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Dubner SE, Rickerich L, Bruckert L, Poblaciones RV, Sproul D, Scala M, Feldman HM, Travis KE. Early, low-dose hydrocortisone and near-term brain connectivity in extremely preterm infants. Pediatr Res 2024; 95:1028-1034. [PMID: 38030826 DOI: 10.1038/s41390-023-02903-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 10/17/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Postnatal steroids are used to prevent bronchopulmonary dysplasia in extremely preterm infants but may have adverse effects on brain development. We assessed connectivity metrics of major cerebral and cerebellar white matter pathways at near-term gestational age among infants who did or did not receive a standardized regimen of hydrocortisone during the first 10 days of life. METHODS Retrospective cohort study. PARTICIPANTS Infants born <28 weeks: Protocol group (n = 33) received at least 50% and not more than 150% of an intended standard dose of 0.5 mg/kg hydrocortisone twice daily for 7 days, then 0.5 mg/kg per day for 3 days; Non-Protocol group (n = 22), did not receive protocol hydrocortisone or completed <50% of the protocol dose. We assessed group differences in near-term diffusion MRI mean fractional anisotropy (FA) and mean diffusivity (MD) across the corticospinal tract, inferior longitudinal fasciculus, corpus callosum and superior cerebellar peduncle. RESULTS Groups were comparable in gestational age, post-menstrual age at scan, medical complications, bronchopulmonary dysplasia, and necrotizing enterocolitis. No significant large effect group differences were identified in mean FA or MD in any cerebral or cerebellar tract. CONCLUSION(S) Low dose, early, postnatal hydrocortisone was not associated with significant differences in white matter tract microstructure at near-term gestational age. IMPACT This study compared brain microstructural connectivity as a primary outcome among extremely preterm infants who did or did not receive early postnatal hydrocortisone. Low dose hydrocortisone in the first 10 days of life was not associated with significant differences in white matter microstructure in major cerebral and cerebellar pathways. Hydrocortisone did not have a significant effect on early brain white matter circuits.
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Affiliation(s)
- Sarah E Dubner
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Lucy Rickerich
- Program in Human Biology, Stanford University, Stanford, CA, USA
| | - Lisa Bruckert
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Rocío Velasco Poblaciones
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Dawson Sproul
- Program in Human Biology, Stanford University, Stanford, CA, USA
| | - Melissa Scala
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Heidi M Feldman
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Katherine E Travis
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA, USA.
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2
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Halbmeijer NM, Sonnaert M, Swarte RM, Koopman-Esseboom C, van Stuijvenberg M, Mulder-de Tollenaer S, Tan RNGB, Mohns T, Bruneel E, Steiner K, Kramer BW, Debeer A, van Weissenbruch MM, Marechal Y, Blom H, Plaskie K, Offringa M, Merkus MP, Onland W, Leemhuis AG, van Kaam AH. Identifying effect modifiers of systemic hydrocortisone treatment initiated 7-14 days after birth in ventilated very preterm infants on long-term outcome: secondary analysis of a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2024; 109:159-165. [PMID: 37722765 DOI: 10.1136/archdischild-2023-325558] [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: 03/08/2023] [Accepted: 08/17/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE To explore clinical effect modifiers of systemic hydrocortisone in ventilated very preterm infants for survival and neurodevelopmental outcome at 2 years' corrected age (CA). DESIGN Secondary analysis of a randomised placebo-controlled trial. SETTING Dutch and Belgian neonatal intensive care units. PATIENTS Infants born <30 weeks' gestational age (GA), ventilator-dependent in the second week of postnatal life. INTERVENTION Infants were randomly assigned to systemic hydrocortisone (cumulative dose 72.5 mg/kg; n=182) or placebo (n=190). MAIN OUTCOME MEASURES The composite of death or neurodevelopmental impairment (NDI) at 2 years' CA and its components. Candidate effect modifiers (GA, small for GA, respiratory index, sex, multiple births, risk of moderate/severe bronchopulmonary dysplasia or death) were analysed using regression models with interaction terms and subpopulation treatment effect pattern plots. RESULTS The composite outcome was available in 356 (96.0%) of 371 patients (one consent withdrawn). For this outcome, treatment effect heterogeneity was seen across GA subgroups (<27 weeks: hydrocortisone (n=141) vs placebo (n=156), 54.6% vs 66.2%; OR 0.61 (95% CI 0.38 to 0.98); ≥27 weeks: hydrocortisone (n=30) vs placebo (n=31), 66.7% vs 45.2%; OR 2.43 (95% CI 0.86 to 6.85); p=0.02 for interaction). This effect was also found for the component death (<27 weeks: 20.1% vs 32.1%; OR 0.53 (95% CI 0.32 to 0.90); ≥27 weeks: 28.1% vs 16.1%; OR 2.04 (95% CI 0.60 to 6.95); p=0.049 for interaction) but not for the component NDI. No differential treatment effects were observed across other subgroups. CONCLUSION This secondary analysis suggests that in infants <27 weeks' GA, systemic hydrocortisone may improve the outcome death or NDI, mainly driven by its component death. There was insufficient evidence for other selected candidate effect modifiers.
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Affiliation(s)
- Nienke Marjolein Halbmeijer
- Neonatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Research Institute, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Michel Sonnaert
- Neonatology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Renate M Swarte
- Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Corine Koopman-Esseboom
- Neonatology, University Medical Centre Utrecht/Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Margriet van Stuijvenberg
- Neonatology, University Medical Centre Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | | | - Ratna N G B Tan
- Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Thilo Mohns
- Neonatology, Maxima Medical Centre, Women Mother and Child Centre, Veldhoven, The Netherlands
| | - Els Bruneel
- Neonatology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Katerina Steiner
- Neonatology, Radboudumc Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Boris W Kramer
- School of Women's and Infants' Health, University of Western Australia, Crawley, Western Australia, Australia
- Research & Development, Neuroplast BV, Maastricht, The Netherlands
| | - Anne Debeer
- Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Mirjam M van Weissenbruch
- Research Institute, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Neonatology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yoann Marechal
- Neonatology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Henry Blom
- Neonatology, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | | | - Martin Offringa
- Neonatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Neonatology and Child Health Evaluative Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maruschka P Merkus
- Epidemiology and Data Science, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Wes Onland
- Neonatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Research Institute, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Aleid G Leemhuis
- Neonatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Research Institute, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Neonatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Research Institute, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
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Boscarino G, Cardilli V, Conti MG, Liguori F, Repole P, Parisi P, Terrin G. Outcomes of postnatal systemic corticosteroids administration in ventilated preterm newborns: a systematic review of randomized controlled trials. Front Pediatr 2024; 12:1344337. [PMID: 38419972 PMCID: PMC10899705 DOI: 10.3389/fped.2024.1344337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Prolonged mechanical ventilation, commonly used to assist preterm newborns, increases the risk of developing bronchopulmonary dysplasia (BPD). In recent decades, studies have demonstrated that systemic corticosteroids play a significant role in the prevention and management of BPD. In this systematic review of randomized controlled trials (RCTs), we evaluated the association between the administration of systemic corticosteroids in preterm infants and its long-term outcomes, such as neurodevelopment, growth, extubation rate, and related adverse effects. Methods We conducted an electronic search in Medline, Scopus, and PubMed using the following terms: "premature infants" and "corticosteroids." We considered all RCTs published up to June 2023 as eligible. We included all studies involving preterm newborns treated with systemic corticosteroids and excluded studies on inhaled corticosteroids. Results A total of 39 RCTs were evaluated. The influence of steroids administered systemically during the neonatal period on long-term neurological outcomes remains unknown, with no influence observed for long-term growth. The postnatal administration of systemic corticosteroids has been found to reduce the timing of extubation and improve respiratory outcomes. Dexamethasone appears to be more effective than hydrocortisone, despite causing a higher rate of systemic hypertension and hyperglycemia. However, in the majority of RCTs analyzed, there were no differences in the adverse effects related to postnatal corticosteroid administration. Conclusion Dexamethasone administered during the neonatal period appears to be more effective than hydrocortisone in terms of respiratory outcomes; however, caution should be taken when administering dexamethasone. Data derived from current evidence, including meta-analyses, are inconclusive on the long-term effects of the administration of systemic steroids in preterm infants or the possibility of neurodevelopmental consequences.
