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Batool M, Cai CL, Aranda JV, Hand I, Beharry KD. Early versus late caffeine and/or non-steroidal anti-inflammatory drugs (NSAIDS) for prevention of intermittent hypoxia-induced neuroinflammation in the neonatal rat. Int J Dev Neurosci 2024; 84:227-250. [PMID: 38459740 DOI: 10.1002/jdn.10321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/17/2024] [Accepted: 02/13/2024] [Indexed: 03/10/2024] Open
Abstract
Preterm infants often experience frequent intermittent hypoxia (IH) episodes which are associated with neuroinflammation. We tested the hypotheses that early caffeine and/or non-steroidal inflammatory drugs (NSAIDs) confer superior therapeutic benefits for protection against IH-induced neuroinflammation than late treatment. Newborn rats were exposed to IH or hyperoxia (50% O2) from birth (P0) to P14. For early treatment, the pups were administered: 1) daily caffeine (Caff) citrate (Cafcit, 20 mg/kg IP loading on P0, followed by 5 mg/kg from P1-P14); 2) ketorolac (Keto) topical ocular solution in both eyes from P0 to P14; 3) ibuprofen (Ibu, Neoprofen, 10 mg/kg loading dose on P0 followed by 5 mg/kg/day on P1 and P2); 4) Caff+Keto co-treatment; 5) Caff+Ibu co-treatment; or 6) equivalent volume saline (Sal). On P14, animals were placed in room air (RA) with no further treatment until P21. For late treatment, pups were exposed from P0 to P14, then placed in RA during which they received similar treatments from P15-P21 (Sal, Caff, and/or Keto), or P15-P17 (Ibu). RA controls were similarly treated. At P21, whole brains were assessed for histopathology, apoptosis, myelination, and biomarkers of inflammation. IH caused significant brain injury and hemorrhage, inflammation, reduced myelination, and apoptosis. Early treatment with Caff alone or in combination with NSAIDs conferred better neuroprotection against IH-induced damage than late treatment. Early postnatal treatment during a critical time of brain development, may be preferable for the prevention of IH-induced brain injury in preterm infants.
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Affiliation(s)
- Myra Batool
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
| | - Charles L Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
| | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Ophthalmology, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
| | - Ivan Hand
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, New York City Health & Hospitals/Kings County, Brooklyn, NY, USA
| | - Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
- Department of Ophthalmology, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
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Strozzi C, Di Battista C, Graziosi A, D'Adamo E, Librandi M, Patacchiola R, Maconi A, Ghiglione V, Pelazzo C, Pasino M, Paterlini G, Bozzetti V, Salvo V, Gazzolo F, Concolino D, Abella L, Spinelli M, Betti M, Bertolotti M, Gazzolo D. Cerebral and systemic near infrared spectroscopy patterns in preterm infants treated by caffeine. Acta Paediatr 2024; 113:700-708. [PMID: 38156367 DOI: 10.1111/apa.17077] [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: 09/17/2023] [Revised: 11/22/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023]
Abstract
AIM To investigate the effects of caffeine loading/maintenance administration on near-infrared spectroscopy cerebral, kidney and splanchnic patterns in preterm infants. METHODS We conducted a multicentre case-control prospective study in 40 preterm infants (gestational age 29 ± 2 weeks) where each case acted as its own control. A caffeine loading dose of 20 mg/kg and a maintenance dose of 5 mg/kg after 24 h were administered intravenously. Near infrared spectroscopy monitoring parameters were monitored 30 min before, 30 min during and 180 min after caffeine therapy administration. RESULTS A significant increase (p < 0.05) in splanchnic regional oxygenation and tissue function and a decrease (p < 0.05) in cerebral tissue function after loading dose was shown. A preferential hemodynamic redistribution from cerebral to splanchnic bloodstream was also observed. After caffeine maintenance dose regional oxygenation did not change in the monitored districts, while tissue function increased in kidney and splanchnic bloodstream. CONCLUSION Different caffeine administration modalities affect cerebral/systemic oxygenation status, tissue function and hemodynamic pattern in preterm infants. Future studies correlating near infrared spectroscopy parameters and caffeine therapy are needed to determine the short/long-term effect of caffeine in preterm infants.
