1
|
Chen LW, Chu CH, Lin YC, Huang CC. The Quartile Levels of Thyroid-stimulating Hormone at Newborn Screening Stratified Risks of Neurodevelopmental Impairment in Extremely Preterm Infants: A Population Cohort Study. J Epidemiol 2024; 34:419-427. [PMID: 38191177 PMCID: PMC11330707 DOI: 10.2188/jea.je20230253] [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: 01/10/2024] Open
Abstract
BACKGROUND To evaluate whether thyroid-stimulating hormone (TSH) measured during newborn screening (NBS) at birth and at discharge can be surrogate markers for neurodevelopmental impairment (NDI) in extremely preterm infants. METHODS The population cohort enrolled infants born <29 weeks' gestation in 2008-2020 in southern Taiwan. Infants with a maternal history of thyroid disorders and infants who required thyroxine supplementation during hospitalization were excluded. TSH levels measured during NBS at birth and at term-equivalent age (TEA)/discharge were respectively categorized into the lowest quartile, the interquartile range, and the highest quartile, which were correlated to NDI outcomes. RESULTS Among 392 patients with paired TSH data, 358 (91%) were prospectively followed until a corrected age of 24 months. At birth, infants with lowest-quartile TSH had higher NDI risks (odds ratio [OR] 2.3; 95% confidence interval [CI], 1.3-4.1, P = 0.004) compared to infants with interquartile-range TSH. Conversely, by TEA/discharge, infants with highest-quartile TSH had increased NDI (OR 1.9; 95% CI, 1.0-3.4, P = 0.03). By paired TSH categories, infants persistently in the lowest TSH quartile (48%; aOR 4.4; 95% CI, 1.4-14.5, P = 0.01) and those with a shift from interquartile range to the highest quartile (32%; aOR 2.7; 95% CI, 1.0-7.4, P = 0.046) had increased NDI risks compared with the reference with consistent interquartile-range TSH. CONCLUSION Extremely preterm infants persistently in the lowest-quartile TSH level at birth and at discharge had the highest NDI risk. TSH quartile levels measured during NBS may serve as a population surrogate biomarker for assessing NDI risks in infants born extremely preterm.
Collapse
Affiliation(s)
- Li-Wen Chen
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | | | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Chao-Ching Huang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
- Department of Pediatrics, College of Medicine, Taipei Medical University
| |
Collapse
|
2
|
Ramaswamy VV, Kumar G, Abdul Kareem P, Somasekhara Aradhya A, Suryawanshi P, Sahni M, Khurana S, Sharma D, More K. Comparative efficacy of volume expansion, inotropes and vasopressors in preterm neonates with probable transitional circulatory instability in the first week of life: a systematic review and network meta-analysis. BMJ Paediatr Open 2024; 8:e002500. [PMID: 38769048 PMCID: PMC11110579 DOI: 10.1136/bmjpo-2024-002500] [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: 01/05/2024] [Accepted: 03/12/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND There exists limited agreement on the recommendations for the treatment of transitional circulatory instability (TCI) in preterm neonates OBJECTIVE: To compare the efficacy of various interventions used to treat TCI METHODS: Medline and Embase were searched from inception to 21st July 2023. Two authors extracted the data independently. A Bayesian random effects network meta-analysis was used. Recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. INTERVENTIONS Dopamine, dobutamine, epinephrine, hydrocortisone, vasopressin, milrinone, volume and placebo. MAIN OUTCOME MEASURES Mortality, major brain injury (MBI) (intraventricular haemorrhage > grade 2 or cystic periventricular leukomalacia), necrotising enterocolitis (NEC) ≥stage 2 and treatment response (as defined by the author). RESULTS 15 Randomized Controlled Trials (RCTs) were included from the 1365 titles and abstracts screened. Clinical benefit or harm could not be ruled out for the critical outcome of mortality. For the outcome of MBI, epinephrine possibly decreased the risk when compared to dobutamine and milrinone (very low certainty). Epinephrine was possibly associated with a lesser risk of NEC when compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Dopamine was possibly associated with a lesser risk of NEC when compared with dobutamine (very low certainty). Vasopressin possibly decreased the risk of NEC compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Clinical benefit or harm could not be ruled out for the outcome response to treatment. CONCLUSIONS Epinephrine may be used as the first-line drug in preterm neonates with TCI, the evidence certainty being very low. We suggest future trials evaluating the management of TCI with an emphasis on objective criteria to define it.
Collapse
Affiliation(s)
| | - Gunjana Kumar
- Neonatology, National Institute of Medical Sciences and Research, Jaipur, Rajasthan, India
| | | | | | - Pradeep Suryawanshi
- Neonatology, Bharati Vidyapeeth University Medical College & Hospital, Pune, Maharashtra, India
| | - Mohit Sahni
- Neonatology, Surat Kids Hospital, Surat, Gujarat, India
| | | | - Deepak Sharma
- Neonatology, National Institute of Medical Sciences and Research, Jaipur, Rajasthan, India
| | - Kiran More
- Neonatology, MRR Children's Hospital, Thane, Maharashtra, India
| |
Collapse
|
3
|
Agakidou E, Chatziioannidis I, Kontou A, Stathopoulou T, Chotas W, Sarafidis K. An Update on Pharmacologic Management of Neonatal Hypotension: When, Why, and Which Medication. CHILDREN (BASEL, SWITZERLAND) 2024; 11:490. [PMID: 38671707 PMCID: PMC11049273 DOI: 10.3390/children11040490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/30/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
Anti-hypotensive treatment, which includes dopamine, dobutamine, epinephrine, norepinephrine, milrinone, vasopressin, terlipressin, levosimendan, and glucocorticoids, is a long-established intervention in neonates with arterial hypotension (AH). However, there are still gaps in knowledge and issues that need clarification. The main questions and challenges that neonatologists face relate to the reference ranges of arterial blood pressure in presumably healthy neonates in relation to gestational and postnatal age; the arterial blood pressure level that potentially affects perfusion of critical organs; the incorporation of targeted echocardiography and near-infrared spectroscopy for assessing heart function and cerebral perfusion in clinical practice; the indication, timing, and choice of medication for each individual patient; the limited randomized clinical trials in neonates with sometimes conflicting results; and the sparse data regarding the potential effect of early hypotension or anti-hypotensive medications on long-term neurodevelopment. In this review, after a short review of AH definitions used in neonates and existing data on pathophysiology of AH, we discuss currently available data on pharmacokinetic and hemodynamic effects, as well as the effectiveness and safety of anti-hypotensive medications in neonates. In addition, data on the comparisons between anti-hypotensive medications and current suggestions for the main indications of each medication are discussed.
Collapse
Affiliation(s)
- Eleni Agakidou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Ilias Chatziioannidis
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Angeliki Kontou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Theodora Stathopoulou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Kosmas Sarafidis
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| |
Collapse
|
4
|
Sarafidis K, Verykouki E, Nikopoulos S, Apostolidou-Kiouti F, Diakonidis T, Agakidou E, Kontou A, Haidich AB. Systematic Review and Meta-Analysis of Cardiovascular Medications in Neonatal Hypotension. Biomed Hub 2022; 7:70-79. [PMID: 35950013 PMCID: PMC9251481 DOI: 10.1159/000525133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/20/2022] [Indexed: 11/19/2022] Open
Abstract
Background Comparative studies among the various cardiovascular medications used for the treatment of neonatal hypotension are lacking. Methods This systematic review and pairwise meta-analysis of the anti-hypotensive treatments in preterm and term infants was conducted to evaluate efficacy and impact on outcome. Electronic databases were searched up to February 2021 for relevant articles. As an extension of the current approach for study selection, a machine learning technique was used. Only randomized controlled trials (RCTs) of inotropes, pressors, volume therapy, and corticosteroids were included. Response to treatment was the primary outcome while secondary outcomes included mortality and common morbidities. Results Nineteen RCTs involving 758 preterm and term neonates were found, and 8 treatments were evaluated. Most studies involved subjects with early hypotension associated with prematurity. Pairwise meta-analysis among treatments showed that dopamine was more effective than dobutamine regarding the response to treatment (restoration of normotension or normalization of blood pressure) (7 trials, 286 neonates, odds ratio, 3.06 [95% CI = 1.06–8.87]; I<sup>2</sup> = 49%, very low quality of the evidence per GRADE). Comparisons of other treatments were not significant. No differences were found among regimens regarding survival and other secondary outcomes. Conclusion In this systematic review and pairwise meta-analysis, only the comparison of dopamine versus dobutamine provided evidence for efficacy of treatment and favored dopamine. No safe conclusions could be reached in regard to other treatments. Data regarding the management of arterial hypotension in conditions other than transition after birth in preterm newborns are sparse both in preterm and term infants.