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Affiliation(s)
- Giovanni Boscarino
- Department of Maternal and Child Health, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Viviana Cardilli
- Department of Maternal and Child Health, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Maria Giulia Conti
- Department of Maternal and Child Health, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Federica Liguori
- Department of Maternal and Child Health, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Paola Repole
- Department of Maternal and Child Health, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Pasquale Parisi
- Pediatrics Unit, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine and Psychology, Sant’ Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Gianluca Terrin
- Department of Maternal and Child Health, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
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Melan N, Pradat P, Godbert I, Pastor-Diez B, Basson E, Picaud JC. Neurodevelopment at 24 months corrected age in extremely preterm infants treated with dexamethasone alternatives during the late postnatal period: a cohort study. Eur J Pediatr 2024; 183:677-687. [PMID: 37955745 PMCID: PMC10912127 DOI: 10.1007/s00431-023-05319-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/18/2023] [Accepted: 10/28/2023] [Indexed: 11/14/2023]
Abstract
The administration of dexamethasone has been associated with suboptimal neurodevelopment. We aimed to compare the development of extremely premature infants treated or not with alternatives to dexamethasone: betamethasone, hydrocortisone hemisuccinate. This retrospective cohort study included infants born before 29 weeks of gestational age, treated or not with late (day ≥ 7) postnatal steroids (betamethasone, hydrocortisone hemisuccinate). The neurodevelopment outcome was evaluated at 24 months corrected age, after adjustment on comorbidities of extreme prematurity. In order to analyse their overall development, data about growth and respiratory outcomes were collected. Among the 192 infants included, 59 (30.7%) received postnatal steroids. Suboptimal neurodevelopment concerned 37/59 (62.7%) postnatal steroid-treated and 43/133 (38.1%; p = 0.002) untreated infants. However, in multivariable analysis, only severe neonatal morbidity (p = 0.007) and male gender (p = 0.027) were associated with suboptimal neurodevelopment outcome at 24 months. Conclusions: Betamethasone or hydrocortisone hemisuccinate treatment was not an independent risk for suboptimal neurological development, growth and respiratory outcomes assessed at 24 months corrected age in extremely premature infants. Registration number: The study was registered on the ClinicalTrials.gov register: NCT05055193. What is Known: • Late postnatal steroids are used to treat bronchopulmonary dysplasia • Meta-analyses warned against the neurological risk of dexamethasone use during neonatal period. Early or late hydrocortisone hemisuccinate has been evaluated in multiple studies, none of which have reported an adverse effect on neurodevelopment at least to 2 years. Data about the use of betamethasone are scarce. What is New: • The risk of suboptimal neurodevelopment was higher among extremely premature infants who received postnatal steroids when compared to those who did not. • Betamethasone and hydrocortisone hemisuccinate treatment was not an independent risk factor for suboptimal neurodevelopment at 24 months corrected age.
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Affiliation(s)
- Nathalie Melan
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Pierre Pradat
- Centre for Clinical Research, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Isabelle Godbert
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Blandine Pastor-Diez
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Eliane Basson
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Jean-Charles Picaud
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France.
- CarMen Laboratory, INSERM, INRA, Université Claude Bernard Lyon 1, Pierre-Bénite, 69310, Lyon, France.
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5
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Baud O, Lehert P. The beneficial effect of prophylactic hydrocortisone treatment in extremely preterm infants improves upon adjustment of the baseline characteristics. Pediatr Res 2024; 95:251-256. [PMID: 37653218 PMCID: PMC10798883 DOI: 10.1038/s41390-023-02785-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Prophylactic low-dose hydrocortisone (HC) was found to improve survival without bronchopulmonary dysplasia (BPD) in extremely preterm infants. However, appropriately adjusting for baseline risks of BPD or death might substantially increase the precision of the HC effect size. METHODS We conducted a secondary analysis of the PREMILOC trial. The treatment effect was evaluated on the primary endpoint through a covariance analysis ANCOVA, adjusting for the baseline covariates using a mixed linear model. Several sensitivity analyses were conducted to assess the potential heterogeneity of the treatment effect across centers and subpopulations. RESULTS The interaction between treatment group and baseline risk for BPD or death was not statistically significant (p = 0.498). After adjusting for the patient's probability of BPD-free survival using baseline predictors alone, the HC treatment exhibited a highly significant effect (OR [95% CI] = 2.053 [1.602-2.501], p = 0.002), with a number needed to treat NNT [95% CI] = 5.8 [4.1-23.0]. Despite a weak interaction with sex, we found a lack of heterogeneity in the treatment effect across specific subpopulations. CONCLUSIONS In the PREMILOC trial, the beneficial effect of prophylactic HC versus placebo on BPD-free survival in extremely preterm neonates was found to be greater when adjusted to baseline risks of BPD or death. REGISTRATION NUMBERS EudraCT number 2007-002041-20, ClinicalTrial.gov number NCT00623740. IMPACT Prophylactic low-dose hydrocortisone (HC) provided past evidence of a beneficial effect in improving survival without BPD in infants born extremely preterm. Adjustment for baseline risks of BPD or death might substantially increase the precision of the HC effect size. The beneficial effect of prophylactic HC vs placebo on BPD-free survival in extremely preterm neonates was found to be greater when adjusted to baseline risks of BPD or death. We evidenced a lack of heterogeneity in the treatment effect in specific subpopulations despite some weak interaction with sex.
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Affiliation(s)
- Olivier Baud
- Division of Neonatology and Pediatric Intensive Care, Children's University Hospital of Geneva and University of Geneva, Geneva, Switzerland.
| | - Philippe Lehert
- Faculty of Medicine, University of Melbourne, Melbourne, Australia
- Faculty of Economics, University of Louvain, Louvain, Belgium
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Ko H, Lakshmanan A, Maxwell JR. Hydrocortisone may spare head growth, but the debate for steroid use rages on. Pediatr Res 2023; 94:1867-1869. [PMID: 37845521 DOI: 10.1038/s41390-023-02845-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 09/15/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Hellen Ko
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Ashwini Lakshmanan
- Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA
| | - Jessie R Maxwell
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM, USA.
- Department of Neurosciences, University of New Mexico Health Science Center, Albuquerque, NM, USA.
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Hay S, Ovelman C, Zupancic JA, Doyle LW, Onland W, Konstantinidis M, Shah PS, Soll R. Systemic corticosteroids for the prevention of bronchopulmonary dysplasia, a network meta-analysis. Cochrane Database Syst Rev 2023; 8:CD013730. [PMID: 37650547 PMCID: PMC10468918 DOI: 10.1002/14651858.cd013730.pub2] [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] [Indexed: 09/01/2023]
Abstract
BACKGROUND Despite considerable improvement in outcomes for preterm infants, rates of bronchopulmonary dysplasia (BPD) remain high, affecting an estimated 33% of very low birthweight infants, with corresponding long-term respiratory and neurosensory issues. Systemic corticosteroids can address the inflammation underlying BPD, but the optimal regimen for prevention of this disease, balancing of the benefits with the potentially meaningful risks of systemic corticosteroids, continues to be a medical quandary. Numerous studies have shown that systemic corticosteroids, particularly dexamethasone and hydrocortisone, effectively treat or prevent BPD. However, concerning short and long-term side effects have been reported and the optimal approach to corticosteroid treatment remains unclear. OBJECTIVES To determine whether differences in efficacy and safety exist between high-dose dexamethasone, moderate-dose dexamethasone, low-dose dexamethasone, hydrocortisone, and placebo in the prevention of BPD, death, the composite outcome of death or BPD, and other relevant morbidities, in preterm infants through a network meta-analysis, generating both pairwise comparisons between all treatments and rankings of the treatments. SEARCH METHODS We searched the Cochrane Library for all systematic reviews of systemic corticosteroids for the prevention of BPD and searched for completed and ongoing studies in the following databases in January 2023: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and clinical trial databases. SELECTION CRITERIA We included randomized controlled trials (RCTs) in preterm infants (< 37 weeks' gestation) at risk for BPD that evaluated systemic corticosteroids (high-dose [≥ 4 mg/kg cumulative dose] dexamethasone, moderate-dose [≥ 2 to < 4 mg/kg] dexamethasone, low-dose [< 2 mg/kg] dexamethasone, or hydrocortisone) versus control or another systemic corticosteroid. DATA COLLECTION AND ANALYSIS Our main information sources were the systematic reviews, with reference to the original manuscript only for data not included in these reviews. Teams of two paired review authors independently performed data extraction, with disagreements resolved by discussion. Data were entered into Review Manager 5 and exported to R software for network meta-analysis (NMA). NMA was performed using a frequentist model with random-effects. Two separate networks were constructed, one for early (< seven days) initiation of treatment and one for late (≥ seven days) treatment initiation, to reflect the different patient populations evaluated. We assessed the certainty of evidence derived from the NMA for our primary outcomes using principles of the GRADE framework modified for application to NMA. MAIN RESULTS We included 59 studies, involving 6441 infants, in our analyses. Only six of the included studies provided direct comparisons between any of the treatment (dexamethasone or hydrocortisone) groups, forcing network comparisons between treatments to rely heavily on indirect evidence through comparisons with placebo/no treatment groups. Thirty-one studies evaluated early corticosteroid treatment, 27 evaluated late corticosteroid treatment, and one study evaluated both early and late corticosteroid treatments. Early treatment (prior to seven days after birth): Benefits:NMA for early treatment showed only moderate-dose dexamethasone to decrease the risk of BPD at 36 weeks' postmenstrual age (PMA) compared with control (RR 0.56, 95% CI 0.39 to 0.80; moderate-certainty evidence), although the other dexamethasone dosing regimens may have similar effects compared with control (high-dose dexamethasone, RR 0.71, 95% CI 0.50 to 1.01; low-certainty evidence; low-dose dexamethasone, RR 0.83, 95% CI 0.67 to 1.03; low-certainty evidence). Other early treatment regimens may have little or no effect on the risk of death at 36 weeks' PMA. Only moderate-dose dexamethasone decreased the composite outcome of death or BPD at 36 weeks' PMA compared with control (RR 0.77, 95% CI 0.60 to 0.98; moderate-certainty evidence). HARMS Low-dose dexamethasone increased the risk for cerebral palsy (RR 1.92, 95% CI 1.12 to 3.28; moderate-certainty evidence) compared with control. Hydrocortisone may decrease the risk of major neurosensory disability versus low-dose dexamethasone (RR 0.65, 95% CI 0.41 to 1.01; low-certainty evidence). Late treatment (at seven days or later after birth): Benefits: NMA for late treatment showed high-dose dexamethasone to decrease the risk of BPD both versus hydrocortisone (RR 0.66, 95% CI 0.51 to 0.85; low-certainty evidence) and versus control (RR 0.72, CI 0.59 to 0.87; moderate-certainty evidence). The late treatment regimens evaluated may have little or no effect on the risk of death at 36 weeks' PMA. High-dose dexamethasone decreased risk for the composite outcome of death or BPD compared with all other treatments (control, RR 0.69, 95% CI 0.59 to 0.80, high-certainty evidence; hydrocortisone, RR 0.69, 95% CI 0.58 to 0.84, low-certainty evidence; low-dose dexamethasone, RR 0.73, 95% CI 0.60 to 0.88, low-certainty evidence; moderate-dose dexamethasone, RR 0.76, 95% CI 0.62 to 0.93, low-certainty evidence). HARMS No effect was observed for the outcomes of major neurosensory disability or cerebral palsy. The evidence for the primary outcomes was of overall low certainty, with notable deductions for imprecision and heterogeneity across the networks. AUTHORS' CONCLUSIONS While early treatment with moderate-dose dexamethasone or late treatment with high-dose dexamethasone may lead to the best effects for survival without BPD, the certainty of the evidence is low. There is insufficient evidence to guide this therapy with regard to plausible adverse long-term outcomes. Further RCTs with direct comparisons between systemic corticosteroid treatments are needed to determine the optimal treatment approach, and these studies should be adequately powered to evaluate survival without major neurosensory disability.