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Affiliation(s)
- Chiara Strozzi
- Neonatal Intensive Care Unit, ASO SS Antonio, Biagio, C. Arrigo, Alessandria, Italy
| | | | | | - Ebe D'Adamo
- Neonatal Intensive Care Unit, G. d'Annunzio University, Chieti, Italy
| | - Michela Librandi
- Department of Pediatrics, G. d'Annunzio University, Chieti, Italy
| | | | - Antonio Maconi
- Neonatal Intensive Care Unit, ASO SS Antonio, Biagio, C. Arrigo, Alessandria, Italy
| | - Valeria Ghiglione
- Neonatal Intensive Care Unit, ASO SS Antonio, Biagio, C. Arrigo, Alessandria, Italy
| | - Claudia Pelazzo
- Neonatal Intensive Care Unit, ASO SS Antonio, Biagio, C. Arrigo, Alessandria, Italy
| | - Marta Pasino
- Neonatal Intensive Care Unit, ASO SS Antonio, Biagio, C. Arrigo, Alessandria, Italy
| | - Giuseppe Paterlini
- Neonatal Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Monza-Brianza, Italy
| | - Valentina Bozzetti
- Neonatal Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Monza-Brianza, Italy
| | - Vincenzo Salvo
- Neonatal Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Messina, Italy
| | - Francesca Gazzolo
- Pediatric Unit, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Daniela Concolino
- Pediatric Unit, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | | | - Martina Spinelli
- Department of Science and Technological Innovation, Piemonte Orientale University, Alessandria, Italy
| | - Marta Betti
- Integrated Activities Research Innovation Department, ASO SS Antonio, Biagio, C. Arrigo, Alessandria, Italy
| | - Marinella Bertolotti
- Integrated Activities Research Innovation Department, ASO SS Antonio, Biagio, C. Arrigo, Alessandria, Italy
| | - Diego Gazzolo
- Neonatal Intensive Care Unit, G. d'Annunzio University, Chieti, Italy
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Moretti C, Gizzi C, Gagliardi L, Petrillo F, Ventura ML, Trevisanuto D, Lista G, Dellacà RL, Beke A, Buonocore G, Charitou A, Cucerea M, Filipović-Grčić B, Jeckova NG, Koç E, Saldanha J, Sanchez-Luna M, Stoniene D, Varendi H, Vertecchi G, Mosca F. A Survey of the Union of European Neonatal and Perinatal Societies on Neonatal Respiratory Care in Neonatal Intensive Care Units. CHILDREN (BASEL, SWITZERLAND) 2024; 11:158. [PMID: 38397269 PMCID: PMC10887601 DOI: 10.3390/children11020158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
(1) Background: Our survey aimed to gather information on respiratory care in Neonatal Intensive Care Units (NICUs) in the European and Mediterranean region. (2) Methods: Cross-sectional electronic survey. An 89-item questionnaire focusing on the current modes, devices, and strategies employed in neonatal units in the domain of respiratory care was sent to directors/heads of 528 NICUs. The adherence to the "European consensus guidelines on the management of respiratory distress syndrome" was assessed for comparison. (3) Results: The response rate was 75% (397/528 units). In most Delivery Rooms (DRs), full resuscitation is given from 22 to 23 weeks gestational age. A T-piece device with facial masks or short binasal prongs are commonly used for respiratory stabilization. Initial FiO2 is set as per guidelines. Most units use heated humidified gases to prevent heat loss. SpO2 and ECG monitoring are largely performed. Surfactant in the DR is preferentially given through Intubation-Surfactant-Extubation (INSURE) or Less-Invasive-Surfactant-Administration (LISA) techniques. DR caffeine is widespread. In the NICUs, most of the non-invasive modes used are nasal CPAP and nasal intermittent positive-pressure ventilation. Volume-targeted, synchronized intermittent positive-pressure ventilation is the preferred invasive mode to treat acute respiratory distress. Pulmonary recruitment maneuvers are common approaches. During NICU stay, surfactant administration is primarily guided by FiO2 and SpO2/FiO2 ratio, and it is mostly performed through LISA or INSURE. Steroids are used to facilitate extubation and prevent bronchopulmonary dysplasia. (4) Conclusions: Overall, clinical practices are in line with the 2022 European Guidelines, but there are some divergences. These data will allow stakeholders to make comparisons and to identify opportunities for improvement.