Collapse
Affiliation(s)
- Kosmas Sarafidis
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
- *Kosmas Sarafidis,
| | - Eleni Verykouki
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Nikopoulos
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Fani Apostolidou-Kiouti
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Diakonidis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Agakidou
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Aggeliki Kontou
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
5
|
Rai R, Singh DK, Bhakhri BK. Hypothyroxinemia in sick term neonates and its risk factors in an extramural neonatal intensive care unit: a prospective cohort study. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:466-471. [PMID: 35657132 PMCID: PMC10697644 DOI: 10.20945/2359-3997000000500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
Objective Thyroid functions in the sick newborns may be altered in the first week of life. Transient hypothyroxinemia has been reported in these babies, which could be due to the immaturity of the hypothalamic-pituitary-thyroid axis or to acute illness. We conducted this study to estimate the incidence of hypothyroxinemia and determine its risk factors in sick term newborns. Materials and methods We analyzed free T4 (FT4) and thyroid-stimulating hormone (TSH) levels in sick term neonates (≤7 days of life) admitted to the neonatal intensive care unit. FT4 and TSH levels were estimated in the first week of life in all the enrolled neonates (N = 98) and then repeated at 14-21 days of life in 46 babies. Risk analysis was conducted using univariate and multivariate logistic regression, and numerical data was compared using the Mann-Whitney U test and t-test. Results Hypothyroxinemia was seen in 10 (10.2%) of the admitted term babies. Male gender, vaginal delivery, presence of hypoxic ischemic encephalopathy, and need for mechanical ventilation (>24 hours) were identified as risk factors. There was a significant negative linear correlation between FT4 level in the first week of life and duration of hospital stay. Conclusion Hypothyroxinemia is common in sick term neonates.
Collapse
Affiliation(s)
- Ruchi Rai
- Department of Neonatology (Maternal Reproductive Health), Super Speciality Pediatric Hospital and Postgraduate Teaching Institute, Noida, UP, India,
| | - D K Singh
- Department of Pediatrics, Super Speciality Pediatric Hospital and Postgraduate Teaching Institute, Noida, UP, India
| | - Bhanu Kiran Bhakhri
- Department of Pediatrics, Super Speciality Pediatric Hospital and Postgraduate Teaching Institute, Noida, UP, India
| |
Collapse
|
6
|
Mikołajczak A, Kufel K, Bokiniec R. Correlation Between Thyroid Hormone Concentrations and Ultrasound Thyroid Volume in Preterm Infants Born Before 33 Weeks of Gestation. Front Endocrinol (Lausanne) 2022; 13:860716. [PMID: 35620396 PMCID: PMC9128814 DOI: 10.3389/fendo.2022.860716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/11/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Thyroid disorders are commonly concomitant with premature birth; however, indications to start therapy remain unclear due to a lack of gestational age (GA)-specific reference ranges. We aimed to evaluate the age-specific thyroid-stimulating hormone (TSH), free thyroxine (FT4) levels and the correlation between TSH and FT4 serum levels and ultrasound thyroid volume in preterm infants. MATERIALS AND METHODS This was an observational, prospective, single-center study of 98 preterm infants born before 33 weeks GA. The infants were divided into the 24-28 weeks and 29-32 weeks GA groups. TSH and FT4 serum levels were measured at two time points: at postnatal age (PNA) 2 weeks and at postmenstrual age (PMA) 32 weeks; the results were compared between groups at two consecutive time points. RESULTS There was a statistically significant between-group difference in FT4 concentration. There was a positive correlation between FT4 and GA at both screening times. FT4 in the 24-28 weeks GA group was significantly lower than in the 29-32 weeks GA group. The mean (standard deviation [SD]) FT4 at PNA 2 weeks was 11.72 ± 2.16 pmol/l for the 24-28 weeks GA group vs. 13.33 ± 1.80 pmol/l for the 29-32 weeks GA group (p<0.001). The mean (SD) FT4 at PMA 32 weeks was 11.96 ± 1.98 pmo/l for the 24-28 weeks GA group vs. 13.33 ± 1.80 pmol/l for the 29-32 weeks GA group (p=0.001). Our results reflect a slow and gradual upward trend of FT4 in the 24-28 weeks GA. It is of interest that the correlation between thyroid volume and FT4 was statistically significant (rho=0.25, p=0.019) for all studied preterm infants. The correlation between thyroid volume and weight was statistically significant for the entire study group (rho=0.37, p<0.001). We did not find statistically significant differences in TSH and FT4 values between consecutive time points at 24-28 weeks GA. The thyroid volume was not significantly different between both groups. The total thyroid volume was 0.26 vs. 0.27 ml for the 24-28 and 29-32 weeks GA groups, respectively. CONCLUSION The results of this study indicate that preterm infants require lower FT4 values depending on GA. Moreover, ultrasound thyroid imaging may facilitate the evaluation of questionable thyroid disorders.
Collapse
Affiliation(s)
| | - Katarzyna Kufel
- Neonatal and Intensive Care Department, Medical University of Warsaw, Warsaw, Poland
| | - Renata Bokiniec
- Neonatal and Intensive Care Department, Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Renata Bokiniec, ;
| |
Collapse
|
7
|
Yilmaz A, Ozer Y, Kaya N, Turan H, Acar HC, Ercan O, Perk Y, Evliyaoglu O, Vural M. The factors associated with transient hypothyroxinemia of prematurity. BMC Pediatr 2021; 21:344. [PMID: 34388993 PMCID: PMC8363484 DOI: 10.1186/s12887-021-02826-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/25/2021] [Indexed: 12/28/2022] Open
Abstract
Background Hypothyroxinemia is defined by low levels of thyroxine (T4) despite low or normal levels of thyroid-stimulating hormone (TSH). This study aimed to evaluate the factors associated with transient hypothyroxinemia of prematurity (THOP) in newborns admitted to the neonatal intensive care unit (NICU). Method This is a single center, retrospective, case-control study. Premature newborns, between 24 and 34 weeks of gestation, hospitalised between January 2014–December 2019 in Istanbul University-Cerrahpasa Faculty of Medicine NICU were analyzed through their medical records. Thyroid function tests were routinely performed between the 10th and 20th days of postnatal life and were evaluated according to the gestational age references. Thirty six possible associated factors (prenatal and postnatal parameters, medical treatments, clinical diagnoses and applications in NICU) were searched in the patient group with THOP (n = 71) and the control group with euthyroid prematures (n = 73). The factors for THOP were identified by univariate analysis, followed by multivariate analysis. Results Mean gestational ages of the study and the control groups were 29.7 ± 2.48 and 30.5 ± 2.30 weeks, respectively (p = 0.606). The birth weight, small for gestational age (SGA), intraventricular hemorrhage (IVH), congenital heart disease (CHD) were found to be the possible associated factors for THOP in the univariate analysis and CHD (p = 0.007, odds ratio [OR]:4.9, 95% confidence interval [CI]: 1.5–15.8), BW (p = 0.004, OR:0.999, 95% CI: 0.9–1.0) and SGA (p = 0.010, OR:4.6, 95% CI: 1.4–14.7) were found to be factors associated with THOP determined by univariate logistic regression analysis. Conclusıons Although some treatment practices might have had direct effects on pituitary–thyroid axis, related with the severity of the newborn clinical conditions, non of them was found to be a associated factor for THOP. However, CHD and SGA may be considered as associated factors with THOP detected in preterm infants.
Collapse
Affiliation(s)
- Aslan Yilmaz
- Department of Neonatology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa, Fatih, 34098, Istanbul, Turkey.
| | - Yavuz Ozer
- Department of Pediatric Endocrinology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa, Fatih, 34098, Istanbul, Turkey
| | - Nesrin Kaya
- Department of Neonatology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa, Fatih, 34098, Istanbul, Turkey
| | - Hande Turan
- Department of Pediatric Endocrinology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa, Fatih, 34098, Istanbul, Turkey
| | - Hazal Cansu Acar
- Department of Public Health, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa, Fatih, 34098, Istanbul, Turkey
| | - Oya Ercan
- Department of Pediatric Endocrinology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa, Fatih, 34098, Istanbul, Turkey
| | - Yildiz Perk
- Department of Neonatology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa, Fatih, 34098, Istanbul, Turkey
| | - Olcay Evliyaoglu
- Department of Pediatric Endocrinology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa, Fatih, 34098, Istanbul, Turkey
| | - Mehmet Vural
- Department of Neonatology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa, Fatih, 34098, Istanbul, Turkey
| |
Collapse
|
8
|
Caiulo S, Corbetta C, Di Frenna M, Medda E, De Angelis S, Rotondi D, Vincenzi G, de Filippis T, Patricelli MG, Persani L, Barera G, Weber G, Olivieri A, Vigone MC. Newborn Screening for Congenital Hypothyroidism: the Benefit of Using Differential TSH Cutoffs in a 2-Screen Program. J Clin Endocrinol Metab 2021; 106:e338-e349. [PMID: 33124651 DOI: 10.1210/clinem/dgaa789] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Analysis of a 2-screen program for congenital hypothyroidism (CH) was performed using differential dried-blood spot thyrotropin (bTSH) cutoffs of 10 mU/L at first screening (all infants) and 5 mU/L at second screening (selected infants). OBJECTIVES This work aimed to characterize CH infants identified by the second screening and compare infants with bTSH of 5.0 to 9.9 and 10 mU/L or greater on second screening. DESIGN AND PATIENTS Maternal and neonatal clinical features were retrospectively analyzed for 119 CH babies detected on the second screen in the Lombardy region of Italy, 2007 to 2014. RESULTS Fifty-two (43.7%) of the 119 CH neonates showed bTSH values ranging from 5.0 to 9.9 mU/L at the second screening (low bTSH group) and 67 (56.3%) bTSH of 10.0 mU/L or greater (high bTSH group). The frequency of thyroid dysgenesis and eutopic gland was similar in both groups, as was the frequency of permanent and transient CH. Moreover, a high frequency of extrathyroidal malformations was found in both groups. The percentage of preterm infants (57.7% vs 23.9%, P < .001) and infants admitted to the neonatal intensive care unit (50.0% vs 17.9%, P < .001) was significantly higher in the low vs the high bTSH group. In addition, maternal treatment with glucocorticoids in pregnancy was significantly more frequent in the low bTSH group than in the high bTSH group (11.5% vs 1.5%, P = .042), as well as maternal hypothyroidism and/or goiter (26.9% vs 10.4%, P = .036). CONCLUSIONS This study has demonstrated that a lower TSH cutoff at the second screening can detect additional cases of CH and that a second bTSH cutoff of 5.0 mU/L is appropriate for identifying preterm newborns and babies with associated risk factors.
