast milk feeding and IVH grading, the VPIs' general information, perinatal factors, growth, and nutritional status during hospitalization, and related complications were compared between the two groups. Results High-proportion breast milk feeding was reported in 63.41% of the VPIs. Furthermore, IVH grades I-II and III-IV were noted in 39.73% (240/604) and 1.66% (10/604) of the VPIs, respectively. Univariate analysis revealed that IVH occurrence in VPIs is influenced by perinatal factors, invasive respiratory therapy, high-proportion breast milk feeding, start feeding with breast milk, the cumulative amount of early parenteral nutrition, postnatal complications, physical growth, and other factors (P < 0.05). After adjustments for gestational age, birth weight, and possible influencing factors through binary logistic regression analysis, the results revealed that high-proportion breast milk feeding and and start feeding with breast milk were associated with a lower total incidence of IVH. Further stratification showed that high-proportion breast milk feeding was associated with a lower incidence of grade I-II IVH. Similarly, after adjusting for the same factors, breast milk feeding >50% in the 1st week was associated with a decreased incidence of total IVH and further stratification showed that it was associated with a lower incidence of grade I-II IVH. Conclusion High-proportion breast milk feeding and breast milk feeding more than 50% of total intake during the 1st week might be protective factors for IVH grade I-II in VPIs, which further verified the neuroprotective effect of breast milk. In clinical practice, the construction of breast milk banks should be strengthened, breast milk feeding should be encouraged in neonatal intensive care units, and efforts should be made to increase breast milk feeding rates to improve the outcomes of VPIs.
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Affiliation(s)
- Zhi Zheng
- Department of Neonatology, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China,Xiamen Key Laboratory of Perinatal-Neonatal Infection, Women and Children's Hospital, Xiamen, Fujian, China
| | - Wei Shen
- Department of Neonatology, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China,Xiamen Key Laboratory of Perinatal-Neonatal Infection, Women and Children's Hospital, Xiamen, Fujian, China,Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Li-Xia Tang
- Department of Neonatology, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China,Xiamen Key Laboratory of Perinatal-Neonatal Infection, Women and Children's Hospital, Xiamen, Fujian, China
| | - Rong Zhang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Rui Cheng
- Department of Neonatology, Children' Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - San-Nan Wang
- Department of Neonatology, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Dong-Mei Chen
- Department of Neonatology, Quanzhou Maternity and Children's Hospital, Quanzhou, Fujian, China
| | - Chao Chen
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China,*Correspondence: Chao Chen ✉
| | - Xin-Zhu Lin
- Department of Neonatology, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China,Xiamen Key Laboratory of Perinatal-Neonatal Infection, Women and Children's Hospital, Xiamen, Fujian, China,Xin-Zhu Lin ✉
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14
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Benlamri A, Murthy P, Zein H, Thomas S, Scott JN, Abou Mehrem A, Esser MJ, Lodha A, Noort J, Tang S, Metcalfe C, Kowal D, Irvine L, Scotland J, Leijser LM, Mohammad K. Neuroprotection care bundle implementation is associated with improved long-term neurodevelopmental outcomes in extremely premature infants. J Perinatol 2022; 42:1380-1384. [PMID: 35831577 DOI: 10.1038/s41372-022-01443-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/08/2022] [Accepted: 06/15/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To study the impact of an evidence-based neuroprotection care (NPC) bundle on long-term neurodevelopmental impairment (NDI) in infants born extremely premature. STUDY DESIGN An NPC bundle targeting predefined risk factors for acute brain injury in extremely preterm infants was implemented. We compared the incidence of composite outcome of death or severe neurodevelopmental impairment (sNDI) at 21 months adjusted age pre and post bundle implementation. RESULTS Adjusting for confounding factors, NPC bundle implementation associated with a significant reduction in death or sNDI (aOR, 0.34; 95% CI 0.17-0.68; P = 0.002), mortality (aOR, 0.31; 95% CI (0.12-0.79); P = 0.015), sNDI (aOR, 0.37; 95% CI: 0.12-0.94; P = 0.039), any motor, language, or cognitive composite score <70 (aOR, 0.48; 95% CI: 0.26-0.90; P = 0.021). CONCLUSION Implementation of NPC bundle targeting predefined risk factors is associated with a reduction in mortality or sNDI in extremely preterm infants.
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Affiliation(s)
- Amina Benlamri
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Prashanth Murthy
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Hussein Zein
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Sumesh Thomas
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - James N Scott
- Department of Diagnostic Imaging, Division of Neuroradiology, University of Calgary, Calgary, AB, Canada
| | - Ayman Abou Mehrem
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Michael J Esser
- Department of Pediatrics, Section of Neurology, University of Calgary, Calgary, AB, Canada
| | - Abhay Lodha
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Jennessa Noort
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Selphee Tang
- Department of Obstetrics and Gynecology, Alberta Health Services, Calgary, AB, Canada
| | - Cathy Metcalfe
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Derek Kowal
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Leigh Irvine
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Jillian Scotland
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Lara M Leijser
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada.
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15
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Andersson NG, Kenet G. Intracranial Hemorrhages in Neonates: Incidence, Risk Factors and Treatment. Semin Thromb Hemost 2022; 49:409-415. [PMID: 36108647 DOI: 10.1055/s-0042-1756195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractHemostasis is a dynamic process that starts in utero. Neonates, especially those who are born preterm, are at high risk of bleeding. The coagulation system evolves with age, and the decreased levels of coagulation factors along with hypo-reactive platelets are counterbalanced with increased activity of von Willebrand factor, high hematocrit and mean corpuscular volume as well as low levels of coagulation inhibitors that promote hemostasis. Neonates with congenital bleeding disorders such as hemophilia are at even higher risk of bleeding complications. This review will focus upon one of the most devastating complications associated with neonatal bleeding: intracranial hemorrhages (ICH). While etiology may be multifactorial and impacted by maternal as well as fetal risk factors, the mode of delivery certainly plays an important role in the pathogenesis of ICH. We will address prematurity and congenital bleeding disorders such as hemophilia A and B and other rare bleeding disorders as risk factors and present an updated approach for treatment and possible prevention.
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Affiliation(s)
- Nadine G. Andersson
- Center for Thrombosis and Hemostasis and Department of Pediatric Hematology and Oncology, Skåne University Hospital, Malmö/Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Gili Kenet
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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16
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Song J, Nilsson G, Xu Y, Zelco A, Rocha-Ferreira E, Wang Y, Zhang X, Zhang S, Ek J, Hagberg H, Zhu C, Wang X. Temporal brain transcriptome analysis reveals key pathological events after germinal matrix hemorrhage in neonatal rats. J Cereb Blood Flow Metab 2022; 42:1632-1649. [PMID: 35491813 PMCID: PMC9441725 DOI: 10.1177/0271678x221098811] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Germinal matrix hemorrhage (GMH) is a common complication in preterm infants and is associated with high risk of adverse neurodevelopmental outcomes. We used a rat GMH model and performed RNA sequencing to investigate the signaling pathways and biological processes following hemorrhage. GMH induced brain injury characterized by early hematoma and subsequent tissue loss. At 6 hours after GMH, gene expression indicated an increase in mitochondrial activity such as ATP metabolism and oxidative phosphorylation along with upregulation of cytoprotective pathways and heme metabolism. At 24 hours after GMH, the expression pattern suggested an increase in cell cycle progression and downregulation of neurodevelopmental-related pathways. At 72 hours after GMH, there was an increase in genes related to inflammation and an upregulation of ferroptosis. Hemoglobin components and genes related to heme metabolism and ferroptosis such as Hmox1, Alox15, and Alas2 were among the most upregulated genes. We observed dysregulation of processes involved in development, mitochondrial function, cholesterol biosynthesis, and inflammation, all of which contribute to neurodevelopmental deterioration following GMH. This study is the first temporal transcriptome profile providing a comprehensive overview of the molecular mechanisms underlying brain injury following GMH, and it provides useful guidance in the search for therapeutic interventions.
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Affiliation(s)
- Juan Song
- Centre for Perinatal Medicine and Health, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China
| | - Gisela Nilsson
- Centre for Perinatal Medicine and Health, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Yiran Xu
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China
| | - Aura Zelco
- Centre for Perinatal Medicine and Health, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eridan Rocha-Ferreira
- Centre for Perinatal Medicine and Health, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Yafeng Wang
- Henan Provincial Key Laboratory of Children's Genetics and Metabolic Diseases, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Xiaoli Zhang
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China
| | - Shan Zhang
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Joakim Ek
- Centre for Perinatal Medicine and Health, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Hagberg
- Centre for Perinatal Medicine and Health, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Xiaoyang Wang
- Centre for Perinatal Medicine and Health, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China.,Centre for Perinatal Medicine and Health, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
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17
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Lai GY, Shlobin N, Garcia RM, Wescott A, Kulkarni AV, Drake J, Dizon ML, Lam SK. Global incidence proportion of intraventricular haemorrhage of prematurity: a meta-analysis of studies published 2010-2020. Arch Dis Child Fetal Neonatal Ed 2022; 107:513-519. [PMID: 34930831 DOI: 10.1136/archdischild-2021-322634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/25/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate differences and calculate pooled incidence of any intraventricular haemorrhage (IVH), severe IVH (Grade III/IV, sIVH) and ventriculoperitoneal shunt (VPS) placement in preterm infants across geographical, health and economic regions stratified by gestational age (GA). DESIGN MEDLINE, Embase, CINAHL and Web of Science were searched between 2010 and 2020. Studies reporting rates of preterm infants with any IVH, sIVH and VPS by GA subgroup were included. Meta-regression was performed to determine subgroup differences between study designs and across United Nations geographical regions, WHO mortality strata and World Bank lending regions. Incidence of any IVH, sIVH and VPS by GA subgroups<25, <28, 28-31, 32-33 and 34-36 weeks were calculated using random-effects meta-analysis. RESULTS Of 6273 publications, 97 met inclusion criteria. Incidence of any IVH (37 studies 87 993 patients) was: 44.7% (95% CI 40.9% to 48.5%) for GA <25 weeks, 34.3% (95% CI 31.2% to 37.6%) for GA <28 weeks, 17.4% (95% CI 13.8% to 21.6%) for GA 28-31 weeks, 11.3% (95% CI 7.3% to 17.0%) for GA32-33 weeks and 4.9% (95% CI 1.4% to 15.2%) for GA 34-36 weeks. Incidence of sIVH (49 studies 328 562 patients) was 23.7% (95% CI 20.9% to 26.7%) for GA <25 weeks, 15.0% (95% CI 13.1% to 17.2%) for GA <28 weeks, 4.6% (95% CI 3.5% to 6.1%) for GA 28-31 weeks, 3.3% (95% CI 2.1% to 5.1%) for GA 32-33 weeks and 1.8% (95% CI 1.2% to 2.8%) for GA 34-36 weeks. Europe had lower reported incidence of any IVH and sIVH relative to North America (p<0.05). Proportion of VPS across all GA groups was 8.4% (95% CI 4.7% to 14.7%) for any IVH and 17.2% (95% CI 12.2% to 26.2%) for sIVH. Heterogeneity was high (I2 >90%) but 64%-85% of the variance was explained by GA and study inclusion criteria. CONCLUSIONS We report the first pooled estimates of IVH of prematurity by GA subgroup. There was high heterogeneity across studies suggesting a need for standardised incidence reporting guidelines.