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Affiliation(s)
- Corrado Moretti
- Department of Pediatrics, Policlinico Umberto I, Sapienza University, 00185 Rome, Italy
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
| | - Camilla Gizzi
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Department of Neonatology and NICU, Ospedale Sant’Eugenio, 00144 Rome, Italy
| | - Luigi Gagliardi
- Division of Neonatology and Pediatrics, Ospedale Versilia, 55043 Viareggio, Italy;
| | - Flavia Petrillo
- Maternal and Child Department ASL Bari, Ospedale di Venere, 70131 Bari, Italy;
| | - Maria Luisa Ventura
- Neonatal Intensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy;
| | - Daniele Trevisanuto
- Department of Woman’s and Child’s Health, University of Padova, 35122 Padova, Italy;
| | - Gianluca Lista
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Division of Pediatrics, Neonatal Intensive Care Unit and Neonatology, Ospedale dei Bambini “V.Buzzi”, ASST FBF SACCO, 20154 Milan, Italy
| | - Raffaele L. Dellacà
- TechRes Lab, Department of Electronics, Information and Biomedical Engineering (DEIB), Politecnico di Milano University, 20133 Milan, Italy;
| | - Artur Beke
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- 1st Department of Obstetrics and Gynecology, Semmelweis University, 1085 Budapest, Hungary
| | - Giuseppe Buonocore
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Department of Pediatrics, Università degli Studi di Siena, 53100 Siena, Italy
| | - Antonia Charitou
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Department of Pediatrics, Rea Maternity Hospital, 17564 Athens, Greece
| | - Manuela Cucerea
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Neonatology Department, University of Medicine Pharmacy Sciences and Technology “George Emil Palade”, 540142 Târgu Mures, Romania
| | - Boris Filipović-Grčić
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Department of Pediatrics, University of Zagreb School of Medicine, 10000 Zagreb, Croatia
| | - Nelly Georgieva Jeckova
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Department of Pediatrics, University Hospital “Majchin Dom”, 1483 Sofia, Bulgaria
| | - Esin Koç
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Division of Neonatology, Department of Pediatrics, School of Medicine, Gazi University, 06570 Ankara, Turkey
| | - Joana Saldanha
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Neonatology Division, Department of Pediatrics, Hospital Beatriz Ângelo, 2674-514 Loures, Portugal
| | - Manuel Sanchez-Luna
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Neonatology Division, Department of Pediatrics, Hospital General Universitario “Gregorio Marañón”, 28007 Madrid, Spain
| | - Dalia Stoniene
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Department of Pediatrics, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania
| | - Heili Varendi
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
- Department of Paediatrics, University of Tartu, Tartu University Hospital, 50406 Tartu, Estonia
| | - Giulia Vertecchi
- Union of European Neonatal and Perinatal Societies (UENPS), 20143 Milan, Italy; (C.G.); (G.L.); (A.B.); (G.B.); (A.C.); (M.C.); (B.F.-G.); (N.G.J.); (E.K.); (J.S.); (M.S.-L.); (D.S.); (G.V.)
