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Chioma R, Healy DB, Finn D, Walsh BH, Reynolds C, O'Sullivan D, Livingstone V, Bussmann N, Dempsey EM. The Bronchopulmonary Dysplasia score: A predictive model for bronchopulmonary dysplasia or death in high-risk preterm infants. Acta Paediatr 2024; 113:1781-1790. [PMID: 38798138 DOI: 10.1111/apa.17304] [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: 09/08/2023] [Revised: 05/16/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
AIM Progressive respiratory deterioration in infants at high risk of bronchopulmonary dysplasia (BPD) is associated with patent ductus arteriosus (PDA) exposure. This study aimed to design an early predictive model for BPD or death in preterm infants using early echocardiographic markers and clinical data. METHODS Infants born with gestational age (GA) ≤ 29 weeks and/or birth weight (BW) < 1500 g at Cork University Maternity Hospital, Ireland were retrospectively evaluated. Those with echocardiography performed between 36 h and 7 days of life were eligible for inclusion. Exclusion criteria were pulmonary hypertension and major congenital anomalies. The primary outcome was a composite of BPD and death before discharge. RESULTS The study included 99 infants. A predictive model for the primary outcome was developed, which included three variables (BW, Respiratory Severity Score and flow pattern across the PDA), and yielding an area under the curve of 0.98 (95% CI 0.96-1.00, p < 0.001). Higher scores were predictive of the primary outcome. A cut-off of -1.0 had positive and negative predictive values of 89% and 98%, and sensitivity and specificity of 98% and 88%, respectively. CONCLUSION Our prediction model is an accessible bedside tool that predicts BPD or death in premature infants.
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Affiliation(s)
- Roberto Chioma
- INFANT Research Centre, University College Cork, Cork, Ireland
- Catholic University of Sacred Heart, Rome, Italy
| | - David B Healy
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Daragh Finn
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Brian H Walsh
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Cole Reynolds
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Deirdre O'Sullivan
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Vicki Livingstone
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Neidin Bussmann
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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Mitra S, Hébert A, Castaldo M, Disher T, El-Naggar W, Dhillon S, Alhassen Z, Koo J, Katheria AC, Hyderi A, Kumaran K, Makoni M, Weisz DE, Jain A, Bacchini F, Cameron A, Hatfield T, Dorling J, McNamara PJ, Thabane L. Selective early medical treatment of the patent ductus arteriosus in extremely low gestational age infants: a pilot randomised controlled trial protocol (SMART-PDA). BMJ Open 2024; 14:e087998. [PMID: 39053961 DOI: 10.1136/bmjopen-2024-087998] [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] [Indexed: 07/27/2024] Open
Abstract
INTRODUCTION Patent ductus arteriosus (PDA) is the most common cardiovascular problem that develops in extremely preterm infants and is associated with poor clinical outcomes. Uncertainty exists on whether early pharmacotherapeutic treatment of a clinically symptomatic and echocardiography-confirmed haemodynamically significant PDA in extremely preterm infants improves outcomes. Given the wide variation in the approach to PDA treatment in this gestational age (GA) group, a randomised trial design is essential to address the question. Before embarking on a large RCT in this vulnerable population, it is important to establish the feasibility of such a trial. METHODS AND ANALYSIS Design: a multi-centre, open-labelled, parallel-designed pilot randomised controlled trial. Participants: preterm infants born <26 weeks of gestation with a PDA diagnosed within 72 hours after birth. Intervention (selective early medical treatment (SMART) strategy): selective early pharmacological treatment of a moderate-severe PDA shunt (identified based on pre-defined clinical signs and routine screening echocardiography) within the first 72 postnatal hours with provision for repeat treatment if moderate-severe shunt persists. Comparison (early conservative management strategy): no treatment of PDA in the first postnatal week. Primary outcomes: (1) proportion of eligible infants recruited during the study period; (2) proportion of randomised infants treated outside of protocol-mandated therapy. Sites and sample size: the study is being conducted in seven neonatal intensive care units across Canada and the USA with a target of 100 randomised infants. Analysis: the primary feasibility outcomes will be expressed as proportions. A pre-planned Bayesian analysis will be conducted for secondary clinical outcomes such as mortality, severe intraventricular haemorrhage, procedural PDA closure and chronic lung disease to aid stakeholders including parent representatives decide on the appropriateness of enrolling this vulnerable population in a larger trial if the feasibility of recruitment in the pilot trial is established. ETHICS AND DISSEMINATION The study has been approved by the IWK Research Ethics Board (#1027298) and six additional participating sites. On the completion of the study, results will be presented at national and international meetings, published in peer-reviewed journals and incorporated into existing systematic reviews. TRIAL REGISTRATION NUMBER NCT05011149 (WHO Trial Registration Data Set in Appendix A). PROTOCOL VERSION Ver 7.2 (dated July 19, 2023).
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Affiliation(s)
- Souvik Mitra
- Department of Pediatrics, Faculty of Medicine, The University of British Columbia & BC Women's Hospital, Vancouver, British Columbia, Canada
- Division of Neonatal Perinatal Medicine, IWK Health, Halifax, Nova Scotia, Canada
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Audrey Hébert
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Michael Castaldo
- Department of Pediatrics, Faculty of Medicine, The University of British Columbia & BC Women's Hospital, Vancouver, British Columbia, Canada
| | - Tim Disher
- Eversana Inc, Sydney, Nova Scotia, Canada
| | - Walid El-Naggar
- Division of Neonatal Perinatal Medicine, IWK Health, Halifax, Nova Scotia, Canada
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Santokh Dhillon
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ziad Alhassen
- Department of Pediatrics, CHOC Children's, Orange County, California, USA
| | - Jenny Koo
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, USA
| | - Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, USA
| | - Abbas Hyderi
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Kumar Kumaran
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Marjorie Makoni
- Department of Pediatrics, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Dany E Weisz
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Austin Cameron
- Division of Neonatal Perinatal Medicine, IWK Health, Halifax, Nova Scotia, Canada
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tara Hatfield
- Division of Neonatal Perinatal Medicine, IWK Health, Halifax, Nova Scotia, Canada
| | - Jon Dorling
- Division of Neonatal Perinatal Medicine, IWK Health, Halifax, Nova Scotia, Canada
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
- Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Patrick J McNamara
- Department of Pediatrics, The University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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3
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Benitz WE, Polin RA. Recommitting to Rules of Evidence and Laws of Inference. J Pediatr 2024; 275:114199. [PMID: 39032771 DOI: 10.1016/j.jpeds.2024.114199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 07/08/2024] [Accepted: 07/15/2024] [Indexed: 07/23/2024]
Affiliation(s)
- William E Benitz
- Division of Neonatal and Development Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Richard A Polin
- Division of Neonatology, Columbia University College of Physicians and Surgeons, New York, NY
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Mitra S, Bischoff AR, Sathanandam S, Lakshminrusimha S, McNamara PJ. Procedural closure of the patent ductus arteriosus in preterm infants: a clinical practice guideline. J Perinatol 2024:10.1038/s41372-024-02052-9. [PMID: 38997403 DOI: 10.1038/s41372-024-02052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/29/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024]
Abstract
IMPORTANCE Transcatheter closure of the patent ductus arteriosus (PDA) is being increasingly adopted as an alternative to surgical PDA closure in preterm infants. OBJECTIVE To develop rigorous clinical practice guideline recommendations on procedural PDA closure in preterm infants. METHODS The principles of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Evidence-to-Decision (EtD) framework were used to develop the guideline recommendations. An e-Delphi survey of 45 experts was conducted and recommendations that reached ≥75% agreement were accepted as consensus. MAIN RECOMMENDATIONS Procedural PDA closure may be considered in extremely preterm infants (<28 weeks gestational age) requiring invasive mechanical ventilation >10 postnatal days and confirmed to have a large hemodynamically significant PDA, at centers with high local rates of death and/or bronchopulmonary dysplasia (conditional recommendation). If sufficient institutional expertise is available and patient characteristics are suitable, transcatheter PDA closure may be considered as the preferred approach over PDA ligation (conditional recommendation).