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Affiliation(s)
- Grace Y Lai
- Neurological Surgery, McGaw Medical Center of Northwestern University, Chicago, Illinois, USA
| | - Nathan Shlobin
- Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Roxanna M Garcia
- Neurological Surgery, McGaw Medical Center of Northwestern University, Chicago, Illinois, USA
| | - Annie Wescott
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Abhaya V Kulkarni
- University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Drake
- University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maria Lv Dizon
- Neonatology, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Sandi K Lam
- Neurological Surgery, McGaw Medical Center of Northwestern University, Chicago, Illinois, USA.,Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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18
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Ilves N, Laugesaar R, Rull K, Metsvaht T, Lintrop M, Laan M, Loorits D, Kool P, Ilves P. Maternal Pyelonephritis as a Potential Cause of Perinatal Periventricular Venous Infarction in Term-Born Children. J Child Neurol 2022; 37:677-688. [PMID: 35821576 DOI: 10.1177/08830738221109340] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: The study was designed to assess the prevalence of pregnancy and delivery associated risk factors in children suffering from neonatal or presumed periventricular venous infarction. Methods: Antenatal records and pregnancy outcome data were retrospectively assessed in children with presumed periventricular venous infarction (n = 43, born ≥36 gestational weeks) or neonatal periventricular venous infarction (n = 86, born <36 gestational weeks) and compared to a matched control group (n = 2168, ≥36 gestational weeks) from a prospective study. Results: Children with presumed periventricular venous infarction had significantly more maternal bacterial infections compared to the control group (47% vs 20%, respectively, P < .001), whereas no difference was found compared to the neonatal periventricular venous infarction group (49%, P = .80). Mothers with bacterial infection in the presumed periventricular venous infarction group had significantly more often pyelonephritis compared to the control group (50% vs 3.4%, respectively, P < .001). Conclusions: Our data show an increased risk for developing periventricular venous infarction in the case of maternal bacterial infections, especially between gestational weeks 21 and 31.
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Affiliation(s)
- Norman Ilves
- 37544Radiology Clinic of Tartu University Hospital; Department of Radiology, Institute of Clinical Medicine, 37546University of Tartu, Tartu, Estonia
| | - Rael Laugesaar
- 37544Children's Clinic of Tartu University Hospital; Department of Pediatrics, Institute of Clinical Medicine, 37546University of Tartu, Tartu, Estonia
| | - Kristiina Rull
- 37544Women's Clinic of Tartu University Hospital; Department of Gynecology, Institute of Clinical Medicine, Institute of Biomedicine and Translational Medicine; University of Tartu, Tartu, Estonia
| | - Tuuli Metsvaht
- 37544Anesthesiology and Intensive Care Clinic of Tartu University Hospital; Department of Pediatrics, Institute of Clinical Medicine, 37546University of Tartu, Tartu, Estonia
| | - Mare Lintrop
- 37544Radiology Clinic of Tartu University Hospital; Department of Radiology, Institute of Clinical Medicine, 37546University of Tartu, Tartu, Estonia
| | - Maris Laan
- Institute of Biomedicine and Translational Medicine; 37544University of Tartu, Tartu, Estonia
| | - Dagmar Loorits
- 37544Radiology Clinic of Tartu University Hospital, Tartu, Estonia
| | - Pille Kool
- Department of Radiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Pilvi Ilves
- 37544Radiology Clinic of Tartu University Hospital; Department of Radiology, Institute of Clinical Medicine, 37546University of Tartu, Tartu, Estonia
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de Figueiredo Vinagre LE, de Siqueira Caldas JP, Martins Marba ST, Procianoy RS, de Cássia Silveira R, Santiago Rego MA, de Lima Mota Ferreira DM, Sales Alves Junior JM, Dos Santos JPF, Gimenes CB, de Mello E Silva NM, Conde Gonzalez MR, da Silva RPGVC, do Amaral Gomez DBC, do Vale MS, de Souza Rugolo LMS, Meneguel Ogata JF, de Albuquerque Diniz EM, Luz JH, de Almeida JHCL, de Souza MPA, Goncalves Ferri WA. Temporal trends in intraventricular hemorrhage in preterm infants: A Brazilian multicenter cohort. Eur J Paediatr Neurol 2022; 39:65-73. [PMID: 35696888 DOI: 10.1016/j.ejpn.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/24/2022] [Accepted: 05/09/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) is a serious problem in preterm infants. Brazilian national data are unknown. OBJECTIVE To evaluate the incidence and temporal trend of IVH in very low birth weight (VLBW) preterm infants of 18 centers of the Brazilian Network on Neonatal Research. STUDY DESIGN National prospective multicenter cohort study including inborn VLBW preterm infants aged 230/7- 336/7 weeks' gestation, admitted between 2013 and 2018. The center with the mean incidence rate was used as reference. We applied two adjustments models using perinatal variables, and perinatal + neonatal diseases. RESULTS Of 6,420 infants, 1951/30.4% (range 27.1-33.8%) had IVH and the disease showed a significant trend towards an overall increase in incidence over time (p = 0.003), especially in three centers. Severe IVH (grade III or IV) occurred in 32.2% (range 29.2-34.5%) of those affected by IVH, with a stable incidence. After adjustments for perinatal variables, the differences persisted among centers: for global IVH, 7 centers had significantly lower rates (OR ranging from 0.31 to 0.62), and 2 presented rates higher than the reference center (OR ranging from 2.00 to 12.46) for severe HIV. Considering perinatal and neonatal variables, 6 centers had significantly lower rates (OR ranging from 0.36 to 0.60) for global IVH than the reference center and 3 had statistically higher rates (OR 1.72, 1.86 and 11.78) for severe forms. CONCLUSION The incidence rate of IVH in this Brazilian cohort was high and it revealed an increasing trend towards over time. The severe IVH rate was also worrisome.
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Affiliation(s)
- Luís Eduardo de Figueiredo Vinagre
- Womens' Hospital, State University of Campinas, Unicamp 101, Alexander Fleming St, Barao Geraldo, Campinas, Sao Paulo, Brazil 13083-881.
| | - Jamil Pedro de Siqueira Caldas
- Departament of Pediatrics, School of Medical Sciences, State University of Campinas - Unicamp, 60, Vital Brasil, St. Cidade Universitaria Zeferino Vaz, Campinas, Sao Paulo, Brazil 13083-888.
| | - Sergio Tadeu Martins Marba
- Departament of Pediatrics, School of Medical Sciences, State University of Campinas - Unicamp, 60, Vital Brasil, St. Cidade Universitaria Zeferino Vaz, Campinas, Sao Paulo, Brazil 13083-888.
| | - Renato Soibelmann Procianoy
- Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul, 2350, Ramiro Barcelos St. - Santa Cecília, Porto Alegre, Rio Grande do Sul, 90035-903, Brazil.
| | - Rita de Cássia Silveira
- Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul, 2350, Ramiro Barcelos St. - Santa Cecília, Porto Alegre, Rio Grande do Sul, 90035-903, Brazil.
| | - Maria Albertina Santiago Rego
- Department of Pediatrics, Faculty of Medicine, Federal University of Minas Gerais, 190, Prof. Alfredo Balena, Av. - Santa Efigenia, Belo Horizonte, Minas Gerais, 30130-100, Brazil.
| | | | - José Mariano Sales Alves Junior
- Departament of Pediatrics, Faculdade de Ciencias Medicas de Minas Gerais, 275, Ezequiel Dias St, - Centro, Belo Horizonte, Minas Gerais, 30130-110, Brazil.
| | - Juliana Paula Ferraz Dos Santos
- Neonatal Intensive Care Unit, Hospital Estadual de Sumare Dr. Leandro Francheschini, 2400, Amizade Av. - Jardim Bela Vista, Sumare, Sao Paulo, CEP 13175-490, Brazil.
| | - Carolina Boschi Gimenes
- Neonatal Intensive Care Unit, Hospital Geral de Pirajussara, 1214, Ibirama av. - Jardim Sao Judas Tadeu, Taboao da Serra, São Paulo, 06785-300, Brazil.
| | - Nathalia Moura de Mello E Silva
- Neonatal Intensive Care Unit, Hospital Estadual de Diadema, 1641, Jose Bonifacio St. - Serraria, Diadema, São Paulo, 09960-120, Brazil.
| | - Maria Rafaela Conde Gonzalez
- Department of Pediatrics, Hospital Universitario, Universidade Estadual de Londrina, Rodovia Celso Garcia Cid, PR-445, Km 380 - Campus Universitario, Londrina, Parana, 86057-970, Brazil.
| | | | - Dafne Barcala Coutinho do Amaral Gomez
- Neonatal Intensive Care Unit, Instituto de Medicina Integral Professor Fernando Figueira - lMIP, 300, Coelhos St, - Boa Vista, Recife, Pernambuco, 50070-550, Brazil.
| | - Marynea Silva do Vale
- Hospital Universitario da Universidade Federal do Maranhao, 227, Barao de Itapari St, - Centro, Sao Luís, Maranhao, 65020-070, Brazil.
| | - Lígia Maria Suppo de Souza Rugolo
- Departament of Pediatrics, Faculdade de Medicina de Botucatu da Universidade Estadual Paulista Julio de Mesquita Filho, Professor Mário Rubens Guimarães Montenegro St, UNESP Campus de Botucatu, Botucatu, Sao Paulo, 18618-687, Brazil.