Collapse
Affiliation(s)
- Silvana Caiulo
- Department of Pediatrics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Corbetta
- Regional Newborn Screening Laboratory of Lombardy Region, Children's Hospital V. Buzzi, Milan, Italy
| | - Marianna Di Frenna
- Department of Pediatrics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emanuela Medda
- Reference Center for Behavioral Sciences and Mental Health, National Institute of Health, Rome, Italy
| | - Simona De Angelis
- Department of Cardiovascular and Endocrine-Metabolic Diseases, and Aging, National Institute of Health, Rome, Italy
| | - Daniela Rotondi
- Department of Cardiovascular and Endocrine-Metabolic Diseases, and Aging, National Institute of Health, Rome, Italy
| | - Gaia Vincenzi
- Department of Pediatrics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Tiziana de Filippis
- Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, Milan, Italy
| | - Maria Grazia Patricelli
- Medical Genetics, Molecular Biology and Citogenetics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Persani
- Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, Milan, Italy
- Department of Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Graziano Barera
- Department of Pediatrics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanna Weber
- Department of Pediatrics, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy
| | - Antonella Olivieri
- Department of Cardiovascular and Endocrine-Metabolic Diseases, and Aging, National Institute of Health, Rome, Italy
| | | |
Collapse
|
9
|
Abstract
Primary function of cardiovascular system is to meet body's metabolic demands. The aim of inotrope therapy is to minimise adverse impact of cardiovascular compromise. Current use of inotropes is primarily guided by the pathophysiology of cardiovascular compromise and anticipated actions of inotropes. Lack of significant reduction in morbidity and mortality associated with cardiovascular compromise despite inotrope use, highlights major gaps in our understanding of circulatory targets, thresholds and choices of inotrope therapy. Thus far, prevention of cardiovascular compromise remains the most effective strategy to optimize outcomes. Studies of alternative design are needed for further advancement in cardiovascular therapy in neonates.
Collapse
Affiliation(s)
- Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia; University of Newcastle, Newcastle, Australia.
| | - Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia; University of Newcastle, Newcastle, Australia
| |
Collapse
|
10
|
Dempsey E, El-Khuffash A. Clinical Trials in Hemodynamic Support: Past, Present, and Future. Clin Perinatol 2020; 47:641-652. [PMID: 32713455 DOI: 10.1016/j.clp.2020.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Managing low blood flow states in the preterm population remains a challenge in neonatal clinical care. The heterogeneity of the trials to date and the relatively low number of infants enrolled, in addition to a desire to oversimplify the underlying pathophysiology, have contributed to an inability to draw meaningful conclusions to direct clinical care. This article reviews the current literature on this topic in the preterm population and outlines the challenges that have been encountered in performing such trials. Alternative studies are proposed, based on the lessons learned over the past number of years.
Collapse
Affiliation(s)
- Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Wilton, Cork, Ireland.
| | - Afif El-Khuffash
- The Rotunda Hospital, Dublin and Royal College of Surgeons, Dublin, Ireland
| |
Collapse
|
11
|
Heo YJ, Lee YA, Lee B, Lee YJ, Lim YH, Chung HR, Shin SH, Shin CH, Yang SW. How can the occurrence of delayed elevation of thyroid stimulating hormone in preterm infants born between 35 and 36 weeks gestation be predicted? PLoS One 2019; 14:e0220240. [PMID: 31442229 PMCID: PMC6707626 DOI: 10.1371/journal.pone.0220240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/11/2019] [Indexed: 12/26/2022] Open
Abstract
Objective We evaluated frequency and risk factors of delayed TSH elevation (dTSH) and investigated follow-up outcomes in the dTSH group with venous TSH (v-TSH) levels of 6–20 mU/L according to whether late preterm infants born at gestational age (GA) 35–36 weeks had risk factors. Methods The medical records of 810 neonates (414 boys) born at Seoul National University Hospital who had a normal neonatal screening test (NST) and underwent the first repeat venous blood test at 10–21 days post birth were reviewed. Results Seventy-three (9.0%) neonates showed dTSH, defined as a v-TSH level ≥6.0 mU/L, 12 of whom (1.5%) were started on levothyroxine medication. A multivariate-adjusted model indicated that a low birth weight (LBW <2,000 g), a congenital anomaly, and exposure to iodine contrast media (ICM) were significant predictors for dTSH (all p < 0.05). Among these 73 dTSH infants, all 5 infants with TSH levels ≥20 mU/L began levothyroxine medication, and 6 of 16 infants with v-TSH levels of 10–20 mU/L were indicated for levothyroxine, regardless of coexisting risk factors. However, only 1 of 52 infants with v-TSH levels of 6–10 mU/L who had a congenital anomaly was indicated for levothyroxine. All healthy late preterm infants, including LBW and multiple births, with v-TSH levels of 6–10 mU/L exhibited normal thyroid function. Conclusions dTSH was detected in 9.0% and levothyroxine was indicated in 1.5% of infants born at GA 35–36 weeks, particularly those with a LBW, a congenital anomaly, or history of ICM exposure. Either levothyroxine or retesting is indicated for late preterm neonates with TSH levels ≥10 mU/L regardless of risk factors. If healthy preterm neonates show v-TSH levels of 6–10 mU/L, a second repeat test may not be necessary; however, further studies are required to set a threshold for retesting.
Collapse
Affiliation(s)
- You Jung Heo
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
- * E-mail:
| | - Bora Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yun Jeong Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Youn Hee Lim
- Institute of Environmental Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Hye Rim Chung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sei Won Yang
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
12
|
Abstract
There is a distinct lack of age-appropriate cardiotonic drugs, and adult derived formulations continue to be administered, without evidence-based knowledge on their dosing, safety, efficacy, and long-term effects. Dopamine remains the most commonly studied and prescribed cardiotonic drug in the neonatal intensive care unit (NICU), but evidence of its effect on endorgan perfusion still remains. Unlike adult and pediatric critical care, there are significant gaps in our knowledge on the use of various cardiotonic drugs in various forms of circulatory failure in the NICU.
Collapse
Affiliation(s)
- Eugene Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Wilton, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland.
| | - Heike Rabe
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Department of Neonatology, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
| |
Collapse
|
13
|
Hyun JK, Choi SY, Jung YJ, Lee JH. Effect of Delayed Elevation of Thyrotropin on Feeding Intolerance in Very Low Birth Weight Infants. NEONATAL MEDICINE 2019. [DOI: 10.5385/nm.2019.26.2.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
14
|
McVea S, Turner A. Which vasoactive drug should be first choice in paediatric septic shock? Arch Dis Child 2019; 104:303-305. [PMID: 30413487 DOI: 10.1136/archdischild-2018-316164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/09/2018] [Accepted: 10/11/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Steven McVea
- Paediatric Intensive Care, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Alastair Turner
- Paediatric Intensive Care, Royal Hospital for Children Glasgow, Glasgow, UK
| |
Collapse
|
15
|
Uchiyama A, Watanabe H, Nakanishi H, Totsu S. Small for gestational age is a risk factor for the development of delayed thyrotropin elevation in infants weighing less than 2000 g. Clin Endocrinol (Oxf) 2018; 89:431-436. [PMID: 29920753 DOI: 10.1111/cen.13793] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/17/2018] [Accepted: 06/16/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Delayed thyrotropin (TSH) elevation (dTSHe) is common in low birthweight infants. We aimed to clarify the risk factors for the development of dTSHe in infants weighing <2000 g at birth. PATIENTS AND METHODS According to Japanese guidelines, infants with birthweight <2000 g underwent second capillary TSH screening within 30 days, either at 1 month of age; or when weight reached 2.5 kg; or at discharge. dTSHe was defined as TSH >20 mIU/L by venous sampling following a normal result (<15 mIU/L) at first screening aged 4-6 days. For each infant who developed dTHSe three babies without dTSHe were selected and matched for gestational age and birth year. Small for gestational age (SGA) was defined as a birthweight <10th percentile for the gestational age and sex. A multivariate analysis was performed to identify risk factors for the development of dTSHe. RESULTS Among the 911 study infants, 17 infants (1.9%) had dTSHe. The median (range) birthweight in the dTSHe group (796 [388-1912] g) was significantly smaller than the comparison group (961 [408-1981] g) (P = 0.04). The number (%) of SGA infants was significantly higher in the dTSHe group (12 [71%]) than in the comparison group (13 [25%]) (P = 0.001). The multivariate analysis revealed that SGA was an independent risk factor for the development of dTSHe (adjusted odds ratio, 9.0; 95% confidence interval, 2.5-32.8; P = 0.001). CONCLUSIONS Small for gestational age is an independent risk factor for the development of dTSHe in infants with a birthweight <2000 g. The influence of prematurity, a matching criterion for this study, on dTSHe requires additional study.