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Affiliation(s)
- Souvik Mitra
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Adrianne R Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, USA
| | - Shyam Sathanandam
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, USA.
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Parkerson S, Sathanandam S, Molloy A. Patent Ductus Arteriosus Occlusion in Premature Infants. Interv Cardiol Clin 2024; 13:355-368. [PMID: 38839169 DOI: 10.1016/j.iccl.2024.02.001] [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: 06/07/2024]
Abstract
Transcatheter ductal closure has proven to be safe and effective to occlude the patent ductus arteriosus (PDA) in premature infants. We have developed a robust multidisciplinary PDA program. After gaining experience performing transcatheter ductal closure in the cardiac catheterization laboratory, we transitioned to performing the procedure at the patient's bedside in the neonatal intensive care unit using echocardiographic guidance. The bedside approach has the potential to expand this therapy to patients who currently undergo expectant PDA management because of lack of availability of this therapy, and allow for earlier referral, which will reduce time of exposure to this pathologic shunt.
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Affiliation(s)
- Sarah Parkerson
- Department of Pediatrics, Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 N Dunlap street, Memphis, TN 38105, USA
| | - Shyam Sathanandam
- Department of Pediatrics, Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 N Dunlap street, Memphis, TN 38105, USA.
| | - Ashley Molloy
- Department of Pediatrics, Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 N Dunlap street, Memphis, TN 38105, USA
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McNamara PJ, Abman SH, Levy PT. Reengagement with Physiology in Neonatal Heart and Lung Care: A Priority for Training and Practice. J Pediatr 2024; 268:113947. [PMID: 38336199 DOI: 10.1016/j.jpeds.2024.113947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/29/2024] [Accepted: 02/04/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Patrick J McNamara
- Department of Pediatrics, The University of Iowa Stead Family, Iowa City, IA; Internal Medicine, The University of Iowa Stead Family, Iowa City, IA.
| | - Steven H Abman
- Department of Pediatrics and Pediatric Heart Lung Center, University of Colorado Anschutz Medical School and Children's Hospital Colorado, Aurora, CO
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics Harvard Medical School, Boston, MA
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Ford A, Beauchene M, Stanford AH, Klein JM, Dagle JM, Rios DR, Larson SA, McNamara PJ, Giesinger RE. Exposure to persistent hemodynamically significant patent ductus arteriosus is associated with retinopathy of prematurity. J AAPOS 2024:103923. [PMID: 38692561 DOI: 10.1016/j.jaapos.2024.103923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Hemodynamically significant patent ductus arteriosus (hsPDA) shunt may predispose infants to retinopathy of prematurity (ROP) because of its higher preductal cardiac output and blood oxygen content, which may augment ocular oxygen delivery. METHODS A retrospective cohort study of preterm infants, born at <27 weeks' gestation and admitted at <24h postnatal age to a large quaternary referral was conducted. The primary composite outcome was death at <32 weeks or moderate-to-severe ROP (≥stage 2 or requiring treatment) in either eye. Secondary outcomes included ROP requiring treatment, and any ROP. Univariate analysis of patient characteristics and outcomes was performed as well as logistic regression. A receiver operating characteristics curve was generated for the outcome of ROP ≥stage 2 or requiring treatment. RESULTS A total of 91 patients were screened, of whom 86 (54 hsPDA, 32 controls) were eligible for inclusion. hsPDA patients were younger and lighter at birth and had a higher burden of hyperglycemia and respiratory illness. The rates of the composite outcome (death <32 weeks or moderate-to-severe ROP) and of any ROP were more frequent in the hsPDA group. hsPDA shunt exposure was independently associated with development of any ROP among survivors to assessment (P = 0.006). PDA cumulative exposure score of 78 (clinical equivalent = 7 days high-volume shunt exposure) predicts moderate-to-severe ROP with 80% sensitivity and 78% specificity. CONCLUSIONS Among infants <27 weeks, hsPDA shunt is associated with increased risks of a composite outcome of death or moderate-to-severe ROP, as well as ROP of any stage. Shunt modulation as a strategy to reduce ROP represents a biologically plausible avenue for investigation.
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Affiliation(s)
- Alison Ford
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Amy H Stanford
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | | | - John M Dagle
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Danielle R Rios
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Scott A Larson
- Department of Ophthalmology, University of Iowa, Iowa City, Iowa
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa, Iowa City, Iowa; Department of Internal Medicine, University of Iowa, Iowa City, Iowa.
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Tomotaki S, Isayama T, Kobayashi T, Masutani S, Kawasaki H, Nakayama A, Ikeda T, Toyoshima K. Proactive Diagnosis and Tailor-Made Treatment of Patent Ductus Arteriosus in Very Preterm Infants with Routine Echocardiography in Japan: A post hoc Analysis of the PLASE Study. Neonatology 2024; 121:503-511. [PMID: 38593757 DOI: 10.1159/000538363] [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: 12/06/2023] [Accepted: 03/12/2024] [Indexed: 04/11/2024]
Abstract
INTRODUCTION A feature of the management of extremely preterm infants in Japan is proactive circulatory management using early routine echocardiography performed by neonatologists. METHODS This study was a post hoc analysis of the Patent ductus arteriosus and Left Atrial Size Evaluation in preterm infants (PLASE) study, which is a prospective cohort study including preterm infants admitted to 34 tertiary neonatal intensive care units in Japan between October 2015 and December 2016. We described the details of the treatment strategy of patent ductus arteriosus (PDA) based on early routine echocardiography. RESULTS In total, 613 preterm infants were included into the analysis. Twenty percent of infants with prophylactic indomethacin were switched to therapeutic cyclooxygenase inhibitor (COX-I) before the completion of the full prophylactic indomethacin course. Therapeutic COX-I was mostly administered based on echocardiographic findings before PDA became symptomatic or hemodynamically significant. Therapeutic COX-I was frequently discontinued after one or two doses before the full course (three doses) was completed. The proportion of infants requiring additional treatment (additional therapeutic COX-I course or surgical PDA closure) after discontinued COX-I courses (<3 doses) compared to infants after completed 3 doses course was significantly lower (after the first therapeutic COX-I course 46% vs. 68%, p < 0.001) or without a significant difference (after the second or third course). CONCLUSIONS The clinical management of PDA in Japan featured (1) COX-I administration based on echocardiographic findings before symptomatic or hemodynamically significant PDA appeared and (2) frequent discontinuation of therapeutic COX-I before completing the standard three doses course.
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Affiliation(s)
- Seiichi Tomotaki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tetsuya Isayama
- Department of Neonatology, National Center for Child Health and Development, Setagaya, Japan
| | - Tohru Kobayashi
- Department of Data Science, Clinical Research Center, National Center for Child Health and Development, Setagaya, Japan
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Hidenori Kawasaki
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Atsushi Nakayama
- Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | | | - Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
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Kaluarachchi DC, Rysavy MA, Carper BA, Chock VY, Laughon MM, Backes CH, Colaizy TT, Bell EF, McNamara PJ. Secular Trends in Patent Ductus Arteriosus Management in Infants Born Preterm in the National Institute of Child Health and Human Development Neonatal Research Network. J Pediatr 2024; 266:113877. [PMID: 38135028 PMCID: PMC10922632 DOI: 10.1016/j.jpeds.2023.113877] [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: 08/29/2023] [Revised: 11/12/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
We evaluated changes in patent ductus arteriosus (PDA) diagnosis and treatment from 2012 through 2021 in a network of US academic hospitals. PDA treatment decreased among infants born at 26-28 weeks but not among infants born at 22-25 weeks. Rates of indomethacin use and PDA ligation decreased while acetaminophen use and transcatheter PDA closure increased.
