Plasma B-type natriuretic peptide cannot predict treatment response to ibuprofen in preterm infants with patent ductus arteriosus

Association between Fluid Balance and Treatment Outcome of Ibuprofen for Patent Ductus Arteriosus in Preterm Infants

Background

Excessive fluid intake is a predictor of the development of patent ductus arteriosus (PDA) in preterm infants. Previous studies have examined the relationship between fluid intake and outcomes following ibuprofen for PDA. However, there is a lack of data to determine whether fluid balance has an effect on ibuprofen treatment for PDA. Therefore, this study sought to determine the relationship between fluid balance and outcomes following treatment with ibuprofen for PDA.

Methods

We conducted a retrospective study of 110 infants admitted to the Children's Hospital of Chongqing Medical University between January 2017 and April 2022, who were treated with ibuprofen for hemodynamically significant PDA (hsPDA). We calculated the average fluid balance before and during the two courses of ibuprofen treatment and whether they were significantly associated with outcomes in hsPDA patients.

Results

In the first course of ibuprofen treatment (FIT), responders had lower fluid balance before FIT compared to non-responders [median 31.82 (18.01, 39.66) vs 34.68 (25.31, 43.56) mL/kg/day; p = 0.049], while the fluid balance during FIT [median 40.61 (33.18, 63.06) vs 42.65 (30.02, 57.96) mL/kg/day; p = 0.703] did not differ between responders and non-responders. Fluid balance before the second course of ibuprofen treatment (SIT) (mean 41.58 ± 14.26 vs 35.74 ± 10.99 mL/kg/day; p = 0.322) and during SIT (mean 39.21 ± 12.65 vs 37.00 ± 21.38 mL/kg/day; p = 0.813) was not found to have a significant association with SIT outcome. Multivariate logistic regression analysis showed fluid balance before FIT was a predictor for FIT success [Odds ratio (OR): 0.967; 95% confidence interval (CI): 0.935-0.999; p = 0.042]. Fluid balance within the first week of life had a greater association with the FIT outcome (OR: 0.967, 95% CI: 0.939-0.996, p = 0.027). Gestational diabetes mellitus and higher Apgar scores decreased the possibility of PDA closure after FIT.

Conclusions

Lower fluid balance before FIT, especially within the first week of life appeared to be a predictor for closure of hsPDA after FIT in preterm infants.

Sex Differences in Patent Ductus Arteriosus Incidence and Response to Pharmacological Treatment in Preterm Infants: A Systematic Review, Meta-Analysis and Meta-Regression

A widely accepted concept in perinatal medicine is that boys are more susceptible than girls to complications of prematurity. However, whether this ‘male disadvantage of prematurity’ also involves persistent patent ductus arteriosus (PDA) has been scarcely investigated. Our aim was to conduct a systematic review and meta-analysis on studies addressing sex differences in the risk of developing PDA among preterm infants. We also investigated whether the response to pharmacological treatment of PDA differs between boys and girls. PubMed/Medline and Embase databases were searched. The random-effects male/female risk ratio (RR) and 95% confidence interval (CI) were calculated. We included 146 studies (357,781 infants). Meta-analysis could not demonstrate sex differences in risk of developing any PDA (37 studies, RR 1.03, 95% CI 0.97 to 1.08), hemodynamically significant PDA (81 studies, RR 1.00, 95% CI 0.97 to 1.02), or in the rate of response to pharmacological treatment (45 studies, RR 1.01, 95% CI 0.98 to 1.04). Subgroup analysis and meta-regression showed that the absence of sex differences was maintained over the years and in different geographic settings. In conclusion, both the incidence of PDA in preterm infants and the response rate to pharmacological treatment of PDA are not different between preterm boys and girls.

Application of B-Type Natriuretic Peptide in Neonatal Diseases

Numerous congenital or secondary diseases, including, heart disease, respiratory disease, sepsis and many others, can lead to neonatal death. B-type natriuretic peptide (BNP) is a peptide hormone secreted by ventricular cells following an increase in ventricular wall tension. BNP functions to promote vasodilation, diuresis, and sodium release to regulate blood pressure. BNP is a sensitive index reflecting ventricular function, which may aid the diagnosis and monitoring of various neonatal diseases. In neonates, there is currently no consensus on a reference BNP level, as the plasma BNP concentration of healthy newborns varies with age, peaks in the first week after birth, and then gradually decreased to a stable level. In disease states, the correlation between the plasma BNP concentration and the results of echocardiography is good, which is of great significance in the screening, monitoring, and prognosis evaluation of neonatal cardiovascular diseases, including congenital heart disease, patent ductus arteriosus, etcetera. It also facilitates the judgment of the efficacy of treatment and perioperative management. Moreover, the monitoring of plasma BNP concentration provides guidance for the diagnosis, evaluation, and treatment selection of certain neonatal respiratory diseases and neonatal sepsis. This review summarizes the normal BNP values and discusses the application value of BNP in relation to physiological and pathological aspects in neonates.