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Affiliation(s)
- Susanne Hay
- Department of Neonatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Colleen Ovelman
- Center for Health Informatics and Evidence Synthesis, RTI International, Durham, NC, USA
| | - John Af Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lex W Doyle
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Menelaos Konstantinidis
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Prakeshkumar S Shah
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto Mount Sinai Hospital, Toronto, Canada
| | - Roger Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Trousson C, Toumazi A, Bourmaud A, Biran V, Baud O. Neurocognitive outcomes at age 5 years after prophylactic hydrocortisone in infants born extremely preterm. Dev Med Child Neurol 2022. [PMID: 36417367 DOI: 10.1111/dmcn.15470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 11/24/2022]
Abstract
AIM To assess the 5-year neurocognitive outcomes of children born extremely preterm exposed to prophylactic hydrocortisone to improve survival without bronchopulmonary dysplasia. METHOD This was a prespecified secondary analysis of the PREMILOC clinical trial (trial registration: EudraCT no. 2007-002041-20, NCT00623740). The primary outcome was full-scale IQ based on the Wechsler Preschool and Primary Scale of Intelligence. RESULTS Among 109 surviving children recruited at the Robert Debré Children's Hospital, Paris, outcome data were available for 42 out of 56 infants (75%) in the group treated with hydrocortisone and 41 out of 53 (77%) in the placebo group. Mean scores were not significantly different between the two groups on full-scale IQ (hydrocortisone: 91.9 [SD = 13.9], placebo: 86.3 [SD = 15.4]; mean difference = 5.7, 95% confidence interval [CI] = -1.0 to 12.3, p = 0.10); however, working memory and retention ability were significantly better in the group treated with hydrocortisone. In a multivariate logistic regression including potential confounding variables, hydrocortisone treatment was significantly associated with a greater chance to survive at 5 years of age with a full-scale IQ equal to or greater than 90 compared to placebo (adjusted odds ratio = 4.26, 95% CI = 1.47-12.36, p = 0.008). INTERPRETATION This exploratory analysis provides reassuring data regarding the long-term neurodevelopmental safety of prophylactic hydrocortisone in infants born extremely preterm.
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Affiliation(s)
- Clémence Trousson
- Assistance Publique-Hôpitaux de Paris, Neonatal Intensive Care Unit, Robert Debré Children's Hospital, Paris, France
| | - Artemis Toumazi
- Assistance Publique-Hôpitaux de Paris, Unit of Clinical Epidemiology, Robert Debré Children's Hospital, University of Paris, Institut National de la Santé et de la Recherche Médicale U1123 and CIC-EC 1426, Paris, France
| | - Aurélie Bourmaud
- Assistance Publique-Hôpitaux de Paris, Unit of Clinical Epidemiology, Robert Debré Children's Hospital, University of Paris, Institut National de la Santé et de la Recherche Médicale U1123 and CIC-EC 1426, Paris, France
| | - Valérie Biran
- Assistance Publique-Hôpitaux de Paris, Neonatal Intensive Care Unit, Robert Debré Children's Hospital, Paris, France.,Institut National de la Santé et de la Recherche Médicale U1141, University of Paris, Paris, France
| | - Olivier Baud
- Institut National de la Santé et de la Recherche Médicale U1141, University of Paris, Paris, France.,Division of Neonatology and Pediatric Intensive Care, Children's University Hospital of Geneva and University of Geneva, Geneva, Switzerland
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9
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Tang B, Ling Q, Yang Q, Li M, Shi W, Wu Q. How to survive a periviable birth baby with birth weight of 450g: A case report. Medicine (Baltimore) 2022; 101:e31356. [PMID: 36281089 PMCID: PMC9592289 DOI: 10.1097/md.0000000000031356] [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] [Indexed: 11/18/2022] Open
Abstract
RATIONALE An increasing number of periviable birth newborns (PVBs) have emerged with concurrent growing high-risk pregnancy. To date, postnatal management of PVBs remains one of the most challenging issues and limited studies have been reported. PATIENT CONCERNS A female baby born at 230/7 weeks of gestation with birth weight of 450g. DIAGNOSIS PVB baby, respiratory distress syndrome (RDS), ventilator associated pneumonia (VAP), intraventricular hemorrhage (IVH), metabolic bone disease of prematurity (MBDP), transient hypothyroxinemia of prematurity (THOP), bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP). INTERVENTIONS Individualized treatment and intensive care, including neonatal resuscitation, effective respiratory and circulatory support, venous access and nutrition, prevention and treatment of infection, management of endocrine and metabolic problems, individualized nursing such as developmental supportive care, integrated oral motor interventions, skin care, family-integrated-care, etc were performed according to existing literature. OUTCOMES The baby was discharged home after 138 days of hospitalization with body weight of 2700 g, a full oral feed achieved, and without any requirement of respiratory support or oxygen supply. Now she is 38-month-old, with no significant long-term adverse sequelae. LESSONS Our case expands the experience and knowledges of individualized and intensive management of PVB babies in their early life days, which increase PVBs' survival and improves their prognosis.
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Affiliation(s)
- Binzhi Tang
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Qiying Ling
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Qian Yang
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Maojun Li
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Wei Shi
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Qing Wu
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
- *Correspondence: Qing Wu, Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, No. 32 West Second Section First Ring Road, Chengdu 610072, Sichuan Province, China (e-mail: )
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10
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Briscoe A, Piyasena C, Meau-Petit V. Tolerance of hydrocortisone prophylaxis administration in extreme preterm neonates: Experience of a single UK level III neonatal unit. Early Hum Dev 2022; 171:105630. [PMID: 35907315 DOI: 10.1016/j.earlhumdev.2022.105630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the safety of the routine use of low-dose prophylactic hydrocortisone to improve survival without bronchopulmonary dysplasia (BPD) in infants born <28 weeks' gestation. DESIGN A single-centre retrospective cohort study of infants born <28 weeks, before and after hydrocortisone implementation. Data was collected from electronic patient records and compared between both groups. MAIN OUTCOME MEASURES The incidence of serious adverse events associated with hydrocortisone use was measured in each group. The rates of spontaneous intestinal perforation (SIP), late onset sepsis (LOS). Necrotising enterocolitis (NEC) and BPD were compared. RESULTS There were 88 infants in the pre-hydrocortisone group and 103 infants in the hydrocortisone group. In comparison to the pre-hydrocortisone group, the incidence of SIP in the hydrocortisone group was 7.7 % (vs 3.4 % p = 0.2), NEC 30 % (vs 25 % p = 0.43) and LOS 34 % (vs 30.6 % p = 0.63) Rates of BPD in the hydrocortisone group were 59 % (vs 52.2 % p = 0.33) mortality 18.4 % (vs 20.4 % p = 0.73) and BPD free survival 26.2 % (vs 27.2 % p = 0.87). Infants who received hydrocortisone had a significantly lower requirement of inotropic support of 32 % vs 48.3 % (p = 0.02). Results remained unchanged after logistic regression analyses for potential confounding factors (ethnicity, chorioamnionitis, multiple pregnancy and antenatal steroids). CONCLUSION Prophylactic administration of low-dose hydrocortisone for BPD to infants born below 28 weeks' gestation was not associated with an increase in serious adverse outcomes in our population.