| | - Joice Fabiola Meneguel Ogata
- Division of Neonatal Medicine, Department of Pediatrics at Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo. 740, Botucatu St. - Vila Clementino, Sao Paulo, São Paulo, 04023-062, Brazil.
| | - Edna Maria de Albuquerque Diniz
- Division of Neonatology, University of São Paulo, Hospital Universitário, 2565, Prof. Lineu Prestes Av. Butanta, Sao Paulo, Sao Paulo, 05508-000, Brazil.
| | - Jorge Hecker Luz
- Department of Pediatrics, Hospital São Lucas, Faculdade de Medicina da Pontifícia Universidade Catolica do Rio Grande do Sul, 6690, Ipiranga Av. - Jardim Botânico, Porto Alegre, Rio Grande do Sul, 90619-900, Brazil.
| | - Joao Henrique Carvalho Leme de Almeida
- Division of Neonatology, Instituto Nacional de Saude da Criança, Mulher e Adolescente Fernandes Figueira, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil. 716, Rui Barbosa Av., - Flamengo, Rio de Janeiro, Rio de Janeiro, 22250020, Brazil.
| | - Márcia Pereira Alves de Souza
- Neonatal Division, Hospital Pedro Ernesto, Universidade Estadual do Rio de Janeiro, 77, 28 de Setembro Blvd, - Vila Isabel, Rio de Janeiro, Rio de Janeiro, 20551-030, Brazil.
| | - Walusa Assad Goncalves Ferri
- Department of Pediatrics, Faculdade de Medicina de Ribeirão Preto, University of São Paulo. 3900, Bandeirantes Av. - Campus da USP, Ribeirao Preto, São Paulo, 14049-900, Brazil.
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Abstract
Advances in perinatal care have seen substantial improvements in survival without disability for extremely preterm infants. Protecting the developing brain and reducing neurodevelopmental sequelae of extremely preterm birth are strategic priorities for both research and clinical care. A number of evidence-based interventions exist for neuroprotection in micropreemies, inclusive of prevention of preterm birth and multiple births with implantation of only one embryo during in vitro fertilisation, as well as antenatal care to optimize fetal wellbeing, strategies for supporting neonatal transition, and neuroprotective developmental care. Avoidance of complications that trigger ischemia and inflammation is vital for minimizing brain dysmaturation and injury, particularly of the white matter. Neurodevelopmental surveillance, early diagnosis of cerebral palsy and early intervention are essential for optimizing long-term outcomes and quality of life. Research priorities include further evaluation of putative neuroprotective agents, and investigation of common neonatal interventions in trials adequately powered to assess neurodevelopmental outcome.
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21
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Debay A, Patel S, Wintermark P, Claveau M, Olivier F, Beltempo M. Association of Delivery Room and Neonatal Intensive Care Unit Intubation, and Number of Tracheal Intubation Attempts with Death or Severe Neurological Injury among Preterm Infants. Am J Perinatol 2022; 39:776-785. [PMID: 33075843 DOI: 10.1055/s-0040-1718577] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The study aimed to assess the association of tracheal intubation (TI) and where it is performed, and the number of TI attempts with death and/or severe neurological injury (SNI) among preterm infants. STUDY DESIGN Retrospective cohort study of infants born 23 to 32 weeks, admitted to a single level-3 neonatal intensive care unit (NICU) between 2015 and 2018. Exposures were location of TI (delivery room [DR] vs. NICU) and number of TI attempts (1 vs. >1). Primary outcome was death and/or SNI (intraventricular hemorrhage grade 3-4 and/or periventricular leukomalacia). Multivariable logistic regression analysis was used to assess association between exposures and outcomes and to adjust for confounders. RESULTS Rate of death and/or SNI was 2.5% (6/240) among infants never intubated, 12% (13/105) among NICU TI, 32% (31/97) among DR TI, 20% (17/85) among infants with one TI attempt and 23% (27/117) among infants with >1 TI attempt. Overall, median number of TI attempts was 1 (interquartile range [IQR]: 1-2). Compared with no TI, DR TI (adjusted odds ratio [AOR]: 9.04, 95% confidence interval [CI]: 3.21-28.84) and NICU TI (AOR: 3.42, 95% CI: 1.21-10.61) were associated with higher odds of death and/or SNI. The DR TI was associated with higher odds of death and/or SNI compared with NICU TI (AOR: 2.64, 95% CI: 1.17-6.22). The number of intubation attempts (1 vs. >1) was not associated with death and/or SNI (AOR: 0.95, 95% CI: 0.47-2.03). CONCLUSION The DR TI is associated with higher odds of death and/or SNI compared with NICU TI, and may help identify higher risk infants. There was no association between the number of TI attempts and death and/or SNI. KEY POINTS · Delivery room intubation correlates with morbidity.. · Less than 2 intubation attempts are not associated with IVH.. · Provider training reduces intubation attempts..
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Affiliation(s)
- Anthony Debay
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Sharina Patel
- McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | - Pia Wintermark
- McGill University Health Center Research Institute, Montreal, Quebec, Canada.,Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - Martine Claveau
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - François Olivier
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - Marc Beltempo
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
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22
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Kramer KP, Minot K, Butler C, Haynes K, Mason A, Nguyen L, Wynn S, Liebowitz M, Rogers EE. Reduction of Severe Intraventricular Hemorrhage in Preterm Infants: A Quality Improvement Project. Pediatrics 2022; 149:184903. [PMID: 35229127 DOI: 10.1542/peds.2021-050652] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The aim of this quality improvement project was to reduce the rate of severe intraventricular hemorrhage (sIVH) by 50% within 3 years for extremely preterm infants born at a children's teaching hospital. METHODS A multidisciplinary team developed key drivers for the development of intraventricular hemorrhage in preterm infants. Targeted interventions included the development of potentially better practice guidelines, promoting early noninvasive ventilation, consistent use of rescue antenatal betamethasone, and risk-based indomethacin prophylaxis. The outcome measure was the rate of sIVH. Process measures included the rate of intubation within 24 hours and receipt of rescue betamethasone and risk-based indomethacin prophylaxis. Common markers of morbidity were balancing measures. Data were collected from a quarterly chart review and analyzed with statistical process control charts. The preintervention period was from January 2012 to March 2016, implementation period was from April 2016 to December 2018, and sustainment period was through June 2020. RESULTS During the study period, there were 268 inborn neonates born at <28 weeks' gestation or <1000 g (127 preintervention and 141 postintervention). The rate of sIVH decreased from 14% to 1.2%, with sustained improvement over 2 and a half years. Mortality also decreased by 50% during the same time period. This was associated with adherence to process measures and no change in balancing measures. CONCLUSIONS A multipronged quality improvement approach to intraventricular hemorrhage prevention, including evidence-based practice guidelines, consistent receipt of rescue betamethasone and indomethacin prophylaxis, and decreasing early intubation was associated with a sustained reduction in sIVH in extremely preterm infants.
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Affiliation(s)
- Katelin P Kramer
- Department of Pediatrics, University of California, San Francisco, San Francisco, California.,University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Kacy Minot
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Colleen Butler
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Kathryn Haynes
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Amber Mason
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Lan Nguyen
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Samantha Wynn
- University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Melissa Liebowitz
- Department of Pediatrics, University of California, San Francisco, San Francisco, California.,University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California, San Francisco, San Francisco, California.,University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
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23
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Kirlangic MM, Sahin E, Madendag Y, Vural Yalman M, Akdemir E, Eraslan Sahin M, Col Madendag I, Acmaz G. The role of the brain-sparing effect of growth-restricted fetuses in newborn germinal matrix/intraventricular hemorrhage. J Perinat Med 2022; 50:93-99. [PMID: 34284527 DOI: 10.1515/jpm-2021-0142] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/23/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate the effect of the brain-sparing effect (BSE) of fetal growth restriction (FGR) in newborn germinal matrix/intraventricular hemorrhage (GM/IVH). METHODS A total of 320 patients who delivered prior to the 34th gestational week were analyzed from data records. 201 patients were divided into two groups according to cerebro-placental ratio (CPR): early fetal growth restriction (FGR) with abnormal CPR group (n=104) and appropriate for gestational age with normal Doppler group (control) (n=97). Using the normal middle cerebral artery (MCA) Doppler as a reference, multivariate logistic regression analysis was used to assess the association between the BSE and the primary outcome. RESULTS The rate of Grade I-II germinal matrix/intraventricular hemorrhage (GM/IVH) was 31(29.8%) in the group possessing early FGR with abnormal CPR and 7(7.2%) in the control group, showing a statistically significant difference. The rate of grade III-IV GM/IVH was 7(6.7%) in the group possessing early FGR with abnormal CPR and 2 (2.1%) in the control group, showing no statistically significant difference. We found that gestational age at delivery <32 weeks was an independent risk factor for GM/IVH. In addition, we found that other variables such as the presence of preeclampsia, fetal weight percentile <10, emergency CS delivery, 48-h completion after the first steroid administration and 24-h completion rate after MgSO4 administration were not independently associated with the primary outcome. CONCLUSIONS Our results indicate that the rate of GM-IVH was increased in the group possessing early FGR with abnormal CPR; however, multivariate logistic regression analysis showed that BSE was not an independent risk factor for GM/IVH.
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Affiliation(s)
- Mehmet Mete Kirlangic
- Department of Obstetrics and Gynecology, Tuzla Government Hospital, Istanbul, Turkey
| | - Erdem Sahin
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Yusuf Madendag
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Merve Vural Yalman
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Esra Akdemir
- Department of Obstetrics and Gynecology, Kayseri City Hospital, Kayseri, Turkey
| | | | - Ilknur Col Madendag
- Department of Obstetrics and Gynecology, Kayseri City Hospital, Kayseri, Turkey
| | - Gokhan Acmaz
- Department of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
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24
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Differential age-dependent development of inter-area brain connectivity in term and preterm neonates. Pediatr Res 2022; 92:1017-1025. [PMID: 35094022 PMCID: PMC9586860 DOI: 10.1038/s41390-022-01939-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Among preterm infants, higher morbidities of neurological disturbances and developmental delays are critical issues. Resting-state networks (RSNs) in the brain are suitable measures for assessing higher-level neurocognition. Since investigating task-related brain activity is difficult in neonates, assessment of RSNs provides invaluable insight into their neurocognitive development. METHODS The participants, 32 term and 71 preterm neonates, were divided into three groups based on gestational age (GA) at birth. Cerebral hemodynamic activity of RSNs was measured using functional near-infrared spectroscopy in the temporal, frontal, and parietal regions. RESULTS High-GA preterm infants (GA ≥ 30 weeks) had a significantly stronger RSN than low-GA preterm infants and term infants. Regression analyses of RSNs as a function of postnatal age (PNA) revealed a steeper regression line in the high-GA preterm and term infants than in the low-GA infants, particularly for inter-area brain connectivity between the frontal and left temporal areas. CONCLUSIONS Slower PNA-dependent development of the frontal-temporal network found only in the low-GA group suggests that significant brain growth optimal in the intrauterine environment takes place before 30 weeks of gestation. The present study suggests a likely reason for the high incidence of neurodevelopmental impairment in early preterm infants. IMPACT Resting-state fNIRS measurements in three neonate groups differing in gestational age (GA) showed stronger networks in the high-GA preterm infants than in the term and low-GA infants, which was partly explained by postnatal age (PNA). Regression analyses revealed a similar PNA-dependence in the development of the inter-area networks in the frontal and temporal lobes in the high-GA and term infants, and significantly slower development in the low-GA infants. These results suggest that optimal intrauterine brain growth takes place before 30 weeks of gestation. This explains one of the reasons for the high incidence of neurodevelopmental impairment in early preterm infants.