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Affiliation(s)
| | - Matthew A Rysavy
- Department of Pediatrics, McGovern Medical School, UTHealth Houston, Houston, TX
| | - Benjamin A Carper
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
| | - Valerie Y Chock
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Matthew M Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Carl H Backes
- Department of Pediatrics, Ohio State University and Nationwide Children's Hospital, Columbus, OH
| | | | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
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Qian A, Jiang S, Gu X, Li S, Lei X, Shi W, Zhou J, Hu L, Xiao T, Zhu Y, Cao Y, Du L, Zhou W, Lee SK, Cheng R, Yin R. Treatment of patent ductus arteriosus and short-term outcomes among extremely preterm infants: a multicentre cohort study. EClinicalMedicine 2024; 67:102356. [PMID: 38125962 PMCID: PMC10730999 DOI: 10.1016/j.eclinm.2023.102356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
Background The optimal treatment strategy for patent ductus arteriosus (PDA) in extremely preterm infants is currently highly controversial. This study aimed to evaluate the association between PDA treatment and short-term outcomes among extremely preterm infants. Methods This cohort study included all extremely preterm infants (≤27 and 6/7 weeks) who were admitted to hospitals participating in the Chinese Neonatal Network from January 2019 to December 2021, and were diagnosed to have PDA by echocardiogram. PDA treatment was defined as medical treatment and/or surgical ligation of PDA during hospitalization. Short-term outcomes included death, bronchopulmonary dysplasia (BPD), death/BPD, retinopathy of prematurity, necrotizing enterocolitis, and severe brain injury. Multivariate logistic regression was used to evaluate the association between PDA treatment and outcomes. Subgroup analysis were performed among infants with different respiratory support on 3 and 7 days of life. Findings A total of 2494 extremely preterm infants with the diagnosis of PDA were enrolled, of which 1299 (52.1%) received PDA treatment. PDA treatment was significantly associated with lower risk of death (adjusted odds ratio, 0.48; 95% confidence interval, 0.38-0.60). The decreased risk of death was accompanied by increased risk of BPD and death/BPD. In subgroup analysis according to respiratory support, PDA treatment was associated with lower risk of death among infants who required invasive ventilation. However, the beneficial effect on death was not significant among infants who did not require invasive ventilation. Interpretation PDA treatment was associated with reduced mortality in extremely preterm infants, but this beneficial effect was mainly present among infants who required invasive ventilation. Funding This study was funded by the Shanghai Science and Technology Commission's Scientific and Technological Innovation Action Plan (21Y21900800) and the Canadian Institutes of Health Research (CTP87518).
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Affiliation(s)
- Aimin Qian
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Siyuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Xinyue Gu
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Shujuan Li
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Xiaoping Lei
- Division of Neonatology, Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wei Shi
- Neonatal Intensive Care Unit, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Jianguo Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Liyuan Hu
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Tiantian Xiao
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yanping Zhu
- Department of Neonatology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Lizhong Du
- Neonatal Intensive Care Unit, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Wenhao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Shoo K. Lee
- Maternal-Infant Care Research Center and Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Rui Cheng
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Rong Yin
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
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Chan B, Singh Y. Personalized Evidence-Based Management of Patent Ductus Arteriosus in Preterm Infants. J Cardiovasc Dev Dis 2023; 11:7. [PMID: 38248877 PMCID: PMC10816643 DOI: 10.3390/jcdd11010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
There is no universal consensus on management of patent ductus arteriosus (PDA) in preterm infants and it varies significantly worldwide, even among the clinicians within units. The decision to treat requires a thorough understanding of the clinical status of the patient, clinical evaluation of PDA, echocardiographic diagnosis, and hemodynamic impact of ductal shunt on the pulmonary and systemic circulation. In this article, updated evidence on the efficacy and adverse effects of pharmacological treatment options and expectant management are presented, while highlighting the long-term benefits of PDA treatment remains equivocal and controversial. The authors propose a schematic targeted PDA treatment approach based on gestational and chronological age for practical clinical use, and they emphasize important future directions including advancement in PDA device closure techniques, diagnostic echo-parameters, hemodynamic evaluation to assess the impact on other organs, and understanding the long-term outcomes.
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Affiliation(s)
- Belinda Chan
- Neonatology Division, Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, USA;
- Department of Radiology and Imaging Science, University of Utah, Salt Lake City, UT 84113, USA
| | - Yogen Singh
- Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
- Department of Pediatrics, Division of Neonatology, University of Southern California (USC), Los Angeles, CA 90007, USA
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Chen YX, Xiao TT, Chen HY, Chen X, Wang YQ, Ni Q, Wu BB, Wang HJ, Lu YL, Hu LY, Cao Y, Cheng GQ, Wang LS, Xiao FF, Yang L, Dong XR, Zhou WH. Risk stratification of hemodynamically significant patent ductus arteriosus by clinical and genetic factors. World J Pediatr 2023; 19:1192-1202. [PMID: 37318723 DOI: 10.1007/s12519-023-00733-7] [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: 01/04/2023] [Accepted: 05/10/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Hemodynamically significant patent ductus arteriosus (hsPDA) is associated with increased comorbidities in neonates. Early evaluation of hsPDA risk is critical to implement individualized intervention. The aim of the study was to provide a powerful reference for the early identification of high-risk hsPDA population and early treatment decisions. METHODS We enrolled infants who were diagnosed with PDA and performed exome sequencing. The collapsing analyses were used to find the risk gene set (RGS) of hsPDA for model construction. The credibility of RGS was proven by RNA sequencing. Multivariate logistic regression was performed to establish models combining clinical and genetic features. The models were evaluated by area under the receiver operating curve (AUC) and decision curve analysis (DCA). RESULTS In this retrospective cohort study of 2199 PDA patients, 549 (25.0%) infants were diagnosed with hsPDA. The model [all clinical characteristics selected by least absolute shrinkage and selection operator regression (all CCs)] based on six clinical variables was acquired within three days of life, including gestational age (GA), respiratory distress syndrome (RDS), the lowest platelet count, invasive mechanical ventilation, and positive inotropic and vasoactive drugs. It has an AUC of 0.790 [95% confidence interval (CI) = 0.749-0.832], while the simplified model (basic clinical characteristic model) including GA and RDS has an AUC of 0.753 (95% CI = 0.706-0.799). There was a certain consistency between RGS and differentially expressed genes of the ductus arteriosus in mice. The AUC of the models was improved by RGS, and the improvement was significant (all CCs vs. all CCs + RGS: 0.790 vs. 0.817, P < 0.001). DCA demonstrated that all models were clinically useful. CONCLUSIONS Models based on clinical factors were developed to accurately stratify the risk of hsPDA in the first three days of life. Genetic features might further improve the model performance. Video Abstract (MP4 86834 kb).