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Affiliation(s)
- Alexandra Briscoe
- St Thomas Hospital, Neonatal Intensive Care Unit, Westminster Bridge Road, London SE1 7EH, United Kingdom of Great Britain and Northern Ireland.
| | - Chinthika Piyasena
- St Thomas Hospital, Neonatal Intensive Care Unit, Westminster Bridge Road, London SE1 7EH, United Kingdom of Great Britain and Northern Ireland
| | - Virginie Meau-Petit
- St Thomas Hospital, Neonatal Intensive Care Unit, Westminster Bridge Road, London SE1 7EH, United Kingdom of Great Britain and Northern Ireland
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11
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Fleming P, Pereira S, Kapellou O, Claxton A, Bamford A, Aladangady N. Possible In Utero Transmission of SARS-CoV-2 and Severe Respiratory Disease in a Preterm Infant. Pediatrics 2022; 150:186766. [PMID: 35425990 DOI: 10.1542/peds.2021-054557] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 12/15/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 infections are uncommon in newborn infants. This report describes possible in utero transmission of the B.1.1.7 (alpha) variant in a preterm infant born at 31 weeks' gestational age who presented with severe respiratory disease. The infant was treated with high-frequency oscillatory ventilation, antiviral medications, and corticosteroids and transitioned to noninvasive respiratory support on day 33. By day 63, she was off positive pressure support and breathing room air and she was discharged from the hospital on day 70. She demonstrated normal growth and development at a 6-month follow-up visit. Placental histopathology revealed placentitis characterized by loss of intervillous spaces resulting from fibrin deposition and inflammatory cell infiltration. Optimum management strategies for treating infants with severe acute respiratory syndrome coronavirus 2 infection have yet to be determined.
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Affiliation(s)
- Paul Fleming
- Neonatal Unit.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Sujith Pereira
- Neonatal Unit.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | | | - Alleyna Claxton
- Department of Microbiology, Homerton University Hospital, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
| | - Alasdair Bamford
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.,University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Narendra Aladangady
- Neonatal Unit.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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12
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Systemic Steroids in Preventing Bronchopulmonary Dysplasia (BPD): Neurodevelopmental Outcome According to the Risk of BPD in the EPICE Cohort. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095600. [PMID: 35564997 PMCID: PMC9106050 DOI: 10.3390/ijerph19095600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/17/2022] [Accepted: 04/27/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Postnatal steroids (PNS) have been used to prevent bronchopulmonary dysplasia (BPD) in preterm infants but have potential adverse effects on neurodevelopment. These effects might be modulated by their risk of BPD. We aimed to compare patients' neurodevelopment with PNS treatment according to their risk of BPD in a European cohort. METHODS We developed a prediction model for BPD to classify infants born between 24 + 0 and 29 + 6 weeks of gestation in three groups and compared patients' neurological outcome at two years of corrected age using the propensity score (PS) method. RESULTS Of 3662 neonates included in the analysis, 901 (24.6%) were diagnosed with BPD. Our prediction model for BPD had an area under the ROC curve of 0.82. In the group with the highest risk of developing BPD, PNS were associated with an increased risk of gross motor impairment: OR of 1.95 after IPTW adjustment (95% CI 1.18 to 3.24, p = 0.010). This difference existed regardless of the type of steroid used. However, there was an increased risk of cognitive anomalies for patients treated with dexa/betamethasone that was no longer observed with hydrocortisone. CONCLUSIONS This study suggests that PNS might be associated with an increased risk of gross motor impairment regardless of the group risk for BPD. Further randomised controlled trials exploring the use of PNS to prevent BPD should include a risk-based evaluation of neurodevelopmental outcomes. This observation still needs to be confirmed in a randomised controlled trial.
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13
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Foo GW, Manley BJ, Davis PG. EBNEO Commentary: Effect of systemic hydrocortisone initiated 7-14 days after birth in ventilated preterm infants on mortality and neurodevelopment at 2 years' corrected age. Acta Paediatr 2022; 111:899-900. [PMID: 34935189 DOI: 10.1111/apa.16212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/08/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Gillian W. Foo
- Neonatal Services The Royal Women’s Hospital Melbourne Vic. Australia
| | - Brett J. Manley
- Neonatal Services The Royal Women’s Hospital Melbourne Vic. Australia
- Department of Obstetrics and Gynaecology The University of Melbourne Melbourne Vic. Australia
- Murdoch Children’s Research Institute Melbourne Vic. Australia
| | - Peter G. Davis
- Neonatal Services The Royal Women’s Hospital Melbourne Vic. Australia
- Department of Obstetrics and Gynaecology The University of Melbourne Melbourne Vic. Australia
- Murdoch Children’s Research Institute Melbourne Vic. Australia
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14
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Abstract
To truly attain effective and safe pharmacotherapy, the similarities and dissimilarities in physiology between micro-preemies and extreme preterm infants should be explored. The higher incidence of pulmonary hypertension and presence of adrenal insufficiency of prematurity in micro-preemies hereby serve as illustrations. The current limited data on pharmacokinetics, -dynamics and safety reflect the obvious need to collect such data, and to tailor modelling tools to their physiology and needs. Drug utilization hereby mirrors different needs and practices and may serve to guide prioritization decisions. Physiological data, combined with even limited observations on pharmacokinetics and -dynamics can be translated to effective modelling tools to attain effective and safe pharmacotherapy. We therefore discuss how valid research tools in pharmacology like physiology-based pharmacokinetic models can be developed, and how clinicians can contribute to such efforts, with the overarching aim to enable this shift from immature pharmacotherapy to pharmacotherapy for the immature.
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15
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Goldsmith JP, Keels E. Recognition and Management of Cardiovascular Insufficiency in the Very Low Birth Weight Newborn. Pediatrics 2022; 149:184900. [PMID: 35224636 DOI: 10.1542/peds.2021-056051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The measurement of blood pressure in the very low birth weight newborn infant is not simple and may be erroneous because of numerous factors. Assessment of cardiovascular insufficiency in this population should be based on multiple parameters and not only on numeric blood pressure readings. The decision to treat cardiovascular insufficiency should be made after considering the potential complications of such treatment. There are numerous potential strategies to avoid or mitigate hypoperfusion states in the very low birth weight infant.
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Affiliation(s)
- Jay P Goldsmith
- Department of Pediatrics, Division of Newborn Medicine, Tulane University, New Orleans, Louisiana
| | - Erin Keels
- Neonatal Practitioner Program, Neonatal Services, Nationwide Children's Hospital, Columbus, Ohio
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16
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Barrington KJ. The most immature infants: Is evidence-based practice possible? Semin Perinatol 2022; 46:151543. [PMID: 34895928 DOI: 10.1016/j.semperi.2021.151543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION At extremely low gestational ages, preterm infants are markedly physiologically immature, thus their responses to common clinical interventions may differ from more mature preterm babies. This study was performed to describe the evidence base which is available to make care decisions for such infants. METHODS A literature search of recent large neonatal randomized controlled trials (RCTs) was performed to determine the representation of infants <25 weeks of gestation, and whether it is clear if the overall results applied to the most immature infants. RESULTS Among 30 multi-centre RCTs in neonatology from the last 5 years, many excluded the most immature infants, and those that included them rarely presented the impacts of the intervention on the most at-risk group. Over 25,000 infants of under 32 weeks gestational age (GA) were included in these trials. Eight trials presented results of the primary outcome for infants of <26 weeks GA (n = 2,152) and a further four trials for infants <25 weeks, n = 711. CONCLUSION The evidence base for treatment decisions for the highest risk infants in the NICU is severely limited. RCTs in extremely preterm infants should not exclude the highest risk group, and lower limits of gestational age (or body weight) should be avoided, any infant receiving intensive care should be eligible regardless of how immature. The results among the most immature infants should be presented separately, or be easily available, in order to build a database of effective treatments among infants of 22,23, and 24 weeks GA.
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17
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Duration of mechanical ventilation is more critical for brain growth than postnatal hydrocortisone in extremely preterm infants. Eur J Pediatr 2021; 180:3307-3315. [PMID: 33993400 DOI: 10.1007/s00431-021-04113-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/30/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
Hydrocortisone is used in preterm infants. However, early disruption of growth velocities was observed in infants exposed to hydrocortisone. This retrospective study aimed to explore the postnatal brain growth of extremely preterm infants requiring hydrocortisone treatment as well as its association with perinatal factors. Extremely preterm infants exposed to hydrocortisone from 2011 to 2016 who survived up to 12 months were included. Each of them was matched with two infants not treated with hydrocortisone exhibiting similar gestational ages and nearly similar birth head circumferences. The outcome variables were brain tissue areas on MRIs performed at term-equivalent age and postnatal head circumference growth up to a corrected age of 12 months. Univariate and multiple regression analyses were performed. Infants treated with hydrocortisone (n=20) were matched with 40 infants not exposed to hydrocortisone. The infants exposed to hydrocortisone exhibited a lower birth weight (p=0.04) and a longer duration of mechanical ventilation (p<0.0001). Infants treated with hydrocortisone exhibited a smaller basal ganglia/thalamus area (p=0.04) at term-equivalent age and a smaller head circumference at a corrected age of 12 months (p=0.003). However, the basal ganglia/thalamus area and the postnatal brain growth were independently associated with the duration of mechanical ventilation and not with hydrocortisone. Interestingly, a significant interaction between hydrocortisone and sex was observed (p=0.04).Conclusion: This study supports previous data that indicated no obvious impact of hydrocortisone on brain growth and highlights the relationship between the severity of the neonatal course and postnatal brain growth in extremely preterm infants. What is Known: • Postnatal hydrocortisone disrupts transiently growth velocities including the head circumference growth. • Postnatal hydrocortisone has less impact on neurodevelopment than dexamethasone. What is New: • Hydrocortisone prescribed for infants in the most severe conditions did not show independent effect on brain growth up to the corrected age of 12 months. However, a different effect of hydrocortisone according to sex can't be excluded and needs further explorations. • Perinatal factors as birth weight and duration of mechanical ventilation were determinant for the subsequent brain growth.