| | - Fabio Mosca
- Department of Pediatrics, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Clinical Sciences and Community Health, University of Milan, 20133 Milan, Italy
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Grainge S, Nair V, Kannan Loganathan P. National survey on caffeine use in neonatal units across the United Kingdom. Acta Paediatr 2023; 112:1865-1869. [PMID: 36529520 DOI: 10.1111/apa.16635] [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: 09/22/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Abstract
AIM To understand the variations in practice for caffeine use among neonatal units in the United Kingdom. METHODS An online survey was sent to every neonatal unit in the United Kingdom. RESULTS We received a response from 92 neonatal units (47%) with the proportion of response from special care, Local neonatal units, neonatal intensive care units and neonatal surgical units were 23%, 34%, 23% and 21% respectively. All the units reported the use of caffeine, and 40 units (46%) initiated caffeine within 24 h of birth. Fifty-nine units (64%) reported routine use of caffeine for pre-term infants <32 weeks. Seventy-one units (77%) reported that they continue caffeine for infants needing mechanical ventilation. Thirty-one units (34%) discontinued caffeine at 34 weeks post-menstrual age, irrespective of the respiratory support. Ten units (11%) reported discontinuation of caffeine only after weaning off all respiratory support, and 40% of units had a variable practice of discontinuing caffeine depending on the individual baby. Seventy-nine units (86%) reported they would regularly optimise caffeine dose based on weight checks. CONCLUSION Our survey showed some variation in practice with regards to the timing of caffeine initiation, gestational age cut-off for routine caffeine prescription and discontinuation.
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Affiliation(s)
| | - Vrinda Nair
- Neonatal Unit, James Cook University Hospital, Middlesbrough, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Prakash Kannan Loganathan
- Neonatal Unit, James Cook University Hospital, Middlesbrough, UK
- Clinical Academic office, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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Szatkowski L, Fateh S, Abramson J, Kwok TC, Sharkey D, Budge H, Ojha S. Observational cohort study of use of caffeine in preterm infants and association between early caffeine use and neonatal outcomes. Arch Dis Child Fetal Neonatal Ed 2023; 108:505-510. [PMID: 36759167 DOI: 10.1136/archdischild-2022-324919] [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: 09/20/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE To quantify trends in caffeine use in infants born at <32 weeks' gestational age (GA), and to investigate the effects of early vs late caffeine on neonatal outcomes. STUDY DESIGN Retrospective propensity score matched cohort study using routinely recorded data from the National Neonatal Research Database of infants born at <32 weeks' GA admitted to neonatal units in England and Wales (2012-2020). RESULTS 89% (58 913/66 081) of infants received caffeine. In 70%, caffeine was started early (on the day of birth or the day after), increasing from 55% in 2012 to 83% in 2020. Caffeine was given for a median (IQR) of 28 (17-43) days starting on day 2 (1-3) and continued up to 34 (33-34) weeks postmenstrual age.In the propensity score matched cohort of 13 045 pairs of infants, the odds of preterm brain injury (early caffeine, 2306/13 045 (17.7%) vs late caffeine, 2528/13 045 (19.4%), OR=0.89 (95% CI 0.84 to 0.95)) and bronchopulmonary dysplasia (BPD) (early caffeine, 4020/13 045 (32.8%) vs late caffeine, 4694/13 045 (37.7%), OR=0.81 (95% CI 0.76 to 0.85)) were lower in the group that received early caffeine compared with those who received it later. CONCLUSIONS Early use of caffeine has increased in England and Wales. This is associated with reduced risks of BPD and preterm brain injury. Randomised trials are needed to find the optimal timing of caffeine use and the groups of infants who will benefit most from early administration of caffeine.