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25
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Characterization of germinal matrix hemorrhage in extremely premature infants: recognition of posterior location and diagnostic pitfalls. Pediatr Radiol 2022; 52:75-84. [PMID: 34528114 DOI: 10.1007/s00247-021-05189-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/12/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Traditionally, descriptions of germinal matrix hemorrhage (GMH), derived from observations in preterm and very preterm infants, indicate its location at the caudothalamic grooves. However, before the germinal matrix begins to recede at approximately 28 weeks' gestational age (GA), it extends along the floor of the lateral ventricles far posterior to the caudothalamic grooves. Germinal matrix-intraventricular hemorrhage (GMH-IVH) can occur along any site from which the germinal matrix has not yet involuted. Therefore, as current advances in neonatology have allowed the routine survival of extremely preterm infants as young as 23 weeks' GA, postnatal GMH-IVH can occur in previously undescribed locations. Hemorrhage in the more posterior GMH on head ultrasound, if unrecognized, may lead to errors in diagnosis and mislocalization of this injury to the periventricular white matter or lateral walls of the lateral ventricles instead of to the subependyma, where it is in fact located. OBJECTIVE Our aim is to describe posterior GMH in extremely premature infants, including its characteristic imaging appearance and potential pitfalls in diagnosis. MATERIALS AND METHODS Over a 5-year period, all consecutive extremely preterm infants of 27 weeks' GA or less who developed GMH-IVH of any grade were included. A consecutive group of 100 very preterm infants of 31 weeks' GA with a GMH-IVH of any grade served as controls. RESULTS In 106 extremely preterm neonates (mean GA: 25 weeks, range: 23.1-26.6 weeks) with 212 potential lateral ventricular germinal matrix bleeding sites, 159 sites had bleeds. In 70/159 (44%), the GMH-IVH was located posterior to the caudothalamic grooves and the foramina of Monro, 52 (32.7%) were both anterior and posterior and 21 (13.2%) were exclusively anterior. In 16 ventricles with intraventricular hemorrhage, an origin site in the germinal matrix could not be determined. In the control population of very preterm infants, all hemorrhages were at the anterior caudothalamic grooves and 95% were grade I. CONCLUSION Unlike the older very preterm and moderately preterm infants that form the basis of our GMH-IVH description and classification, the extremely preterm infants now routinely surviving have a more fetal pattern of germinal matrix distribution, which is reflected in a different distribution and size of germinal matrix injury. We report the postnatal occurrence of subependymal GMH-IVH in extremely preterm infants in these more primitive, posterior locations, its potential imaging pitfalls and sonographic findings.
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26
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Piccolo B, Marchignoli M, Pisani F. Intraventricular hemorrhage in preterm newborn: Predictors of mortality. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022041. [PMID: 35546030 PMCID: PMC9171888 DOI: 10.23750/abm.v93i2.11187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/12/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND AND AIM Intraventricular haemorrhage (IVH) is a cause of morbidity and mortality in preterm infants. It occurs primarily in preterm newborns with an incidence of about 20% and, despite the evolution of neonatal care that allows more and better survival, continues to be a cause of morbidity and mortality in all intensive care units. Our research aimed to evaluate the independent risk factors of mortality and the relative odds ratio for each degree of IVH. METHODS In this retrospective study were included 96 preterm infants, born between 23^ and 36^ weeks of gestational age, which developed IVH of degree two-three-four diagnosed by means of cranial ultrasound. It was made a comparison within the sample by distinguishing the group with IVH degree two from degrees three and four. RESULTS IVH of degree three and four was independently associated with mortality. We found a higher number of deaths in the GAs <= 26 weeks (p <0.01), which was also an independent predictor of mortality. CONCLUSION With this study it was further highlighted the high mortality of patients with an elevated degrees of IVH and low birth weight and early gestational age. These data, of important clinical relevance, oblige us to find new therapeutic strategies aimed at reducing the serious consequences of that disease.
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Affiliation(s)
- Benedetta Piccolo
- Child Neuropsychiatry, Mother and Child Department, University Hospital of Parma, Parma, Italy
| | - Mariacristina Marchignoli
- Child Neuropsychiatry, Dipartimento Assistenziale Integrato Salute Mentale Dipendenze Patologiche, Fidenza, Parma, Italy
| | - Francesco Pisani
- Child Neuropsychiatry, Department of Medicine and Surgery, University of Parma, Parma, Italy
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27
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Law JB, Wood TR, Gogcu S, Comstock BA, Dighe M, Perez K, Puia-Dumitrescu M, Mayock DE, Heagerty PJ, Juul SE. Intracranial Hemorrhage and 2-Year Neurodevelopmental Outcomes in Infants Born Extremely Preterm. J Pediatr 2021; 238:124-134.e10. [PMID: 34217769 PMCID: PMC8551011 DOI: 10.1016/j.jpeds.2021.06.071] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/26/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To determine the incidence, timing, progression, and risk factors for intracranial hemorrhage (ICH) in infants 240/7 to 276/7 weeks of gestational age and to characterize the association between ICH and death or neurodevelopmental impairment (NDI) at 2 years of corrected age. STUDY DESIGN Infants enrolled in the Preterm Erythropoietin Neuroprotection Trial had serial cranial ultrasound scans performed on day 1, day 7-9, and 36 weeks of postmenstrual age to evaluate ICH. Potential risk factors for development of ICH were examined. Outcomes included death or severe NDI as well as Bayley Scales of Infant and Toddler Development, 3rd Edition, at 2 years of corrected age. RESULTS ICH was identified in 38% (n = 339) of 883 enrolled infants. Multiple gestation and cesarean delivery reduced the risk of any ICH on day 1. Risk factors for development of bilateral Grade 2, Grade 3, or Grade 4 ICH at day 7-9 included any ICH at day 1; 2 or more doses of prenatal steroids decreased risk. Bilateral Grade 2, Grade 3, or Grade 4 ICH at 36 weeks were associated with previous ICH at day 7-9. Bilateral Grade 2, any Grade 3, and any Grade 4 ICH at 7-9 days or 36 weeks of postmenstrual age were associated with increased risk of death or severe NDI and lower Bayley Scales of Infant and Toddler Development, 3rd Edition, scores. CONCLUSIONS Risk factors for ICH varied by timing of bleed. Bilateral and increasing grade of ICH were associated with death or NDI in infants born extremely preterm.
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Affiliation(s)
- Janessa B Law
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
| | - Thomas R. Wood
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
| | - Semsa Gogcu
- Division of Neonatology, Department of Pediatrics, Wake
Forest School of Medicine, NC
| | | | - Manjiri Dighe
- Department of Radiology, University of Washington, Seattle,
WA
| | - Krystle Perez
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
| | | | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
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Abstract
There are many neuro-imaging studies on the presence of brain lesions in the preterm infant, using cranial ultrasound (cUS) and/or term equivalent age MRI (TEA-MRI). These studies however tend to focus on germinal matrix-intraventricular hemorrhage (GMH-IVH) and white matter injury. Data about perinatal arterial ischemic stroke (PAIS) or cerebral sinovenous thrombosis (CSVT) in the preterm infant are very limited. In fact, several large cohort studies on neuro-imaging in preterm infants do not even mention neonatal stroke.1-4 Most studies about PAIS exclude preterm infants.5 The aim of this review was to provide an update on neonatal stroke in the preterm infant, with a focus on neuro-imaging findings.
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Çelik E, Öztürk A. Evaluation of the Mortality and Morbidity of Premature Infants During a Five-Year Period in the Neonatal Intensive Care Unit. Cureus 2021; 13:e17790. [PMID: 34660001 PMCID: PMC8496339 DOI: 10.7759/cureus.17790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 11/05/2022] Open
Abstract
Background Premature birth is the most important cause of perinatal mortality and morbidity. This study aimed to evaluate mortality and morbidity in premature infants over a five-year period at a university hospital providing tertiary intensive care health services. Methodology All premature infants born alive at ≤37 gestational weeks and hospitalized in neonatal intensive care units were included in the study. Data such as maternal and perinatal characteristics, characteristics of the newborn, respiratory and related problems, neonatal morbidities, and causes of death were retrieved retrospectively from file records. Results A total of 1,780 patients (53.7% male and 46.3% female) were included in the study. High-risk pregnancy was present in 55% of women. Respiratory distress syndrome (RDS) developed in 50.4% of the patients, intracranial hemorrhage in 8.4%, and necrotizing enterocolitis in 5.6%. Mortality was observed in 20.9% of the patients. The most frequent cause of death was RDS and related complications (11.8%), and 66.4% of mortality occurred during the early neonatal period, that is, the first 24 hours of life. Conclusions High-risk pregnancies were significantly associated with neonatal morbidity and mortality. Therefore, the management of maternal health factors should be the priority for controlling neonatal mortality.