Collapse
Affiliation(s)
- Atsushi Uchiyama
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Hirokazu Watanabe
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Hidehiko Nakanishi
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Satsuki Totsu
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| |
Collapse
|
16
|
Dopamine and the Risk for Hospital-Acquired Infections. Pediatr Crit Care Med 2018; 19:269-270. [PMID: 29499024 DOI: 10.1097/pcc.0000000000001446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Verma RP, Dasnadi S, Zhao Y, Chen HH. A comparative analysis of ante- and postnatal clinical characteristics of extremely premature neonates suffering from refractory and non-refractory hypotension: Is early clinical differentiation possible? Early Hum Dev 2017; 113:49-54. [PMID: 28750269 DOI: 10.1016/j.earlhumdev.2017.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/19/2017] [Accepted: 07/02/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND About 25% of hypotensive ELBW infants are refractory to intravascular volume expansion and inotropic drugs (VI) and require hydrocortisone (HC). Such neonates suffer from complications of prolonged hypotension and extended therapy with VI. ELBW infants with refractory hypotension (RH) are clinically and biochemically indistinguishable from those who respond to VI. OBJECTIVE Early identification and differentiation of ELBW infants susceptible to steroid dependent hypotension from those who respond to inotropic medications. METHODS In a retrospective study the ante- and postnatal clinical characteristics of ELBW infants who received hydrocortisone (HC) for refractory hypotension (RH) were compared to those who responded to volume-inotropes (VI). RESULTS Infants in HC group had lower birth weight (BW, 675±121g) and gestational age (GA, 25.1±1.3weeks) and higher mean airway pressure and oxygen requirements, all independent of antenatal steroid (ANS) exposure. The receipt of ANS (p 0.01) and occurrences of maternal diabetes mellitus (GDM, p 0.01) were lower in HC group. ANS (OR 0.5, 95% CI 0.2-0.9, p 0.01) and GDM (OR 0.3, 95% CI 0.09-0.9, p 0.04) reduced the risk for RH. HC group had higher risk for IVH (OR 2.1, 95% CI 1.02-4.2 p=0.04) which declined in the multivariate analysis. A trend towards lower risk of ventriculomegaly (VM) was noted in HC group (OR 0.3, 95% CI 0.1-1.1), which became significant after controlling for BW (OR 0.2 95% CI 0.07-0.9, p 0.04). Similar trend was noted for maternal hypertension. CONCLUSION Hypotension in ELBW infants who are ≤25wks of GA and unexposed to ANS and GDM is refractory to VI therapy. Such neonates may benefit from an initial therapy with, or earlier institution of hydrocortisone. The trend towards a higher risk for VM with VI therapy needs validation in future studies.
Collapse
Affiliation(s)
- Rita P Verma
- Nassau University Medical Center, Department of Pediatrics, Division of Neonatology, 2201 Hempstead Turnpike, East Meadow, NY 11554, United States.
| | - Shaeequa Dasnadi
- Houston Methodist Sugarland Nurseries, Department of Pediatrics Section of Neonatology, Baylor College of Medicine, 6621 Fannin Street # B 06104, Houston, TX 77030, United States.
| | - Yuan Zhao
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, NY 11794, United States.
| | - Hegang H Chen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 113 Howard Hall, 660 W. Redwood Street, Baltimore, MD 21201, United States.
| |
Collapse
|
18
|
Zung A, Bier Palmon R, Golan A, Troitzky M, Eventov-Friedman S, Marom R, Keidar R, Kats N, Almashanu S, Flidel-Rimon O. Risk Factors for the Development of Delayed TSH Elevation in Neonatal Intensive Care Unit Newborns. J Clin Endocrinol Metab 2017. [PMID: 28637222 DOI: 10.1210/jc.2017-00701] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Delayed thyrotropin (TSH) elevation (dTSH) is defined as elevated TSH at the second neonatal screening (after normal TSH levels at the initial screening) in premature, low-birth-weight, and ill newborns, mostly in the neonatal intensive care unit (NICU) setting. The pathogenesis of dTSH is elusive. OBJECTIVE To identify the risk factors for dTSH development among newborns in the NICU. DESIGN, SETTING, AND PATIENTS A retrospective medical record review of neonates with dTSH was conducted in eight university-affiliated NICUs. Two controls were selected for each patient, matched for sex and birth weight. The risk factors for dTSH were identified by univariate analysis, followed by multivariate analysis. MAIN OUTCOME MEASURES Maternal variables, types of NICU treatments and procedures, syndromes, and various medical conditions were compared between dTSH patients and their matched controls. RESULTS We enrolled 100 dTSH patients and 200 matched controls and 46 variables were compared between the two groups. Twelve risk factors for dTSH were identified on univariate analysis: cesarean section, mechanical ventilation, patent ductus arteriosus (PDA), pneumothorax, and administration of cefotaxime, vancomycin, fluconazole, dopamine, ibuprofen, furosemide, insulin, and packed red blood cells. On multivariate analysis, four risk factors were identified: PDA and vancomycin, insulin, and furosemide administration. In 26 twin pairs, in which one twin had dTSH, all variables presented similarly in both twins. CONCLUSIONS Although some variables had direct effects on pituitary-thyroid axis dysfunction, these variables, altogether, reflect the severity of the clinical conditions in the NICU, which is the common basis for dTSH.
Collapse
Affiliation(s)
- Amnon Zung
- Pediatric Endocrinology Unit, Kaplan Medical Center, and the Hebrew University of Jerusalem, Rehovot 76100, Israel
| | | | - Agneta Golan
- Neonatal Department, Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva 8499000, Israel
| | - Mara Troitzky
- Neonatal Intensive Care Unit, The Barzilai Medical Center, affiliated with the Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva 8499000, Israel
| | - Smadar Eventov-Friedman
- Neonatology Unit, Hadassah Ein Kerem Hospital, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
| | - Ronella Marom
- Neonatology, Tel Aviv Medical Center, Tel Aviv University, Sackler Faculty of Medicine, Tel Aviv 6997801, Israel
| | - Rimona Keidar
- Neonatal Intensive Care Unit, Assaf Harofeh Medical Center, Zerifin 70300, Israel
| | - Neri Kats
- Neonatal Intensive Care Unit, Wolfson Medical Center, Holon 5822012, Israel
| | - Shlomo Almashanu
- National Newborn Screening Program, Department of Community Genetics, Public Health Services, Ministry of Health, Ramat Gan 5265601, Israel
| | - Orna Flidel-Rimon
- Neonatoloy Unit, Kaplan Medical Center, and the Hebrew University of Jerusalem, Rehovot 76100, Israel
| |
Collapse
|
19
|
Abstract
Hypotension is a common problem in neonates with complex underlying pathophysiology. Although treatment of low blood pressure is common, clinicians must use all available information to target neonates with compromised perfusion. Pharmacotherapy should be tailored to the specific physiologic perturbations of the individual neonate. Dopamine is the most commonly utilized agent and may be the most appropriate agent for septic shock with low diastolic blood pressure. However, alternative therapies should be considered for other etiologies of hypotension, including milrinone and vasopressin for persistent pulmonary hypertension of the newborn and dobutamine for patent ductus arteriosus. Additional studies are required to refine the approach to neonatal hypotension and document the long-term outcomes of treated neonates.
Collapse
|
20
|
García-Canales A, Peña-Juárez RA, Sandoval-Franco LDM. [Vasopressors and inotropes: use in paediatrics]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 88:39-50. [PMID: 28336302 DOI: 10.1016/j.acmx.2017.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 11/16/2022] Open
Abstract
The cardiovascular system is a dynamic system, which is required to ensure adequate delivery of oxygen, nutrients, and hormones to the tissues that are necessary for cell metabolism. It also synthesises and modifies the vasoactive components that regulate vascular tone and myocardial function. These vasoactive components have demonstrated their beneficial effects in the management of paediatric patients in a critical condition with heart failure and shock. However, their use and abuse brings harmful effects, increases mortality, and is associated with arrhythmias. An increase in myocardial oxygen consumption favours the presence of ischaemia, therefore it is necessary to know the mechanism of action and indications of these drugs to minimise their harmful effects. The purpose of this review is to describe the pharmacology and clinical applications of inotropic and vasopressor agents in the paediatric patient in acritical condition.
Collapse
Affiliation(s)
- Adrián García-Canales
- Departamento de Terapia Intensiva Pediátrica, Hospital Regional Valentín Gómez Farías, ISSSTE, Zapopan, Jalisco, México.
| | | | | |
Collapse
|
21
|
Congenital hypothyroidism with delayed thyroid-stimulating hormone elevation in premature infants born at less than 30 weeks gestation. J Perinatol 2017; 37:277-282. [PMID: 27906195 DOI: 10.1038/jp.2016.213] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/12/2016] [Accepted: 10/19/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Congenital hypothyroidism (CH) with delayed thyroid-stimulating hormone (TSH) elevation is a common form of thyroid dysfunction among premature infants. Routine newborn screening (NBS) may miss infants with CH with delayed TSH elevation. The objective of the study is to determine the prevalence of CH with delayed TSH elevation in premature infants and to identify associated risk factors. STUDY DESIGN Retrospective analysis of serum thyroid function screening (TFS) at day of life 30 in premature infants <30 weeks gestation, admitted to University of Iowa Neonatal Intensive Care Unit between 1 July 2012 to 30 June 2015. Serum free thyroxine and TSH levels were obtained in premature infants <30 weeks gestation on day of life 30. Follow-up testing and pediatric endocrinology consultation were done according to the institutional protocol. RESULT In total, 286 infants were included. All infants underwent routine NBS and 280 patients underwent TFS. Twenty-six patients (9.1%) were diagnosed with thyroid dysfunction. NBS identified only three patients. CH with delayed TSH elevation was diagnosed in 20 patients (6.9%) and was significantly associated with multiple gestation, lower birth weight, higher gestational age and lower 5 min APGAR score. CONCLUSION Thyroid dysfunction is common among premature infants born before 30 weeks gestation. The majority of cases with thyroid dysfunction had CH with delayed TSH elevation, which was not detected by NBS. We recommend measurement of serum TSH and free T4 levels on day of life 30 in premature infants born at <30 weeks gestation to identify patients with CH with delayed TSH elevation.