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Affiliation(s)
- Yu-Xi Chen
- Center for Molecular Medicine of Children's Hospital of Fudan University, Institutes of Biomedical Sciences, Fudan University, 138 Yi Xue Yuan Road, Shanghai, China
| | - Tian-Tian Xiao
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Hui-Yao Chen
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Xiang Chen
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Ya-Qiong Wang
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Qi Ni
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Bing-Bing Wu
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Hui-Jun Wang
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Yu-Lan Lu
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Li-Yuan Hu
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Guo-Qiang Cheng
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Lai-Shuan Wang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Fei-Fan Xiao
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Lin Yang
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Xin-Ran Dong
- Center for Molecular Medicine, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China.
| | - Wen-Hao Zhou
- Center for Molecular Medicine of Children's Hospital of Fudan University, Institutes of Biomedical Sciences, Fudan University, 138 Yi Xue Yuan Road, Shanghai, China.
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.
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13
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Liguori MB, Ali SKM, Bussman N, Colaizy T, Hundscheid T, Phad N, Clyman R, de Boode WP, de Waal K, El-Khuffash A, Gupta S, Laughon M. Patent Ductus Arteriosus in Premature Infants: Clinical Trials and Equipoise. J Pediatr 2023; 261:113532. [PMID: 37269903 DOI: 10.1016/j.jpeds.2023.113532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 06/05/2023]
Affiliation(s)
- Macrina B Liguori
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Sanoj K M Ali
- Division of Neonatology, Sidra Medicine, Ar-Rayyan, Doha, Qatar
| | - Neidín Bussman
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Tarah Colaizy
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Tim Hundscheid
- Division of Neonatology, Department of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, New South Wales, Australia
| | - Ronald Clyman
- Department of Pediatrics and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Willem-Pieter de Boode
- Division of Neonatology, Department of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital, University of Newcastle, Newcastle, New South Wales, Australia
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Samir Gupta
- Division of Neonatology, Sidra Medicine, Ar-Rayyan, Doha, Qatar; Department of Neonatology, Durham University, Durham, United Kingdom
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
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14
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Mitra S. EBNEO Commentary: Precision management of the patent ductus arteriosus in micropreemies. Acta Paediatr 2023; 112:2018-2019. [PMID: 37246268 DOI: 10.1111/apa.16853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/22/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Souvik Mitra
- Department of Pediatrics, Department of Community Health & Epidemiology, Dalhousie University & IWK Health, Halifax, Canada
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15
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Zong H, Huang Z, Lin B, Zhao J, Fu Y, Yu Y, Sun H, Yang C. The Predictive Value of Lung Ultrasound Score on Hemodynamically Significant Patent Ductus Arteriosus among Neonates ≤25 Weeks. Diagnostics (Basel) 2023; 13:2263. [PMID: 37443657 DOI: 10.3390/diagnostics13132263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/26/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023] Open
Abstract
Lung ultrasound (LU) is increasingly used to diagnose and monitor neonatal pulmonary disorders; however, its role in hemodynamically significant patent ductus arteriosus (hsPDA) has not been elucidated. This prospective study investigated the predictive value of the LU score (LUS) for hsPDA in preterm infants with gestational age (GA) ≤ 25 weeks. Preterm infants with GA ≤ 25 weeks were enrolled in this study. LU was conducted on the fourth day of life (DOL). Six lung regions in every lung were scanned, with each region rated as 0-4 points. The performance of the LUS in predicting hsPDA among infants aged ≤25 weeks was analyzed by plotting the receiver operating characteristic (ROC) curve. A total of 81 infants were included in this study. GA, birth weight (BW), gender, Apgar score, delivery mode, antenatal steroids, meconium-stained amniotic fluid, premature rapture of membrane, and early-onset sepsis were not significantly different, but infants in the hsPDA group had increased LUS (38.2 ± 2.8 vs. 30.3 ± 4.3, p < 0.001) compared with non-hsPDA group. The area under the ROC curve (AUC) value of the LUS on the fourth DOL was 0.94 (95% CI: 0.93-0.99) in predicting hsPDA. The LUS threshold at 33 achieved 89% sensitivity and 83% specificity, with the positive and negative predictive values (PPV and NPV) being 87 and 86%, respectively. The LUS can predict hsPDA in extremely preterm infants at an early stage.
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Affiliation(s)
- Haifeng Zong
- Department of Neonatology and Neonatal Intensive Care Unit, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen 518028, China
| | - Zhifeng Huang
- Department of Neonatology and Neonatal Intensive Care Unit, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen 518028, China
| | - Bingchun Lin
- Department of Neonatology and Neonatal Intensive Care Unit, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen 518028, China
| | - Jie Zhao
- Department of Neonatology and Neonatal Intensive Care Unit, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen 518028, China
| | - Yongping Fu
- Department of Neonatology and Neonatal Intensive Care Unit, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen 518028, China
| | - Yanliang Yu
- Department of Neonatology and Neonatal Intensive Care Unit, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen 518028, China
| | - Hongyan Sun
- Department of Neonatology and Neonatal Intensive Care Unit, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen 518028, China
| | - Chuanzhong Yang
- Department of Neonatology and Neonatal Intensive Care Unit, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen 518028, China
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16
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Sathanandam S, McNamara P, Pedra C, Toyoshima K, Malekzadeh-Milani S, Patkai J, Baspinar O, Uslu HS, Promphan W, Khorana M, Wang JN, Lin YC, Fujii T, Mainzer G, Salazar-Lizárraga D, Márquez-Gonzalez H, Popat H, Mervis J, Hong NS, Alwi M, Wonwandee R, Schranz D, Stanimir G, Philip R, Ing F. A Global Perspective on PDA Management in the Extremely Premature: Shifting Trend Toward Transcatheter Closure. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100968. [PMID: 39131651 PMCID: PMC11307882 DOI: 10.1016/j.jscai.2023.100968] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 08/13/2024]
Abstract
Patent ductus arteriosus (PDA) is a frequently encountered defect in infants born extremely premature (≤26 weeks' gestation). Historically, closure of the PDA was performed using cyclooxygenase inhibitor medications or by surgical ligations. However, the benefits of PDA closure using these therapies have never been demonstrated, albeit studies have previously not focused on the extremely premature infants. Therefore, there was a worldwide trend toward conservative management of the PDA. With improved survival of extremely premature infants, comorbidities associated with the PDA has increased, resulting in finding alternate treatments such as transcatheter patent ductus arteriosus closure (TCPC) for this population. Currently, there is a renewed interest toward selective treatment of the PDA in this high-risk cohort of small infants. This Comprehensive Review article inspects the globally changing trends in the management of the PDA in premature infants, with a special focus on the rising adoption of TCPC. Moreover, this article compiles data from several neonatal networks worldwide to help understand the problem at hand. Understanding the current management of premature infants and their outcomes is fundamentally essential if pediatric cardiologists are to offer TCPC as a viable therapeutic option for this population. This article aims to serve as a guide for pediatric cardiologists on this topic by compiling the results on landmark clinical trials on PDA management and the controversies that arise from these trials. Comparative outcomes from several countries are presented, including interpretations and opinions of the data from experts globally. This is a step toward coming to a global consensus in PDA management in premature infants.
