Late postnatal systemic steroids predispose to retinopathy of prematurity in very-low-birth-weight infants: a comparative study

Risk factor-based models to predict severe retinopathy of prematurity in preterm Thai infants

PURPOSE

To develop prediction models for severe retinopathy of prematurity (ROP) based on risk factors in preterm Thai infants to reduce unnecessary eye examinations in low-risk infants.

METHODS

This retrospective cohort study included preterm infants screened for ROP in a tertiary hospital in Bangkok, Thailand, between September 2009 and December 2020. A predictive score model and a risk factor-based algorithm were developed based on the risk factors identified by a multivariate logistic regression analysis. Validity scores, and corresponding 95% confidence intervals (CIs), were reported.

RESULTS

The mean gestational age and birth weight (standard deviation) of 845 enrolled infants were 30.3 (2.6) weeks and 1264.9 (398.1) g, respectively. The prevalence of ROP was 26.2%. Independent risk factors across models included gestational age, birth weight, no antenatal steroid use, postnatal steroid use, duration of oxygen supplementation, and weight gain during the first 4 weeks of life. The predictive score had a sensitivity (95% CI) of 92.2% (83.0, 96.6), negative predictive value (NPV) of 99.2% (98.1, 99.6), and negative likelihood ratio (NLR) of 0.1. The risk factor-based algorithm revealed a sensitivity of 100% (94, 100), NPV of 100% (99, 100), and NLR of 0. Similar validity was observed when "any oxygen supplementation" replaced "duration of oxygen supplementation." Predictive score, unmodified, and modified algorithms reduced eye examinations by 71%, 43%, and 16%, respectively.

CONCLUSIONS

Our risk factor-based algorithm offered an efficient approach to reducing unnecessary eye examinations while maintaining the safety of infants at risk of severe ROP. Prospective validation of the model is required.

Impact of postnatal steroids on peripheral avascular retina and severity of retinopathy of prematurity

BACKGROUND

We investigated the role of postnatal steroids on the severity of retinopathy of prematurity (ROP) and its impact on peripheral avascular retina (PAR).

METHODS

A retrospective cohort study of infants born at ≤32 weeks gestation and/or birth weight ≤1500 g. Demographics, the dose and duration of steroid treatment, and age when full retinal vascularization occurred were collected. The primary outcomes were the severity of ROP and time to full vascularization of the retina.

RESULTS

A total of 1695 patients were enrolled, 67% of whom received steroid therapy. Their birth weight was 1142 ± 396 g and gestational age was 28.6 ± 2.7 weeks. The total hydrocortisone-equivalent dose prescribed was 28.5 ± 74.3 mg/kg. The total days of steroid treatment were 8.9 ± 35.1 days. After correction for major demographic differences, infants who received a higher cumulative dose of steroids for a longer duration had a significantly increased incidence of severe ROP and PAR (P < 0.001). For each day of steroid treatment, there was a 3.2% increase in the hazard of the severe form of ROP (95% CI: 1.022-1.043) along with 5.7% delay in achieving full retinal vascularization (95% CI: 1.04-1.08) (P < 0.001).

CONCLUSION

Cumulative dose and duration of postnatal steroid use were independently associated with the severity of ROP and PAR. Thus, postnatal steroids should be used very prudently.

IMPACT

We report ROP outcomes in a large cohort of infants from two major healthcare systems where we have studied the impact of postnatal steroids on the severity of ROP, growth, and development of retinal vessels. After correcting our data for three major outcome measures, we show that high-dose postnatal steroids used for a prolonged duration of time are independently associated with severe ROP and delay in retinal vascularization. Postnatal steroids impact the visual outcomes of VLBW infants significantly, so their clinical use needs to be moderated.

Let's Talk about Dex: When do the Benefits of Dexamethasone for Prevention of Bronchopulmonary Dysplasia Outweigh the Risks?

Bronchopulmonary dysplasia (BPD) is the most common complication of extreme prematurity and carries increased respiratory morbidity into childhood and adulthood. Systemic administration of dexamethasone during the preterm period has been shown to decrease the incidence of BPD in this population. However, enthusiasm about its use has been tempered by early evidence that suggested potential adverse neurodevelopmental outcomes. More recent studies suggest that the timing, dosing, and duration of therapy may have a significant impact on the safety and efficacy of dexamethasone administration and that side effects and harms may be minimized if its use is appropriately targeted. Focusing on studies published since the 2010s American Academy of Pediatrics (AAP) statement on dexamethasone, this review seeks to examine the evidence from recent clinical trials to present the current state of knowledge regarding the systemic dexamethasone administration to prevent BPD in extremely premature infants and how dose, duration, and timing might impact its safety and efficacy in this vulnerable population.