Collapse
|
22
|
Leeuwen L, van Heijst AFJ, Vijfhuize S, Beurskens LWJE, Weijman G, Tibboel D, van den Akker ELT, IJsselstijn H. Nationwide Evaluation of Congenital Hypothyroidism Screening during Neonatal Extracorporeal Membrane Oxygenation. Neonatology 2017; 111:93-99. [PMID: 27639769 PMCID: PMC5296890 DOI: 10.1159/000448238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 07/08/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Thyroid hormone concentrations may deviate from normal values during critical illness. This condition is known as nonthyroidal illness syndrome (NTIS), and it can influence the results of screening for congenital hypothyroidism (CH) during neonatal extracorporeal membrane oxygenation (ECMO). OBJECTIVES To determine the incidence of aberrant CH screening results in ECMO-treated neonates, to identify possible determinants, and to follow up patients with abnormal thyroid hormone concentrations. METHODS In this retrospective cohort study, we included 168 ECMO-treated neonates admitted from 2004 to 2014 and screened by protocol and divided them into the following 3 groups: group 1 (screened during ECMO, n = 107), group 2 (screened shortly before ECMO, n = 26), and group 3 (screened shortly after ECMO, n = 35). RESULTS CH screening results were aberrant in 67.3% (72/107) of the neonates screened during ECMO, in 73.1% (19/26) of the neonates screened before ECMO, and in 31.4% (11/35) of the neonates screened after ECMO (p < 0.001). Of the neonates with an aberrant screening result, all but 2 (i.e. 98%) had a low thyroxine concentration with a normal thyrotropin concentration at screening, as is seen in NTIS. None was diagnosed with CH. Mortality did not significantly differ between neonates with an aberrant screening result (32.4%) and neonates with a normal screening result (22.7%; p = 0.18). Screening before ECMO (OR 5.92; 95% CI 1.93-18.20), screening during ECMO (OR 4.49; 95% CI 1.98-10.19), and a higher Pediatric Logistic Organ Dysfunction-2 score (OR 1.31; 95% CI 1.04-1.66) were associated with an aberrant screening result. CONCLUSIONS Aberrant CH screening results were found in most ECMO-treated neonates screened before or during ECMO, which is likely due to NTIS. Follow-up of thyroid hormone concentrations is best started after recovery from critical illness. Our results suggest that thyroxine therapy is not required during ECMO.
Collapse
Affiliation(s)
- Lisette Leeuwen
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Double-Blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock. Pediatr Crit Care Med 2016; 17:e502-e512. [PMID: 27673385 DOI: 10.1097/pcc.0000000000000954] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We compared efficacy of dopamine and epinephrine as first-line vasoactive therapy in achieving resolution of shock in fluid-refractory hypotensive cold septic shock. DESIGN Double-blind, pilot, randomized controlled study. SETTING Pediatric emergency and ICU of a tertiary care teaching hospital. PATIENTS Consecutive children 3 months to 12 years old, with fluid-refractory hypotensive septic shock, were enrolled between July 2013 and December 2014. INTERVENTION Enrolled children were randomized to receive either dopamine (in incremental doses, 10 to 15 to 20 μg/kg/min) or epinephrine (0.1 to 0.2 to 0.3 μg/kg/min) till end points of resolution of shock were achieved. After reaching maximum doses of test drugs, open-label vasoactive was started as per discretion of treating team. Primary outcome was resolution of shock within first hour of resuscitation. The study was registered (CTRI/2014/02/004393) and was approved by institute ethics committee. MEASUREMENTS AND MAIN RESULTS We enrolled 29 children in epinephrine group and 31 in dopamine group. Resolution of shock within first hour was achieved in greater proportion of children receiving epinephrine (n = 12; 41%) than dopamine (n = 4; 13%) (odds ratio, 4.8; 95% CI, 1.3-17.2; p = 0.019); the trend persisted even at 6 hours (48.3% vs 29%; p = 0.184). Children in epinephrine group had lower Sequential Organ Function Assessment score on day 3 (8 vs 12; p = 0.05) and more organ failure-free days (24 vs 20 d; p = 0.022). No significant difference in adverse events (16.1% vs 13.8%; p = 0.80) and mortality (58.1% vs 48.3%; p = 0.605) was observed between the two groups. CONCLUSION Epinephrine is more effective than dopamine in achieving resolution of fluid-refractory hypotensive cold shock within the first hour of resuscitation and improving organ functions.
Collapse
|
24
|
Zung A, Yehieli A, Blau A, Almashanu S. Characteristics of Delayed Thyroid Stimulating Hormone Elevation in Neonatal Intensive Care Unit Newborns. J Pediatr 2016; 178:135-140.e1. [PMID: 27546202 DOI: 10.1016/j.jpeds.2016.07.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 05/09/2016] [Accepted: 07/11/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To elucidate the incidence, clinical characteristics, and short-term outcome of delayed thyroid stimulating hormone (TSH) elevation (dTSH) in a large cohort of newborns admitted to the neonatal intensive care unit. STUDY DESIGN Data were gathered from a cohort of 13 201 newborns admitted to the neonatal intensive care unit born between January 1, 2008, and October 31, 2014, who underwent TSH measurements because of low T4 levels on the second screen. The data from the newborn screening program included gestational age, birth weight (BW), T4 levels, and short-term outcome. RESULTS Of 13 201 newborns, 333 (1:40) presented with dTSH (TSH >15 IU/L). dTSH had a peak proportion at gestational age of 37-39 weeks, and 66% of the patients had BW >1500 g. T4 levels in the 333 patients were negatively correlated with TSH levels (R = -0.505; P < .001), and significantly lower than levels in the other newborns: 5.9 ± 2.8 vs 7.6 ± 1.7 µg/dL; P < .001. TSH levels in dTSH newborns were already higher on the initial screen compared with the other newborns: 8.3 ± 5.2 vs 4.2 ± 3.7 IU/L; P < .001. Fifty-eight percent of 193 patients with dTSH were started on levothyroxine treatment. CONCLUSIONS dTSH has a higher incidence than previously reported, especially among newborns with BW >1500 g. Relatively high TSH and low T4 levels on the initial and second screen respectively are predictors for dTSH. Levothyroxine treatment is required in most cases.
Collapse
Affiliation(s)
- Amnon Zung
- Pediatric Endocrinology Unit, Kaplan Medical Center, Rehovot, Israel; Hebrew University of Jerusalem, Jerusalem, Israel.
| | | | - Ayala Blau
- The National Center for Newborn Screening, Ministry of Health, Tel-HaShomer, Israel
| | - Shlomo Almashanu
- The National Center for Newborn Screening, Ministry of Health, Tel-HaShomer, Israel
| |
Collapse
|
25
|
Vesoulis ZA, El Ters N, Foster A, Trivedi SB, Liao SM, Mathur AM. Response to dopamine in prematurity: a biomarker for brain injury? J Perinatol 2016; 36:453-8. [PMID: 26890555 PMCID: PMC4882223 DOI: 10.1038/jp.2016.5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To identify factors associated with responsiveness to dopamine therapy for hypotension and the relationship to brain injury in a cohort of preterm infants. STUDY DESIGN The pharmacy database at St Louis Children's Hospital was retrospectively queried to identify infants who (a) were born <28 weeks gestation between 2012 and 2014, (b) received dopamine and (c) had blood pressure measurements from an umbilical arterial catheter. A control group was constructed from contemporaneous infants who did not receive dopamine. Mean arterial blood pressure (MABP) at baseline, 1 h and 3 h after initiating dopamine were obtained for each dopamine-exposed infant. MABP measurements at matched time points were obtained in the control group. RESULT Sixty-nine dopamine-treated and 45 control infants were included. Mean ΔMABP at 3 h was 4.5±6.3 mm of Hg for treated infants vs 1±2.9 for the control. Median dopamine starting dose was 2.5 μg kg(-1) min(-1). Dopamine-treated infants were less mature and of lower birth weight while also more likely to be intubated at 72 h, diagnosed with intraventricular hemorrhage (IVH) and to die. Failure to respond to dopamine was associated with greater likelihood of developing IVH (odds ratio (OR) 5.8, 95% confidence interval (CI) 1.1-42.3), while a strong response (ΔMABP>10 mm Hg) was associated with a reduction in risk of IVH (OR 0.1, 95% CI 0.01-0.8). CONCLUSION Low-moderate dose dopamine administration results in modest blood pressure improvements. A lack of response to dopamine is associated with a greater risk of IVH, whereas a strong response is associated with a decreased risk. Further research into underlying mechanisms and management strategies is needed.
Collapse
Affiliation(s)
- Zachary A. Vesoulis
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Nathalie El Ters
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Allison Foster
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Shamik B. Trivedi
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Steve M. Liao
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M. Mathur
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
26
|
Bhayat SI, Gowda HMS, Eisenhut M. Should dopamine be the first line inotrope in the treatment of neonatal hypotension? Review of the evidence. World J Clin Pediatr 2016; 5:212-222. [PMID: 27170932 PMCID: PMC4857235 DOI: 10.5409/wjcp.v5.i2.212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 12/17/2015] [Accepted: 01/19/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine if dopamine is effective in treating neonatal hypotension and safe to use comparing to other inotropes.
