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Loth C, Treluyer L, Pierrat V, Ego A, Aubert AM, Debillon T, Zeitlin J, Torchin H, Chevallier M. Variations in neonatal mortality of preterm infants with intraparenchymal haemorrhage in Europe: the EPICE cohort. Arch Dis Child Fetal Neonatal Ed 2024; 109:488-494. [PMID: 38272659 DOI: 10.1136/archdischild-2023-326038] [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: 07/02/2023] [Accepted: 01/14/2024] [Indexed: 01/27/2024]
Abstract
OBJECTIVE The aim of this study was to investigate variations in mortality before neonatal intensive care unit (NICU) discharge of infants born preterm with intraparenchymal haemorrhage (IPH) in Europe with a special interest for withdrawing life-sustaining therapy (WLST). DESIGN Secondary analysis of the Effective Perinatal Intensive Care in Europe (EPICE) cohort, 2011-2012. SETTING Nineteen regions in 11 European countries. PATIENTS All infants born between 24+0 and 31+6 weeks' gestational age (GA) with a diagnosis of IPH. MAIN OUTCOME MEASURES Mortality rate with multivariable analysis after adjustment for GA, antenatal steroids and gender. WLST policies were described among NICUs and within countries. RESULTS Among 6828 infants born alive between 24+0 and 31+6 weeks' GA and without congenital anomalies admitted to NICUs, IPH was diagnosed in 234 infants (3.4%, 95% CI 3.3% to 3.9%) and 138 of them (59%) died. The median age at death was 6 days (3-13). Mortality rates varied significantly between countries (extremes: 30%-81%; p<0.004) and most infants (69%) died after WLST. After adjustment and with reference to the UK, mortality rates were significantly higher for France, Denmark and the Netherlands, with ORs of 8.8 (95% CI 3.3 to 23.6), 5.9 (95% CI 1.6 to 21.4) and 4.8 (95% CI 1.1 to 8.9). There were variations in WLST between European regions and countries. CONCLUSION In infants with IPH, rates of death before discharge and death after WLST varied between European countries. These variations in mortality impede studying reliable outcomes in infants with IPH across European countries and encourage reflection of clinical practices of WLST across European units.
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Affiliation(s)
- Charline Loth
- University Grenoble Alpes, Neonatology Department, CHU Grenoble-Alpes, Grenoble, France
| | - Ludovic Treluyer
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
| | - Véronique Pierrat
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
| | - Anne Ego
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
- Grenoble Alpes, Inserm CIC1406, CHU Grenoble, Grenoble, France
| | - Adrien M Aubert
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
| | - Thierry Debillon
- University Grenoble Alpes, Neonatology Department, CHU Grenoble-Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, Public Health Department CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, Institute of Engineering, University Grenoble Alpes, Grenoble, France
| | - Jennifer Zeitlin
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
| | - Heloise Torchin
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
- Neonatal Intensive Care Unit, Port-Royal Maternity, Paris, Île-de-France, France
| | - Marie Chevallier
- University Grenoble Alpes, Neonatology Department, CHU Grenoble-Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, Public Health Department CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, Institute of Engineering, University Grenoble Alpes, Grenoble, France
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Chevallier M, Barrington KJ, Terrien Church P, Luu TM, Janvier A. Decision-making for extremely preterm infants with severe hemorrhages on head ultrasound: Science, values, and communication skills. Semin Fetal Neonatal Med 2023; 28:101444. [PMID: 37150640 DOI: 10.1016/j.siny.2023.101444] [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: 05/09/2023]
Abstract
Severe intracranial hemorrhages are not rare in extremely preterm infants. They occur early, generally when babies require life-sustaining interventions. This may lead to ethical discussions and decision-making about levels of care. Prognosis is variable and depends on the extent, location, and laterality of the lesions, and, importantly also on the subsequent occurrence of other clinical complications or progressive ventricular dilatation. Decision-making should depend on prognosis and parental values. This article will review prognosis and the uncertainty of outcomes for different lesions and provide an outline of ways to conduct an ethically appropriate discussion on the decision of whether to continue life sustaining therapy. It is possible to communicate in a compassionate and honest way with parents and engage in decision-making, focussing on personalized information and decisions, and on function, as opposed to diagnosis.
