The cardiac murmur in relation to symptoms in the newborn

Clinical outcomes of different patent ductus arteriosus treatment in preterm infants born between 28 and 32 weeks in Taiwan

BACKGROUND

The patent ductus arteriosus (PDA) treatment in very preterm infants is controversial. This study focused on preterm infants born at 28-32 weeks of gestation and analyzed the association between various PDA treatments and clinical outcomes.

METHODS

We conducted a retrospective cohort study of infants born at 28-32 weeks of gestation between 2016 and 2019 at 22 hospitals in the Taiwan Premature Infant Follow-up Network. We categorized the infants into four groups according to treatment strategies: medication, primary surgery, medication plus surgery, or conservative treatment.

RESULTS

A total of 1244 infants presented with PDA, and 761 (61.1%) were treated. Medication was the predominant treatment (50.0%), followed by conservative treatment (38.9%), medication plus surgery (7.6%), and primary surgery (3.5%). The risk of mortality was not reduced in the active treatment group compared to the conservative treatment group. There was a higher prevalence of severe intraventricular hemorrhage, necrotizing enterocolitis (NEC), and any degree of bronchopulmonary dysplasia (BPD) in both the primary surgery and medication plus surgery groups than in the conservative treatment group. After adjustment, both the primary surgery and medication plus surgery groups still had higher odds ratios for the occurrence of NEC and any degree of BPD.

CONCLUSIONS

Compared with active PDA treatment, conservative treatment for PDA did not increase the risk of mortality and morbidity in very preterm infants born at 28-32 weeks of gestation. The risks and benefits of surgery (PDA ligation) in these infants must be considered cautiously.

Conservative Non-intervention Approach for Hemodynamically Significant Patent Ductus Arteriosus in Extremely Preterm Infants

While persistent patent ductus arteriosus (PDA) in preterm infants has been known to be associated with increased mortality and morbidities including bronchopulmonary dysplasia, and necrotizing enterocolitis, there is minimal evidence supporting their causal relationships, and most traditional medical and/or surgical treatments have failed to show improvements in these outcomes. As such, the pendulum has swung toward the conservative non-intervention approach for the management of persistent PDA during the last decade; however, the benefits and risks of this approach are unclear. In this mini review, we focused on whom, when, and how to apply the conservative non-intervention approach for persistent PDA, especially in extremely preterm infants.

The use of non-steroidal anti-inflammatory drugs for patent ductus arteriosus closure in preterm infants

Over the last four decades, non-steroidal anti-inflammatory drugs have been widely used to induce closure of the patent ductus arteriosus (PDA) in preterm infants. Evidence to support this practice is lacking, despite performance of >50 randomized trials. The credibility of those trials may have been compromised by high rates of open treatment in controls, era of study prior to advent of modern practices, or inclusion of insufficient numbers of very immature infants. Meta-analyses show little impact of those factors on main conclusions. Essentially all trials reporting important long-term outcomes (other than mortality) initiated treatment within five days after birth, so no evidence regarding later treatment is available. Accruing clinical experience suggests that long-term outcomes are not compromised, and may be improved, with non-interventional management strategies. Future studies to identify preterm infants at greatest risk of potential harm from a persistent PDA, particularly after the second postnatal week, are urgently needed.

Treatment of persistent patent ductus arteriosus in preterm infants: time to accept the null hypothesis?

Medical and surgical interventions are widely used to close a persistently patent ductus arteriosus in preterm infants. Objective evidence to support these practices is lacking, causing some to question their usage. Emerging evidence suggests that treatments that close the patent ductus may be detrimental. This review examines the history of and evidence underlying these treatments. Neither individual trials, pooled data from groups of randomized-controlled trials, nor critical examination of the immediate consequences of treatment provide evidence that medical or surgical closure of the ductus is beneficial in preterm infants. These conclusions are supported by sufficient evidence. Neither continued routine use of these treatments nor additional clinical trials using similar designs seems to be justified. A definitive trial, comparing current standard management with novel strategies not primarily intended to achieve ductal closure, may be necessary to resolve doubts regarding the quality or conduct of prior studies.

Echocardiographic screening for congenital heart disease: a randomized study

OBJECTIVES

To assess the effectiveness and potential cost of an echocardiographic screening program for congenital heart disease (CHD).

PATIENTS AND METHODS

Between 01/11/94 and 28/02/98 there were 9697 deliveries in The Royal Maternity Hospital Belfast. Mothers were randomized before delivery. 4875 infants were allocated to the scan group, while 4822 were assigned to clinical assessment alone. High-risk infants were considered separately. Cases of CHD detected before hospital discharge were documented. The annual cost of screening was estimated and the time to accurate diagnosis in each group was assessed.

RESULTS

During the study 124 scan allocated infants and 50 controls were identified as having significant CHD before hospital discharge. With a minimum of 3 years follow-up there were 27 additional late diagnoses in controls and 1 in scanned infants. During a single year of the study the mean time to complete diagnosis was 2 days for scanned cases and 110 in controls. The projected cost of screening for all infants was 22 Pounds/infant for the first year.

CONCLUSIONS

Adding echocardiography to clinical examination greatly enhances early detection of CHD. Although screening is expensive, once established it may reduce the cost of unnecessary outpatient referrals.

Early diagnosis of congenital heart disease

Routine examination of apparently healthy newborn babies detects less than half of those with congenital cardiac malformations because they are asymptomatic and without signs. More severe cardiac malformations are not detected more easily. A normal clinical examination does not exclude serious congenital cardiac malformation. Left heart obstruction is easily overlooked but often causes serious deterioration in less than 3 weeks. It is important to arrange early echocardiography of babies with signs and to consider cardiac malformation in a sick baby even if a previous routine examination was normal. All babies with Down syndrome should have early expert cardiological assessment.

Prevalence and clinical significance of cardiac murmurs in neonates

AIM

To determine the prevalence and clinical significance of murmurs detected during routine neonatal examination.

METHODS

In a two year prospective study, 7204 newborn babies underwent routine examination by senior house officers. All those with murmurs underwent echocardiographic examination. All babies presenting later in infancy were also identified, to ascertain the total prevalence of congenital heart disease in infancy.

RESULTS

Murmurs were detected in 46 babies (0.6%) of whom 25 had a cardiac malformation. The most common diagnosis was a ventricular septal defect, although four babies had asymptomatic left heart outflow obstruction. A further 32 infants from the same birth cohort had a normal neonatal examination but were found to have a cardiac malformation before 12 months of age.

CONCLUSIONS

The neonatal examination detects only 44% of cardiac malformations which present in infancy. If a murmur is heard there is a 54% chance of there being an underlying cardiac malformation. Parents and professionals should be aware that a normal neonatal examination does not preclude a clinically significant cardiac malformation. The detection of a murmur should prompt early referral to a paediatric cardiologist for diagnosis or appropriate reassurance.

Patent ductus arteriosus and retinopathy of prematurity in infants below 27 weeks gestation

Retrospective study of infants who survived the neonatal period after delivery at 24-26 weeks gestation revealed patency of the ductus arteriosus (PDA) in 44%. The mean birthweight of infants who developed PDA was lower. Retinopathy of prematurity (ROP) was seen in 79% of survivors with 24% having grade III or IV involvement. All but one of the more severe grades of ROP occurred among infants with PDA. Infants with PDA required more prolonged ventilatory support. Perinatal factors did not have a significant role in the development of these complications.

The formation of pulmonary hyaline membranes in the newborn baby

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