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18
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Gao S, Zhang X, Du W, Zhou X, Xi Y, Ju R. Systematic review and meta-analysis: the effect of bronchopulmonary dysplasia on neurodevelopment in very low birth weight premature infants. Transl Pediatr 2021; 10:3023-3033. [PMID: 34976768 PMCID: PMC8649609 DOI: 10.21037/tp-21-449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/29/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A meta-analysis was performed to study the effect of steroid intervention on the neurodevelopment of extremely low birth weight preterm infants complicated with bronchopulmonary dysplasia, and to provide a theoretical basis for clinical treatment. METHODS The Wanfang database, Chinese Biomedical Literature database, VIP database, Baidu Academic, CNKI database, The Cochrane Library, Medline, Embase, and PubMed database were searched by computer from establishment to 2021. Randomized controlled trials on the effect of steroids on neurodevelopment in very low birth weight preterm infants with bronchial dysplasia published from January 10, 2007 were retrieved. The included literature was evaluated for bias risk, then analyzed using RevMan 5.3 software. RESULTS A total of 9 studies were included, with a total of 2,453 patients. The funnel plot showed that the circles and the midline of some studies were basically symmetrical, and there was no bias in the publications. The conclusions obtained were relatively reliable. Cerebral palsy, neurodevelopmental indicators, and MRI findings of preterm infants were analyzed. The cognitive impairment of very low birth weight preterm infants complicated with bronchial dysplasia (RR =0.83, 95% CI: 0.72-0.96, P=0.01) in the treatment group was significantly different from that in the control group, while cerebral palsy (RR =0.99, 95% CI: 0.75-1.29, P=0.93), speech impairment (RR =0.75, 95% CI: 0.46-1.21, P=0.24), hearing loss requiring amplification (RR =0.60, 95% CI: 0.35-1.03, P=0.06), bilateral blindness RR =0.81, 95% CI: 0.52-1.24, P=0.32), severe intraventricular hemorrhage (IVH) (RR =0.71, 95% CI: 0.33-1.50, P=0.37), and cystic periventricular leukomalacia (RR =0.82, 95% CI: 0.43-1.57, P=0.56) had no significant differences compared with the control group. DISCUSSION In this meta-analysis, we found that the use of steroids in very low birth weight preterm infants complicated with bronchial dysplasia had significant effects on cognition, but no significant effects on hearing, vision, or language function.
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Affiliation(s)
- Shuqiang Gao
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaolong Zhang
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Weina Du
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaofeng Zhou
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yufeng Xi
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Rong Ju
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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19
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Koo JK, Steinhorn R, C Katheria A. Optimizing respiratory management in preterm infants: a review of adjuvant pharmacotherapies. J Perinatol 2021; 41:2395-2407. [PMID: 34244615 DOI: 10.1038/s41372-021-01139-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/25/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023]
Abstract
Adjuvant respiratory therapies in preterm neonates aim to reduce long-term morbidities and mortality. Commonly utilized therapies include caffeine, systemic glucocorticosteroids, inhaled steroids, inhaled bronchodilators, and diuretics. This review discusses the available literature that supports some of these practices and points out where clinical practices are not corroborated by evidence. Therapies with no proven clinical benefit must be weighed against potential adverse effects.
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Affiliation(s)
- Jenny K Koo
- Sharp Mary Birch, Hospital for Women & Newborns, San Diego, CA, USA.,Sharp Neonatal Research Institute, San Diego, CA, USA
| | - Robin Steinhorn
- University of California San Diego, San Diego, CA, USA.,Rady Children's Hospital, San Diego, CA, USA
| | - Anup C Katheria
- Sharp Mary Birch, Hospital for Women & Newborns, San Diego, CA, USA. .,Sharp Neonatal Research Institute, San Diego, CA, USA.
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20
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Rysavy MA, Mehler K, Oberthür A, Ågren J, Kusuda S, McNamara PJ, Giesinger RE, Kribs A, Normann E, Carlson SJ, Klein JM, Backes CH, Bell EF. An Immature Science: Intensive Care for Infants Born at ≤23 Weeks of Gestation. J Pediatr 2021; 233:16-25.e1. [PMID: 33691163 PMCID: PMC8154715 DOI: 10.1016/j.jpeds.2021.03.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Matthew A Rysavy
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA.
| | - Katrin Mehler
- Division of Neonatology, Children's Hospital, University of Cologne, Cologne, Germany
| | - André Oberthür
- Division of Neonatology, Children's Hospital, University of Cologne, Cologne, Germany
| | - Johan Ågren
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Satoshi Kusuda
- Department of Pediatrics, Neonatal Research Network of Japan, Kyorin University, Tokyo, Japan
| | - Patrick J McNamara
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Regan E Giesinger
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Angela Kribs
- Division of Neonatology, Children's Hospital, University of Cologne, Cologne, Germany
| | - Erik Normann
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Susan J Carlson
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Jonathan M Klein
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Carl H Backes
- Departments of Pediatrics and Obstetrics & Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Edward F Bell
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
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21
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Ramaswamy VV, Bandyopadhyay T, Nanda D, Bandiya P, Ahmed J, Garg A, Roehr CC, Nangia S. Assessment of Postnatal Corticosteroids for the Prevention of Bronchopulmonary Dysplasia in Preterm Neonates: A Systematic Review and Network Meta-analysis. JAMA Pediatr 2021; 175:e206826. [PMID: 33720274 PMCID: PMC7961472 DOI: 10.1001/jamapediatrics.2020.6826] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE The safety of postnatal corticosteroids used for prevention of bronchopulmonary dysplasia (BPD) in preterm neonates is a controversial matter, and a risk-benefit balance needs to be struck. OBJECTIVE To evaluate 14 corticosteroid regimens used to prevent BPD: moderately early-initiated, low cumulative dose of systemic dexamethasone (MoLdDX); moderately early-initiated, medium cumulative dose of systemic dexamethasone (MoMdDX); moderately early-initiated, high cumulative dose of systemic dexamethasone (MoHdDX); late-initiated, low cumulative dose of systemic dexamethasone (LaLdDX); late-initiated, medium cumulative dose of systemic dexamethasone (LaMdDX); late-initiated, high cumulative dose of systemic dexamethasone (LaHdDX); early-initiated systemic hydrocortisone (EHC); late-initiated systemic hydrocortisone (LHC); early-initiated inhaled budesonide (EIBUD); early-initiated inhaled beclomethasone (EIBEC); early-initiated inhaled fluticasone (EIFLUT); late-initiated inhaled budesonide (LIBUD); late-initiated inhaled beclomethasone (LIBEC); and intratracheal budesonide (ITBUD). DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, World Health Organization's International Clinical Trials Registry Platform (ICTRP), and CINAHL were searched from inception through August 25, 2020. STUDY SELECTION In this systematic review and network meta-analysis, the randomized clinical trials selected included preterm neonates with a gestational age of 32 weeks or younger and for whom a corticosteroid regimen was initiated within 4 weeks of postnatal age. Peer-reviewed articles and abstracts in all languages were included. DATA EXTRACTION AND SYNTHESIS Two independent authors extracted data in duplicate. Network meta-analysis used a bayesian model. MAIN OUTCOMES AND MEASURES Primary combined outcome was BPD, defined as oxygen requirement at 36 weeks' postmenstrual age (PMA), or mortality at 36 weeks' PMA. The secondary outcomes included 15 safety outcomes. RESULTS A total of 62 studies involving 5559 neonates (mean [SD] gestational age, 26 [1] weeks) were included. Several regimens were associated with a decreased risk of BPD or mortality, including EHC (risk ratio [RR], 0.82; 95% credible interval [CrI], 0.68-0.97); EIFLUT (RR, 0.75; 95% CrI, 0.55-0.98); LaHdDX (RR, 0.70; 95% CrI, 0.54-0.87); MoHdDX (RR, 0.64; 95% CrI, 0.48-0.82); ITBUD (RR, 0.73; 95% CrI, 0.57-0.91); and MoMdDX (RR, 0.61; 95% CrI, 0.45-0.79). Surface under the cumulative ranking curve (SUCRA) value ranking showed that MoMdDX (SUCRA, 0.91), MoHdDX (SUCRA, 0.86), and LaHdDX (SUCRA, 0.76) were the 3 most beneficial interventions. ITBUD (RR, 4.36; 95% CrI, 1.04-12.90); LaHdDX (RR, 11.91; 95% CrI, 1.64-44.49); LaLdDX (RR, 6.33; 95% CrI, 1.62-18.56); MoHdDX (RR, 4.96; 95% CrI, 1.14-14.75); and MoMdDX (RR, 3.16; 95% CrI, 1.35-6.82) were associated with more successful extubation from invasive mechanical ventilation. EHC was associated with a higher risk of gastrointestinal perforation (RR, 2.77; 95% CrI, 1.09-9.32). MoMdDX showed a higher risk of hypertension (RR, 3.96; 95% CrI, 1.10-30.91). MoHdDX had a higher risk of hypertrophic cardiomyopathy (RR, 5.94; 95% CrI, 1.95-18.11). CONCLUSIONS AND RELEVANCE This study suggested that MoMdDX may be the most appropriate postnatal corticosteroid regimen for preventing BPD or mortality at a PMA of 36 weeks, albeit with a risk of hypertension. The quality of evidence was low.