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Affiliation(s)
- M Chevallier
- Department of Neonatal Intensive Care Unit, CHU Grenoble, Grenoble, France; TIMC-IMAG Research Department; Grenoble Alps University; Grenoble, France
| | - K J Barrington
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - P Terrien Church
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - T M Luu
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - A Janvier
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada; Bureau de L'éthique Clinique, Université de Montréal, Canada; Unité D'éthique Clinique, Unité de Soins Palliatifs, Bureau Du Partenariat Patients-Familles-Soignants; CHU Sainte-Justine, Montréal, Canada.
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3
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Tréluyer L, Chevallier M, Jarreau PH, Baud O, Benhammou V, Gire C, Marchand-Martin L, Marret S, Pierrat V, Ancel PY, Torchin H. Intraventricular Hemorrhage in Very Preterm Children: Mortality and Neurodevelopment at Age 5. Pediatrics 2023; 151:e2022059138. [PMID: 36919442 PMCID: PMC10071431 DOI: 10.1542/peds.2022-059138] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVES The objectives were to describe mortality and causes of death in children with intraventricular hemorrhage (IVH) and to study neurodevelopmental outcomes. METHODS The study was a secondary analysis of the French national prospective and population-based cohort EPIPAGE-2. Children were recruited in 2011. A standardized assessment was conducted at age 5. Children born before 32 weeks' gestation and admitted to a NICU were eligible. Exposure was IVH defined by the Papile classification. Main outcomes were mortality, causes of death, and neurodevelopmental outcomes at age 5. RESULTS Among the 3468 children included, 578 (16.7%) had grade 1 IVH, 424 (12.2%) grade 2 IVH, and 114 (3.3%) grade 3 IVH; 144 (4.1%) had intraparenchymal hemorrhage (IPH). Mortality was 29.7% (36 of 114) for children with grade 3 IVH and 74.4% (109 of 144) for those with IPH; 67.6% (21 of 31) and 88.7% (86 of 97) of deaths, respectively, were because of withholding and withdrawing of life-sustaining treatment. As compared with no IVH, low-grade IVH was not associated with measured neurodevelopmental disabilities at age 5. High-grade IVH was associated with moderate and severe neurodevelopmental disabilities, reduced full-scale IQ, and cerebral palsy. CONCLUSIONS Rates of neurodevelopmental disabilities at age 5 did not differ between children without IVH and those with low-grade IVH. For high-grade IVH, mortality rate was high, mostly because of withholding and withdrawal of life-sustaining treatment, and we found a strong association with overall neurodevelopmental disabilities in survivors.
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Affiliation(s)
- Ludovic Tréluyer
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Université Paris Cité, Paris, France
- Department of Neonatal Medicine of Port Royal, Cochin Hospital, FHU PREMA, AP-HP Centre – Université Paris Cité, Paris, France
| | - Marie Chevallier
- NICU, Grenoble Alps University Hospital Centre Couples and Children Section, Grenoble, France
- TIMC-IMAG Research Department, Grenoble Alps University, Grenoble, France
| | - Pierre-Henri Jarreau
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Université Paris Cité, Paris, France
- Department of Neonatal Medicine of Port Royal, Cochin Hospital, FHU PREMA, AP-HP Centre – Université Paris Cité, Paris, France
| | - Olivier Baud
- Division of Neonatology and Pediatric Intensive Care, Children’s University Hospital of Geneva, Geneva, Switzerland
- Université Paris Cité, Inserm U1141, Paris, France
| | - Valérie Benhammou
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Université Paris Cité, Paris, France
| | - Catherine Gire
- Department of Neonatology, North Hospital, University Hospital of Marseille,Chemin des Bourrelys, CEDEX 20, Marseille, France
| | - Laetitia Marchand-Martin
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Université Paris Cité, Paris, France
| | - Stéphane Marret