A safety review of drugs used for the treatment of retinopathy of prematurity

INTRODUCTION

Retinopathy of Prematurity (ROP) is a sight-threatening disease representing one of the main disabling diseases affecting premature newborns. Presently, ROP is treated by surgical interventions and drug therapies are limited to the off-label use of a little amount of molecules approved for other pathologies.

AREAS COVERED

Many drugs that may potentially be used in treating ROP are recently proposed, in many cases after the demonstration of their effectiveness in preclinical studies. In this review, the authors discuss safety and effectiveness of the main proposed approaches in the pharmacologic treatment of the disease, including approaches based on oxygen therapy and nutritional interventions.

EXPERT OPINION

Surgical approaches to ROP are not without side effects. However, most of the proposed pharmacologic interventions can also raise specific concerns. In particular, these approaches follow a curative paradigm and are proposed in patients once the disease has progressed, with an effectiveness that is often smaller than expected. A goal in the treatment of ROP would be moving the paradigm toward a preventive approach that could be potentially effective in treating extremely low birth weight preterm infants before ROP becomes manifest.

Pharmacologic interventions for the prevention and treatment of retinopathy of prematurity

Retinopathy of prematurity (ROP), a significant morbidity in prematurely born infants, is the most common cause of visual impairment and blindness in children and persists till adulthood. Strict control of oxygen therapy and prevention of intermittent hypoxia are the keys in the prevention of ROP, but pharmacologic interventions have decreased risk of ROP. Various drug classes such as methylxanthines (caffeine), VEGF inhibitors, antioxidants, and others have decreased ROP occurrence. The timing of pharmacologic intervention remains unsettled, but early prevention rather than controlling disease progression may be preferred. These drugs act through different mechanisms, and synergistic approaches should be considered to maximize efficacy and safety.

Retinopathy of prematurity: incidence, risk factors, and evaluation of screening criteria

BACKGROUND/AIM

The goal of this study was to investigate the incidence of retinopathy of prematurity (ROP) and the relationship between risk factors and disease in premature newborns in our neonatal intensive care unit.

MATERIALS AND METHODS

A total of 219 premature subjects were retrospectively evaluated for retinopathy. Demographic information, clinical data, and risk factors were reviewed.

RESULTS

The gestational ages of the infants included in the study ranged between 25 and 36 weeks, and the birth weights ranged between 670 and 4460 g. In this study, the incidence of ROP was 20.1% (44) in preterm infants: 16 had stage 1 (36.4%), 15 had stage 2 (34.1%), 11 had stage 3 (25%), 1 had stage 4 (2.3%), 1 had stage 5 (2.3%), and 6 had plus (+) disease (7.2%). The risk factors associated with the development of ROP included low birth weight, ventilation treatment, bronchopulmonary dysplasia, and maternal preeclampsia. The risk factors were analyzed with logistic regression analysis. The odds ratios were 5.952 (95% confidence interval [CI]: 2.030-17.447), 20.070 (95% CI: 4.213-95.600), 5.879 (1.916-18.037), and 3.200 (95% CI: 1.002-11.535), respectively.

CONCLUSION

In this study, birth weight, ventilation treatment, bronchopulmonary dysplasia, and maternal preeclampsia were the most important risk factors for the development of ROP.

A prospective study on hyperglycemia and retinopathy of prematurity

OBJECTIVE

Retinopathy of prematurity (ROP) constitutes a significant morbidity in premature infants that can lead to blindness. Multiple retrospective studies have identified neonatal hyperglycemia as a risk for developing ROP. However, in the absence of any reported prospective study, it is not clear whether hyperglycemia is associated with ROP independent of the commonly associated comorbidities. The objective of this study was to investigate whether hyperglycemia in premature infants is independently associated with ROP.

STUDY DESIGN

Premature infants (<1500 g or⩽32 weeks gestational age) were enrolled in a prospective longitudinal cohort study. All demographic, clinical and laboratory data were collected. Bedside whole-blood glucose concentration was measured every 8 h daily for 7 days. For any glucose reading<50 or>150 mg dl(-1), serum sample was sent to the laboratory for confirmation. Hyperglycemia was defined as any blood glucose level⩾150 mg dl(-1). ROP patients were compared with non-ROP patients in a bivariate analysis. Variables significantly associated with ROP were studied in a logistic regression model.