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Affiliation(s)
- Viraraghavan Vadakkencherry Ramaswamy
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom,Ankura Hospital for Women and Children, Hyderabad, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Debasish Nanda
- Department of Neonatology, Institute of Medical Sciences and SUM Hospital, Orissa, India
| | - Prathik Bandiya
- Department of Neonatology, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Javed Ahmed
- Women’s Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Anip Garg
- Department of Neonatology, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Charles C. Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom,National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College, New Delhi, India
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22
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Postnatal steroid management in preterm infants with evolving bronchopulmonary dysplasia. J Perinatol 2021; 41:1783-1796. [PMID: 34012057 PMCID: PMC8133053 DOI: 10.1038/s41372-021-01083-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/06/2021] [Accepted: 04/28/2021] [Indexed: 02/04/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a chronic lung disease commonly affecting extremely preterm infants. Although mechanical ventilation and oxygen requirements in premature infants are identified as inciting mechanisms for inflammation and the development of BPD over time, data now support an array of perinatal events that may stimulate the inflammatory cascade prior to delivery. Corticosteroids, such as dexamethasone and hydrocortisone, have proven beneficial for the prevention and management of BPD postnatally due to their anti-inflammatory characteristics. This review aims to examine the pharmacologic properties of several corticosteroids, appraise the existing evidence for postnatal corticosteroid use in preterm infants, and assess steroid management strategies to ameliorate BPD. Finally, we aim to provide guidance based on clinical experience for managing adrenal suppression resulting from prolonged steroid exposure since this is an area less well-studied.
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23
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Billion E, Hadchouel A, Garcelon N, Delacourt C, Drummond D. Intravenous pulses of methylprednisolone for infants with severe bronchopulmonary dysplasia and respiratory support after 3 months of age. Pediatr Pulmonol 2021; 56:74-82. [PMID: 33034950 DOI: 10.1002/ppul.25109] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/27/2020] [Accepted: 10/05/2020] [Indexed: 11/10/2022]
Abstract
INTRODUCTION There are few published data on the efficacy of systemic corticosteroids in preterm infants with very severe forms of bronchopulmonary dysplasia (BPD), requiring respiratory support after 3 months of age. The aim of this study was to report the use of pulses of methylprednisolone in this population and its consequences on the level of respiratory support. METHODS This retrospective monocentre study included infants over 3 months of age with severe BPD who received at least one pulse of methylprednisolone (300 mg/m2 /day intravenous [IV] over 3 days). The primary outcome was the evolution of the pulmonary severity score (PSS) during the 3 months preceding and the 5 months following the first pulse. The evolution of the median PSS over time was analyzed using linear segmented regression for interrupted time series. RESULTS Ten infants were included. During the 3 months preceding the first pulse, a significant increase in the median PSS was observed (p = .01), followed by a progressive decrease during the 5 months after administration of the first pulse (p < .01). Greater effects were observed in more severe infants requiring mechanical or noninvasive ventilation than in those receiving supplemental oxygen through nasal cannula. CONCLUSION High-dose IV pulses of methylprednisolone were associated with a decrease in the level of respiratory support required by infants with very severe forms of BPD, with a greater effect in those on mechanical or noninvasive ventilation. Further studies are warranted to confirm these preliminary results and assess the long-term safety of this therapy.
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Affiliation(s)
- Elodie Billion
- Department of Pediatric Pulmonology, University Hospital Necker-Enfants Malades, AP-HP, Paris, France
| | - Alice Hadchouel
- Department of Pediatric Pulmonology, University Hospital Necker-Enfants Malades, AP-HP, Paris, France.,Faculty of Medicine, University of Paris, Paris, France
| | - Nicolas Garcelon
- Faculty of Medicine, University of Paris, Paris, France.,Department of Informatics, Imagine Institute, University of Paris, Paris, France.,INSERM Unit 1138, Centre de Recherche des Cordeliers, INSERM, Paris, France
| | - Christophe Delacourt
- Department of Pediatric Pulmonology, University Hospital Necker-Enfants Malades, AP-HP, Paris, France.,Faculty of Medicine, University of Paris, Paris, France
| | - David Drummond
- Department of Pediatric Pulmonology, University Hospital Necker-Enfants Malades, AP-HP, Paris, France.,Faculty of Medicine, University of Paris, Paris, France.,INSERM Unit 1138, Centre de Recherche des Cordeliers, INSERM, Paris, France
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24
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He Y, Zhang Y, Gao S, Wang X, He N, Zhang D, Dong W, Wieg C, Lei X. Hydrocortisone to treat early bronchopulmonary dysplasia in very preterm infants: study protocol for a randomized controlled trial. Trials 2020; 21:762. [PMID: 32883333 PMCID: PMC7469331 DOI: 10.1186/s13063-020-04698-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 08/20/2020] [Indexed: 12/20/2022] Open
Abstract
Background Bronchopulmonary dysplasia (BPD) is still a common complication in very premature infants. At present, there is no effective treatment for BPD. Glucocorticoids are drugs commonly used to prevent or treat BPD before and after birth. In very premature infants with high risk factors for BPD, early use of dexamethasone can reduce the rate of death and/or BPD but may cause long-term adverse neurodevelopmental outcomes. Hydrocortisone (HC), as an alternative drug to dexamethasone, has been increasingly used to prevent BPD. However, no study has reported the efficacy and safety of HC to treat early BPD diagnosed at postnatal day (PND) 28. Methods This study protocol is for a multicenter double-blind randomized controlled trial of low-dose HC in the treatment of early BPD. Early BPD infants will be randomly assigned to the HC treatment group or control group. Infants in the HC group will receive 0.5 mg/kg HC twice a day for 7 days and then 0.5 mg/kg HC once a day for 3 days. The control group will be given the same volume of placebo and no intervention on the basis of routine treatment. The primary outcome is survival without moderate or severe BPD at 36 weeks postmenstrual age. Secondary outcomes are the short- and long-term effects on growth, metabolism, neurodevelopment, and other possible complications. Discussion This trial will determine the efficacy and safety of low-dose HC administration compared to placebo for the reduction of moderate or severe BPD at 36 weeks postmenstrual age in very preterm infants with early BPD. Trial registration China Clinical Trial Registration Center ChiCTR1900021854. Registered on 13 March 2019.
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Affiliation(s)
- Yuan He
- Department of Neonatology, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, 646000, Sichuan, China
| | - Yong Zhang
- Department of Neonatology, Sichuan Provincial Hospital for Women and Children, Chengdu, Sichuan, China
| | - Shuqiang Gao
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, China
| | - Xiaoling Wang
- Department of Neonatology, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, 646000, Sichuan, China
| | - Na He
- Department of Neonatology, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, 646000, Sichuan, China
| | - Deshuang Zhang
- Department of Neonatology, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, 646000, Sichuan, China
| | - Wenbin Dong
- Department of Neonatology, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, 646000, Sichuan, China.,Birth Defects Clinical Medical Research Center of Sichuan Province, Luzhou, Sichuan, China.,Department of Perinatology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Christian Wieg
- Department of Neonatology, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, 646000, Sichuan, China. .,Department of Perinatology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China. .,Department of Neonatology, Klinikum Aschaffenburg, Am Hasenkopf 1, Aschaffenburg, 63739, Aschaffenburg, Bavaria, Germany.
| | - Xiaoping Lei
- Department of Neonatology, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, 646000, Sichuan, China. .,Birth Defects Clinical Medical Research Center of Sichuan Province, Luzhou, Sichuan, China. .,Department of Perinatology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
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25
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Alison M, Tilea B, Toumazi A, Biran V, Mohamed D, Alberti C, Bourmaud A, Baud O. Prophylactic hydrocortisone in extremely preterm infants and brain MRI abnormality. Arch Dis Child Fetal Neonatal Ed 2020; 105:520-525. [PMID: 31980445 DOI: 10.1136/archdischild-2019-317720] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 12/18/2019] [Accepted: 01/02/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether early low-dose hydrocortisone treatment in extremely preterm infants is associated with brain damage assessed by MRI at term equivalent of age (TEA). PATIENTS AND OUTCOMES This is a predefined secondary analysis of brain abnormalities, observed by MRI at TEA, of patients randomly assigned to receive either placebo or hydrocortisone in the PREMILOC trial. Outcomes were based on brain abnormalities graded according to Kidokoro scores. RESULTS Among 412 survivors at TEA, 300 MRIs were performed and 295 were suitable for analysis. Kidokoro scoring was completed for 119/148 and 110/147 MRIs in the hydrocortisone and placebo groups, respectively. The distribution of the Kidokoro white matter (WM) subscore and other subscores was not significantly different between the two groups. There was, however, a significant association between a higher overall Kidokoro score and hydrocortisone treatment (5.84 (SD 3.51) for hydrocortisone and 4.98 (SD 2.52) for placebo; mean difference, 0.86; 95% CI 0.06 to 1.66; p=0.04). However, hydrocortisone was not statistically associated with moderate-to-severe brain lesions (Kidokoro overall score ≥6) in a multivariate logistic regression model accounting for potential confounding variables (adjusted OR (95% CI) 1.27 (0.75 to 2.14), p=0.38). Bronchopulmonary dysplasia at 36 weeks postmenstrual age significantly predicted both WM damage (adjusted OR (95% CI) 2.70 (1.03 to 7.14), p=0.04) and global brain damage (adjusted OR (95% CI) 2.18 (1.19 to 3.99), p=0.01). CONCLUSIONS Early hydrocortisone exposure in extremely preterm infants is not statistically associated with either WM brain damage or overall moderate-to-severe brain lesions when adjusted for other neonatal variables. TRIAL REGISTRATION NUMBER EudraCT number 2007-002041-20, NCT00623740.