- Department of Neonatal Pediatrics, Intensive Care, and Neuropediatrics, Rouen University Hospital, Rouen, France and INSERM Unit 1245, Team Perinatal Handicap, School of Medicine of Rouen, Normandy University, Normandy, France
| | - Véronique Pierrat
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Université Paris Cité, Paris, France
- Department of Neonatal Medicine, CHU Lille, Jeanne de Flandre Hospital, Lille, France
| | - Pierre-Yves Ancel
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Université Paris Cité, Paris, France
- Clinical Research Unit, Center for Clinical Investigation P1419, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Héloïse Torchin
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Université Paris Cité, Paris, France
- Department of Neonatal Medicine of Port Royal, Cochin Hospital, FHU PREMA, AP-HP Centre – Université Paris Cité, Paris, France
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Syltern J, Ursin L, Solberg B, Støen R. Postponed Withholding: Balanced Decision-Making at the Margins of Viability. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:15-26. [PMID: 33998962 DOI: 10.1080/15265161.2021.1925777] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support into an ethical dilemma. Shared decision-making with parents has gained ground. However, the need to start immediate life support and the ensuing difficulty of withdrawing treatment stands in tension with the possibility of a fair decision-making process. Both the parental "instinct of saving" and "withdrawal resistance" involved can preclude shared decision-making. To help health care personnel and empower parents, we propose a novel approach labeled "postponed withholding." In the absence of a prenatal advance directive, life support is started at birth, followed by planned redirection to palliative care after one week, unless parents, after a thorough counseling process, actively ask for continued life support. Despite the emotional challenges, this approach can facilitate ethically balanced decision-making processes in the gray zone.
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Affiliation(s)
- Janicke Syltern
- Norwegian University of Science and Technology
- St Olavs Hospital University Hospital in Trondheim
| | - Lars Ursin
- The Norwegian University of Science and Technology
| | | | - Ragnhild Støen
- Norwegian University of Science and Technology
- St Olavs Hospital University Hospital in Trondheim
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Hayakawa K, Tanda K, Nishimoto M, Nishimura A, Kinoshita D, Sano Y. The Incidence of Intraventricular Hemorrhage in Low-Birth-Weight Infants: Assessment by Magnetic Resonance Imaging. Neuropediatrics 2022; 53:246-250. [PMID: 35843217 DOI: 10.1055/s-0042-1750736] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Intraventricular hemorrhage (IVH) is common in infants with a low-birth-weight (LBW) and has been suggested to cause major impairment not only of future motor development but also of cognitive function and learning ability. The purpose of the present study is to assess the frequency of IVH using magnetic resonance imaging (MRI) in LBW infants and its clinical neurodevelopmental outcomes. METHODS We enrolled a consecutive series of 247 neonates with an LBW of < 1,500 g hospitalized in the newborn intensive care unit between 2010 and 2015. The presence of IVH was examined using T2* MRI at term-equivalent age (TEA). We then investigated the clinical outcome at ≥3 years of age and its correlation with the IVH grade. RESULTS The overall incidence of IVH among LBW infants was 16.2%. The proportion of infants with IVH showing a favorable outcome did not differ significantly from that of infants without IVH. The proportion of neonates showing a poor outcome was 6.7% for those with IVH and 1.9% for those without IVH and 2.7% for those with and without IVH combined. CONCLUSION We were able to clarify the frequency of IVH in LBW infants using MRI at TEA. We demonstrated the lower incidence of mortality and IVH, the higher incidence of a favorable outcome, and the lower incidence of poor outcome.