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Affiliation(s)
- Elif Çelik
- Department of Paediatrics, Adnan Menderes University, Aydın, TUR
| | - Adnan Öztürk
- Pediatrics and Neonatology, Erciyes University, Kayseri, TUR
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Çizmeci MN, Akın MA, Özek E. Turkish Neonatal Society Guideline on the Diagnosis and Management of Germinal Matrix Hemorrhage-Intraventricular Hemorrhage and Related Complications. Turk Arch Pediatr 2021; 56:499-512. [PMID: 35110121 PMCID: PMC8849013 DOI: 10.5152/turkarchpediatr.2021.21142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Germinal matrix hemorrhage-intraventricular hemorrhage (GMH-IVH) remains an important cause of brain injury in preterm infants, and is associated with high rates of mortality and adverse neurodevelopmental outcomes, despite the recent advances in perinatal care. Close neuroimaging is recommended for both the detection of GMH-IVH and for the follow-up of serious complications, such as post-hemorrhagic ventricular dilatation (PHVD). Although the question when best to treat PHVD remains a matter of debate, recent literature on this topic shows that later timing of interventions predicted higher rates of neurodevelopmental impairment, emphasizing the importance of a well-structured neuroimaging protocol and timely interventions. In this guideline, pathophysiologic mechanisms, preventive measures, and clinical presentations of GMH-IVH and PHVD will be presented, and a neuroimaging protocol as well as an optimal treatment approach will be proposed in light of the recent literature.
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Affiliation(s)
- Mehmet Nevzat Çizmeci
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Mustafa Ali Akın
- Division of Neonatology, Department of Pediatrics, Ondokuz Mayıs University, Samsun, Turkey
| | - Eren Özek
- Division of Neonatology, Department of Pediatrics, Marmara University, Istanbul, Turkey,Corresponding author:Eren Özek ✉
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Ma J, Tang S, Shen L, Chen L, Li X, Li W, Wu L, Shi Y. A randomized single-center controlled trial of synchronized intermittent mandatory ventilation with heliox in newborn infants with meconium aspiration syndrome. Pediatr Pulmonol 2021; 56:2087-2093. [PMID: 33831271 DOI: 10.1002/ppul.25390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 03/02/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This study aimed to investigate the beneficial effects of synchronized intermittent mandatory ventilation (SIMV) with heliox in newborn infants with meconium aspiration syndrome (MAS). METHODS Seventy-one newborn infants with MAS in the neonatal intensive care unit (NICU) of Daping Hospital of Army Medical University were enrolled in the trial. Infants treated with SIMV were randomized and divided into the heliox group (n = 35) and control group (n = 36). The heliox group received heliox for 6 h followed by air-oxygen mixed gas, and the control group received air-oxygen mixed gas. The primary outcome measures were PaO2 /FiO2 (P/F) and the extubation time. The secondary outcome measures were the incidence of mechanical ventilation complications, hospital length of stay in the NICU, blood gas analysis, and inflammation markers. RESULTS The P/F in the heliox group was significantly better than that in the control group (p < .001). The extubation time and hospital length of stay in the NICU in the heliox group were shorter than those in the control group (p < .001). The inflammation markers at 6 h and myocardial injury markers at 24 h were decreased compared with those at 0 h, and those in the heliox group were more significantly decreased than those in the control group ([interleukin {IL}-6/IL-8/tumor necrosis factor α] p < .001, [C-reaction protein] p = .012; [creatine kinase] p < .001, [CK-MB] p = .041). CONCLUSION Heliox appears to be more effective in reducing the length of ventilation and increasing carbon dioxide eliminations than an air-oxygen mixture in infants with MAS under the support of SIMV.
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Affiliation(s)
- Juan Ma
- Department of Pediatrics, North-Kuanren General Hospital, Chongqing, China.,Department of Pediatrics, Daping Hospital, Army Medical University, Chongqing, China
| | - Shifang Tang
- Department of Pediatrics, North-Kuanren General Hospital, Chongqing, China
| | - Leilei Shen
- Department of Pediatrics, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Long Chen
- Department of Neonatology, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xue Li
- Department of Pediatrics, Daping Hospital, Army Medical University, Chongqing, China
| | - Wanwei Li
- Department of Pediatrics, Daping Hospital, Army Medical University, Chongqing, China
| | - Li Wu
- Department of Pediatrics, Daping Hospital, Army Medical University, Chongqing, China
| | - Yuan Shi
- Department of Neonatology, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
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Daigneault J, White H, Dube A, Shi Q, Gauguet JM, Rhein L. Lack of Progression of Intraventricular Hemorrhage in Premature Infants: Implications for Head Ultrasound Screening. Glob Pediatr Health 2021; 8:2333794X211010729. [PMID: 34046517 PMCID: PMC8138291 DOI: 10.1177/2333794x211010729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 03/17/2021] [Accepted: 03/25/2021] [Indexed: 11/21/2022] Open
Abstract
Very preterm infants are at risk for germinal matrix hemorrhage- intraventricular
hemorrhage (GH-IVH). Severe GH-IVH may cause death or severe neurodevelopmental
disability while mild GH-IVH is considered a static, non-progressive disease.
This retrospective study aimed to determine if infants with no GH-IVH or mild
GH-IVH on initial screening head ultrasound (HUS) advanced to severe GH-IVH. A
total of 353 eligible infants with birth gestational age ≤32 0/7 weeks who
received a HUS during hospitalization were identified. Of the 343 (97%) infants
who had mild GH-IVH (grade II or less) on initial screening, only 4 (1.2%)
progressed to severe (grade III or IV). Each of these infants required
mechanical ventilation for at least 40 days. Therefore, premature infants who
have no GH-IVH or mild GH-IVH on initial routine screening HUS without other
risk factors may not require follow-up HUSs. Infants with prolonged mechanical
ventilation may require further screening despite reassuring initial HUS
findings.
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Affiliation(s)
| | - Heather White
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Alexandra Dube
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Qiming Shi
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Lawrence Rhein
- University of Massachusetts Medical School, Worcester, MA, USA
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Population Improvement Bias Observed in Estimates of the Impact of Antenatal Steroids to Outcomes in Preterm Birth. J Pediatr 2021; 232:17-22.e2. [PMID: 33275981 DOI: 10.1016/j.jpeds.2020.11.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/06/2020] [Accepted: 11/25/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the hypothesis that increasing rates and differential uptake of antenatal steroids would bias estimation of impact of antenatal steroids on neonatal death and severe (grade III-IV) intraventricular hemorrhage (IVH). STUDY DESIGN The study population included infants born between 24 and 28 weeks of gestational age in the California Perinatal Quality Care Collaborative. Outcomes were in-hospital mortality and severe IVH. Mixed multivariable logistic regression models estimated the effect of antenatal steroid exposure, one model accounting for individual risk factors as fixed effects, and a second model incorporating a predicted probability factor estimating overall risk status for each time period. RESULTS The study cohort included 28 252 infants. Antenatal steroid exposure increased from 80.1% in 2005 to 90.3% in 2016, severe IVH decreased from 14.5% to 9.0%, and mortality decreased from 12.8% to 9.1%. When stratified by group, 3-year observed outcomes improved significantly in infants exposed to antenatal steroids (12.5%-8.6% for IVH, 11.5%-8.8% for death) but not in those not exposed (20.7%-19.1% and 16.6%-15.5%, respectively). Women not receiving antenatal steroids had greater risk profile (such as no prenatal care) and greater predicted probability for severe IVH and mortality. Both outcomes exhibited little change (P > .05) over time for the group without antenatal steroids. In contrast, in women receiving antenatal steroids, observed and adjusted rates for both outcomes decreased (P < .0001). CONCLUSIONS As the population's proportion of antenatal steroid use increased, the observed positive effect of antenatal steroids also increased. This apparent increase may be designated as the "population improvement bias."
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Yoon SJ, Lim J, Han JH, Shin JE, Eun HS, Park MS, Park KI, Lee SM. Impact of neonatal resuscitation changes on outcomes of very-low-birth-weight infants. Sci Rep 2021; 11:9003. [PMID: 33903706 PMCID: PMC8076314 DOI: 10.1038/s41598-021-88561-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 04/06/2021] [Indexed: 11/12/2022] Open
Abstract
The improvement of delivery room care, according to the 2015 International Consensus, may affect neonatal outcome, especially in very-low-birth-weight infants. We aimed to investigate the current practice of neonatal resuscitation by year and analyze the association with neonatal outcomes. A total of 8142 very-low-birth-weight infants, registered in the Korean Neonatal Network between 2014 and 2017 were included. A significant decreasing trend of intubation (64.5% vs 55.1%, P < 0.0001) and markedly increasing trend of positive pressure ventilation (PPV) (11.5% vs 22.9%, P < 0.0001) were noted. The annual PPV rate differed significantly by gestation (P < 0.0001). The highest level of resuscitation was also shown as an independent risk factor for mortality within 7 days and for bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and periventricular leukomalacia. PPV and intubation were associated with significantly decreased risk of mortality and morbidities compared to epinephrine use. When considering association, the incidence of mortality within 7 days, IVH, PVL, and BPD or mortality showed significant differences by combination of year, gestational age, and level of resuscitation. According to updated guidelines, changes in the highest level of resuscitation significantly associated with reducing mortality and morbidities. More meticulous delivery room resuscitation focusing on extreme prematurity is needed.
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Affiliation(s)
- So Jin Yoon
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Joohee Lim
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Jung Ho Han
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Jeong Eun Shin
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Ho Seon Eun
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Min Soo Park
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Kook In Park
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea.
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Egesa WI, Odoch S, Odong RJ, Nakalema G, Asiimwe D, Ekuk E, Twesigemukama S, Turyasiima M, Lokengama RK, Waibi WM, Abdirashid S, Kajoba D, Kumbakulu PK. Germinal Matrix-Intraventricular Hemorrhage: A Tale of Preterm Infants. Int J Pediatr 2021; 2021:6622598. [PMID: 33815512 PMCID: PMC7987455 DOI: 10.1155/2021/6622598] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 02/26/2021] [Indexed: 12/15/2022] Open
Abstract
Germinal matrix-intraventricular hemorrhage (GM-IVH) is a common intracranial complication in preterm infants, especially those born before 32 weeks of gestation and very-low-birth-weight infants. Hemorrhage originates in the fragile capillary network of the subependymal germinal matrix of the developing brain and may disrupt the ependymal lining and progress into the lateral cerebral ventricle. GM-IVH is associated with increased mortality and abnormal neurodevelopmental outcomes such as posthemorrhagic hydrocephalus, cerebral palsy, epilepsy, severe cognitive impairment, and visual and hearing impairment. Most affected neonates are asymptomatic, and thus, diagnosis is usually made using real-time transfontanellar ultrasound. The present review provides a synopsis of the pathogenesis, grading, incidence, risk factors, and diagnosis of GM-IVH in preterm neonates. We explore brief literature related to outcomes, management interventions, and pharmacological and nonpharmacological prevention strategies for GM-IVH and posthemorrhagic hydrocephalus.