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Affiliation(s)
- Shyam Sathanandam
- LeBonheur Children’s Hospital, University of Tennessee, Memphis, Tennessee
| | | | - Carlos Pedra
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | | | | | - Juliana Patkai
- Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | - Hasan Sinan Uslu
- Istanbul Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Worakan Promphan
- Queen Sirikit National Institute of Child Health, Bangkok, Thailand
| | - Meera Khorana
- Queen Sirikit National Institute of Child Health, Bangkok, Thailand
| | | | | | | | | | | | | | - Himanshu Popat
- The Children’s Hospital at Westmead and The University of Sydney, Sydney, Australia
| | - Jonathan Mervis
- The Children’s Hospital at Westmead and The University of Sydney, Sydney, Australia
| | - Neoh Siew Hong
- Kuala Lumpur Women’s and Children’s Hospital, Kuala Lumpur, Malaysia
| | - Mazeni Alwi
- Institut Jantung Negara, Kuala Lumpur, Malaysia
| | | | | | | | - Ranjit Philip
- LeBonheur Children’s Hospital, University of Tennessee, Memphis, Tennessee
| | - Frank Ing
- UC Davis Medical Center, Sacramento, California
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17
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Mižíková I, Thébaud B. Perinatal origins of bronchopulmonary dysplasia-deciphering normal and impaired lung development cell by cell. Mol Cell Pediatr 2023; 10:4. [PMID: 37072570 PMCID: PMC10113423 DOI: 10.1186/s40348-023-00158-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/26/2023] [Indexed: 04/20/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a multifactorial disease occurring as a consequence of premature birth, as well as antenatal and postnatal injury to the developing lung. BPD morbidity and severity depend on a complex interplay between prenatal and postnatal inflammation, mechanical ventilation, and oxygen therapy as well as associated prematurity-related complications. These initial hits result in ill-explored aberrant immune and reparative response, activation of pro-fibrotic and anti-angiogenic factors, which further perpetuate the injury. Histologically, the disease presents primarily by impaired lung development and an arrest in lung microvascular maturation. Consequently, BPD leads to respiratory complications beyond the neonatal period and may result in premature aging of the lung. While the numerous prenatal and postnatal stimuli contributing to BPD pathogenesis are relatively well known, the specific cell populations driving the injury, as well as underlying mechanisms are still not well understood. Recently, an effort to gain a more detailed insight into the cellular composition of the developing lung and its progenitor populations has unfold. Here, we provide an overview of the current knowledge regarding perinatal origin of BPD and discuss underlying mechanisms, as well as novel approaches to study the perturbed lung development.
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Affiliation(s)
- I Mižíková
- Experimental Pulmonology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - B Thébaud
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Pediatrics, Children's Hospital of Eastern Ontario (CHEO), CHEO Research Institute, University of Ottawa, Ottawa, ON, Canada
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18
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Francescato G, Capolupo I, Cerbo RM, Doni D, Ficial B, Fiocchi S, Matina F, Milani GP, Mizzoni F, Salvadori S, Savoia M, Corsini I. Fluid restriction in management of patent ductus arteriosus in Italy: a nationwide survey. Eur J Pediatr 2023; 182:393-401. [PMID: 36374300 DOI: 10.1007/s00431-022-04685-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/22/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022]
Abstract
UNLABELLED We aimed at establishing the state of the art in fluid restriction practice in our national setting and providing a foundation for future research efforts. A prospective cross-sectional survey was conducted among all 114 Italian Neonatal Units in order to address conservative management of patent ductus arteriosus (PDA) in preterm infants below 29 weeks' gestational age (GA), with specific regard to fluid restriction. Response rate was 80%. Conservative measures for PDA management are provided in the majority of NICUs and 80% of centers reduce fluid intake in neonates with PDA. No relationship can be found among pharmacologically or surgically treated patients per year and the approach to fluid restriction. The minimum intake administered at regimen when fluid restriction is applied is associated to the ratio between the maximum number of neonates managed pharmacologically and number of admitted < 29 weeks' GA newborns. CONCLUSION Our survey shows an extreme variability among centers in terms of use of fluid restriction as a prophylactic tool but also in terms of its use (both opportunity and modality) when a hemodynamically significant PDA is diagnosed. This variability, that can be also found in randomized trials and observational studies, suggests that further evidence is needed to better understand its potential beneficial effects and its potential harms such as dehydration, hypotension, decreased end-organ perfusion, and reduced caloric intake. WHAT IS KNOWN • The lack of demonstrable improvement following the treatment of patent ductus arteriosus has recently paved the way to a more conservative approach. • Fluid restriction is the most commonly applied conservative treatment of PDA. WHAT IS NEW • Among Italian NICUs an extreme variability in terms of indications, timing and modalities of application of Fluid restriction can be found. • This variability reflects the lack of standardization of this practice and the contrasting evidence on its efficacy.
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Affiliation(s)
- Gaia Francescato
- NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Irma Capolupo
- Neonatal Intensive Care Unit, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Rosa Maria Cerbo
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Daniela Doni
- Neonatal Intensive Care Unit FMBBM San Gerardo, Monza, Italy
| | - Benjamim Ficial
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Federico Matina
- Neonatal Intensive Care Unit, Villa Sofia-Cervello Hospital, Palermo, Italy
| | - Gregorio Paolo Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Fabio Mizzoni
- Division of Neonatology and NICU San Camillo-Forlanini Hospital, Rome, Italy
| | - Sabrina Salvadori
- Neonatal Intensive Care Unit, Azienda Ospedaliera-Università di Padova, Padova, Italy
| | - Marilena Savoia
- Neonatal Intensive Care Unit, S Maria Della Misericordia Hospital, Udine, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
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19
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Clyman RI, Hills NK. Effects of prophylactic indomethacin on morbidity and mortality in infants <25 weeks' gestation: a protocol driven intention to treat analysis. J Perinatol 2022; 42:1662-1668. [PMID: 36310242 PMCID: PMC9712120 DOI: 10.1038/s41372-022-01547-7] [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: 09/20/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine if prophylactic indomethacin (PINDO) decreases death or bronchopulmonary dysplasia-grades 2 and 3 (death/BPD) in newborns <25 weeks. STUDY DESIGN Intention-to-treat, cohort-controlled study of 106 infants admitted during three alternating epochs of PINDO or Expectant patent ductus arteriosus (PDA) management. RESULTS At 7-8 days 85% of Expectant Management epoch infants had a moderate/large PDA (median exposure was 23 days). Among PINDO epoch infants only 24% still had a PDA at 7-8 days. There were no significant differences in the incidence of death/BPD or of secondary outcomes (BPD, death, necrotizing enterocolitis/spontaneous perforations, or intraventricular hemorrhage (grades 3 or 4)) in either unadjusted or adjusted comparisons between infants born in a PINDO epoch and those born in the Expectant Management epoch. CONCLUSION Despite being at high risk for PDA-related morbidities, PINDO did not appear to alter the rates of our primary and secondary outcomes in infants <25 weeks.
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Affiliation(s)
- Ronald I Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
- 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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20
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Scerbo D, Cua CL, Rivera BK, Marzec LC, Smith CV, Slaughter JL, Berman DP, Backes CH. Percutaneous Closure of the Patent Ductus Arteriosus in Very-Low-Weight Infants. Neoreviews 2021; 21:e469-e478. [PMID: 32611564 DOI: 10.1542/neo.21-7-e469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In view of the known complications of drug therapy and open surgical ligation, and the potential for prolonged patent ductus arteriosus (PDA) exposure to be harmful, health care practitioners have sought new approaches to achieve definitive ductal closure. Interest in percutaneous (catheter-based) PDA closure has emerged within the neonatal community as a viable treatment option, because it has been fueled by recent procedural and device modifications, as well as mounting feasibility and safety data. Herein, we provide a contemporary review of percutaneous PDA closure among infants at the crux of the medical debate-very-low-weight infants (≤1,500 g), including: 1) characterization of traditional PDA treatments (drug therapy, open surgical ligation) and conservative (nonintervention) management options; 2) a general overview of the major procedural steps of percutaneous ductal closure, including efforts to reduce thrombotic complications and the emergence of a novel US Food and Drug Administration-approved device; 3) a systematic review and meta-analysis to better understand risk profiles of percutaneous PDA closure in this population; and 4) discussion of current gaps in our understanding of optimal PDA care, including the critical need for well-designed, randomized, controlled clinical trials.