METHODS: This is a review of evidence on inotropic treatment of neonatal hypotension. Databases searched were MEDLINE and the Cochrane Library, a total of 134 studies were identified. Only studies with high quality evidence (level 1a and b and 2a) were included. After review, only eight studies were included in the final analysis. Pooled risk ratios derived for each outcome [Mantel-Haenzel (M-H) fixed effect] with CI, as reported in the Cochrane reviews were plotted in forest plot form.
RESULTS: Eight articles met inclusion criteria, which all included treatment in preterm infants. Dopamine increased mean arterial blood pressure (BP) (n = 163; r = 0.88, 95%CI: 0.76 to 0.94) and systolic BP (n = 142; r = 0.81, 95%CI: 0.42 to 0.94) comparing to placebo. Dopamine has been shown overall to be statistically more effective in increasing BP than dobutamine (n = 251, r = 0.26, 95%CI: 0.20-0.32). However there were no differences in short term outcomes (periventricular leucomalacia, periventricular haemorrhage) and mortality between both drugs. There is no statistical evidence of dopamine being more effective than adrenaline or corticosteroids. There was no difference in morbidity and mortality outcomes when dopamine was compared to hydrocortisone (RR 1.81, 95%CI: 0.18 to 18.39) or adrenaline.
CONCLUSION: In preterms, dopamine is the most studied drug, and we suggest it could be used as first line treatment in hypotension.
Collapse
|
27
|
Mahoney L, Shah G, Crook D, Rojas-Anaya H, Rabe H. A Literature Review of the Pharmacokinetics and Pharmacodynamics of Dobutamine in Neonates. Pediatr Cardiol 2016; 37:14-23. [PMID: 26346024 DOI: 10.1007/s00246-015-1263-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/27/2015] [Indexed: 01/09/2023]
Abstract
Since its discovery in 1975 dobutamine has been used off-label for treating hemodynamic insufficiency in newborns and children. We present a structured literature review of pharmacokinetic and pharmacodynamic data for dobutamine in the pediatric population. Structured searches were conducted to identify relevant articles according to pre-defined inclusion criteria. Where possible, results for the pharmacodynamic and pharmacokinetic effect of dobutamine were reported as pooled data. Forty-six papers met the inclusion criteria. With regard to pharmacodynamic data a number of studies reported significant increases in a number of clinical parameters such as heart rate, blood pressure, cardiac output across a wide range of pediatric populations. With regard to pharmacokinetic data studies reported that the infusion rate was positively correlated to plasma dobutamine concentration. There was great variability with regard to dobutamine clearance between individuals and as to whether it followed first- or zero-order elimination kinetics. While the pharmacodynamic effects of dobutamine appear to reflect the pharmacological profile of the drug, the pharmacokinetic data are difficult to interpret due to inhomogeneity between study populations ages, comorbidities, dobutamine dosages and methodologies. High-quality prospective pharmacokinetic and pharmacodynamic data especially in newborns are urgently required prior to a large randomized study.
Collapse
Affiliation(s)
- Liam Mahoney
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Royal Alexandra Children's Hospital, Level 6, Room 663, Eastern Road, Brighton, BN2 5BE, UK.
| | - Geetika Shah
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Royal Alexandra Children's Hospital, Level 6, Room 663, Eastern Road, Brighton, BN2 5BE, UK
| | - David Crook
- Clinical Investigation and Research Unit, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Hector Rojas-Anaya
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Royal Alexandra Children's Hospital, Level 6, Room 663, Eastern Road, Brighton, BN2 5BE, UK
| | - Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Royal Alexandra Children's Hospital, Level 6, Room 663, Eastern Road, Brighton, BN2 5BE, UK
| |
Collapse
|
28
|
Olivieri A, Fazzini C, Medda E. Multiple factors influencing the incidence of congenital hypothyroidism detected by neonatal screening. Horm Res Paediatr 2015; 83:86-93. [PMID: 25572470 DOI: 10.1159/000369394] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/21/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Over the years a rise in the incidence of congenital hypothyroidism (CH) has been described worldwide. The aim of our study was to investigate trends in the incidence of CH in Italy over the period 1987-2008, and to investigate which factors may have influenced the CH incidence in our country. METHODS Data were derived from the Italian National Registry of Infants with Congenital Hypothyroidism. Since 1998 the laboratory procedures related to neonatal screening for CH have changed drastically. Accordingly, we estimated the CH incidence during the period 1987-1998 (period 1) and the period 1999-2008 (period 2). RESULTS The incidence of CH confirmed at birth (including transient hypothyroidism) has increased from 1:3,000 liveborn infants in period 1 to 1:1,940 in period 2 (+54%), whereas the incidence of purely permanent CH increased from 1:3,200 to 1:2,320 (+38%). Lowering of the TSH cutoff was the most important factor contributing to the increase of CH incidence in Italy. Moreover, an increment of 58% of preterm babies with permanent CH was found in period 2 compared with period 1. CONCLUSION Our results suggest that more than one cause is responsible for the rise in the increasing CH incidence, with lowering of the screening TSH cutoff and an increased survival rate of a growing number of preterm babies both playing an important role.
Collapse
Affiliation(s)
- Antonella Olivieri
- Department of Cell Biology and Neuroscience, Istituto Superiore di Sanità, Rome, Italy
| | | | | | | |
Collapse
|
29
|
Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015; 43:2292-302. [DOI: 10.1097/ccm.0000000000001260] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
30
|
Vigone MC, Di Frenna M, Weber G. Heterogeneous phenotype in children affected by non-autoimmune hypothyroidism: an update. J Endocrinol Invest 2015; 38:835-40. [PMID: 25916430 DOI: 10.1007/s40618-015-0288-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 04/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In the last decades, a higher incidence of congenital hypothyroidism (CH) has been recorded in Italy (1:1940) and worldwide, mainly due to the shift to lower screening TSH cutoffs. Although CH can also be caused by dysgenetic defects, most CH cases have recently been found to be more frequently associated with functional defects of an in situ thyroid gland. Although the clinical phenotype is milder with high prevalence of transient forms, some cases eventually prove to be permanent. RESULTS Possible explanations of the raised incidence of CH are ethnic modifications of the screened population and the increasing incidence of preterm birth and multiple pregnancies. These findings are important in terms of public health and standardization of screening programmes for special at-risk categories such as preterms, acutely ill term neonates, low birth weight and very low birth weight infants, and newborns with specific drug exposure. Other environmental factors have contributed to the increased incidence of hypothyroidism, including thyroid disrupting chemicals, iodine supply (excess/deficiency), and drugs interfering with thyroid function. Finally, an increased prevalence of hypothyroidism has been documented in obese children and patients with syndromic forms (Williams, Down, Turner, pseudohypoparathyroidism). The clinical and molecular phenotype of patients with CH will be better defined thanks to novel genetic approach based on the systematic analysis of a panel of genes (TSHR, DUOX2, DUOXA, TPO, PDS, TG, NKX2.1, JAG1, GLIS3, FOXE1, PAX-8). CONCLUSIONS This review summarizes significant advances in the epidemiology and aetiology of non-autoimmune hypothyroidism, with a focus on thyroid dysfunction in preterm infants.
Collapse
Affiliation(s)
- M C Vigone
- Department of Pediatrics, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, via Olgettina 60, 20132, Milan, Italy
| | | | | |
Collapse
|
31
|
Dempsey EM. Challenges in Treating Low Blood Pressure in Preterm Infants. CHILDREN-BASEL 2015; 2:272-88. [PMID: 27417363 PMCID: PMC4928758 DOI: 10.3390/children2020272] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/05/2015] [Indexed: 01/02/2023]
Abstract
Whilst the prevalence of low blood pressure in preterm infants seems to have fallen over the last number of years, the problem is still frequently encountered in the neonatal intensive care unit and many babies continue to receive intervention. Great variability in practice persists, with a significant number of extremely low gestational age newborns in some institutions receiving some form of intervention, and in other units substantially less. A great degree of this variability relates to the actual criteria used to define hypotension, with some using blood pressure values alone to direct therapy and others using a combination of clinical, biochemical and echocardiography findings. The choice of intervention remains unresolved with the majority of centres continuing to administer volume followed by dopamine as a first line inotrope/vasopressor agent. Despite over 40 years of use there is little evidence that dopamine is of benefit both in the short term and long-term. Long-term follow up is available in only two randomised trials, which included a total of 99 babies. An under recognized problem relates to the administration of inotrope infusions in very preterm infants. There are no pediatric specific inotrope formulations available and so risks of errors in preparation and administration remain. This manuscript outlines these challenges and proposes some potential solutions.
Collapse
Affiliation(s)
- Eugene M Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork City post code, Ireland.
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland.
- Department of Paediatrics and Child Health, Cork University Maternity Hospital, Wilton Cork, Ireland.
| |
Collapse
|
32
|
Léger J, Olivieri A, Donaldson M, Torresani T, Krude H, van Vliet G, Polak M, Butler G. European Society for Paediatric Endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism. Horm Res Paediatr 2015; 81:80-103. [PMID: 24662106 DOI: 10.1159/000358198] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Accepted: 09/18/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim was to formulate practice guidelines for the diagnosis and management of congenital hypothyroidism (CH). EVIDENCE A systematic literature search was conducted to identify key articles relating to the screening, diagnosis, and management of CH. The evidence-based guidelines were developed with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, describing both the strength of recommendations and the quality of evidence. In the absence of sufficient evidence, conclusions were based on expert opinion. CONSENSUS PROCESS Thirty-two participants drawn from the European Society for Paediatric Endocrinology and five other major scientific societies in the field of pediatric endocrinology were allocated to working groups with assigned topics and specific questions. Each group searched the literature, evaluated the evidence, and developed a draft document. These papers were debated and finalized by each group before presentation to the full assembly for further discussion and agreement. RECOMMENDATIONS The recommendations include: worldwide neonatal screening, approaches to assess the cause (including genotyping) and the severity of the disorder, the immediate initiation of appropriate L-T4 supplementation and frequent monitoring to ensure dose adjustments to keep thyroid hormone levels in the target ranges, a trial of treatment in patients suspected of transient CH, regular assessments of developmental and neurosensory functions, consulting health professionals as appropriate, and education about CH. The harmonization of diagnosis, management, and routine health surveillance would not only optimize patient outcomes, but should also facilitate epidemiological studies of the disorder. Individuals with CH require monitoring throughout their lives, particularly during early childhood and pregnancy.
