Prolonged ventilation and postnatal growth of preterm infants

Predictors of extubation failure in newborns: a systematic review and meta-analysis

Extubation failure (EF) is a significant concern in mechanically ventilated newborns, and predicting its occurrence is an ongoing area of research. To investigate the predictors of EF in newborns undergoing planned extubation, we conducted a systematic review and meta-analysis. A systematic literature search was conducted in PubMed, Web of Science, Embase, and Cochrane Library for studies published in English from the inception of each database to March 2023. The PRISMA guidelines were followed in all phases of this systematic review. The Risk of Bias Assessment for Nonrandomized Studies tool was used to assess methodological quality. Thirty-four studies were included, 10 of which were overall low risk of bias, 15 of moderate risk of bias, and 9 of high risk of bias. The studies reported 43 possible predictors in six broad categories (intrinsic factors; maternal factors; diseases and adverse conditions of the newborn; treatment of the newborn; characteristics before and after extubation; and clinical scores and composite indicators). Through a qualitative synthesis of 43 predictors and a quantitative meta-analysis of 19 factors, we identified five definite factors, eight possible factors, and 22 unclear factors related to EF. Definite factors included gestational age, sepsis, pre-extubation pH, pre-extubation FiO2, and respiratory severity score. Possible factors included age at extubation, anemia, inotropic use, mean airway pressure, pre-extubation PCO2, mechanical ventilation duration, Apgar score, and spontaneous breathing trial. With only a few high-quality studies currently available, well-designed and more extensive prospective studies investigating the predictors affecting EF are still needed. In the future, it will be important to explore the possibility of combining multiple predictors or assessment tools to enhance the accuracy of predicting extubation outcomes in clinical practice.

Defining postnatal growth failure among preterm infants in Indonesia

Background

Postnatal growth failure (PGF) frequently occurred among preterm infants with malnutrition. The decline in a weight-for-age z-score of ≥1.2 has been proposed to define PGF. It was unknown whether this indicator would be useful among Indonesian preterm infants.

Methods

Infants of <37 weeks of gestational age born between 2020 and 2021, both stable and unstable, were recruited for a prospective cohort study during hospitalization in the level III neonatal intensive care unit at the Cipto Mangunkusumo General Hospital, Jakarta, Indonesia. The prevalence of PGF as defined by a weight-for-age z-score of <−1.28 (<10th percentile) at discharge, a weight-for-age z-score of <−1.5 (<7th percentile) at discharge, or a decline in a weight-for-age z-score of ≥1.2 from birth till discharge was compared. The association between those PGF indicators with the preterm subcategory and weight gain was assessed. The association between the decline in a weight-for-age z-score of ≥1.2 with the duration to achieve full oral feeding and the time spent for total parenteral nutrition was analyzed.

Results

Data were collected from 650 preterm infants who survived and were discharged from the hospital. The weight-for-age z-score of <−1.28 or <−1.5 was found in 307 (47.2%) and 270 (41.5%) subjects with PGF, respectively. However, both indicators did not identify any issue of weight gain among subjects with PGF, questioning their reliability in identifying malnourished preterm infants. By contrast, the decline in a weight-for-age z-score of ≥1.2 was found in 51 (7.8%) subjects with PGF, in which this indicator revealed that subjects with PGF had an issue of weight gain. Next, a history of invasive ventilation was identified as a risk factor for preterm infants to contract PGF. Finally, the decline in a weight-for-age z-score of ≥1.2 confirmed that preterm infants with PGF took a longer time to be fully orally fed and a longer duration for total parenteral nutrition than the ones without PGF.

Conclusion

The decline in a weight-for-age z-score of ≥1.2 was useful to identify preterm infants with PGF within our cohort. This could reassure pediatricians in Indonesia to use this new indicator.

Prediction of extubation failure among low birthweight neonates using machine learning

OBJECTIVE

To develop machine learning models predicting extubation failure in low birthweight neonates using large amounts of clinical data.

STUDY DESIGN

Retrospective cohort study using MIMIC-III, a large single-center, open-source clinical dataset. Logistic regression and boosted-tree (XGBoost) models using demographics, medications, and vital sign and ventilatory data were developed to predict extubation failure, defined as reintubation within 7 days.

RESULTS

1348 low birthweight (≤2500 g) neonates who received mechanical ventilation within the first 7 days were included, of which 350 (26%) failed a trial of extubation. The best-performing model was a boosted-tree model incorporating demographics, vital signs, ventilator parameters, and medications (AUROC 0.82). The most important features were birthweight, last FiO2, average mean airway pressure, caffeine use, and gestational age.

CONCLUSIONS

Machine learning models identified low birthweight ventilated neonates at risk for extubation failure. These models will need to be validated across multiple centers to determine generalizability of this tool.

Developmental outcome of extremely preterm infants is improved after less invasive surfactant application: Developmental outcome after LISA

AIM

The aim of this study was to evaluate neurocognitive outcome at 24 months of corrected age after less invasive surfactant application (LISA) in preterm infants born at 23-26 weeks of gestational age.

METHODS

Surviving participants of a LISA trial conducted in 13 German level III neonatal intensive care units were reviewed for assessment of developmental outcome, hearing and vision problems, growth and rehospitalisation days. Maternal depression, breastfeeding rates and socio-economic factors were evaluated as potentially confounding factors.

RESULTS

In total, 156/182 infants took part in the study, 78 had received surfactant via LISA and 78 via endotracheal intubation. 22% of LISA infants compared to 42% of intubated infants had a psychomotor development index (PDI) <70 (0.012). A significant difference in mental development index (MDI) was observed in the stratum of more mature infants (25 and 26 weeks of GA). For this group, MDI < 70 was observed in 4% of LISA infants vs 21% of intubated infants (P = 0.008).

CONCLUSION

At 24 months of age, the LISA-treated infants scored less often PDI < 70 and had similar results in MDI. Infants born at 25 and 26 weeks treated with LISA had lower rates of severe disability. LISA is safe and may be superior.