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Affiliation(s)
- Danielle Scerbo
- The Ohio University Heritage College of Osteopathic Medicine, Athens, OH.,Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Clifford L Cua
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Brian K Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Laura C Marzec
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Charles V Smith
- Center for Integrated Brain Research, Seattle Children's Hospital, Seattle, WA
| | - Jonathan L Slaughter
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH.,Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH
| | - Darren P Berman
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Carl H Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,The Heart Center, Nationwide Children's Hospital, Columbus, OH.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
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21
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Angelis D, Jagarapu J, Wan-Huen P, Savani RC, Jaleel M. Part II. Acetaminophen and closure of ductus arteriosus in the newborns: Mechanisms of action, clinical studies, safety and efficacy. Early Hum Dev 2021; 159:105407. [PMID: 34147306 DOI: 10.1016/j.earlhumdev.2021.105407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Dimitrios Angelis
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Jawahar Jagarapu
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Phyllis Wan-Huen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rashmin C Savani
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mambarambath Jaleel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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22
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Altit G, Saeed S, Beltempo M, Claveau M, Lapointe A, Basso O. Outcomes of Extremely Premature Infants Comparing Patent Ductus Arteriosus Management Approaches. J Pediatr 2021; 235:49-57.e2. [PMID: 33864797 DOI: 10.1016/j.jpeds.2021.04.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/14/2021] [Accepted: 04/08/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate the change in the proportion of deaths/bronchopulmonary dysplasia (BPD) among premature infants (born <26 and 26-29 weeks of gestational age) following a policy change to a strict nonintervention approach, compared with standard treatment. STUDY DESIGN We examined 1249 infants (341 born <26 weeks of gestational age) at 2 comparable sites. Site 1 (control) continued medical treatment/ligation, and site 2 (exposed) changed to a nonintervention policy in late 2013. Using the difference-in-differences approach, which accounts for time-invariant differences between sites and secular trends, we assessed changes in death or BPD separately among infants born 26-29 weeks and <26 weeks of gestational age in 2 epochs (epoch 1: 2011-2013; epoch 2: 2014-2017). RESULTS Baseline characteristics were similar across sites and epochs. Medical treatment/ligation use remained stable at site 1 but declined progressively to 0% at site 2, indicating adherence to policy. We saw no difference in death/BPD among infants born at 26-29 weeks of gestational age (12%, 95% CI -1% to 24%). However, incidence of death/BPD increased by 31% among infants born <26 weeks of gestational age (95% CI 10%-51%) in site 2, whereas there was no change in outcomes in site 1. The Score for Neonatal Acute Physiology-Version II, used as a control outcome, did not change in either site, suggesting that our findings were not due to changes in patients' severity. CONCLUSIONS Adherence to a strict conservative policy did not impact death or BPD among 26 weeks but was associated with a significant rise in infants born <26 weeks.
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Affiliation(s)
- Gabriel Altit
- Division of Neonatology, McGill University Health Center, Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.
| | - Sahar Saeed
- Department of Epidemiology, Washington University, St. Louis, MO
| | - Marc Beltempo
- Division of Neonatology, McGill University Health Center, Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Martine Claveau
- Division of Neonatology, McGill University Health Center, Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
| | - Anie Lapointe
- Department of Neonatology, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Olga Basso
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, McGill University Health Center; Montreal, Quebec, Canada
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Lopata SM, Slaughter JC, Gillam-Krakauer M, Reese J. The patent ductus arteriosus management debate: it's not over yet. J Perinatol 2021; 41:923-925. [PMID: 33859354 PMCID: PMC11058539 DOI: 10.1038/s41372-021-01059-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Susan M Lopata
- Departments of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - James C Slaughter
- Biostatistics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Maria Gillam-Krakauer
- Departments of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Jeff Reese
- Departments of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
- Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA.
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Patent ductus arteriosus shunt elimination results in a reduction in adverse outcomes: a post hoc analysis of the PDA RCT cohort. J Perinatol 2021; 41:1134-1141. [PMID: 33686119 DOI: 10.1038/s41372-021-01002-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/14/2021] [Accepted: 02/05/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A post hoc appraisal of the PDA RCT to assess the relationship between early patent ductus arteriosus (PDA) shunt elimination and chronic lung disease or death (CLD/Death). STUDY DESIGN Infants <29 weeks were divided into four groups: intervention arm in whom PDA closure was achieved (n = 17); intervention arm in whom PDA closure was not achieved (n = 13); placebo arm (n = 30); low risk infants (n = 13). The main outcome measure was CLD/Death. RESULTS The rates of CLD/Death were lower in the Intervention Success Group (29%) when compared to the Intervention Failure Group (85%) or the Placebo Group (60%, all p < 0.05). There was no difference in CLD/Death between the Intervention Success and Low Risk Groups (8%, p > 0.05). A persistent PDA beyond Day 8 was associated with CLD/Death (aOR 6.5 [1.7-25.5]). CONCLUSIONS Early shunt elimination in preterm infants with a PDA may reduce respiratory morbidity when compared to infants with prolonged shunt exposure.
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Abstract
Despite important advances in neonatal care, rates of bronchopulmonary dysplasia (BPD) have remained persistently high. Numerous drugs and ventilator strategies are used for the prevention and treatment of BPD. Some, such as exogenous surfactant, volume targeted ventilation, caffeine, and non-invasive respiratory support, are associated with modest but important reductions in rates of BPD and long-term respiratory morbidities. Many other therapies, such as corticosteroids, diuretics, nitric oxide, bronchodilators and anti-reflux medications, are widely used despite conflicting, limited or no evidence of efficacy and safety. This paper examines the range of therapies used for the prevention or treatment of BPD. They are classified into those supported by evidence of effectiveness, and those which are widely used despite limited evidence or unclear risk to benefit ratios. Finally, the paper explores emerging therapies and approaches which aim to prevent or reduce BPD and long-term respiratory morbidity.