Collapse
Affiliation(s)
- Juliane Léger
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Is Dopamine an Iatrogenic Disruptor of Thyroid and Cortisol Function in the Extremely Premature Infant? ACTA ACUST UNITED AC 2014. [DOI: 10.1155/2014/973184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Dopamine is frequently used as an inotropic and vasoactive agent in neonatal intensive care units. Recent studies have reported that treatment with dopamine is associated with hypothyroxinaemia of prematurity. Objectives. The aim of this study was to determine if dopamine treatment in extremely premature infants altered thyroid and cortisol function. Methods. We prospectively measured plasma cortisol, TSH, free T4, total T4, and free triiodothyronine concentrations in babies born below 28 weeks’ gestation within 5 days of birth, who were either treated with dopamine (D+) or who did not receive any dopamine (D−) within 12 hours of birth. Clinical Risk Index for Babies scores, lowest mean arterial pressure and highest plasma lactate concentrations in the first 12 hours, were recorded. Results. There were 78 babies included in the study (43 males). Mean gestational age was 25 weeks and 3 days (SD 1.3 weeks). Univariate analyses showed significant differences in cortisol and thyroid function between D+ and D−. Multivariable analyses showed that dopamine, gestation, and CRIB were independent factors affecting FT4 concentrations. No independent factors were shown to affect cortisol or TSH concentrations. Conclusion. Dopamine administration appeared to affect FT4 concentrations but not cortisol concentrations. The mechanisms are unclear but the effect does not appear to be related to hypotension or tissue underperfusion.
Collapse
|
34
|
Farrugia R, Rojas H, Rabe H. Diagnosis and management of hypotension in neonates. Future Cardiol 2014; 9:669-79. [PMID: 24020669 DOI: 10.2217/fca.13.59] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The diagnosis and management of hypotension in neonates is a frequently encountered issue in the intensive care setting. There is an ongoing debate as to the appropriateness of blood pressure monitoring as an indicator of organ perfusion and tissue hypoxia. These ultimately determine morbidity and mortality in the sick newborn. This article explores the methods available for the assessment of organ perfusion and speculates on other means that may become available in the future. Different modalities of treatment currently in use are discussed, with the aim of using information gained from perfusion monitoring techniques to determine the optimal choice of therapy.
Collapse
Affiliation(s)
- Ryan Farrugia
- Neonatal & Paediatric Intensive Care Unit, Department of Paediatrics, Mater Dei Hospital, Malta.
| | | | | |
Collapse
|
35
|
Léger J, Olivieri A, Donaldson M, Torresani T, Krude H, van Vliet G, Polak M, Butler G. European Society for Paediatric Endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism. J Clin Endocrinol Metab 2014; 99:363-84. [PMID: 24446653 PMCID: PMC4207909 DOI: 10.1210/jc.2013-1891] [Citation(s) in RCA: 258] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim was to formulate practice guidelines for the diagnosis and management of congenital hypothyroidism (CH). EVIDENCE A systematic literature search was conducted to identify key articles relating to the screening, diagnosis, and management of CH. The evidence-based guidelines were developed with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, describing both the strength of recommendations and the quality of evidence. In the absence of sufficient evidence, conclusions were based on expert opinion. CONSENSUS PROCESS Thirty-two participants drawn from the European Society for Paediatric Endocrinology and five other major scientific societies in the field of pediatric endocrinology were allocated to working groups with assigned topics and specific questions. Each group searched the literature, evaluated the evidence, and developed a draft document. These papers were debated and finalized by each group before presentation to the full assembly for further discussion and agreement. RECOMMENDATIONS The recommendations include: worldwide neonatal screening, approaches to assess the cause (including genotyping) and the severity of the disorder, the immediate initiation of appropriate L-T4 supplementation and frequent monitoring to ensure dose adjustments to keep thyroid hormone levels in the target ranges, a trial of treatment in patients suspected of transient CH, regular assessments of developmental and neurosensory functions, consulting health professionals as appropriate, and education about CH. The harmonization of diagnosis, management, and routine health surveillance would not only optimize patient outcomes, but should also facilitate epidemiological studies of the disorder. Individuals with CH require monitoring throughout their lives, particularly during early childhood and pregnancy.
Collapse
Affiliation(s)
- Juliane Léger
- Université Paris Diderot (J.L.), Sorbonne Paris Cité, F-75019 Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique et Centre de Référence des Maladies Endocriniennes Rares de la Croissance, F-75019, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Unité Mixte de Recherche 676, F-75019 Paris, France; Department of Cell Biology and Neurosciences (A.O.), Istituto Superiore di Sanità, 00161 Rome, Italy; Child Health Section of Glasgow University School of Medicine (M.D.), Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ, Scotland, United Kingdom; Swiss Neonatal Screening Laboratory (T.T.), University Children's Hospital, CH-8032 Zurich, Switzerland; Department of Pediatric Endocrinology and Diabetes (H.K.), Charite Children's Hospital, Berlin 10117, Germany; Endocrinology Service and Research Center (G.v.V.), Centre Hospitalier Universitaire Sainte-Justine and Department of Pediatrics, University of Montreal, Montreal, Canada H3T 1C5; AP-HP, Hôpital Necker Enfants-Malades, Endocrinologie, Gynécologie et Diabétologie Pédiatriques (M.P.), Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Université Paris Descartes, Sorbonne Paris Cité, INSERM, Unité 845, F-75015 Paris, France; and Department of Paediatric and Adolescent Medicine and Endocrinology (G.B.), University College London Hospital, and University College London Institute of Child Health, London NW1 2PQ, United Kingdom
| | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
Controversy surrounds the assessment of perfusion and the methods currently utilised to define hypotension, especially blood pressure. There is growing agreement to assess heart function when selecting inotropic therapy and use bedside tools such as echocardiography for assessing at-risk infants. Both dopamine and dobutamine have comparative efficacy, and in certain disease states with immature myocardium there could be potential advantages in using dobutamine. The concomitant use of hydrocortisone has been shown to be beneficial when escalating doses of first-line inotropes are used. Other inotropes require further study through randomised trials for their safety and efficacy to be established.
Collapse
Affiliation(s)
- Samir Gupta
- Department of Paediatrics, University Hospital of North Tees and University of Durham, Stockton-on-Tees, UK.
| | - Steven M Donn
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| |
Collapse
|
37
|
Dempsey EM, Barrington KJ, Marlow N, O'Donnell CP, Miletin J, Naulaers G, Cheung PY, Corcoran D, Pons G, Stranak Z, Van Laere D. Management of hypotension in preterm infants (The HIP Trial): a randomised controlled trial of hypotension management in extremely low gestational age newborns. Neonatology 2014; 105:275-81. [PMID: 24576799 DOI: 10.1159/000357553] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 11/24/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Extremely preterm babies (delivered at <28 completed weeks of gestation) are frequently diagnosed with hypotension and treated with inotropic and pressor drugs in the immediate postnatal period. Dopamine is the most commonly used first-line drug. Babies who are treated for hypotension more frequently sustain brain injury, have long-term disability or die compared to those who are not. Despite the widespread use of drugs to treat hypotension in such infants, evidence for efficacy is lacking, and the effect of these agents on long-term outcomes is unknown. HYPOTHESIS In extremely preterm babies, restricting the use of dopamine when mean blood pressure (BP) values fall below a nominal threshold and using clinical criteria to determine escalation of support ('restricted' approach) will result in improved neonatal and longer-term developmental outcomes. RESEARCH PLAN: In an international multi-centre randomised trial, 830 infants born at <28 weeks of gestation, and within 72 h of birth, will be allocated to 1 of 2 alternative treatment options (dopamine vs. restricted approach) to determine the better strategy for the management of BP, using a conventional threshold to commence treatment. The first co-primary outcome of survival without brain injury will be determined at 36 weeks' postmenstrual age and the second co-primary outcome (survival without neurodevelopmental disability) will be assessed at 2 years of age, corrected for prematurity. DISCUSSION It is essential that appropriately designed trials be performed to define the most appropriate management strategies for managing low BP in extremely preterm babies.
Collapse
Affiliation(s)
- E M Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Wilton, Cork, Ireland
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Cassio A, Corbetta C, Antonozzi I, Calaciura F, Caruso U, Cesaretti G, Gastaldi R, Medda E, Mosca F, Pasquini E, Salerno MC, Stoppioni V, Tonacchera M, Weber G, Olivieri A. The Italian screening program for primary congenital hypothyroidism: actions to improve screening, diagnosis, follow-up, and surveillance. J Endocrinol Invest 2013; 36:195-203. [PMID: 23404215 DOI: 10.3275/8849] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The Italian screening program for primary congenital hypothyroidism (CH) is an integrated system including neonatal screening, diagnosis, treatment, follow-up, and nationwide surveillance of the disease. The aim of the Italian screening program for CH is to identify not only babies with severe permanent CH (core target), but also babies with mild persistent and transient forms of CH who could have a benefit from an early replacement therapy (secondary target). In the last years, despite the important results obtained in terms of standardization of screening and follow-up procedures, it has become clear the need of optimizing the program in order to harmonize the screening strategy and the screening procedures among Regions, and to improve the diagnostic and therapeutic approach in all affected infants. On the basis of available guidelines, the experience of the Italian screening and clinical reference centers, and the knowledge derived from the nation-wide surveillance activity performed by the Italian National Registry of Infants with CH, the Italian Society for Pediatric Endocrinology and Diabetology together with the Italian Society for the Study of Metabolic Diseases and Neonatal Screening and the Italian National Institute of Health promoted actions aimed at improving diagnosis, treatment, follow-up and surveillance of CH in our country. In this paper the most important actions to improve the Italian screening program for CH are described.