Discriminant Analysis of Main Prognostic Factors Associated with Hemodynamically Significant PDA: Apgar Score, Silverman-Anderson Score, and NT-Pro-BNP Level

Hemodynamically significant patent ductus arteriosus (hsPDA) in premature newborns is associated with a risk of PDA-related morbidities. Classification into risk groups may have a clinical utility in cases of suspected hsPDA to decrease the need for echocardiograms and unnecessary treatment. This prospective observational study included 99 premature newborns with extremely low body weight, who had an echocardiogram performed within the first three days of life. Discriminant analysis was utilized to find the best combination of prognostic factors for evaluation of hsPDA. We used binary logistic regression analysis to predict the relationship between parameters and hsPDA. The cohort's mean and standard deviation gestational age was 27.6 ± 2.55 weeks, the mean birth weight was 1015 ± 274 g. Forty-six (46.4%) infants had a PDA with a mean diameter of 2.78 mm. Median NT-pro-BNP levels were 17,600 pg/mL for infants with a PDA and 2773 pg/mL in the non-hsPDA group. The combination of prognostic factors of hsPDA in newborns of extremely low body weight on the third day of life was determined: NT-pro-BNP, Apgar score, Silverman-Anderson score (Se = 82%, Sp = 88%). A cut-off value of NT-pro-BNP of more than 8500 pg/mL can predict hsPDA (Se = 84%, Sp = 86%).

Predictive Value of Blood N-Terminal Pro-Brain Natriuretic Peptide Concentrations for Early Patent Ductus Closure in Very Preterm Infants

Objectives

It has been shown that blood concentrations of NT-proBNP may be useful in identifying preterm infants at risk of hemodynamically significant patent ductus arteriosus and its complications. The aim of the study was to assess predictive value of serum NT-proBNP levels for early ductus arteriosus (DA) closure in very preterm newborns.

Methods

Fifty-two infants <32 weeks’ gestation aged <72 hours with patent ductus arteriosus (PDA) diameter >1.5 mm were involved in a randomized study. Twenty-seven (52%) of them were treated with ibuprofen or paracetamol starting within the first 3 days of life. Expectant management was applied to 25 (48%) infants. All patients underwent planned echocardiographic (daily) and two serum NT-proBNP measurements within the first 10 days after birth. Depending on the DA closure within the first 10 days of life, 2 groups of patients were formed retrospectively, with closed (n = 30) or patent (n = 22) DA by this age.

Results

In the first 10 days of life, DA closure occurred in 19 (70%) treated infants and in 11 (44%) infants managed expectantly (p > 0,05). Initial concentrations of NT-proBNP were significantly higher in infants that had patent ductus arteriosus (PDA) at 10 days of life. By the eighth day, median NT-proBNP values in both groups significantly decreased but remained considerably higher in newborns with PDA. NT-proBNP serum concentrations on the second day of life could reliably predict DA closure within the first 10 days after birth in treated babies (the AUC was significant 0.81 [95% CI: 0.58–1.03], p < 0.05) but not in infants who were managed expectantly.

Conclusions

Serum NT-proBNP concentrations on the second day of life could reliably predict early PDA closure in treated but not in expectantly managed very preterm infants.

Early Urinary Metabolomics in Patent Ductus Arteriosus Anticipates the Fate: Preliminary Data

Introduction: In premature neonates, the persistence of hemodynamically significant ductus arteriosus (hsPDA) can be associated with short- and long-term consequences, impairing their outcome. The correct strategy of management for such condition is under debate, especially regarding contraindications and/or side effects. In recent years, metabolomics was applied to several perinatal, pediatric, and adult conditions to investigate potential biomarkers of disease, which have become useful for early diagnosis and/or therapeutic management. Aim of the Study: The main purpose of our exploratory study was to asses, through ¹H-NMR metabolomics analysis of urinary samples at birth, possible metabolic pathways differentiating, with a significant predictive power, those preterm neonates who will subsequently develop hsPDA and neonates of comparable gestational age (GA) who will undergo spontaneous ductal closure or the persistence of an irrelevant PDA (no-hsPDA). Moreover, we investigated potential prenatal or perinatal clinical factors potentially influencing the development of hsPDA. Materials and Methods: We enrolled n = 35 preterm neonates with GA between 24 and 32 weeks; urinary samples were collected within the first 12 h of life. Patients were closely monitored regarding intensive care, respiratory support, fluid balance and administered drugs; an echocardiogram was performed at 48-72 h. Results: Our results reported a significant correlation between lower GA at birth and the development of hsPDA. Moreover, neonates with GA ≤ 30w developing hsPDA were characterized by lower Apgar scores at 1' and 5', higher rates of perinatal asphyxia, higher need of delivery room resuscitation and subsequent surfactant administration. Interestingly, metabolomics analysis at birth detected a clear separation between the ¹H-NMR urinary spectra of subjects GA ≤ 30w not developing hsPDA (n = 19) and those of subjects born at GA ≤ 30w in which hsPDA was confirmed at 48-72 h of life (n = 5). Conclusions: This is the first study applying metabolomics to investigate the PDA condition. Although preliminary and conducted on a limited sample, our results reveal that metabolomics could be a promising tool in the early identification of hsPDA, potentially superior to the clinical or laboratory predictive tools explored to date and even to the clinical observations and correlations in our sample, through the detection of specific urinary metabolites.