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Mitra S, Scrivens A, von Kursell AM, Disher T. Early treatment versus expectant management of hemodynamically significant patent ductus arteriosus for preterm infants. Cochrane Database Syst Rev 2020; 12:CD013278. [PMID: 33301630 PMCID: PMC8812277 DOI: 10.1002/14651858.cd013278.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is associated with significant morbidity and mortality in preterm infants. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to prevent or treat a PDA. There are concerns regarding adverse effects of NSAIDs in preterm infants. Controversy exists on whether early targeted treatment of a hemodynamically significant (hs) PDA improves clinical outcomes. OBJECTIVES To assess the effectiveness and safety of early treatment strategies versus expectant management for an hs-PDA in reducing mortality and morbidity in preterm infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 6) in the Cochrane Library; MEDLINE via PubMed (1966 to 31 May 2019), Embase (1980 to 31 May 2019), and CINAHL (1982 to 31 May 2019). An updated search was run on 2 October 2020 in the following databases: CENTRAL via CRS Web and MEDLINE via Ovid. We searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials (RCT) and quasi-randomized trials. SELECTION CRITERIA We included RCTs in which early pharmacological treatment, defined as treatment initiated within the first seven days after birth, was compared to no intervention, placebo or other non-pharmacological expectant management strategies for treatment of an hs-PDA in preterm (< 37 weeks' postmenstrual age) or low birth weight (< 2500 grams) infants. DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of Cochrane Neonatal. Our primary outcome was all-cause mortality during hospital stay. We used the GRADE approach to assess the certainty of evidence for selected clinical outcomes. MAIN RESULTS We included 14 RCTs that enrolled 910 infants. Seven RCTs compared early treatment (defined as treatment initiated by seven days of age) versus expectant management and seven RCTs compared very early treatment (defined as treatment initiated by 72 hours of age) versus expectant management. No difference was demonstrated between early treatment versus expectant management (no treatment initiated within the first seven days after birth) for an hs-PDA for the primary outcome of 'all-cause mortality' (6 studies; 500 infants; typical RR 0.80, 95% CI 0.46 to 1.39; typical RD -0.02; 95% CI -0.07 to 0.03; moderate-certainty evidence), or other important outcomes such as surgical PDA ligation (4 studies; 432 infants; typical RR 1.08, 95% CI 0.65 to 1.80; typical RD -0.03; 95% CI -0.09 to 0.03; very low-certainty evidence), chronic lung disease (CLD) (4 studies; 339 infants; typical RR 0.90, 95% CI 0.62 to 1.29; typical RD -0.03; 95% CI -0.10 to 0.03; moderate-certainty evidence), severe intraventricular hemorrhage (IVH) (2 studies; 171 infants; typical RR 0.83,95% CI 0.32 to 2.16; typical RD -0.01; 95% CI -0.08 to 0.06; low-certainty evidence), and necrotizing enterocolitis (NEC) (5 studies; 473 infants; typical RR 2.34,95% CI 0.86 to 6.41; typical RD 0.04; 95% CI 0.01 to 0.08; low-certainty evidence). Infants receiving early treatment in the first seven days after birth were more likely to receive any PDA pharmacotherapy compared to expectant management (2 studies; 232 infants; typical RR 2.30, 95% CI 1.86 to 2.83; typical RD 0.57; 95% CI 0.48 to 0.66; low-certainty evidence). No difference was demonstrated between very early treatment versus expectant management (no treatment initiated within the first 72 hours after birth) for an hs-PDA for the primary outcome of 'all-cause mortality' (7 studies; 384 infants; typical RR 0.94, 95% CI 0.58 to 1.53; typical RD -0.03; 95% CI -0.09 to 0.04; moderate-certainty evidence) or other important outcomes such as surgical PDA ligation (5 studies; 293 infants; typical RR 0.88, 95% CI 0.36 to 2.17; typical RD -0.01; 95% CI -0.05 to 0.02; moderate-certainty evidence), CLD (7 studies; 384 infants; typical RR 0.83, 95% CI 0.63 to 1.08; typical RD -0.05; 95% CI -0.13 to 0.04; low-certainty evidence), severe IVH (4 studies, 240 infants; typical RR 0.64, 95% CI 0.21 to 1.93; typical RD -0.02; 95% CI -0.07 to 0.04; moderate-certainty evidence), NEC (5 studies; 332 infants; typical RR 1.08, 95% CI 0.53 to 2.21; typical RD 0.01; 95% CI -0.04 to 0.06; moderate-certainty evidence) and neurodevelopmental impairment (1 study; 79 infants; RR 0.27, 95% CI 0.03 to 2.31 for moderate/severe cognitive delay at 18 to 24 months; RR 0.54, 95% CI 0.05 to 5.71 for moderate/severe motor delay at 18 to 24 months; RR 0.54, 95% CI 0.10 to 2.78 for moderate/severe language delay at 18 to 24 months; low-certainty evidence). Infants receiving very early treatment in the first 72 hours after birth were more likely to receive any PDA pharmacotherapy compared to expectant management (4 studies; 156 infants; typical RR 1.64, 95% CI 1.31 to 2.05; typical RD 0.69; 95% CI 0.60 to 0.79; very low-certainty evidence). Very early treatment, however, shortened the duration of hospitalization compared to expectant management (4 studies; 260 infants; MD -5.35 days; 95% CI -9.23 to -1.47; low-certainty evidence). AUTHORS' CONCLUSIONS Early or very early pharmacotherapeutic treatment of an hs-PDA probably does not reduce mortality in preterm infants (moderate-certainty evidence). Early pharmacotherapeutic treatment of hs-PDA may increase NSAID exposure (low-certainty evidence) without likely reducing CLD (moderate-certainty evidence), severe IVH or NEC (low-certainty evidence). We are uncertain whether very early pharmacotherapeutic treatment of hs-PDA also increases NSAID exposure (very low-certainty evidence). Very early treatment probably does not reduce surgical PDA ligation, severe IVH or NEC (moderate-certainty evidence), and may not reduce CLD or neurodevelopmental impairment (low-certainty evidence). Additional large trials that specifically include preterm infants at the highest risk of PDA-attributable morbidity, are adequately powered for patient-important outcomes and are minimally contaminated by open-label treatment are required to explore if early targeted treatment of hs-PDA improves clinical outcomes. There are currently two trials awaiting classification and two ongoing trials exploring this question.
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Affiliation(s)
- Souvik Mitra
- Departments of Pediatrics, Community Health & Epidemiology, Dalhousie University & IWK Health Centre, Halifax, Canada
| | - Alexandra Scrivens
- Neonatal Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Tim Disher
- Evidence Synthesis and Data Analytics, EVERSANA Inc, Sydney, Canada
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Does crossover treatment of control subjects invalidate results of randomized trials of patent ductus arteriosus treatment? J Perinatol 2020; 40:1863-1870. [PMID: 33024260 DOI: 10.1038/s41372-020-00848-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/14/2020] [Accepted: 09/24/2020] [Indexed: 02/07/2023]
Abstract
Optimal management of patent ductus arteriosus (PDA) in extremely preterm infants remains controversial. There is paucity of evidence on the benefits of PDA treatment in reducing mortality and morbidities in extremely preterm infants. Failure of randomized clinical trials to demonstrate beneficial effects of PDA treatment on outcomes has often been attributed to open treatment of control subjects. This perspective examines the PDA treatment trials to date, with specific focus on rates of and ages of subjects at open rescue treatment. Although these trials demonstrate that ductal closure is significantly increased with treatment, that does not translate to a significant decrease in major morbidities or mortality in premature infants, even when trials with high rates of rescue treatment of controls are excluded. Trials in which enrollment occurred after 7 days of age include insufficient numbers of subjects to evaluate this relationship.
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28
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Hamrick SEG, Sallmon H, Rose AT, Porras D, Shelton EL, Reese J, Hansmann G. Patent Ductus Arteriosus of the Preterm Infant. Pediatrics 2020; 146:e20201209. [PMID: 33093140 PMCID: PMC7605084 DOI: 10.1542/peds.2020-1209] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2020] [Indexed: 02/07/2023] Open
Abstract
Postnatal ductal closure is stimulated by rising oxygen tension and withdrawal of vasodilatory mediators (prostaglandins, nitric oxide, adenosine) and by vasoconstrictors (endothelin-1, catecholamines, contractile prostanoids), ion channels, calcium flux, platelets, morphologic maturity, and a favorable genetic predisposition. A persistently patent ductus arteriosus (PDA) in preterm infants can have clinical consequences. Decreasing pulmonary vascular resistance, especially in extremely low gestational age newborns, increases left-to-right shunting through the ductus and increases pulmonary blood flow further, leading to interstitial pulmonary edema and volume load to the left heart. Potential consequences of left-to-right shunting via a hemodynamically significant patent ductus arteriosus (hsPDA) include increased risk for prolonged ventilation, bronchopulmonary dysplasia, necrotizing enterocolitis or focal intestinal perforation, intraventricular hemorrhage, and death. In the last decade, there has been a trend toward less aggressive treatment of PDA in preterm infants. However, there is a subgroup of infants who will likely benefit from intervention, be it pharmacologic, interventional, or surgical: (1) prophylactic intravenous indomethacin in highly selected extremely low gestational age newborns with PDA (<26 + 0/7 weeks' gestation, <750 g birth weight), (2) early targeted therapy of PDA in selected preterm infants at particular high risk for PDA-associated complications, and (3) PDA ligation, catheter intervention, or oral paracetamol may be considered as rescue options for hsPDA closure. The impact of catheter-based closure of hsPDA on clinical outcomes should be determined in future prospective studies. Finally, we provide a novel treatment algorithm for PDA in preterm infants that integrates the several treatment modalities in a staged approach.