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Affiliation(s)
- Walufu Ivan Egesa
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - Simon Odoch
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - Richard Justin Odong
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - Gloria Nakalema
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - Daniel Asiimwe
- Department of Surgery, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - Eddymond Ekuk
- Department of Surgery, Faculty of Medicine, Mbarara University of Science and Technology, Uganda
| | - Sabinah Twesigemukama
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - Munanura Turyasiima
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - Rachel Kwambele Lokengama
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - William Mugowa Waibi
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - Said Abdirashid
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - Dickson Kajoba
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
| | - Patrick Kumbowi Kumbakulu
- Department of Paediatrics and Child Health, Faculty of Clinical Medicine and Dentistry, Kampala International University, Uganda
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Kusuda S, Bennett M, Gould J. Outcomes of Infants with Very Low Birth Weight Associated with Birthplace Difference: A Retrospective Cohort Study of Births in Japan and California. J Pediatr 2021; 229:182-190.e6. [PMID: 33058856 DOI: 10.1016/j.jpeds.2020.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/26/2020] [Accepted: 10/06/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine whether outcomes among infants with very low birth weight (VLBW) vary according to the birthplace (Japan or California) controlling for maternal ethnicity. STUDY DESIGN Severe intraventricular hemorrhage (IVH) and mortality were ascertained for infants with VLBW born at 24-29 weeks of gestation during 2008-2017 and retrospectively analyzed by the country of birth for mothers and infants (Japan or California). RESULTS Rates of severe IVH, mortality, or combined IVH/mortality were lower in the 24 095 infants born in Japan (5.1%, 5.0%, 8.8% respectively) compared with infants born in California either to 157 mothers with Japanese ethnicity (12.5%, 9.7%, 17.8%) or to a comparison group of 6173 non-Hispanic white mothers (8.4%, 8.8%, 14.6%). ORs for adverse outcomes were increased for infants born in California to mothers with Japanese ethnicity compared with infants born in Japan for severe IVH (OR, 3.31; 95% CI, 1.93-5.68), mortality (3.73; 95% CI, 2.03-6.86), and the combined outcome (3.26; 95% CI, 2.02-5.27). The odds of these outcomes also were increased for infants born in California to non-Hispanic white mothers compared with infants born in Japan. Outcomes of infants born in California did not differ by Japanese or non-Hispanic white maternal ethnicity. CONCLUSIONS Low rates of severe IVH and mortality for infants with VLBW born in Japan were not seen in infants born in California to mothers with Japanese ethnicity. Differences in systems of regional perinatal care, social environment, and the quality of perinatal care may partially account for these differences in outcomes.
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Affiliation(s)
- Satoshi Kusuda
- Department of Pediatrics, Kyorin University, Tokyo, Japan.
| | - Mihoko Bennett
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics Stanford University School of Medicine, CA
| | - Jeffrey Gould
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics Stanford University School of Medicine, CA
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Badawi N, Mcintyre S, Hunt RW. Perinatal care with a view to preventing cerebral palsy. Dev Med Child Neurol 2021; 63:156-161. [PMID: 33251607 PMCID: PMC7839537 DOI: 10.1111/dmcn.14754] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 01/02/2023]
Abstract
Birth prevalence of cerebral palsy (CP) is declining in high-income countries, to as low as 1.4 per 1000 live births in the most recent international reports. This represents a 35% reduction in birth prevalence over a 15-year period. This reduction is underpinned by a heightened focus of attention towards all aspects of CP, including: increased awareness, better data collection, development of national networks and registries, an explosion of research in basic science, perinatal care, neonatal neurology, public health, early detection, and targeted early intervention. Quick uptake of evidence into practice has ensued and overall improvements in clinical care occurred concurrently. It is anticipated that with continued partnerships with families, ongoing research driving further clinical improvement and vice versa, birth prevalence and severity of CP will further decline and the focus will shift to prevention in low- and middle-income countries. WHAT THIS PAPER ADDS: Research in the field of perinatal care and cerebral palsy (CP) prevention has increased significantly. In high-income countries, increased awareness of CP and scientific advances have improved clinical care. Population-based registers have limitations but remain the best mechanism to quantify birth prevalence of CP and accurately track trends. There have been recent reductions in the birth prevalence of CP.
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Affiliation(s)
- Nadia Badawi
- Grace Centre for Newborn CareChildren's Hospital at Westmead Sydney Children's Hospital NetworkSydneyNSWAustralia,Cerebral Palsy Alliance Research InstituteSpecialty of Child & Adolescent HealthSydney Medical SchoolFaculty of Medicine & HealthThe University of SydneySydneyNSWAustralia
| | - Sarah Mcintyre
- Cerebral Palsy Alliance Research InstituteSpecialty of Child & Adolescent HealthSydney Medical SchoolFaculty of Medicine & HealthThe University of SydneySydneyNSWAustralia
| | - Rod W Hunt
- Department of PaediatricsMonash UniversityMelbourneVICAustralia,Neonatal ResearchClinical SciencesMurdoch Children's Research InstituteMelbourneVICAustralia,Monash NewbornMonash HealthMelbourneVICAustralia
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38
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MacLeod R, Paulson JN, Okalany N, Okello F, Acom L, Ikiror J, Cowan FM, Tann CJ, Dyet LE, Hagmann CF, Burgoine K. Intraventricular haemorrhage in a Ugandan cohort of low birth weight neonates: the IVHU study. BMC Pediatr 2021; 21:12. [PMID: 33407279 PMCID: PMC7786968 DOI: 10.1186/s12887-020-02464-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/10/2020] [Indexed: 11/10/2022] Open
Abstract
Background Globally, 15 million neonates are born prematurely every year, over half in low income countries (LICs). Premature and low birth weight neonates have a higher risk of intraventricular haemorrhage (IVH). There are minimal data regarding IVH in sub-Saharan Africa. This study aimed to examine the incidence, severity and timing of and modifiable risk factors for IVH amongst low-birth-weight neonates in Uganda. Methods This is a prospective cohort study of neonates with birthweights of ≤2000 g admitted to a neonatal unit (NU) in a regional referral hospital in eastern Uganda. Maternal data were collected from interviews and medical records. Neonates had cranial ultrasound (cUS) scans on the day of recruitment and days 3, 7 and 28 after birth. Risk factors were tabulated and are presented alongside odds ratios (ORs) and adjusted odds ratios (aORs) for IVH incidence. Outcomes included incidence, timing and severity of IVH and 28-day survival. Results Overall, 120 neonates were recruited. IVH was reported in 34.2% of neonates; 19.2% had low grade (Papile grades 1–2) and 15% had high grade (Papile grades 3–4). Almost all IVH (90.2%) occurred by day 7, including 88.9% of high grade IVH. Of those with known outcomes, 70.4% (81/115) were alive on day 28 and survival was not associated with IVH. We found that vaginal delivery, gestational age (GA) < 32 weeks and resuscitation in the NU increased the odds of IVH. Of the 6 neonates who received 2 doses of antenatal steroids, none had IVH. Conclusion In this resource limited NU in eastern Uganda, more than a third of neonates born weighing ≤2000 g had an IVH and the majority of these occurred by day 7. We found that vaginal birth, earlier gestation and need for resuscitation after admission to the NU increased the risk of IVH. This study had a high rate of SGA neonates and the risk factors and relationship of these factors with IVH in this setting needs further investigation. The role of antenatal steroids in the prevention of IVH in LICs also needs urgent exploration. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-020-02464-4.
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Affiliation(s)
- R MacLeod
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda
| | - J N Paulson
- Department of Biostatistics, Product Development, Genentech, Inc., South San Francisco, California, USA
| | - N Okalany
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda
| | - F Okello
- Varimetrics Group Limited, P. O Box 2190, Mbale, Uganda
| | - L Acom
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda
| | - J Ikiror
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda
| | - F M Cowan
- Department of Paediatrics, Imperial College London, London, UK
| | - C J Tann
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK.,MRC/UVRI & LSHTM Uganda Research Unit, PO Box 149, Entebbe, Uganda.,Neonatal Medicine, University College London Hospitals NHS Trust, 235 Euston Road, London, UK
| | - L E Dyet
- Neonatal Medicine, University College London Hospitals NHS Trust, 235 Euston Road, London, UK
| | - C F Hagmann
- Department of Neonatology and Pediatric Intensive Care, Children's University Hospital of Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - K Burgoine
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda.
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Abstract
The neonatal hemostatic system is strikingly different from that of adults. Among other differences, neonates exhibit hyporeactive platelets and decreased levels of coagulation factors, the latter translating into prolonged clotting times (PT and PTT). Since pre-term neonates have a high incidence of bleeding, particularly intraventricular hemorrhages, neonatologists frequently administer blood products (i.e., platelets and FFP) to non-bleeding neonates with low platelet counts or prolonged clotting times in an attempt to overcome these "deficiencies" and reduce bleeding risk. However, it has become increasingly clear that both the platelet hyporeactivity as well as the decreased coagulation factor levels are effectively counteracted by other factors in neonatal blood that promote hemostasis (i.e., high levels of vWF, high hematocrit and MCV, reduced levels of natural anticoagulants), resulting in a well-balanced neonatal hemostatic system, perhaps slightly tilted toward a prothrombotic phenotype. While life-saving in the presence of active major bleeding, the administration of platelets and/or FFP to non-bleeding neonates based on laboratory tests has not only failed to decrease bleeding, but has been associated with increased neonatal morbidity and mortality in the case of platelets. In this review, we will present a clinical overview of bleeding in neonates (incidence, sites, risk factors), followed by a description of the key developmental differences between neonates and adults in primary and secondary hemostasis. Next, we will review the clinical tests available for the evaluation of bleeding neonates and their limitations in the context of the developmentally unique neonatal hemostatic system, and will discuss current and emerging approaches to more accurately predict, evaluate and treat bleeding in neonates.