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Affiliation(s)
- Lisa Szatkowski
- Centre for Perinatal Research, Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sheeza Fateh
- Centre for Perinatal Research, Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Janine Abramson
- Centre for Perinatal Research, Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - T'ng Chang Kwok
- Centre for Perinatal Research, Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Don Sharkey
- Centre for Perinatal Research, Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Helen Budge
- Centre for Perinatal Research, Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Shalini Ojha
- Centre for Perinatal Research, Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Bruschettini M, Brattström P, Russo C, Onland W, Davis PG, Soll R. Caffeine dosing regimens in preterm infants with or at risk for apnea of prematurity. Cochrane Database Syst Rev 2023; 4:CD013873. [PMID: 37040532 PMCID: PMC10089673 DOI: 10.1002/14651858.cd013873.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND Very preterm infants often require respiratory support and are therefore exposed to an increased risk of bronchopulmonary dysplasia (chronic lung disease) and later neurodevelopmental disability. Caffeine is widely used to prevent and treat apnea (temporal cessation of breathing) associated with prematurity and facilitate extubation. Though widely recognized dosage regimes have been used for decades, higher doses have been suggested to further improve neonatal outcomes. However, observational studies suggest that higher doses may be associated with harm. OBJECTIVES To determine the effects of higher versus standard doses of caffeine on mortality and major neurodevelopmental disability in preterm infants with (or at risk of) apnea, or peri-extubation. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and clinicaltrials.gov in May 2022. The reference lists of relevant articles were also checked to identify additional studies. SELECTION CRITERIA We included randomized (RCTs), quasi-RCTs and cluster-RCTs, comparing high-dose to standard-dose strategies in preterm infants. High-dose strategies were defined as a high-loading dose (more than 20 mg of caffeine citrate/kg) or a high-maintenance dose (more than 10 mg of caffeine citrate/kg/day). Standard-dose strategies were defined as a standard-loading dose (20 mg or less of caffeine citrate/kg) or a standard-maintenance dose (10 mg or less of caffeine citrate/kg/day). We specified three additional comparisons according to the indication for commencing caffeine: 1) prevention trials, i.e. preterm infants born at less than 34 weeks' gestation, who are at risk for apnea; 2) treatment trials, i.e. preterm infants born at less than 37 weeks' gestation, with signs of apnea; 3) extubation trials: preterm infants born at less than 34 weeks' gestation, prior to planned extubation. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. MAIN RESULTS: We included seven trials enrolling 894 very preterm infants (reported in Comparison 1, i.e. any indication). Two studies included infants for apnea prevention (Comparison 2), four studies for apnea treatment (Comparison 3) and two for extubation management (Comparison 4); in one study, indication for caffeine administration was both apnea treatment and extubation management (reported in Comparison 1, Comparison 3 and Comparison 4). In the high-dose groups, loading and maintenance caffeine doses ranged from 30 mg/kg to 80 mg/kg, and 12 mg/kg to 30 mg/kg, respectively; in the standard-dose groups, loading and maintenance caffeine doses ranged from 6 mg/kg to 25 mg/kg, and 3 mg/kg to 10 mg/kg, respectively. Two studies had three study groups: infants were randomized in three different doses (two of them matched our definition of high dose and one matched our definition of standard dose); high-dose caffeine and standard-dose caffeine were compared to theophylline administration (the latter is included in a separate review). Six of the seven included studies compared high-loading and high-maintenance dose to standard-loading and standard-maintenance dose, whereas in one study standard-loading dose and high-maintenance dose was compared to standard-loading dose and standard-maintenance dose. High-dose caffeine strategies (administration for any indication) may have little or no effect on mortality prior to hospital discharge (risk ratio (RR) 0.86, 95% confidence of interval (CI) 0.53 to 1.38; risk difference (RD) -0.01, 95% CI -0.05 to 0.03; I² for RR and RD = 0%; 5 studies, 723 participants; low-certainty evidence). Only one study enrolling 74 infants reported major neurodevelopmental disability in children aged three to five years (RR 0.79, 95% CI 0.51 to 1.24; RD -0.15, 95% CI -0.42 to 0.13; 46 participants; very low-certainty evidence). No studies reported the outcome mortality or major neurodevelopmental disability in children aged 18 to 24 months and 3 to 5 years. Five studies reported bronchopulmonary