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Affiliation(s)
- Marianne Alison
- Pediatric Radiology, Hôpital Universitaire Robert Debré, Paris, France
| | - Bogdana Tilea
- Pediatric Radiology, Hôpital Universitaire Robert Debré, Paris, France
| | - Artemis Toumazi
- Pediatric Radiology, Hôpital Universitaire Robert Debré, Paris, France
| | - Valérie Biran
- Neonatal Intensive Care Unit, Hopital Universitaire Robert Debre, Paris, Île-de-France, France.,Inserm U1141, University of Paris, Paris, France
| | - Damir Mohamed
- Centre d'Investigation Clinique-Epidémiologie Clinique, Hopital Universitaire Robert Debre, Paris, France
| | - Corinne Alberti
- Centre d'Investigation Clinique-Epidémiologie Clinique, Hopital Universitaire Robert Debre, Paris, France
| | - Aurélie Bourmaud
- Pediatric Radiology, Hôpital Universitaire Robert Debré, Paris, France
| | - Olivier Baud
- Inserm U1141, University of Paris, Paris, France .,DFEA, Hôpitaux Universitaires de Genève, Geneva, Switzerland
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26
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Wang SH, Tsao PN. Phenotypes of Bronchopulmonary Dysplasia. Int J Mol Sci 2020; 21:ijms21176112. [PMID: 32854293 PMCID: PMC7503264 DOI: 10.3390/ijms21176112] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/18/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic morbidity in preterm infants. In the absence of effective interventions, BPD is currently a major therapeutic challenge. Several risk factors are known for this multifactorial disease that results in disrupted lung development. Inflammation plays an important role and leads to persistent airway and pulmonary vascular disease. Since corticosteroids are potent anti-inflammatory agents, postnatal corticosteroids have been used widely for BPD prevention and treatment. However, the clinical responses vary to a great degree across individuals, and steroid-related complications remain major concerns. Emerging studies on the molecular mechanism of lung alveolarization during inflammatory stress will elucidate the complicated pathway and help discover novel therapeutic targets. Moreover, with the advances in metabolomics, there are new opportunities to identify biomarkers for early diagnosis and prognosis prediction of BPD. Pharmacometabolomics is another novel field aiming to identify the metabolomic changes before and after a specific drug treatment. Through this "metabolic signature," a more precise treatment may be developed, thereby avoiding unnecessary drug exposure in non-responders. In the future, more clinical, genetic, and translational studies would be required to improve the classification of BPD phenotypes and achieve individualized care to enhance the respiratory outcomes in preterm infants.
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Affiliation(s)
- Shih-Hsin Wang
- Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City 22060, Taiwan;
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 100225, Taiwan
- Center for Developmental Biology & Regenerative Medicine, National Taiwan University, Taipei 100226, Taiwan
- Correspondence: ; Tel.: +886-2-23123456 (ext. 71013)
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27
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Lemyre B, Dunn M, Thebaud B. L’administration postnatale de corticostéroïdes pour prévenir ou traiter la dysplasie bronchopulmonaire chez les nouveau-nés prématurés. Paediatr Child Health 2020. [DOI: 10.1093/pch/pxaa072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Résumé
Les corticostéroïdes ont longtemps été administrés pendant la période postnatale pour prévenir et traiter la dysplasie bronchopulmonaire (DBP), une cause importante de morbidité et de mortalité chez les nouveau-nés prématurés. L’administration préventive de dexaméthasone pendant la première semaine de vie est liée à une augmentation du risque de paralysie cérébrale, et l’administration précoce de corticostéroïdes inhalés semble être associée à une hausse du risque de mortalité. À l’heure actuelle, aucune de ces deux approches n’est recommandée pour prévenir la DBP. Selon de nouvelles données probantes, un traitement prophylactique d’hydrocortisone à des doses physiologiques, entrepris avant 48 heures de vie sans ajout d’indométacine, améliore la survie sans DBP, et n’a pas d’effets neurodéveloppementaux indésirables à l’âge de deux ans. Les cliniciens peuvent envisager ce traitement pour les nouveau-nés les plus à risque de DBP. Il n’est pas recommandé d’entreprendre un traitement systématique de dexaméthasone pour tous les nouveau-nés sous assistance respiratoire, mais après la première semaine de vie, les cliniciens peuvent envisager un court traitement de dexaméthasone à faible dose (0,15 mg/kg/jour à 0,2 mg/kg/jour) pour certains nouveau-nés à haut risque de DBP ou atteints d’une DBP évolutive. Aucune donnée probante n’indique que l’hydrocortisone remplace la dexaméthasone avec efficacité ou innocuité dans le traitement d’une DBP évolutive ou établie. Les données à jour n’appuient pas l’administration de corticostéroïdes inhalés pour traiter la DBP.
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Affiliation(s)
- Brigitte Lemyre
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | - Michael Dunn
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | - Bernard Thebaud
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
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28
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Lemyre B, Dunn M, Thebaud B. Postnatal corticosteroids to prevent or treat bronchopulmonary dysplasia in preterm infants. Paediatr Child Health 2020; 25:322-331. [PMID: 32765169 DOI: 10.1093/pch/pxaa073] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 05/23/2019] [Indexed: 12/23/2022] Open
Abstract
Historically, postnatal corticosteroids have been used to prevent and treat bronchopulmonary dysplasia (BPD), a significant cause of morbidity and mortality in preterm infants. Administering dexamethasone to prevent BPD in the first 7 days post-birth has been associated with increasing risk for cerebral palsy, while early inhaled corticosteroids appear to be associated with an increased risk of mortality. Neither medication is presently recommended to prevent BPD. New evidence suggests that prophylactic hydrocortisone, when initiated in the first 48 hours post-birth, at a physiological dose, and in the absence of indomethacin, improves survival without BPD, with no adverse neurodevelopmental effects at 2 years. This therapy may be considered by clinicians for infants at highest risk for BPD. Routine dexamethasone therapy for all ventilator-dependent infants is not recommended, but after the first week post-birth, clinicians may consider a short course of low-dose dexamethasone (0.15 mg/kg/day to 0.2 mg/kg/day) for individual infants at high risk for, or with evolving, BPD. There is no evidence that hydrocortisone is an effective or safe alternative to dexamethasone for treating evolving or established BPD. Current evidence does not support inhaled corticosteroids for the treatment of BPD.
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Affiliation(s)
- Brigitte Lemyre
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Michael Dunn
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Bernard Thebaud
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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29
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Nuytten A, Behal H, Duhamel A, Jarreau PH, Torchin H, Milligan D, Maier RF, Zemlin M, Zeitlin J, Truffert P. Postnatal Corticosteroids Policy for Very Preterm Infants and Bronchopulmonary Dysplasia. Neonatology 2020; 117:308-315. [PMID: 32454484 DOI: 10.1159/000507195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/10/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Postnatal corticosteroids (PNC) are effective for reducing bronchopulmonary dysplasia (BPD) in very preterm neonates but are associated with adverse effects including an increased risk of cerebral palsy. PNC use in Europe is heterogeneous across regions. This study aimed to assess whether European neonatal intensive care units (NICUs) with a low use of PNC or an explicit policy to reduce PNC use had higher risks of mortality or BPD. METHODS We included 3,126 infants in 105 NICUs born between 24 + 0 and 29 + 6 weeks' gestational age in 19 regions in 11 countries in the EPICE cohort. First, we identified clusters of NICUs using hierarchical clustering based on PNC use and BPD prevalence and compared case mix and mortality between the clusters. Second, a multilevel analysis was performed to evaluate the association between a restrictive PNC policy and BPD occurrence. RESULTS There were 3 clusters of NICUs: 52 with low PNC use and a low BPD rate, 37 with low PNC use and a high BPD rate, and 16 with high PNC use and a medium BPD rate. Neonatal mortality did not differ between clusters (p = 0.88). A unit policy of restricted PNC use was not associated with a higher risk of BPD (odds ratio 0.68; 95% confidence interval: 0.45-1.03) after adjustment. CONCLUSION Up to 49% of NICUs had low PNC use and low BPD rates, without a difference in mortality. Infants hospitalized in NICUs with a stated policy of low PNC use did not have an increased risk of BPD.