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Affiliation(s)
- Katsumi Hayakawa
- Department of Diagnostic Radiology, Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Koichi Tanda
- Department of Neonatology, Red Cross Kyoto Daiichi Hospital, Kyoto, Japan.,Department of Pediatrics, Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Masakazu Nishimoto
- Department of Diagnostic Radiology, Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Akira Nishimura
- Department of Neonatology, Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Daisuke Kinoshita
- Department of Neonatology, Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Yuko Sano
- Department of Diagnostic Radiology, Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
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6
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Ethical considerations in the management of infants with severe intraventricular hemorrhage. Semin Perinatol 2022; 46:151599. [PMID: 35450739 DOI: 10.1016/j.semperi.2022.151599] [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] [Indexed: 11/22/2022]
Abstract
Intrinsic and extrinsic factors unique to neonatal care can complicate predictions of neurological outcomes for infants who suffer from severe intraventricular hemorrhage. While care decisions are driven by the same bioethical principles used in other domains, neurological prognostication can challenge concepts of futility, require careful examination of parental values, uncover biases and/or potentially compromise the best interests of the future child. In the following chapter we will review bioethical principles and relevant concepts, explore challenges to decision-making surrounding diagnoses of severe intraventricular hemorrhage and conclude with a brief review of practical approaches for counseling parents about neurodevelopmental impairment given the constraints of prognostic uncertainty and assumptions related to quality of life. We will argue that neurological findings alone, even in the setting of severe intraventricular hemorrhage, often do not constitute enough evidence for redirection of care but can be permissible when the entire neonatal condition is considered.
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7
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Desai S, Athalye-Jape G, Madhala S, Tee W, Sharp M, Nathan E, Shrestha D, Patole S. Comparison of Papile versus Laterality-Based Al-Abdi System to Predict Neurodevelopmental Impairment in Extreme Preterm Infants after Severe Germinal Matrix Hemorrhage-Intraventricular Hemorrhage: A Retrospective Comparative Observational Study. AJNR Am J Neuroradiol 2022; 43:486-492. [PMID: 35210279 PMCID: PMC8910795 DOI: 10.3174/ajnr.a7434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/01/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The traditional Papile classification system for severe germinal matrix hemorrhage-intraventricular hemorrhage is limited in objectivity and interrater variability for accurate prediction of neurodevelopmental impairment in extremely preterm infants. Many extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage are still offered "redirection of care" in spite of the recent evidence suggesting that many of these infants can have normal outcomes. Therefore, it is important to consider the laterality and extent of brain hemisphere involvement while classifying severe germinal matrix hemorrhage-intraventricular hemorrhage to predict neurodevelopmental impairment. The aim of the present study was to compare the Al-Abdi system with the Papile system for their accuracy in predicting neurodevelopmental impairment in extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage. MATERIALS AND METHODS This is a retrospective study of extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage admitted to a tertiary neonatal intensive care unit (2006-2016). Cranial sonograms were independently re-reviewed by 2 radiologists as per the Al-Abdi system. The prognostic statistical indices for both systems to predict neurodevelopmental impairment were calculated. RESULTS A total of 91 infants with severe germinal matrix hemorrhage-intraventricular hemorrhage survived, and 83 (median gestational age, 26.3 weeks; and median birth weight, 890 g) completed developmental assessment. The receiver operating characteristic areas under the curve to predict neurodevelopmental impairment by the Papile versus Al-Abdi systems were 0.702 versus 0.723, respectively (P = .474). Corresponding Al-Abdi cutoff scores of 19, 20, 21, and 22 demonstrated increased specificity (76.36%-85.45%) and correct classification (69.88%-72.29%) to predict moderate-to-severe neurodevelopmental impairment. CONCLUSIONS The Al-Abdi system is comparable with the Papile system for predicting neurodevelopmental impairment for extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage, with higher Al-Abdi scores being more specific. This finding may prove useful for neonatal health care providers and parents in their decision regarding "continuation of care." Future multicentric studies are warranted to ascertain the validity of individual Al-Abdi scores.