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Affiliation(s)
- Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States
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Volpe J. Commentary – Severe IVH: Time for newer, earlier interventions to prevent brain injury? J Neonatal Perinatal Med 2020; 13:435-439. [PMID: 32925116 PMCID: PMC7836057 DOI: 10.3233/npm-200539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- J.J. Volpe
- Department of Neurology, Harvard Medical School, Boston, MA, USA
- Department of Pediatric Newborn Medicine, Harvard Medical School, Boston, MA, USA
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41
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Abstract
Neuroimaging of the preterm infant is a common assessment performed in the NICU. Timely and focused studies can be used for diagnostic, therapeutic, and prognostic information. However, significant variability exists among neonatal units as to which modalities are used and when imaging studies are obtained. Appropriate timing and selection of neuroimaging studies can help identify neonates with brain injury who may require therapeutic intervention or who may be at risk for neurodevelopmental impairment. This clinical report reviews the different modalities of imaging broadly available to the clinician. Evidence-based indications for each modality, optimal timing of examinations, and prognostic value are discussed.
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Affiliation(s)
- Ivan L Hand
- Department of Pediatrics, New York City Health + Hospitals/Kings County, State University of New York Downstate Medical Center, Brooklyn, New York;
| | - Renée A Shellhaas
- Pediatric Neurology Division, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan; and
| | - Sarah S Milla
- Departments of Radiology and Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
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42
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de Waal K, Kluckow M. Superior vena cava flow: Role, assessment and controversies in the management of perinatal perfusion. Semin Fetal Neonatal Med 2020; 25:101122. [PMID: 32467039 DOI: 10.1016/j.siny.2020.101122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The superior vena cava (SVC) is a large vein responsible for the venous return of blood from structures located superior to the diaphragm. The flow in the SVC can be assessed with Doppler ultrasound and can be used as a proxy for cerebral perfusion. Early clinical research studies showed that low SVC flow, particularly if for a prolonged period, was associated with short term morbidity such as intraventricular hemorrhage, mortality, and poorer neurodevelopmental outcomes. However, these findings have not been consistently reported in more recent studies, and the role of SVC flow in early management and as a predictor of poor long-term neurodevelopment has been questioned. This paper provides an overview of SVC assessment, the expected range of findings, and reviews the role of SVC flow as a diagnostic and monitoring tool for the assessment of perinatal perfusion.
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Affiliation(s)
- Koert de Waal
- John Hunter Children's Hospital Department of Neonatology and University of Newcastle, Newcastle, NSW, Australia.
| | - Martin Kluckow
- Royal North Shore Hospital Department of Neonatology and University of Sydney, Sydney, NSW, Australia
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43
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Kristiansson A, Gram M, Flygare J, Hansson SR, Åkerström B, Storry JR. The Role of α 1-Microglobulin (A1M) in Erythropoiesis and Erythrocyte Homeostasis-Therapeutic Opportunities in Hemolytic Conditions. Int J Mol Sci 2020; 21:ijms21197234. [PMID: 33008134 PMCID: PMC7582998 DOI: 10.3390/ijms21197234] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 02/06/2023] Open
Abstract
α1-microglobulin (A1M) is a small protein present in vertebrates including humans. It has several physiologically relevant properties, including binding of heme and radicals as well as enzymatic reduction, that are used in the protection of cells and tissue. Research has revealed that A1M can ameliorate heme and ROS-induced injuries in cell cultures, organs, explants and animal models. Recently, it was shown that A1M could reduce hemolysis in vitro, observed with several different types of insults and sources of RBCs. In addition, in a recently published study, it was observed that mice lacking A1M (A1M-KO) developed a macrocytic anemia phenotype. Altogether, this suggests that A1M may have a role in RBC development, stability and turnover. This opens up the possibility of utilizing A1M for therapeutic purposes in pathological conditions involving erythropoietic and hemolytic abnormalities. Here, we provide an overview of A1M and its potential therapeutic effect in the context of the following erythropoietic and hemolytic conditions: Diamond-Blackfan anemia (DBA), 5q-minus myelodysplastic syndrome (5q-MDS), blood transfusions (including storage), intraventricular hemorrhage (IVH), preeclampsia (PE) and atherosclerosis.
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Affiliation(s)
- Amanda Kristiansson
- Section for Infection Medicine, Department of Clinical Sciences, Lund University, 221 84 Lund, Sweden;
- Division of Hematology and Transfusion Medicine, Department of Laboratory Medicine, Lund University, 221 84 Lund, Sweden;
- Correspondence:
| | - Magnus Gram
- Department of Clinical Sciences Lund, Pediatrics, Lund University, 221 84 Lund, Sweden;
| | - Johan Flygare
- Department of Molecular Medicine and Gene Therapy, Lund Stem Cell Center, Lund University, 221 84 Lund, Sweden;
| | - Stefan R. Hansson
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences Lund, Lund University, 221 84 Lund, Sweden;
| | - Bo Åkerström
- Section for Infection Medicine, Department of Clinical Sciences, Lund University, 221 84 Lund, Sweden;
| | - Jill R. Storry
- Division of Hematology and Transfusion Medicine, Department of Laboratory Medicine, Lund University, 221 84 Lund, Sweden;
- Department of Clinical Immunology and Transfusion Medicine, Office of Medical Services, 221 85 Lund, Sweden
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44
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Murthy P, Zein H, Thomas S, Scott JN, Abou Mehrem A, Esser MJ, Lodha A, Metcalfe C, Kowal D, Irvine L, Scotland J, Leijser L, Mohammad K. Neuroprotection Care Bundle Implementation to Decrease Acute Brain Injury in Preterm Infants. Pediatr Neurol 2020; 110:42-48. [PMID: 32473764 DOI: 10.1016/j.pediatrneurol.2020.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND We assessed the impact of an evidence-based neuroprotection care bundle on the risk of brain injury in extremely preterm infants. METHODS We implemented a neuroprotection care bundle consisting of a combination of neuroprotection interventions such as minimal handling, midline head position, deferred cord clamping, and protocolization of hemodynamic and respiratory managements. These interventions targeted risk factors for acute brain injury in extremely preterm infants (born at gestational age less than 29 weeks) during the first three days of birth. Implementation occurred in a stepwise manner, including care bundle development by a multidisciplinary care team based on previous evidence and experience, standardization of outcome assessment tools, and education. We compared the incidence of the composite outcome of acute preterm brain injury or death preimplementation and postimplementation. RESULTS Neuroprotection care bundle implementation associated with a significant reduction in acute brain injury risk factors such as the use of inotropes (24% before, 7% after, P value < 0.001) and fluid boluses (37% before, 19% after, P value < 0.001), pneumothorax (5% before, 2% after, P value = 0.002), and opioid use (19% before, 7% after, P value < 0.001). Adjusting for confounding factors, the neuroprotection care bundle significantly reduced death or severe brain injury (adjusted odds ratio, 0.34; 95% confidence interval, 0.20 to 0.59; P value < 0.001) and severe brain injury (adjusted odds ratio, 0.31; 95% confidence interval, 0.17 to 0.58; P < 0.001). CONCLUSIONS Implementation of neuroprotection care bundle targeting predefined risk factors is feasible and effective in reducing acute brain injury in extremely preterm infants.
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Affiliation(s)
- Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Hussein Zein
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Sumesh Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - James N Scott
- Division of Neuroradiology, Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Ayman Abou Mehrem
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Esser
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Abhay Lodha
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Metcalfe
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Derek Kowal
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Leigh Irvine
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jillian Scotland
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Lara Leijser
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
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45
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Gluski J, Zajciw P, Hariharan P, Morgan A, Morales DM, Jea A, Whitehead W, Marupudi N, Ham S, Sood S, McAllister JP, Limbrick DD, Harris CA. Characterization of a multicenter pediatric-hydrocephalus shunt biobank. Fluids Barriers CNS 2020; 17:45. [PMID: 32682437 PMCID: PMC7368709 DOI: 10.1186/s12987-020-00211-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pediatric hydrocephalus is a devastating and costly disease. The mainstay of treatment is still surgical shunting of cerebrospinal fluid (CSF). These shunts fail at a high rate and impose a significant burden on patients, their families and society. The relationship between clinical decision making and shunt failure is poorly understood and multifaceted, but catheter occlusion remains the most frequent cause of shunt complications. In order to investigate factors that affect shunt failure, we have established the Wayne State University (WSU) shunt biobank. METHODS To date, four hospital centers have contributed various components of failed shunts and CSF from patients diagnosed with hydrocephalus before adulthood. The hardware samples are transported in paraformaldehyde and transferred to phosphate-buffered saline with sodium azide upon deposit into the biobank. Once in the bank, they are then available for study. Informed consent is obtained by the local center before corresponding clinical data are entered into a REDCap database. Data such as hydrocephalus etiology and details of shunt revision history. All data are entered under a coded identifier. RESULTS 293 shunt samples were collected from 228 pediatric patients starting from May 2015 to September 2019. We saw a significant difference in the number of revisions per patient between centers (Kruskal-Wallis H test, p value < 0.001). The leading etiology at all centers was post-hemorrhagic hydrocephalus, a fisher's exact test showed there to be statistically significant differences in etiology between center (p = 0.01). Regression showed age (p < 0.01), race (p = 0.038) and hospital-center (p < 0.001) to explain significant variance in the number of revisions. Our model accounted for 31.9% of the variance in revisions. Generalized linear modeling showed hydrocephalus etiology (p < 0.001), age (p < 0.001), weight and physician (p < 0.001) to impact the number of ventricular obstructions. CONCLUSION The retrospective analysis identified that differences exist between currently enrolled centers, although further work is needed before clinically actionable recommendations can be made. Moreover, the variables collected from this chart review explain a meaningful amount of variance in the number of revision surgeries. Future work will expand on the contribution of different site-specific and patient-specific factors to identify potential cause and effect relationships.
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Affiliation(s)
- Jacob Gluski
- Wayne State University School of Medicine, 540 E. Canfield Avenue, Detroit, MI, 48201, USA
| | - Paul Zajciw
- Wayne State University Dept. of Chemical Engineering and Materials Science, 6135 Woodward Avenue, Rm 1413, Detroit, MI, 48202, USA
| | - Prashant Hariharan
- Wayne State University Dept. of Chemical Engineering and Materials Science, 6135 Woodward Avenue, Rm 1413, Detroit, MI, 48202, USA
| | - Amanda Morgan
- Washington University School of Medicine Dept. of Neurological Surgery, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Diego M Morales
- Washington University School of Medicine Dept. of Neurological Surgery, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Andrew Jea
- Riley Hospital for Children at IU Health, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - William Whitehead
- Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Suite 1230.01, Houston, TX, 77030, USA
| | - Neena Marupudi
- Children's Hospital of Michigan Dept. of Neurosurgery, 3901 Beaubien Boulevard, 2nd Floor Carl's Building, Detroit, MI, 48201, USA
| | - Steven Ham
- Children's Hospital of Michigan Dept. of Neurosurgery, 3901 Beaubien Boulevard, 2nd Floor Carl's Building, Detroit, MI, 48201, USA
| | - Sandeep Sood
- Children's Hospital of Michigan Dept. of Neurosurgery, 3901 Beaubien Boulevard, 2nd Floor Carl's Building, Detroit, MI, 48201, USA
| | - James P McAllister
- Washington University School of Medicine Dept. of Neurological Surgery, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - David D Limbrick
- Washington University School of Medicine Dept. of Neurological Surgery, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Carolyn A Harris
- Wayne State University Dept. of Chemical Engineering and Materials Science, 6135 Woodward Avenue, Rm 1413, Detroit, MI, 48202, USA.