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Affiliation(s)
- Alexandra Nuytten
- Department of Neonatology, Jeanne de Flandre Hospital, Lille CHRU, Lille, France,
- Université Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France,
| | - Hélène Behal
- Université Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | - Alain Duhamel
- Université Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | - Pierre-Henri Jarreau
- Université Paris Descartes and Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaire Paris Centre Site Cochin, Service de Médecine et Réanimation néonatales de Port-Royal, Paris, France
- Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (Epopé), INSERM UMR 1153, Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France
| | - Heloïse Torchin
- Université Paris Descartes and Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaire Paris Centre Site Cochin, Service de Médecine et Réanimation néonatales de Port-Royal, Paris, France
- Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (Epopé), INSERM UMR 1153, Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France
| | | | - Rolf F Maier
- Children's Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | - Michael Zemlin
- Department for General Pediatrics and Neonatology, Saarland University, Homburg, Germany
| | - Jennifer Zeitlin
- Obstetrical, Perinatal, and Pediatric Epidemiology Research Team (Epopé), INSERM UMR 1153, Center for Epidemiology and Biostatistics Sorbonne Paris Cité, Paris Descartes University, Paris, France
| | - Patrick Truffert
- Department of Neonatology, Jeanne de Flandre Hospital, Lille CHRU, Lille, France
- Université Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France
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30
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Kovacs K, Szakmar E, Meder U, Szakacs L, Cseko A, Vatai B, Szabo AJ, McNamara PJ, Szabo M, Jermendy A. A Randomized Controlled Study of Low-Dose Hydrocortisone Versus Placebo in Dopamine-Treated Hypotensive Neonates Undergoing Hypothermia Treatment for Hypoxic-Ischemic Encephalopathy. J Pediatr 2019; 211:13-19.e3. [PMID: 31155392 DOI: 10.1016/j.jpeds.2019.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/10/2019] [Accepted: 04/05/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate whether hydrocortisone supplementation increases blood pressure and decreases inotrope requirements compared with placebo in cooled, asphyxiated neonates with volume-resistant hypotension. STUDY DESIGN A double-blind, randomized, placebo-controlled clinical trial was conducted in a Level III neonatal intensive care unit in 2016-2017. Thirty-five asphyxiated neonates with volume-resistant hypotension (defined as a mean arterial pressure [MAP] < gestational age in weeks) were randomly assigned to receive 0.5 mg/kg/6 hours of hydrocortisone or placebo in addition to standard dopamine treatment during hypothermia. RESULTS More patients reached the target of at least 5-mm Hg increment of MAP in 2 hours after randomization in the hydrocortisone group, compared with the placebo group (94% vs 58%, P = .02, intention-to-treat analysis). The duration of cardiovascular support (P = .001) as well as cumulative (P < .001) and peak inotrope dosage (P < .001) were lower in the hydrocortisone group. In a per-protocol analysis, regression modeling predicted that a 4-mm Hg increase in MAP in response to hydrocortisone treatment was comparable with the effect of 15 μg/kg/min of dopamine in this patient population. Serum cortisol concentrations were low before randomization in both the hydrocortisone and placebo groups (median 3.5 and 3.3 μg/dL, P = .87; respectively), suggesting inappropriate adrenal function. Short-term clinical outcomes were similar in the 2 groups. CONCLUSIONS Hydrocortisone administration was effective in raising the blood pressure and decreasing inotrope requirement in asphyxiated neonates with volume-resistant hypotension during hypothermia treatment. TRIAL REGISTRATION ClinicalTrials.gov: NCT02700828.
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Affiliation(s)
- Kata Kovacs
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Eniko Szakmar
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Unoke Meder
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | | | - Anna Cseko
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Barbara Vatai
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Attila J Szabo
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary; MTA-SE Pediatric and Nephrology Research Group, Budapest, Hungary
| | | | - Miklos Szabo
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Agnes Jermendy
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary.
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31
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Baud O, Watterberg KL. Prophylactic postnatal corticosteroids: Early hydrocortisone. Semin Fetal Neonatal Med 2019; 24:202-206. [PMID: 31043325 DOI: 10.1016/j.siny.2019.04.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Inflammation is a key contributor to the pathogenesis of bronchopulmonary dysplasia (BPD) in preterm infants, and cortisol plays a central role in controlling inflammation. Insufficient cortisol limits the ability of the sick newborn to handle stress and inhibit pulmonary inflammation. Evidence of lower cortisol and lower response to adrenocorticotropic hormone in infants subsequently developing BPD led to studies of early low-dose hydrocortisone to prevent BPD. Based on four randomised clinical trials enrolling almost 1000 extremely preterm infants, prophylaxis of early adrenal insufficiency with low-dose hydrocortisone significantly decreased BPD and mortality, as well as medical treatment for a patent ductus arteriosus. An increase in late-onset sepsis reported in the most immature infants had no adverse effect on mortality or neurodevelopmental outcomes. There was no increase in gastrointestinal perforation in the absence of indomethacin. The demonstrated beneficial effects of early low-dose hydrocortisone make a strong case for its use in extremely preterm infants at high risk for BPD.
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Affiliation(s)
- Olivier Baud
- Division of Neonatology and Pediatric Intensive Care, University Hospitals Geneva, Geneva, Switzerland.
| | - Kristi L Watterberg
- Division of Neonatology, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GHA, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update. Neonatology 2019; 115:432-450. [PMID: 30974433 PMCID: PMC6604659 DOI: 10.1159/000499361] [Citation(s) in RCA: 654] [Impact Index Per Article: 130.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.
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Affiliation(s)
- David G Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, United Kingdom,
| | - Virgilio Carnielli
- Department of Neonatology, Polytechnic University of Marche, and Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Pediatrics and Adolescence, Oulu University Hospital, and PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan Te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C Roehr
- Department of Paediatrics, University of Oxford, Medical Sciences Division, Newborn Services, John Radcliffe Hospitals, Oxford, United Kingdom
| | - Ola D Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
| | - Umberto Simeoni
- Division of Pediatrics, CHUV & University of Lausanne, Lausanne, Switzerland
| | - Christian P Speer
- Department of Pediatrics, University Children's Hospital, Würzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerhard H A Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, United Kingdom
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Leviton A, Allred EN, Joseph RM, O’Shea TM, Majzoub J, Kuban KC. Behavioural dysfunctions of 10-year-old children born extremely preterm associated with corticotropin-releasing hormone expression in the placenta. Acta Paediatr 2018; 107:1932-1936. [PMID: 29992644 PMCID: PMC6179924 DOI: 10.1111/apa.14494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/13/2018] [Accepted: 07/09/2018] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the relationship between corticotropin-releasing hormone (CRH) expression in the placenta and the risk of school-related dysfunctions at the age of 10 years among children born extremely preterm (EP). METHODS Corticotropin-releasing hormone expression was measured in the placenta of 761 EP children, who had the following assessments at the age of 10 years: Differential Ability Scales, Oral and Written Language Scales, the Wechsler Individual Achievement Test-III, NEPSY-II and the Child Symptom Inventory-4. We evaluated whether lowest and highest quartiles of CRH mRNA were associated with undesirable scores on these assessments. With 272 evaluations, we would expect 14 to be significant at p < 0.05. RESULTS Only 16 associations were statistically significant. On the other hand, seven of these were social limitations among girls whose placenta CRH mRNA was in the top quartile. Adjusting for delivery indication or restricting the sample to one delivery indication group resulted in few differences. CONCLUSION Overall, placenta CRH mRNA concentrations in the top or bottom quartiles were not associated with increased risks of dysfunctions 10 years later. Girls whose placenta CRH expression was in the top quartile, however, were at increased risk of seven indicators/correlates of social limitations.
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Affiliation(s)
- Alan Leviton
- Boston Children’s Hospital and Harvard Medical School, Boston MA, USA
| | | | | | - T. Michael O’Shea
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Joseph Majzoub
- Boston Children’s Hospital and Harvard Medical School, Boston MA, USA
| | - Karl C.K. Kuban
- Boston University School of Medicine, Boston, MA, USA
- Boston Medical Center, Boston MA, USA
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Abstract
Bronchopulmonary dysplasia (BPD) is a complex disorder with multiple factors implicated in its etiopathogenesis. Despite the scientific advances in the field of neonatology, the incidence of BPD has remained somewhat constant due to increased survival of extremely premature infants. Surfactant deficiency in the immature lung, exposure to invasive mechanical ventilation leading to volutrauma, barotrauma and lung inflammation are some of the critical contributing factors to the pathogenesis of BPD. Hence, strategies to prevent BPD in the postnatal period revolve around mitigation of this injury and inflammation. This article reviews the progress made in the last 5 years in the development of new preparations of surfactant, use of corticosteroids and non-invasive ventilation in the prevention of BPD. Emerging techniques of surfactant delivery through minimally invasive and non-invasive routes are also discussed.
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Affiliation(s)
- Vikramaditya Dumpa
- Division of Neonatology, Department of Pediatrics, NYU Winthrop Hospital, 259 First Street, Mineola, NY 11501, United States
| | - Vineet Bhandari
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, 160 East Erie Avenue, Philadelphia, PA 19134, United States.
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