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Affiliation(s)
- S. Desai
- From the Neonatal Directorate (S.D., G.A.-J., M.S., D.S., S.P.),Perth Children’s Hospital (D.S, S.M., W.T., M.S.), Perth, Western Australia, Australia
| | - G. Athalye-Jape
- From the Neonatal Directorate (S.D., G.A.-J., M.S., D.S., S.P.),School of Medicine (G.A.-J., M.S., S.P.)
| | - S. Madhala
- Department of Radiology (S.M., W.T.),Perth Children’s Hospital (D.S, S.M., W.T., M.S.), Perth, Western Australia, Australia
| | - W. Tee
- Department of Radiology (S.M., W.T.),Perth Children’s Hospital (D.S, S.M., W.T., M.S.), Perth, Western Australia, Australia
| | - M. Sharp
- From the Neonatal Directorate (S.D., G.A.-J., M.S., D.S., S.P.),Perth Children’s Hospital (D.S, S.M., W.T., M.S.), Perth, Western Australia, Australia,School of Medicine (G.A.-J., M.S., S.P.)
| | - E. Nathan
- Women and Infants Research Foundation (E.N.), King Edward Memorial Hospital for Women, Perth, Western Australia, Australia,Division of Obstetrics and Gynaecology (E.N.), University of Western Australia, Perth, Western Australia, Australia
| | - D. Shrestha
- From the Neonatal Directorate (S.D., G.A.-J., M.S., D.S., S.P.)
| | - S. Patole
- From the Neonatal Directorate (S.D., G.A.-J., M.S., D.S., S.P.),School of Medicine (G.A.-J., M.S., S.P.)
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8
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Campbell H, Check J, Kuban KCK, Leviton A, Joseph RM, Frazier JA, Douglass LM, Roell K, Allred EN, Fordham LA, Hooper SR, Jara H, Paneth N, Mokrova I, Ru H, Santos HP, Fry RC, O’Shea TM. Neonatal Cranial Ultrasound Findings among Infants Born Extremely Preterm: Associations with Neurodevelopmental Outcomes at 10 Years of Age. J Pediatr 2021; 237:197-205.e4. [PMID: 34090894 PMCID: PMC8478718 DOI: 10.1016/j.jpeds.2021.05.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine the association between neonatal cranial ultrasound (CUS) abnormalities among infants born extremely preterm and neurodevelopmental outcomes at 10 years of age. STUDY DESIGN In a multicenter birth cohort of infants born at <28 weeks of gestation, 889 of 1198 survivors were evaluated for neurologic, cognitive, and behavioral outcomes at 10 years of age. Sonographic markers of white matter damage (WMD) included echolucencies in the brain parenchyma and moderate to severe ventricular enlargement. Neonatal CUS findings were classified as intraventricular hemorrhage (IVH) without WMD, IVH with WMD, WMD without IVH, and neither IVH nor WMD. RESULTS WMD without IVH was associated with an increased risk of cognitive impairment (OR 3.5, 95% CI 1.7, 7.4), cerebral palsy (OR 14.3, 95% CI 6.5, 31.5), and epilepsy (OR 6.9; 95% CI 2.9, 16.8). Similar associations were found for WMD accompanied by IVH. Isolated IVH was not significantly associated these outcomes. CONCLUSIONS Among children born extremely preterm, CUS abnormalities, particularly those indicative of WMD, are predictive of neurodevelopmental impairments at 10 years of age. The strongest associations were found with cerebral palsy.