RESULT

A total of 65 patients were enrolled with gestational age 31.1±1.2 weeks and birth weight 1385±226 g. Thirty-one patients (48%) were identified with hyperglycemia. On eye examination, 19 cases (29.2%) had ROP (13 with stage 1, 4 with stage 2 and 2 with stage 3). There were more cases of ROP in the hyperglycemia group compared with the euglycemia group (45% vs 15%, P=0.007). Patients who developed ROP had significantly higher maximum and average glucose concentrations when compared with non-ROP patients. Multiple factors have been associated with ROP on bivariate analysis, including gestational age, exposure to oxygen, respiratory support and poor weight gain. However, in a logistic regression model including all significant variables, average blood glucose in the first week of life was the factor independently associated with ROP with an odds ratio of: 1.77 (95% confidence interval: 1.08 to 2.86), P=0.024.

CONCLUSION

In a cohort of premature infants, elevated average blood glucose concentrations in the first week of life is independently associated with the development of ROP.

Reduction in screening for retinopathy of prematurity through risk factor adjusted inclusion criteria

AIMS

To develop a new national screening guideline for retinopathy of prematurity (ROP).

METHODS

Included were infants of the 2009 prospective ROP inventory in The Netherlands with gestational age (GA) <32 weeks and/or birth weight (BW) <1500 g. Five models were studied, based on GA and BW in combination with no, one or a set of five risk factors for ROP. Risk factors were determined by logistic regression. In MEDLINE and EMBASE, additional risk factors were searched. A precondition was that no infants with severe ROP would be missed. Receiver operating characteristic curves or classical measures were used to determine diagnostic accuracy.

RESULTS

The model including all infants with severe ROP comprised screening of infants with GA <30 weeks and/or BW <1250 g and a selection of infants with GA 30-32 weeks and/or BW 1250-1500 g, with at least one of the following risk factors: artificial ventilation (AV), sepsis, necrotising enterocolitis (NEC), postnatal glucocorticoids or cardiotonica. This model would not detect 4.8% (95% CI 2.5% to 8.0%) of infants with mild ROP and would reduce infants eligible for screening by 29%.

CONCLUSIONS

In The Netherlands, screening may be safely reduced using a new guideline based on GA, BW, AV, sepsis, NEC, postnatal glucocorticoids and cardiotonica.

A psychoneuroimmunologic examination of cumulative perinatal steroid exposures and preterm infant behavioral follow-up

PURPOSE

This study's aim was to explore relationships between preterm infant behavioral outcomes and maternal/infant glucocorticoid (dexamethasone [DEX]) treatments using a psychoneuroimmunologic approach. Research questions were (a) do relationships exist between infant cumulative perinatal steroid (PNS) exposure and child behavioral problems? and (b) do maternal/infant characteristics (e.g., immune markers and biophysiologic stressors) influence these relationships?

METHODS

The convenience sample comprised 45 mother-child dyads in which the children (mean age 8 years ± 2.3) had been born at a mean postconceptional age of 28 weeks (± 4.2). We used the Child Behavior Checklist (CBCL) to assess behavior, the Clinical Risk Index for Babies (CRIB) to score stress at birth, and retrospective record review to identify additional perinatal factors (PNS dosage, sepsis, and maternal and infant complete blood counts near delivery).

RESULTS

Children were dichotomized into high (> 0.2 mg/kg; n = 20) versus low-no (≤0.2 mg/kg; n = 25) PNS exposure groups. Significant relationships existed between CBCL Total Problems score and sepsis, PNS exposure, timing of initial PNS, and infant length percentile at discharge. Competence problems were significantly associated with PNS, neonatal intensive care unit (NICU) infant length percentile, CRIB score, sepsis, retinopathy of prematurity, hearing deficit, and immunity markers (i.e., maternal lymphocyte percentage and infant band/seg ratio). Children in the higher PNS group exhibited more behavioral problems (e.g., withdrawn, attention, conduct, social, and rule breaking problems), but there were no significant differences. The findings are reassuring regarding long-term effects of this PNS dose on preterm infant behavioral outcomes.

Analysis of risk factors for progression to treatment-requiring ROP in a single neonatal intensive care unit: is the exposure time relevant?

OBJECTIVE

Retinopathy of prematurity (ROP) is a multifactorial disease whose pathogenesis is organized in two phases. We hypothesized that postnatal risk factors may differently exert their effect in a phase dependent way.