Collapse
Affiliation(s)
- A Cassio
- Department of Pediatrics, University of Bologna, Bologna, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Batton BJ, Li L, Newman NS, Das A, Watterberg KL, Yoder BA, Faix RG, Laughon MM, Van Meurs KP, Carlo WA, Higgins RD, Walsh MC. Feasibility study of early blood pressure management in extremely preterm infants. J Pediatr 2012; 161:65-9.e1. [PMID: 22336574 PMCID: PMC3357442 DOI: 10.1016/j.jpeds.2012.01.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 11/22/2011] [Accepted: 01/05/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the feasibility of a randomized placebo controlled trial (RCT) of blood pressure (BP) management for extremely preterm infants. STUDY DESIGN This was a prospective pilot RCT of infants 23-0/7 to 26-6/7 weeks gestation who had protocol-defined low BP in the first 24 postnatal hours. Enrolled infants were administered a study infusion (dopamine or placebo) and a study syringe medication (hydrocortisone or placebo). RESULTS Of the 366 infants screened, 119 (33%) had low BP, 58 (16%) met all entry criteria, and 10 (3%) were enrolled. A total of 161 infants (44%) were ineligible because they received early indomethacin. Only 17% of eligible infants were enrolled. Problems with consent included insufficient time, parent unavailability, and physician unwillingness to enroll critically ill infants. Two infants were withdrawn from the study because of the potential risk of intestinal perforation with simultaneous administration of hydrocortisone and indomethacin. CONCLUSIONS This pilot RCT was not feasible because of low eligibility and consent rates. An RCT of BP management for extremely preterm infants may require a waiver of consent for research in emergency care. The frequent use of early indomethacin and the associated risk of intestinal perforation when used with hydrocortisone may limit future investigations to only inotropic medications.
Collapse
Affiliation(s)
- Beau J Batton
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
A meta-analysis of dopamine use in hypotensive preterm infants: blood pressure and cerebral hemodynamics. J Perinatol 2011; 31:647-55. [PMID: 21273985 DOI: 10.1038/jp.2011.2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Dopamine administration results in variable effects on blood pressure in hypotensive preterm infants. The clinical benefits of dopamine administration in increasing cerebral blood flow (CBF) and reducing adverse neurological outcomes in hypotensive preterm neonates are unclear. The objective of this study was to examine the efficacy of dopamine for treatment of hypotension and investigate the changes in cerebral hemodynamics and central nervous system injury in hypotensive preterm infants following dopamine administration. STUDY DESIGN Standard meta-analytic techniques, including random and fixed effects models, were used to calculate combined effect size correlations and significance levels. RESULT Random effects meta-analysis found that dopamine increases mean arterial blood pressure (12 studies; N=163; r=0.88, 95% confidence interval (CI)=0.76 to 0.94) and systolic blood pressure (8 studies; N=142; r=0.81, 95% CI=0.42 to 0.94). For the increase in blood pressure, dopamine administration was associated with a significantly greater overall efficacy than dobutamine (seven studies; N=251; r=0.26; 95% CI=0.20 to 0.32), colloid (two studies; N=67; r=0.60; 95% CI=0.41 to 0.74) and hydrocortisone (one study; N=28; r=0.40; 95% CI=0.034 to 0.67). CBF increased following dopamine administration (five studies; N=75; r=0.36; 95% CI=-0.059 to 0.67) and the increase in CBF was greater in hypotensive than normotensive preterm infants (eight studies; N=153; r=0.16; 95% CI=-0.0080 to 0.32). There were no statistically significant differences in adverse neurological outcome between dopamine and dobutamine (three studies; N=118; r=-0.13; 95% CI=-0.31 to 0.059), epinephrine (two studies; N=46; r=0.06; 95% CI=-0.23 to 0.34), colloid (two studies; N=80; r=0.0070; 95% CI=-0.218 to 0.23) or hydrocortisone administration (one study; N=40; r=-0.10; 95% CI=-0.40 to 0.22). CONCLUSION Dopamine administration increases mean and systolic blood pressure in hypotensive preterm infants, and is more effective than dobutamine, colloid or hydrocortisone alone. Dopamine administration is associated with increased CBF, with greater increases in CBF in hypotensive than in normotensive preterm infants. Dopamine is not associated with a greater incidence of adverse effects than other therapies used to treat hypotension.
Collapse
|
41
|
Lafranchi SH. Congenital hypothyroidism: delayed detection after birth and monitoring treatment in the first year of life. J Pediatr 2011; 158:525-7. [PMID: 21220141 DOI: 10.1016/j.jpeds.2010.11.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 11/10/2010] [Indexed: 10/18/2022]
|
42
|
Goissen C, Fontaine C, Braun K, Bony H, Al-Hosri J, Ramadan-Ghostine G, Léké A, Boudailliez B, Tourneux P. Étude prospective à une semaine de vie de la fonction thyroïdienne chez 97 prématurés consécutifs de terme inférieur à 32 semaines d’aménorrhée. Arch Pediatr 2011; 18:253-60. [DOI: 10.1016/j.arcped.2010.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 12/07/2010] [Accepted: 12/17/2010] [Indexed: 10/18/2022]
|
43
|
Arai H, Goto R, Matsuda T, Takahashi T. Relationship between free T4 levels and postnatal steroid therapy in preterm infants. Pediatr Int 2009; 51:800-3. [PMID: 19419509 DOI: 10.1111/j.1442-200x.2009.02852.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transient hypothyroxinemia is the most common thyroid dysfunction in preterm infants. Hypothalamic-pituitary-thyroid immaturity and non-thyroidal illness contribute to its etiology. The aim of the present study was therefore to determine the relationship between thyroid hormone status and early postnatal steroid therapy in preterm infants. METHODS A prospective study of premature infants born at <28 weeks of gestation between July 2001 and June 2007 was conducted. Selective postnatal steroid (dexamethasone) therapy was used in lung disease treatment if the infants needed high mean airway pressure-assisted ventilation and supplemental oxygen at 2 weeks of age. Free T4 (FT4) and thyroid-stimulating hormone (TSH) levels were assessed at 2 weeks after birth. Blood samples in eight infants were available after starting steroid therapy. Infants receiving steroids (steroid (+); n= 8) were compared to those not receiving steroids (steroid (-); n= 73). RESULTS The demographic data were not significantly different between the two groups. The neonatal illnesses and drug use were also not significantly different between the groups. The steroid (+) group had significantly lower FT4 and TSH levels at 2 weeks after birth than the steroid (-) group. The increase in FT4 levels after steroid withdrawal was greater than that during the same period in the steroid (-) patients. CONCLUSION Even if it cannot be excluded that reduced FT4 and TSH concentrations are caused by non-thyroidal illness, the present study suggests that postnatal steroid treatment reduces the FT4 and TSH levels in premature infants born at <28 weeks of gestation.
Collapse
Affiliation(s)
- Hirokazu Arai
- Department of Pediatrics, Akita Red Cross Hospital, Akita, Japan.
| | | | | | | |
Collapse
|
44
|
Batton B, Zhu X, Fanaroff J, Kirchner HL, Berlin S, Wilson-Costello D, Walsh M. Blood pressure, anti-hypotensive therapy, and neurodevelopment in extremely preterm infants. J Pediatr 2009; 154:351-7, 357.e1. [PMID: 19026429 DOI: 10.1016/j.jpeds.2008.09.017] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2008] [Revised: 08/21/2008] [Accepted: 09/08/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare neurodevelopment (ND) in 3 cohorts of extremely preterm infants: untreated with normal blood pressure (BP), untreated with low BP, and treated with low BP. STUDY DESIGN We conducted a retrospective study of infants 23 to 25 weeks gestation. Low BP was defined as >or=3 mean arterial pressures <or=25 mm Hg in the first 72 hours of life. Treatment included fluids, inotropes, and corticosteroids. RESULTS We examined 67 infants with normal BP, 31 infants with untreated low BP, and 70 infants with treated low BP. A total of 75% survived to be discharged from the hospital, and 95% of survivors had ND assessment. Perinatal variables differed between treated infants with low BP and the other groups. Untreated infants with low BP had similar survival rates, but more cerebral palsy, deafness, or any ND impairment when compared with infants with normal BP. Treated infants with low BP had more mortality, worse ND, and less survival without ND impairment compared with infants who had normal BP. Results were unchanged after logistic regression adjusting for prenatal steroids, maternal education, race, sex, bronchopulmonary dysplasia, and postnatal dexamethasone exposure. CONCLUSIONS Infants with low BP-regardless of treatment-had worse ND than infants with normal BP. Early low BP may be independently associated with a poor outcome.
Collapse
Affiliation(s)
- Beau Batton
- Rainbow Babies and Children's Hospital, Department of Neonatology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | | | | | | | | | | | | |
Collapse
|