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Affiliation(s)
- Heather Campbell
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Jennifer Check
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Karl C. K. Kuban
- Department of Pediatrics, Division of Pediatric Neurology, Boston University Medical Center, Boston, MA
| | - Alan Leviton
- Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Robert M Joseph
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA
| | - Jean A. Frazier
- Eunice Kennedy Shriver Center, University of Massachusetts Medical School, Worcester, MA
| | - Laurie M. Douglass
- Department of Pediatrics, Division of Pediatric Neurology, Boston University Medical Center, Boston, MA
| | - Kyle Roell
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Elizabeth N. Allred
- Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Lynn Ansley Fordham
- Department of Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Stephen R. Hooper
- Department of Allied Health, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Hernan Jara
- Department of Radiology, Boston University Medical Center, Boston, MA
| | - Nigel Paneth
- Michigan State University College of Human Medicine, East Lansing, MI
| | | | - Hongyu Ru
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Hudson P. Santos
- Biobehavioral Laboratory, School of Nursing, University of North Carolina, Chapel Hill, NC
| | - Rebecca C. Fry
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - T. Michael O’Shea
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
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Weydig HM, Rosenfeld CR, Jaleel MA, Burchfield PJ, Frost MS, Brion LP. Association of antenatal steroids with neonatal mortality and morbidity in preterm infants born to mothers with diabetes mellitus and hypertension. J Perinatol 2021; 41:1660-1668. [PMID: 34035455 DOI: 10.1038/s41372-021-01090-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/14/2021] [Accepted: 04/29/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Randomized trials of antenatal steroids (ANS) included women at 24-33 weeks gestational age (GA); however, few women had preeclampsia and women with diabetes mellitus (DM) were excluded. METHODS Cohort study including preterm births at 230/7-286/7 weeks GA before (Epoch-1) and after (Epoch-2) expansion of ANS administration to women with DM and hypertensive disorders (HTN). We compared Group-A (neither DM nor HTN) and Group-B (DM and/or HTN). RESULTS Among 747 neonates the adjusted odds ratio (aOR) for surfactant administration, in-hospital mortality, severe intraventricular hemorrhage (IVH) and death or severe IVH were lower in ANS-exposed neonates than unexposed neonates. In Group-B, ANS administration was independently associated with less severe IVH and less death or severe IVH, but not less surfactant use or mortality. CONCLUSIONS Increased ANS administration in women with DM and/or HTN was independently associated with less severe IVH and less death or severe IVH but without decrease in surfactant administration.
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Affiliation(s)
- Heather M Weydig
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Charles R Rosenfeld
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mambarambath A Jaleel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patti J Burchfield
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mackenzie S Frost
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Luc P Brion
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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10
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McCauley KE, Carey EC, Weaver AL, Mara KC, Clark RH, Carey WA, Collura CA. Survival of Ventilated Extremely Premature Neonates With Severe Intraventricular Hemorrhage. Pediatrics 2021; 147:e20201584. [PMID: 33727247 PMCID: PMC8015160 DOI: 10.1542/peds.2020-1584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Severe intraventricular hemorrhage (IVH) is a leading mortality risk factor among extremely premature neonates. Because other life-threatening conditions also occur in this population, it is unclear whether severe IVH is independently associated with death. The existence and potential implications of regional variation in severe IVH-associated mortality are unknown. METHODS We performed a retrospective cohort study of mechanically ventilated neonates born at 22 to 29 weeks' gestation who received care in 242 American NICUs between 2000 and 2014. After building groups composed of propensity score-matched and center-matched pairs, we used the Cox proportional hazards analysis to test our hypothesis that severe IVH would be associated with greater all-cause in-hospital mortality, defined as death before transfer or discharge. We also performed propensity score-matched subgroup analyses, comparing severe IVH-associated mortality among 4 geographic regions of the United States. RESULTS In our analysis cohort, we identified 4679 patients with severe IVH. Among 2848 matched pairs, those with severe IVH were more likely to die compared with those without severe IVH (hazard ratio 2.79; 95% confidence interval 2.49-3.11). Among 1527 matched pairs still hospitalized at 30 days, severe IVH was associated with greater risk of death (hazard ratio 2.03; 95% confidence interval 1.47-2.80). Mortality associated with severe IVH varied substantially between geographic regions. CONCLUSIONS The early diagnosis of severe IVH is independently associated with all-cause in-hospital mortality in extremely premature neonates. Regional variation in severe IVH-associated mortality suggests that shared decision-making between parents and neonatologists is strongly influenced by ultrasound-based IVH assessment and classification.