METHODS

Data obtained from medical records of 93 very low birth weight neonates with stage ≥ 3 ROP were analyzed. Perinatal ROP risk factors were compared between infants with stage 3 ROP not requiring surgery and infants with treatment-requiring ROP with relation to newborn's lifetime exposure.

RESULTS

In the first two weeks and in the whole first month of life length of oxygen administration was an independent risk factor for treatment-requiring ROP. In the first month of life also sepsis was identified as independent risk factor for surgical ROP. Sepsis and Candida pneumonia in the time frame from birth to ROP diagnosis and prolonged mechanical ventilation from diagnosis to prethreshold ROP were associated to treatment-requiring ROP. Blood transfusions are the only risk factor for treatment-requiring ROP identified in all the periods analyzed.

CONCLUSION

Risk factors for ROP play their role since birth. Beside scrupulous oxygen-administration monitoring and prevention of infections, blood transfusions are of primary importance in the development of treatment-requiring ROP.

The role of hemoglobin variant replacement in retinopathy of prematurity

OBJECTIVE

To conduct tests of relationships between different factors that could influence the course of retinopathy of prematurity (ROP) and ROP, particularly the role of hemoglobin variant replacement in adult blood transfusions.

METHODS

A retrospective, observational study of 83 infants born between 23 and 34 wks gestation was conducted.

RESULTS

The infants without ROP, with 1 and 2 stage of ROP and with ≥ 3 stage of ROP received Q 28 (12-134); 51 (14-149); 156 (38-244) ml/kg of transfused blood, respectively, and the factor Qt was 1,545 (560-10,045); 3,093 (614-13,419); 11,907 (1,288-20,638) (ml/kg)·day, respectively. For the same groups MCV(35) (mean cell volume at the arbitrary time of the 35(th) wk post-conception) was 92.3 (82.9-110.5); 91.0 (79.3-101.4); 87.1 (80.2-94.8) fl, respectively, and factor P(MCV)/t was 99.5 (89.2-108.8); 96.3 (84.6-106.3); 90.7 (85.3-96.5) fl, respectively. There is high influence on the stage of ROP of the amount of transfused blood and MCV, both with or without the time factor. The statistical differences between P(MCV)/t were more significant than the differences between MCV(35), for different stages of ROP.

CONCLUSIONS

The influence of the time factor on the statistical differences of MCV but not on the amount of transfused adult blood suggests that HbF - HbA replacement may play a role in ROP development.

Contribution of early glycemic status in the development of severe retinopathy of prematurity in a cohort of ELBW infants

OBJECTIVE

The objective of this study is to investigate the relationship between glycemic status and severe retinopathy of prematurity (ROP).

STUDY DESIGN

This is a retrospective cohort study of 114 infants <1000 g admitted to a level IV neonatal intensive care unit within 48 h of life. A cumulative, time-weighted glucose level (TWGL) derived from plotting glucose values over time was included in logistic regression analysis to identify predictors for severe ROP.

RESULT

Infants had 26.6 ± 2 weeks gestational age and had a birth weight of 782 ± 136 g. TWGL during first 10 and 30 days of life were greater in the severe ROP group (P<0.01). Unlike single events of glucose levels ≥ 150 mg dl(-1), 10 days TWGL ≥ 100 mg dl(-1) (odds ratio (OR) 5.2, P<0.02) and 30 days TWGL ≥ 118 mg dl(-1) (OR 5.7, P<0.02) were predictors for severe ROP (univariate). Multivariate regression confirmed 30 days TWGL ≥ 118 mg dl(-1) (OR 9.4 to 10) and gram-positive sepsis (OR 4.1 to 5) as predictors for severe ROP (P<0.05).

CONCLUSION

High overall glycemic status is associated with the development of severe ROP.

[Early administration of erythropoietin in the extreme premature, a risk factor for retinopathy of prematurity?]

INTRODUCTION

Erythropoietin (EPO) stimulates angiogenesis and may favour the appearance of retinopathy of prematurity (ROP). The objective was to determine if EPO+Fe administered from the 5th day of life could be an independent risk factor for ROP appearance and its severity.

PATIENTS AND METHOD

The study included 718 preterm newborns with a birth weight ≤1,500g or a gestational age ≤32 weeks (and 6 days), admitted between 2001 and 2008. During these years, the target SaO₂ was between 88% and 93%. EPO treatment began at 5-7 days of life, with a dose of 250 UI/Kg, 3 times a week, subcutaneously, together with Fe, 5-6mg/kg/day, both until 34 weeks of corrected age or discharge.