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Affiliation(s)
- Shannon E G Hamrick
- Divisions of Neonatology and
- Cardiology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | | | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elaine L Shelton
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Jeff Reese
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
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Bischoff AR, Giesinger RE, Bell EF, McNamara PJ. Precision medicine in neonatal hemodynamics: need for prioritization of mechanism of illness and defining population of interest. J Perinatol 2020; 40:1446-1449. [PMID: 32719495 DOI: 10.1038/s41372-020-0741-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/15/2020] [Accepted: 07/10/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Adrianne Rahde Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Regan E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Edward F Bell
- Division of Neonatology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.
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Abstract
More than 70 randomized controlled trials have been conducted on the management of patent ductus arteriosus (PDA) in preterm infants. Yet, clinicians are unsure if treating a PDA improves clinically important outcomes. Earlier clinical trials have primarily explored which pharmacotherapeutic agent effectively closes the PDA. Because many of these trials included older infants, had widely varying PDA definitions, and provided open-label treatment, it is difficult to draw inferences on clinical outcomes based on the results of these trials. These flaws in trial design might have contributed to the growing notion that "no treatment" is a feasible option irrespective of the clinical characteristics of the infant and the PDA shunt volume.
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31
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Terrin G, Di Chiara M, Boscarino G, Versacci P, Di Donato V, Giancotti A, Pacelli E, Faccioli F, Onestà E, Corso C, Ticchiarelli A, De Curtis M. Echocardiography-Guided Management of Preterms With Patent Ductus Arteriosus Influences the Outcome: A Cohort Study. Front Pediatr 2020; 8:582735. [PMID: 33409261 PMCID: PMC7779760 DOI: 10.3389/fped.2020.582735] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction: Echocardiography (ECHO) with color flow Doppler is considered as the gold standard to identify a hemodynamic patent ductus arteriosus (hs-PDA). However, the optimal diagnostic and therapeutic management for newborns with hs-PDA is still controversial. We aimed to investigate two clinical strategies: (1) targeted treatment based on ECHO criteria and (2) treatment based on ECHO criteria in addition to clinical signs and symptoms. Materials and Methods: This is a cohort study including all neonates consecutively admitted in the Neonatal Intensive Care Unit of University La Sapienza in Rome, with gestational age <32 weeks or body birth weight <1,500 g and with a diagnosis of hs-PDA as confirmed by ECHO evaluation performed within 72 h of life. We classified the babies in two cohorts: (A) pharmacological treatment immediately after ECHO screening and (B) pharmacological therapy for PDA was administered when the relevance of a hs-PDA was associated with clinical signs of hemodynamic instability. Results: We considered as primary outcome newborns who survived without any morbidities (A: 48.1% vs. B: 22.2%, p = 0.022). In particular, we found that the rate of intraventricular hemorrhage stage ≥2 was increased in cohort B (A: 3.7% vs. B 24.4%, p = 0.020). A multivariate analysis showed that assignment to cohort A independently influences the primary outcome. Conclusions: Adopting an hs-PDA management option based on ECHO-directed therapy regardless of symptoms may reduce the morbidity and improve the survival of very low birth weight infants.
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Affiliation(s)
- Gianluca Terrin
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Maria Di Chiara
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Giovanni Boscarino
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Paolo Versacci
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Violante Di Donato
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Elisabetta Pacelli
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Francesca Faccioli
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Elisa Onestà
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | - Chiara Corso
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
| | | | - Mario De Curtis
- Department of Maternal and Child Health, University of Rome La Sapienza, Rome, Italy
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Sung SI, Chang YS, Ahn SY, Jo HS, Yang M, Park WS. Conservative Non-intervention Approach for Hemodynamically Significant Patent Ductus Arteriosus in Extremely Preterm Infants. Front Pediatr 2020; 8:605134. [PMID: 33425816 PMCID: PMC7786118 DOI: 10.3389/fped.2020.605134] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/07/2020] [Indexed: 12/15/2022] Open
Abstract
While persistent patent ductus arteriosus (PDA) in preterm infants has been known to be associated with increased mortality and morbidities including bronchopulmonary dysplasia, and necrotizing enterocolitis, there is minimal evidence supporting their causal relationships, and most traditional medical and/or surgical treatments have failed to show improvements in these outcomes. As such, the pendulum has swung toward the conservative non-intervention approach for the management of persistent PDA during the last decade; however, the benefits and risks of this approach are unclear. In this mini review, we focused on whom, when, and how to apply the conservative non-intervention approach for persistent PDA, especially in extremely preterm infants.
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Affiliation(s)
- Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - So Yoon Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Heui Seung Jo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Misun Yang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Pharmacological closure of the patent ductus arteriosus: when treatment still makes sense. J Perinatol 2019; 39:1439-1441. [PMID: 31591487 PMCID: PMC7055580 DOI: 10.1038/s41372-019-0518-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 01/30/2023]
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Khanafer-Larocque I, Soraisham A, Stritzke A, Al Awad E, Thomas S, Murthy P, Kamaluddeen M, Scott JN, Mohammad K. Intraventricular Hemorrhage: Risk Factors and Association With Patent Ductus Arteriosus Treatment in Extremely Preterm Neonates. Front Pediatr 2019; 7:408. [PMID: 31696098 PMCID: PMC6817605 DOI: 10.3389/fped.2019.00408] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 09/20/2019] [Indexed: 11/22/2022] Open
Abstract
Objectives: To assess maternal and neonatal risk factors for intraventricular hemorrhage (IVH). To examine the association of patent ductus arteriosus (PDA) and its treatment, with IVH and its severity. Study design: In this retrospective cohort study, we included preterm neonates born at <29 weeks, admitted to a tertiary level III Neonatal Intensive Care Unit in Calgary, Canada, between 2013 and 2016, who had a head ultrasound in the first 7 days of life. A subset analysis included neonates who also had cardiac ultrasound in the first 3 days of life. Results: Of the 495 neonates, 121 (24.4%) had IVH of any grade and 48 (9.7%) had severe IVH. Identified risk factors were small birth gestation and weight, lack of antenatal corticosteroids, maternal chorioamnionitis, Apgar score <5 at 5 min, umbilical cord pH < 7, respiratory distress syndrome, early onset sepsis, hypercapnia, pCO2 fluctuations, prolonged intubation, inhaled nitric oxide, inotropes or normal saline boluses, metabolic derangements, opioids infusions, and bicarbonate/THAM therapy. In a primary analysis of the total cohort, when the decision to treat a PDA was used as a surrogate marker of its clinical significance, a PDA requiring treatment was associated with a higher risk of IVH. There was no significant difference in the incidence of IVH between neonates with early treatment of a clinically significant PDA compared to late, however early indomethacin treatment was associated with reduced severity of IVH. In the subset analysis, the presence of a hemodynamically significant PDA (hs-PDA) was not associated with a higher probability of IVH. Of those with severe IVH, 18 (55%) had a hs-PDA; this is clinically but not statistically significant. Conclusions: Identified risk factors should be the target of IVH reduction bundles. Early indomethacin treatment for a clinically significant PDA may reduce IVH severity.
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Affiliation(s)
- Ijab Khanafer-Larocque
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
- Section of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Amuchou Soraisham
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Amelie Stritzke
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Essa Al Awad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Sumesh Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Majeeda Kamaluddeen
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - James N. Scott
- Departments of Diagnostic Imaging and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
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