dysplasia at 36 weeks' postmenstrual age (RR 0.75, 95% CI 0.60 to 0.94; RD -0.08, 95% CI -0.15 to -0.02; number needed to benefit (NNTB) = 13; I² for RR and RD = 0%; 723 participants; moderate-certainty evidence). High-dose caffeine strategies may have little or no effect on side effects (RR 1.66, 95% CI 0.86 to 3.23; RD 0.03, 95% CI -0.01 to 0.07; I² for RR and RD = 0%; 5 studies, 593 participants; low-certainty evidence). The evidence is very uncertain for duration of hospital stay (data reported in three studies could not be pooled in meta-analysis because outcomes were expressed as medians and interquartile ranges) and seizures (RR 1.42, 95% CI 0.79 to 2.53; RD 0.14, 95% CI -0.09 to 0.36; 1 study, 74 participants; very low-certainty evidence). We identified three ongoing trials conducted in China, Egypt, and New Zealand. AUTHORS' CONCLUSIONS High-dose caffeine strategies in preterm infants may have little or no effect on reducing mortality prior to hospital discharge or side effects. We are very uncertain whether high-dose caffeine strategies improves major neurodevelopmental disability, duration of hospital stay or seizures. No studies reported the outcome mortality or major neurodevelopmental disability in children aged 18 to 24 months and 3 to 5 years. High-dose caffeine strategies probably reduce the rate of bronchopulmonary dysplasia. Recently completed and future trials should report long-term neurodevelopmental outcome of children exposed to different caffeine dosing strategies in the neonatal period. Data from extremely preterm infants are needed, as this population is exposed to the highest risk for mortality and morbidity. However, caution is required when administering high doses in the first hours of life, when the risk for intracranial bleeding is highest. Observational studies might provide useful information regarding potential harms of the highest doses.
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Affiliation(s)
- Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | | | | | - Wes Onland
- Department of Neonatology, Amsterdam University Medical Centers, VU University Medical Center, Emma Children's Hospital, University of Amsterdam, Amsterdam, Netherlands
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia
| | - Roger Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GH, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology 2023; 120:3-23. [PMID: 36863329 PMCID: PMC10064400 DOI: 10.1159/000528914] [Citation(s) in RCA: 74] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).
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Affiliation(s)
- David G. Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
| | - Virgilio P. Carnielli
- Department of Neonatology, University Polytechnic Della Marche, University Hospital Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Children and Adolescents, Oulu University Hospital and Medical Research Center, University of Oulu, Oulu, Finland
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Vienna, Austria
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C. Roehr
- Faculty of Health Sciences, University of Bristol, UK and National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Ola D. Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Christian P. Speer
- Department of Pediatrics, University Children's Hospital, Wuerzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerry H.A. Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L. Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, UK
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8
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Norman M, Jonsson B, Wallström L, Sindelar R. Respiratory support of infants born at 22-24 weeks of gestational age. Semin Fetal Neonatal Med 2022; 27:101328. [PMID: 35400604 DOI: 10.1016/j.siny.2022.101328] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lung immaturity and acute respiratory failure are the major problems in the care of extremely preterm infants. Most infants with gestational age (GA) 22-24 weeks will need mechanical ventilation and many will depend on some type of respiratory support, invasive and non-invasive for extended periods. There is ongoing gap in knowledge regarding optimal respiratory support and applying strategies that are effective in more mature populations is not easy or even suitable because lung maturation differs in smaller infants. Better strategies on how to avoid lung damage and to promote growth and development of the immature lung are warranted since increased survival is accompanied by increasing rates of bronchopulmonary dysplasia and concerns over long-standing reductions in lung function. This review focuses on some aspects of respiratory care of infants born at 22-24 weeks of GA.
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Affiliation(s)
- Mikael Norman
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Neonatal Medicine, S3:03 Norrbacka, Karolinska University Hospital, SE-171 76, Stockholm, Sweden.