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46
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Gano D, Cowan FM, de Vries LS. Cerebral palsy after very preterm birth - an imaging perspective. Semin Fetal Neonatal Med 2020; 25:101106. [PMID: 32317152 DOI: 10.1016/j.siny.2020.101106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Neonatal brain imaging undoubtedly can provide the most accurate information from which to determine whether cerebral palsy is likely to affect an individual infant born preterm. The sensitivity and specificity of that information is different between cranial ultrasound and MRI, depending on what approaches and sequences are used and the timing of the examinations. In this chapter we highlight the changing incidence of different patterns of brain injury in the preterm newborn and present a comparison of cranial ultrasound and MRI for predicting cerebral palsy in preterm infants affected by the commoner intracranial pathologies.
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Affiliation(s)
- Dawn Gano
- Department of Neurology, University of California, San Francisco, CA, United States
| | - Frances M Cowan
- Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Linda S de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.
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Yeo KT, Thomas R, Chow SS, Bolisetty S, Haslam R, Tarnow-Mordi W, Lui K. Improving incidence trends of severe intraventricular haemorrhages in preterm infants <32 weeks gestation: a cohort study. Arch Dis Child Fetal Neonatal Ed 2020; 105:145-150. [PMID: 31201252 DOI: 10.1136/archdischild-2018-316664] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/08/2019] [Accepted: 05/14/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe the trend and risk factors for severe intraventricular haemorrhage (IVH) among infants <32 weeks gestation. DESIGN Population-based cohort study. SETTING Australia and New Zealand. PATIENTS All preterm infants <32 weeks gestation in the Australian and New Zealand Neonatal Network (ANZNN) from 1995 to 2012. INTERVENTIONS Comparison of IVH incidence between 6-year epochs. MAIN OUTCOME MEASURES Overall IVH and severe IVH incidence. RESULTS A total of 60 068 infants were included, and overall survival to discharge increased from 89% to 93% over the three epochs. As the percentage of infants with IVH decreased from 23.6% to 21.3% and 21.4% (p<0.001) from epoch 1 to 3, respectively, fewer survivors had severe IVH (4.0%, 3.3% and 2.8%, respectively, p<0.001). Over time, there were fewer antenatal complications, higher antenatal steroid usage and more caesarean-section births. Fewer infants were intubated at birth, had low 5 min Apgar score, had sepsis or pneumothorax needing drainage. Adjusted for perinatal confounders, there was significant reduction in odds of severe IVH from epoch 1 to 3 (adjusted OR (AOR) 0.8, 95% CI 0.7 to 0.9). Factors associated with development of severe IVH include no antenatal steroids (AOR 1.7, 95% CI 1.5 to 1.9), male (AOR 1.3, 95% CI 1.2 to 1.4), 5 min Apgar score <7 (AOR 2.0, 95% CI 1.9 to 2.2), intubated at birth (AOR 2.0, 95% CI 1.8 to 2.2), extremely low gestational age (AOR 4.0, 95% CI 3.7 to 4.4), outborn (AOR 1.6, 95% CI 1.5 to 1.8) and vaginal delivery (AOR 1.4, 95% CI 1.3 to 1.6). CONCLUSIONS Along with increased survival among infants born <32 weeks gestation, the incidence of severe IVH has decreased over the 18 years, especially in the most recent period. This coincided with reduction in rates of risk factors for severe IVH development.
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Affiliation(s)
- Kee Thai Yeo
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia.,Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | - Reji Thomas
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia.,Mount Gambier Hospital, Mount Gambier, South Australia, Australia
| | - Sharon Sw Chow
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia.,School of Women's & Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Srinivas Bolisetty
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's & Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ross Haslam
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - William Tarnow-Mordi
- National Health & Medical Research Council Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Kei Lui
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's & Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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48
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Differential effects of delivery hospital on mortality and morbidity in minority premature and low birth weight neonates. J Perinatol 2020; 40:404-411. [PMID: 31235781 DOI: 10.1038/s41372-019-0423-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 05/08/2019] [Accepted: 05/22/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To describe variation in mortality and morbidity effects of high-level, high-volume delivery hospital between racial/ethnic groups and insurance groups. STUDY DESIGN Retrospective cohort including infants born at 24-32 weeks gestation or birth weights ≤2500 g in California, Missouri, and Pennsylvania between 1995 and 2009 (n = 636,764). Multivariable logistic random-effects models determined differential effects of birth hospital level/volume on mortality and morbidity through an interaction term between delivery hospital level/volume and either maternal race or insurance status. RESULT Compared to non-Hispanic white neonates, odds of complications of prematurity were 14-25% lower for minority infants in all gestational age and birth weight cohorts delivering at high-level, high-volume centers (odds ratio (ORs) 0.75-0.86, p < 0.001-0.005). Effect size was greatest for Hispanic infants. No difference was noted by insurance status. CONCLUSIONS Neonates of minority racial/ethnic status derive greater morbidity benefits than non-Hispanic white neonates from delivery at hospitals with high-level, high-volume neonatal intensive care units.
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49
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Cizmeci MN, de Vries LS, Ly LG, van Haastert IC, Groenendaal F, Kelly EN, Traubici J, Whyte HE, Leijser LM. Periventricular Hemorrhagic Infarction in Very Preterm Infants: Characteristic Sonographic Findings and Association with Neurodevelopmental Outcome at Age 2 Years. J Pediatr 2020; 217:79-85.e1. [PMID: 31706634 DOI: 10.1016/j.jpeds.2019.09.081] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/02/2019] [Accepted: 09/30/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To describe the sonographic characteristics of periventricular hemorrhagic infarction (PVHI) and their association with mortality and neurodevelopmental disability in very preterm infants born in 2008-2013. STUDY DESIGN Retrospective multicenter observational cohort study. Diagonal PVHI size was measured and severity score assessed. PVHI characteristics were scored and temporal trends were assessed. Neurodevelopmental outcome at 2 years of corrected age was assessed using either the Bayley Scales of Infant and Toddler Development, Third Edition or the Griffiths Mental Development Scales. Multigroup analyses were applied as appropriate. RESULTS We enrolled 160 infants with median gestational age of 26.6 weeks. PVHI was mostly unilateral (90%), associated with an ipsilateral grade III intraventricular hemorrhage (84%), and located in the parietal lobe (51%). Sixty-four (40%) infants with PVHI died in the neonatal period. Of the survivors assessed at 2 years of corrected age, 65% had normal cognitive and 69% had normal motor outcomes. The cerebral palsy rate was 42%. The composite outcome of death or severe neurodevelopmental disability was observed in 58%, with no trends over the study period (P = .6). Increasing PVHI severity score was associated with death (P < .001). Increasing PVHI size and severity score were negatively associated with gross motor scores (P = .01 and .03, respectively). Trigone involvement was associated with cerebral palsy (41% vs 14%; P = .004). Associated posthemorrhagic ventricular dilation (36%) was an independent risk factor for poorer cognitive and motor outcomes (P < .001 for both). CONCLUSIONS Increasing PVHI size and severity score were predictive of less optimal gross motor outcome and death in very preterm infants.
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Affiliation(s)
- Mehmet N Cizmeci
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands; Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Linh G Ly
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Ingrid C van Haastert
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Edmond N Kelly
- Division of Neonatology, Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Jeffrey Traubici
- Department of Radiology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Hilary E Whyte
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Lara M Leijser
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
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50
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Boghossian NS, Geraci M, Lorch SA, Phibbs CS, Edwards EM, Horbar JD. Racial and Ethnic Differences Over Time in Outcomes of Infants Born Less Than 30 Weeks' Gestation. Pediatrics 2019; 144:peds.2019-1106. [PMID: 31405887 PMCID: PMC6813804 DOI: 10.1542/peds.2019-1106] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To examine changes in care practices over time by race and ethnicity and whether the decrease in hospital mortality and severe morbidities has benefited infants of minority over infants of white mothers. METHODS Infants 22 to 29 weeks' gestation born between January 2006 and December 2017 at a Vermont Oxford Network center in the United States were studied. We examined mortality and morbidity rate differences and 95% confidence intervals for African American and Hispanic versus white infants by birth year. We tested temporal differences in mortality and morbidity rates between white and African American or Hispanic infants using a likelihood ratio test on nested binomial regression models. RESULTS Disparities for certain care practices such as antenatal corticosteroids and for some in-hospital outcomes have narrowed over time for minority infants. Compared with white infants, African American infants had a faster decline for mortality, hypothermia, necrotizing enterocolitis, and late-onset sepsis, whereas Hispanic infants had a faster decline for mortality, respiratory distress syndrome, and pneumothorax. Other morbidities showed a constant rate difference between African American and Hispanic versus white infants over time. Despite the improvements, outcomes including hypothermia, mortality, necrotizing enterocolitis, late-onset sepsis, and severe intraventricular hemorrhage remained elevated by the end of the study period, especially among African American infants. CONCLUSIONS Racial and ethnic disparities in vital care practices and certain outcomes have decreased. That the quality deficit among minority infants occurred for several care practice measures and potentially modifiable outcomes suggests a critical role for quality improvement initiatives tailored for minority-serving hospitals.
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Affiliation(s)
- Nansi S. Boghossian
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Marco Geraci
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Scott A. Lorch
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;,Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ciaran S. Phibbs
- Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California;,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont;,Department of Mathematics and Statistics, University of Vermont, Burlington, Vermont; and,Department of Pediatrics, College of Medicine, University of Vermont, Burlington, Vermont
| | - Jeffrey D. Horbar
- Vermont Oxford Network, Burlington, Vermont;,Department of Pediatrics, College of Medicine, University of Vermont, Burlington, Vermont
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