RESULTS

A total of 493 preterms (68.7%) did not have ROP, 139 (19.4%) had a grade 1 ROP, 50 (7.0%) a grade 2 ROP and 36 (5.0%) a grade 3 ROP. Laser therapy was required by 27 severe ROP was associated with lower birth weight and gestational age, more neonatal morbidity and a more aggressive treatment (duration of oxygen supplements or mechanical ventilation, number of blood transfusions). Risk factors independently and significantly associated with any ROP grade were: lower birth weight, no caesarean section, EPO administration and need for blood transfusion. EPO administration increased the risk of ROP by 2.4, but this only happened in case of grade 1 ROP (OR: 5.50).

CONCLUSIONS

EPO+Fe administration is associated and perhaps stimulates the appearance of grade 1 ROP.

[The use of postnatal corticosteroid therapy in premature infants to prevent or treat bronchopulmonary dysplasia: current situation and recommendations]

In the last few years, several studies related to the benefit/risk balance of postnatal corticosteroids administered to premature neonates for prevention or treatment of bronchopulmonary dysplasia (BPD) have been published. These data encourage caution, given the risk of long-term adverse neurodevelopmental outcomes. In the meantime, the clinical profile of BPD has been altered based on the progress made in the pre- and postnatal care of premature infants. In 2006, a survey conducted in France in neonatal centers showed that corticosteroids were still frequently used (57% of the centers) following various protocols in very preterm-born infants for respiratory impairment. To promote safer practices and rational use of corticosteroids in the prevention and treatment of BPD in preterm-born neonates, we reviewed the available data in order to establish recommendations. Systemic administration of corticosteroids for prevention or treatment of BPD: (i) should not be used during the first 4 days of life; (ii) is not indicated in the first 3 weeks of life nor (iii) in extubated infants (nasal ventilation or oxygen therapy). The systemic administration of steroids can only be considered after the first 3 weeks of life in very preterm-born ventilator-dependent infants to facilitate extubation (or prevent reintubation related to the severity of BPD). Postnatal dexamethasone administration studied in several randomized clinical trials was shown to have an unfavorable benefit/risk profile, mainly because of the long-term adverse neurocognitive outcomes. Very few studies have been conducted with betamethasone in the postnatal period. According to sparse data, this drug might be as efficacious as dexamethasone, but its long-term risk profile is unknown. It should be noted that following prenatal administration, the benefit/risk profile of betamethasone is better than that of dexamethasone, especially with regard to neurocognitive development. Intravenous hydrocortisone administered at an early stage for the prevention of BPD is being evaluated and should not be administered in this indication, except within clinical trials approved by the ethics committee. No other corticosteroids have been evaluated in the postnatal period in respiratory indications. In conclusion, in the situations described above for which systemic corticosteroids could be justified, the use of betamethasone (or hydrocortisone) appears to be better. As usual, the lowest possible dose of corticosteroids should be administered for the shortest possible duration. The betamethasone-equivalent dose of 0.125 mg/kg/day for 3 days is deemed adequate. If inhaled, corticosteroid therapy may facilitate extubation. Neither its efficacy in respiratory diseases nor its long-term risk profile has been so far established.

[Risk factors and prevention of retinopathy of prematurity]

The history of retinopathy of prematurity (ROP) gives a prime example of how dangerous the uncontrolled introduction of a new medical treatment--particularly in the field of neonatology--may be. The most important risk factors for the development of ROP are the immaturity of premature infants as well as uncontrolled and/or inadequate treatment with oxygen. In comparison to the fetus, the premature infant is exposed to a nonphysiologically high oxygen concentration. This hyperoxia leads to formation of aggressive oxygen radicals on the one hand and, on the other hand, to temporarily reduced production of growth factors such as vascular endothelial growth factor and erythropoietin, which both play an important role in the pathogenesis of ROP. The most important measure to prevent ROP is restrictive and carefully monitored oxygen treatment. Medical treatment to prevent ROP includes injection of D-penicillamine and retinol, but the available data are still limited, particularly with regard to the long-term effects of this treatment. A higher oxygenation in prethreshold ROP does not lead to recovery of ocular findings, but it increases the incidence of pulmonary complications. A reduction of light intensity in neonatal intensive care units proved not to be efficient for preventing ROP. To avoid blindness, standardized screening of the risk group is needed.