| | - Baldvin Jonsson
- Department of Neonatal Medicine, S3:03 Norrbacka, Karolinska University Hospital, SE-171 76, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Linda Wallström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Department of Pediatrics, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
| | - Richard Sindelar
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Department of Pediatrics, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
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9
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Elmowafi M, Mohsen N, Nour I, Nasef N. Prophylactic versus therapeutic caffeine for apnea of prematurity: a randomized controlled trial. J Matern Fetal Neonatal Med 2021; 35:6053-6061. [PMID: 33771081 DOI: 10.1080/14767058.2021.1904873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Therapeutic initiation of methyxanthines for treatment of apnea in preterm infants was the standard policy. Caffeine therapy is beneficial for various outcomes of preterm infants. AIM To evaluate the efficacy of early prophylactic compared to routine therapeutic caffeine therapy on duration of oxygen support and other outcomes of preterm infants. METHODS In a randomized controlled trial including preterm infants < 32 weeks' gestation, prophylactic (in the first 72 h of life) versus therapeutic (only if apnea exists or infant requires mechanical ventilation) decision of caffeine was compared. The primary outcome was the duration of oxygen therapy. Secondary outcomes included duration of respiratory support modalities; bronchoplumonary dysplasia (BPD); necrotizing enterocolitis; intra-ventricular hemorrhage; retinopathy of prematurity; length of hospital stay (LOS); neonatal mortality; and caffeine side effects. RESULTS We enrolled 90 infants in the prophylactic and 91 infants in therapeutic groups respectively. Prophylactic caffeine decreased the duration of oxygen therapy [median and IQR of 28 (18-36) days versus 34 (23-51) days, p = .005 respectively]. Prophylactic caffeine significantly decreased the durations of respiratory support modalities, LOS, and incidences of mild to moderate BPD without reported effects on the incidence of severe BPD or other clinical outcomes compared to therapeutic caffeine. A significantly higher proportion of infants in the prophylactic caffeine group did not require mechanical ventilation during their NICU admission and a significant lower proportion required late mechanical ventilation compared to the prophylactic caffeine group. CONCLUSION Prophylactic caffeine decreased the duration of oxygen therapy, invasive and noninvasive ventilation, incidences of mild to moderate BPD, and LOS in preterm infants.
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Affiliation(s)
- Mohamed Elmowafi
- Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Nada Mohsen
- Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, Egypt.,Departement of Pediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt
| | - Islam Nour
- Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, Egypt.,Departement of Pediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt
| | - Nehad Nasef
- Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, Egypt.,Departement of Pediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt
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10
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Immature control of breathing and apnea of prematurity: the known and unknown. J Perinatol 2021; 41:2111-2123. [PMID: 33712716 PMCID: PMC7952819 DOI: 10.1038/s41372-021-01010-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/05/2021] [Accepted: 02/16/2021] [Indexed: 02/05/2023]
Abstract
This narrative review provides a broad perspective on immature control of breathing, which is universal in infants born premature. The degree of immaturity and severity of clinical symptoms are inversely correlated with gestational age. This immaturity presents as prolonged apneas with associated bradycardia or desaturation, or brief respiratory pauses, periodic breathing, and intermittent hypoxia. These manifestations are encompassed within the clinical diagnosis of apnea of prematurity, but there is no consensus on minimum criteria required for diagnosis. Common treatment strategies include caffeine and noninvasive respiratory support, but other therapies have also been advocated with varying effectiveness. There is considerable variability in when and how to initiate and discontinue treatment. There are significant knowledge gaps regarding effective strategies to quantify the severity of clinical manifestations of immature breathing, which prevent us from better understanding the long-term potential adverse outcomes, including neurodevelopment and sudden unexpected infant death.
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11
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Abstract
Caffeine as tested in the CAP trial is safe and effective for preterm infants with birthweights less than 1250 g. Evidence for its use beyond the indications and timing used in this trial is of low quality and conflicting. Some studies suggest that earlier use of caffeine increases the risk of mortality while others suggest it has important benefits. It appears that infants with apnea of prematurity and those receiving assisted ventilation are the most likely to benefit from caffeine. Based on currently available evidence, routine early prescription of caffeine does not appear to be indicated. Infants continue to have potentially damaging episodes of hypoxia secondary to apnea beyond 34 weeks' postmenstrual age. It is unclear whether prolonged use of caffeine improves outcomes in these infants. Randomized trials to resolve these uncertainties are required. They need to be large, at least the size of the CAP trial, and include neurodevelopmental outcomes.
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Affiliation(s)
- Peter G Davis
- Department of Newborn Research, The Royal Women's Hospital, The University of Melbourne, 20 Flemington Rd, Parkville, VIC, 3052, Australia.
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