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Affiliation(s)
| | | | - Amy L Weaver
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Kristin C Mara
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Reese H Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
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11
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Tauber KA, Cummings JJ. Decision-Making for Extremely Preterm Infants With Severe Intraventricular Hemorrhage. Pediatrics 2021; 147:peds.2021-050057. [PMID: 33727248 DOI: 10.1542/peds.2021-050057] [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] [Accepted: 01/12/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Kate A Tauber
- Bernard and Millie Duker Children's Hospital, Albany, New York; .,Department of Pediatrics, Albany Medical Center, Albany, New York; and
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12
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Pascal A, Naulaers G, Ortibus E, Oostra A, De Coen K, Michel S, Cloet E, Casaer A, D'haese J, Laroche S, Jonckheere A, Plaskie K, Van Mol C, Delanghe G, Bruneel E, Van Hoestenberghe MR, Samijn B, Govaert P, Van den Broeck C. Neurodevelopmental outcomes of very preterm and very-low-birthweight infants in a population-based clinical cohort with a definite perinatal treatment policy. Eur J Paediatr Neurol 2020; 28:133-141. [PMID: 32788055 DOI: 10.1016/j.ejpn.2020.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND With constant changes in neonatal care practices, recent information is valuable for healthcare providers and for parental counselling. The aim of the study was to describe the neurodevelopmental outcome in a cohort of very preterm (VPT)/very-low-birthweight (VLBW) infants at 2 years corrected age (CA). MATERIAL AND METHODS This is a population-based cohort study of all infants born with a GA <31 weeks and/or BW < 1500 g between 2014 and 2016 admitted to the Flemish (Belgium) neonatal intensive care units. Infants had routine clinical follow-up around 2 years CA. The diagnosis of cerebral palsy (CP), visual and hearing impairments were recorded. Motor, cognitive and language outcomes were assessed using the Bayley-III. Neurodevelopmental impairment (NDI) was classified as mild (<1 standard deviation [SD]) or moderate-severe (<2SD) based on the defined categories of motor, cognitive, hearing, and vision impairments. RESULTS Of the 1941 admissions, 92% survived to discharge and follow-up data were available for 1089 infants (61.1%). Overall, 19.3%, 18.9% and 41.8% of infants had a motor, cognitive and language delay, respectively. CP was diagnosed in 4.3% of the infants. Mild and moderate-to-severe NDI was observed in 25.2% and 10.9% of the infants, respectively. The number of infants with a normal outcome increased from nearly 40% in the category of GA<26 weeks to 70% for infants in the category of 30─31 weeks GA. CONCLUSION At 2 years CA, 64% were free from NDI and 90% were free from moderate-to-severe NDI. However, a lower GA and BW are associated with higher rates of adverse neurodevelopmental outcomes at 2 years CA.
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Affiliation(s)
- Aurelie Pascal
- Department of Rehabilitation Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium; Department of Development and Regeneration, Katholieke Universiteit Leuven, Herestraat 49, 3000, Leuven, Belgium. http://
| | - Gunnar Naulaers
- Department of Neonatology, University Hospital Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium.
| | - Els Ortibus
- Centre for Developmental Disorders, University Hospital Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium.
| | - Ann Oostra
- Centre for Developmental Disorders, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Kris De Coen
- Department of Neonatology, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Sonnaert Michel
- Department of Neonatology, University Hospital Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Eva Cloet
- Department of Pediatric Neurology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Belgium.
| | - Alexandra Casaer
- Department of Neonatology, AZ Sint-Jan, Brugge, Ruddershove 10, 8000, Brugge, Belgium; Centre for Developmental Disorders, University Hospital Ghent, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - James D'haese
- Department of Neonatology, AZ Sint-Jan, Brugge, Ruddershove 10, 8000, Brugge, Belgium.
| | - Sabrina Laroche
- Department of Neonatology, University Hospital Antwerp, Wilrijkstraat 10, 2650, Antwerp, Belgium; Centre for Developmental Disorders, University Hospital Antwerp, Wilrijkstraat 10, 2650, Antwerp, Belgium.
| | - An Jonckheere
- Centre for Developmental Disorders, University Hospital Antwerp, Wilrijkstraat 10, 2650, Antwerp, Belgium.
| | - Katleen Plaskie
- Department of Neonatology, GasthuisZusters Antwerpen, Oosterveldlaan 24, Antwerp, Belgium.
| | - Christine Van Mol
- Department of Neonatology, GasthuisZusters Antwerpen, Oosterveldlaan 24, Antwerp, Belgium.
| | - Gwenda Delanghe
- Department of Neonatology, Algemeen Ziekenhuis Middelheim, Lindendreef 1, 2020, Antwerp, Belgium.
| | - Els Bruneel
- Department of Neonatology, Algemeen Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | | | - Bieke Samijn
- Department of Rehabilitation Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Paul Govaert
- Department of Rehabilitation Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Christine Van den Broeck
- Department of Rehabilitation Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
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Parodi A, Govaert P, Horsch S, Bravo MC, Ramenghi LA. Cranial ultrasound findings in preterm germinal matrix haemorrhage, sequelae and outcome. Pediatr Res 2020; 87:13-24. [PMID: 32218535 PMCID: PMC7098890 DOI: 10.1038/s41390-020-0780-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Germinal matrix-intraventricular haemorrhage (GMH-IVH), periventricular haemorrhagic infarction (PHI) and its complication, post-haemorrhagic ventricular dilatation (PHVD), are still common neonatal morbidities in preterm infants that are highly associated with adverse neurodevelopmental outcome. Typical cranial ultrasound (CUS) findings of GMH-IVH, PHI and PHVD, their anatomical substrates and underlying mechanisms are discussed in this paper. Furthermore, we propose a detailed descriptive classification of GMH-IVH and PHI that may improve quality of CUS reporting and prediction of outcome in infants suffering from GMH-IVH/PHI.
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Affiliation(s)
- Alessandro Parodi
- IRCCS, Istituto Giannina Gaslini, DINOGMI Department University of Genoa, Via Gaslini 5, 16148, Genoa, Italy
| | - Paul Govaert
- Department of Neonatology, Erasmus Medical Center University, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Neonatology, ZNA Middelheim, Antwerp, Belgium
- Department of Rehabilitation and Physical Therapy, Gent University Hospital, Gent, Belgium
| | - Sandra Horsch
- Department of Neonatology, Helios Klinikum Berlin Buch, Berlin, Germany
| | | | - Luca A Ramenghi
- IRCCS, Istituto Giannina Gaslini, DINOGMI Department University of Genoa, Via Gaslini 5, 16148, Genoa, Italy.
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Luo J, Luo Y, Zeng H, Reis C, Chen S. Research Advances of Germinal Matrix Hemorrhage: An Update Review. Cell Mol Neurobiol 2018; 39:1-10. [PMID: 30361892 DOI: 10.1007/s10571-018-0630-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 10/19/2018] [Indexed: 02/02/2023]
Abstract
Germinal matrix hemorrhage (GMH) refers to bleeding that derives from the subependymal (or periventricular) germinal region of the premature brain. GMH can induce severe and irreversible damage attributing to the vulnerable structure of germinal matrix and deleterious circumstances. Molecular mechanisms remain obscure so far. In this review, we summarized the newest preclinical discoveries recent years about GMH to distill a deeper understanding of the neuropathology, and then discuss the potential diagnostic or therapeutic targets among these pathways. GMH studies mostly in recent 5 years were sorted out and the authors generalized the newest discoveries and ideas into four parts of this essay. Intrinsic fragile structure of preterm germinal matrix is the fundamental cause leading to GMH. Many molecules have been found effective in the pathophysiological courses. Some of these molecules like minocycline are suggested active to reduce the damage in animal GMH model. However, researchers are still trying to find efficient diagnostic methods and remedies that are available in preterm infants to rehabilitate or cure the sequent injury. Merits have been obtained in the last several years on molecular pathways of GMH, but more work is required to further unravel the whole pathophysiology.
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Affiliation(s)
- Jinqi Luo
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Rd, Hangzhou, 310009, Zhejiang, China
| | - Yujie Luo
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Rd, Hangzhou, 310009, Zhejiang, China
| | - Hanhai Zeng
- Department of Neurological Surgery, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Cesar Reis
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Rd, Hangzhou, 310009, Zhejiang, China.
- Department of Neurosurgery, Taizhou Hospital, Wenzhou Medical University, Linhai, Zhejiang, China.
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